D. Fabre

Total Endovascular Treatment of Aortic Arch Disease Using an Arch Endograft With 3 Inner Branches

Purpose: To report early experience with a new endovascular graft developed for aortic arch aneurysm repair in patients unfit for open surgery. Case Report: Three consecutive men (62, 74, and 69 years old) at high risk for open repair were treated for postdissection aortic arch aneurysms using a custom-made 3 inner branched endovascular graft. The 2 proximal branches are antegrade and perfuse the innominate artery and the left common carotid artery; the third branch is retrograde and perfuses the left subclavian artery. The latter is preloaded with a catheter and wire to aid cannulation. Technical success was achieved in each case. The mean procedure time, fluoroscopy duration, and contrast volume were 180 minutes, 35 minutes, and 145 mL, respectively. The perioperative period was uneventful. All branches were patent on 6-month computed tomography and duplex ultrasound imaging. Conclusion: This new patient-specific device allows total endovascular revascularization of the supra-aortic trunks during arch repair. These encouraging results support its more widespread use.

Comparison of cardiac allograft vasculopathy in heart and heart–lung transplantations: A 15-year retrospective study

BACKGROUNDnCardiac allograft vasculopathy (CAV) is a major factor limiting long-term survival after heart transplantation (HTx). Specific determinants of CAV and long-term outcome after CAV occurrence have been poorly investigated after heart-lung transplantation (HLTx).nnnMETHODSnBetween January 1996 and December 2006, 79 patients underwent HLTx (36.3 ± 12.2 years old; 47% men) and 141 patients underwent HTx (49.2 ± 12.3 years old; 77% men) at two different institutions. CAV grading was reviewed in both groups according to the 2010 standardized nomenclature of the International Society for Heart and Lung Transplantation. The mean post-transplant follow-up was 94 (1 to 181) months.nnnRESULTSnOverall 10-year survival rate was 58% after HTx and 43% after HLTx (p = 0.11). The Grade 1 (or higher) CAV-free survival rate was 95% at 4 years and 69% at 10 years after HLTx, and 77% and 39%, respectively, after HTx (p < 0.01). Mean cyclosporine blood levels were similar between the groups at 3, 6, 12, 24 and 36 months. The main causes of mortality beyond 5 years after HTx and HLTx were malignancies and bronchiolitis obliterans, respectively. By multivariate analysis, recipients who developed >3 acute myocardial rejections during the first year post-transplant were exposed to a higher risk of CAV (95% CI 1.065 to 2.33, p = 0.02). Episodes of acute pulmonary rejection and bronchiolitis obliterans were not associated with an increased risk of CAV (p = 0.52 and p = 0.30).nnnCONCLUSIONnHLTx recipients appeared protected from CAV compared with HTx patients in this retrospective study. Repeated acute cardiac rejections were independent predictors of CAV. Unlike bronchiolitis obliterans, CAV had a very low impact on long-term survival after HLTx.

Complex endovascular repair of postdissection arch and thoracoabdominal aneurysms

OBJECTIVEnWe report our experience of the treatment of postdissection arch aneurysms and thoracoabdominal aortic aneurysms (TAAAs) by endovascular repair using fenestrated and branched endografts.nnnMETHODSnThis study includes all patients presenting with chronic postdissection aneurysms >55xa0mm in diameter deemed unfit for open surgery and treated by complex endografting between October 2011 and April 2017. Where appropriate, staged management strategies including left subclavian artery revascularization, thoracic endografting, dissection flap fenestration, and tear enlargement were performed before the complex endovascular repair. Outcome data were collected prospectively, specifically including technical success, endoleaks, target vessel patency, aneurysm diameter, adverse events, reinterventions, and mortality.nnnRESULTSnWe treated 40 patients with a median age of 63xa0years (55-71xa0years). In total, 43 procedures were performed: 19 arch repairs using inner branch endografts (one to three branches) and 24 TAAA repairs using fenestrated or branched endografts. Three patients were treated using both arch and TAAA repair. The median time between initial presentation with acute dissection and the first complex aortic repair was 5xa0years (3.0-10.0xa0years). Staged procedures were performed in 33 of 40 patients (82.5%). The technical success rate was 93%, the median procedure length was 240xa0minutes (170-285xa0minutes), and the median dose-area product was 80xa0Gy · cm2 (54.3-138.4xa0Gy · cm2). The 30-day and in-hospital mortality rates were 2.3% (1/43) and 4.7% (2/43), respectively. The spinal cord ischemia rate was 7% and occurred only after TAAA repair. One stroke with partial recovery and one transient ischemic attack were observed (4.7%) after arch repair. Six early reinterventions (14%) were performed: three for access complications, two to treat acute hemorrhage, and one to treat a type II endoleak. Median follow-up was 25.5xa0months (11-42.25xa0months). The 1- and 5-year survival rates were 90% and 76.4%, respectively. Late reinterventions were required in eight patients, two in the arch group (to treat endoleaks at 3 and 33xa0months) and six in the TAAA group (2 iliac and 1 bifurcated endograft extensions, 2 additional renal stents, 1 inferior mesenteric artery embolization). Aneurysm diameter was stable (72%) or shrank (23%) during follow-up. Enlargement was shown in two patients with endoleaks.nnnCONCLUSIONSnComplex endovascular repair of postdissection aneurysms is a safe procedure in patients deemed unfit for open surgery. Our experience suggests that close follow-up is mandatory as secondary procedures are frequently required to completely exclude the false lumen.

Case series of aortic arch disease treated with branched stent‐grafts

Surgical repair of aortic arch pathology is complex and associated with significant morbidity and mortality. Alternative approaches have been developed to reduce these risks, including the use of thoracic stent‐grafts with fenestrations or in combination with bypass procedures to maintain supra‐aortic trunk blood flow. Branched stent‐grafts are a novel approach to treat aortic arch pathology.