S. Sadie Ahanchi

Left subclavian artery revascularization in zone 2 thoracic endovascular aortic repair is associated with lower stroke risk across all aortic diseases

Background: The best management strategy for the left subclavian artery (LSA) in pathologic processes of the aorta requiring zone 2 thoracic endovascular aortic repair (TEVAR) remains controversial. We compared LSA coverage with or without revascularization as well as the different means of LSA revascularization. Methods: A retrospective chart review was conducted of patients with any aortic diseases who underwent zone 2 TEVAR deployment from 2007 to 2014. Primary end points included 30‐day stroke and 30‐day spinal cord injury (SCI). Secondary end points were 30‐day procedure‐related reintervention, freedom from aorta‐related reintervention, aorta‐related mortality, and all‐cause mortality. Results: We identified 96 patients with zone 2 TEVAR who met our inclusion criteria. The mean age of the patients was 62 years, with 61.5% male. Diseases included acute aortic dissections (n = 25), chronic aortic dissection with aneurysmal degeneration (n = 22), primary aortic aneurysms (n = 21), penetrating aortic ulcers/intramural hematomas (n = 17), and traumatic aortic injuries (n = 11). Strategies for the LSA included coverage with revascularization (n = 54) or without revascularization (n = 42). Methods of LSA revascularization included laser fenestration with stenting (n = 33) and surgical revascularization: transposition (n = 10) or bypass (n = 11). Of the 54 patients with LSA revascularization, 44 (81.5%) underwent LSA intervention at the time of TEVAR and 10 (18.5%) at a mean time of 33 days before TEVAR (range, 4‐63 days). For the entire cohort, the overall incidence of 30‐day stroke was 7.3%; of 30‐day SCI, 2.1%; and of procedure‐related reintervention, 5.2%. At a mean follow‐up of 24 months (range, 1‐79 months), aorta‐related reintervention was 15.6%, aorta‐related mortality was 12.5%, and all‐cause mortality was 29.2%. The 30‐day stroke rate was highest for LSA coverage without revascularization (6/42 [14.3%]) compared with any form of LSA revascularization (1/54 [1.9%]; P = .020), with no difference between LSA interventions done synchronously with TEVAR (1/44 [2.3%]) vs metachronously with TEVAR (0/10 [0%]; P = .63). There was no significant difference in 30‐day SCI in LSA coverage without revascularization (2/42 [4.8%]) vs with revascularization (0/54 [0%]; P = .11). There was no difference in aorta‐related reintervention, aorta‐related mortality, or all‐cause mortality in coverage without revascularization (5/42 [11.9%], 6/42 [14.3%], and 14/42 [33.3%]) vs with revascularization (10/54 [18.5%; P = .376], 6/54 [11.1%; P = .641], and 14/54 [25.9%; P = .43], respectively). After univariate and multivariable analysis, we identified LSA coverage without revascularization as associated with a higher rate of 30‐day stroke (hazard ratio, 17.2; 95% confidence interval, 1.3‐220.4; P = .029). Conclusions: Our study suggests that coverage of the LSA without revascularization increases the risk of stroke and possibly SCI.

Techniques and Results of Endovascular In Situ Arch Fenestrations

Thoracic endovascular aortic repair (TEVAR) has been widely applied to treat acute and chronic diseases of the aorta. Successful endovascular repair of the thoracic aorta requires adequate proximal and distal apposition of the endograft to healthy aorta. To achieve a good proximal seal, this can require coverage of one or more of the aortic arch vessels. In situ arch fenestration is an endovascular technique that involves endovascular modification of a thoracic endograft to achieve arch vessel revascularization. This is most commonly applied to the left subclavian artery (LSA) but can be utilized in any arch vessel. Fenestration of a thoracic endograft can be performed with needle puncture, laser energy, or radiofrequency wire followed by balloon angioplasty of the fenestration and placement of a covered stent across the endograft fenestration into the target vessel. Technical success of this method is most limited by aortic arch type, angulation of arch vessels, and target vessel anatomy. This chapter describes the technical aspects and results of in situ arch fenestration, history, pathology, anatomic limitations, patient selection, different methods of fenestration, a complex case, and application of new endovascular tools.

The impact of intravascular ultrasound on outcomes of endovascular repair of blunt traumatic aortic injury

Introduction Endovascular repair has become first-line therapy for traumatic aortic injury. Proper endograft sizing is critical to outcomes following traumatic aortic injury repair; however, the adequacy of standard imaging modalities for this purpose remains uncertain. We assessed the impact of intravascular ultrasound on outcomes of endovascular traumatic aortic injury repair. Methods A retrospective review was conducted for all traumatic aortic injury patients from 2005 to 2015. Primary endpoints were 30-day aortic-related complications (aortic-related mortality, stroke, and spinal cord ischemia) and late device-related complications (collapse, migration, endoleak, and reintervention) over the duration of follow-up. Aortic measurements were calculated from three-dimensional-reconstructed computerized tomography studies and intravascular ultrasound images. Aortic remodeling was quantified by volume change between initial and first follow-up computerized tomography scans. Results Twenty-five patients were included (mean age 41, 72% male). Intravascular ultrasound was used in 14 patients. No differences in demographics or injury characteristics were observed between intravascular ultrasound and non-intravascular ultrasound patients. Proximal neck diameter was 1.2 mm greater on intraoperative intravascular ultrasound than initial computerized tomography imaging (P = .048). Endograft oversizing in relation to initial computerized tomography was 25% in intravascular ultrasound patients versus 9% in non-intravascular ultrasound patients (P = .001). No significant differences in aortic-related complications were noted. Device-related complications occurred more frequently in the non-intravascular ultrasound group at a mean follow-up of 252 days (36.4% vs. 0%, P = .026). Aortic remodeling rate was 4.41 cm3/day in the intravascular ultrasound group versus 2.34 cm3/day in the non-intravascular ultrasound group (P = .256). Conclusions Intravascular ultrasound significantly impacts endograft sizing and was associated with decreased device-related complications following endovascular traumatic aortic injury repair.