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Comparison of Total Arch and Partial Arch Transposition During Hybrid Endovascular Repair for Aortic Arch Disease
Eur J Vasc Endovasc Surg (2016) 52, 173e178
Comparison of Total Arch and Partial Arch Transposition During Hybrid Endovascular Repair for Aortic Arch Disease W.C. Kang a, Y.-G. Ko
b,*
, P.C. Oh a, E.K. Shin a, C.-H. Park c, D. Choi b, Y.N. Youn d, D.Y. Lee
e
a
Cardiology, Gachon University Gil Medical Center, Incheon, Republic of Korea Cardiothoracic Surgery, Gachon University Gil Medical Center, Incheon, Republic of Korea Cardiology, Severance Cardiovascular Hospital, Yonsei University, Seoul, Republic of Korea d Cardiothoracic Surgery, Severance Cardiovascular Hospital, Yonsei University, Seoul, Republic of Korea e Radiology, Severance Cardiovascular Hospital, Yonsei University, Seoul, Republic of Korea b c
WHAT THIS PAPER ADDS To the authors’ knowledge, this is the first comparative study on hybrid endovascular repair using TAT or PAT for aortic arch disease to include zone 2 repair. Previous studies have focused mainly on comparisons between zone 0 and zone 1. In the present study, it was noted that morbidity and mortality were high within the first year of hybrid endovascular repair for aortic arch disease, and peri-operative mortality/stroke and long-term survival were found to be similar for hybrid endovascular repair with TAT or PAT. It was concluded that hybrid endovascular therapy for aortic arch disease could be considered irrespective of arch reconstruction type, when it is clinically indicated.
Objective: Total arch transposition (TAT) during hybrid endovascular repair for aortic arch disease is believed to allow a better landing zone, but also to be associated with higher peri-operative mortality than partial arch transposition (PAT). Information on this issue is limited. Method: This study was a retrospective analysis. All 53 consecutive patients with aortic arch disease (41 males, mean age 65.0 years) who underwent hybrid endovascular repair with TAT (zone 0, n¼20) or PAT (zone 1 or 2, n¼33) from 2008 to 2014 were analyzed retrospectively. The peri-operative and late outcomes of these two groups were compared. Results: Baseline characteristics, including EuroSCORE II results, were similar in the two groups. After procedures, peri-operative mortalities and stroke rates were similar in the two groups (5.0% vs. 9.1%, p¼1.000, and 10.0% vs. 6.1%, p¼.627). Interestingly, all four strokes occurred in patients with a type III aortic arch irrespective of transposition type. Primary success rates (80.0% vs. 69.7%, p¼.527) and type I endoleak incidences (20.0% vs. 27.3%, p¼.744) were not significantly different. During follow up (mean duration 36.9 months), overall survival (89.7% vs. 87.4% at 1 year and 89.7% vs. 79.3% at 3 years; p¼.375) and re-intervention free survival rates (78.6% vs. 92.0% at 1 year; 72.0% vs. 62.2% at 3 years, p¼.872) were similar in the two groups. Conclusion: Morbidity and mortality were high within the first year of hybrid endovascular therapy for aortic arch disease, implying that candidates for hybrid procedures need to be selected carefully. Hybrid endovascular repair with TAT was found to have peri-operative mortality, stroke, and long-term survival rates comparable with PAT, so hybrid endovascular repair may be considered, irrespective of type of arch reconstruction, when clinically indicated. Ó 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. Article history: Received 28 January 2016, Accepted 1 June 2016, Available online 23 June 2016 Keywords: Hybrid endovascular repair, Total arch transposition, Partial arch transposition, Stent graft, Mortality, Re-intervention
INTRODUCTION
* Corresponding author. Cardiology, Severance Cardiovascular Hospital, Yonsei University, 50e1 Yonsei-ro, Seodaemun-gu, Seoul 120e752, Republic of Korea. E-mail address: [email protected] (Y.-G. Ko). 1078-5884/Ó 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejvs.2016.06.001
Open surgical repair for aortic arch disease carries a high risk of significant morbidity and mortality.1,2 Although endovascular repair represents a significant advance in the management of aortic disease, the aortic arch presents specific challenges because of acute arch angulation, its branches, high blood flow, and the pulsatile nature of the proximal aorta. Hybrid endovascular repair involves extraanatomic, supra-aortic vessel transposition to provide an
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adequate proximal landing zone and to maintain cerebral perfusion before endovascular repair, and has emerged as an alternative to open surgical repair of aortic arch diseases. Furthermore, several early reports have described favorable clinical outcomes.3e5 The choice of arch transposition for hybrid endovascular repair depends on the morphologic features of the aortic arch and the extent of aortic disease. Total arch transposition (TAT) allows for a better landing zone, but is believed to have a higher peri-operative mortality rate than the less invasive partial arch transposition (PAT). Nevertheless, the type of arch vessel transposition that minimizes procedural invasiveness without losing effectiveness and long-term durability remains a subject of debate.6e10 The purpose of this study was to compare the outcomes of TAT and PAT during hybrid endovascular repair for aortic arch disease. MATERIALS AND METHODS Study design and patient population This retrospective analysis was performed on 53 consecutive patients who underwent hybrid endovascular repair for aortic arch diseases at the Gachon University Gil Medical Center and Yonsei University Severance Cardiovascular Hospital. Patients for hybrid endovascular repair were selected from patients unsuitable for open surgical repair because of a coexisting condition or conventional endovascular repair because of extensive disease involvement of the aortic arch. The indications for hybrid endovascular repair were as follows: (1) maximum aortic diameter 55 mm; (2) rapid aortic enlargement (10 mm per year). The type of arch transposition was decided by multidisciplinary teams of cardiovascular surgeons, interventional cardiologists, and radiologists. An aortic arch segment of diameter <42 mm and length >20 mm was considered to be a suitable proximal landing zone for implantation of a stent graft during hybrid endovascular repair. Medical records and radiographic data were reviewed. The institutional review boards of the two study institutions approved this study and waived the requirement for informed consent because of the retrospective nature of the analysis.
Analysis of pre-procedural CT angiography Analysis of aortic diameter and distance between each branch was performed on a three dimensional workstation (AquariusWS; Terarecon, San Francisco, CA, USA). A flow centerline was generated using the semi-automated centerline algorithms on the workstation. The calculated centerline was confirmed manually by scrolling through the images in axial, coronal, and sagittal planes to ensure that it accurately reflected the center point of the arterial lumen. Reconstructions perpendicular to the centerline of flow were then displayed in a two-dimensional format from which diameter and length measurements were measured.
W.C. Kang et al.
Hybrid endovascular repair Arch transposition. All arch transposition operations were performed in an operation room or hybrid angiography suite located in an operation room. The type of arch transposition was based on considerations of aortic arch disease extent and morphologic appearance of the proximal landing zone for the stent graft. For treatment of zone 0 arch disease, through a sternotomy approach, an anastomosis is performed between the proximal portion of the prosthesis and the ascending aorta. Then, an end to end anastomosis is performed between the first branch of the prosthesis and the brachiocephalic artery (BA). Afterward, an end to end anastomosis is performed between the second branch of the prosthesis and the left subclavian artery (LSCA). Finally, the left common carotid artery (LCCA) is reinserted into the branch to the LSCA. For treatment of zone 1 arch disease, a carotid-carotid crossover bypass using a retro-esophageal route is routine. After exposure of all supra-aortic branches, an end to side anastomosis is performed between the LCCA and the BA. Next, an end to side anastomosis between the LSCA and the LCCA finalizes the procedure. Treatment of zone 2 arch disease is done by a standard approach through a skin incision parallel to the left clavicle. The LSCA is divided at its origin at the level of the aortic arch. The vessel is guided dorsal to the left jugular vein, and an end to side anastomosis is performed between the LSCA and the LCCA.3 The LSCA is ligated proximally when possible, and when not possible vascular plugs are used to achieve subclavian occlusion. Stent graft placement. All endovascular procedures were performed in an angiography suite. The common femoral artery (CFA) was used for access in all cases for stent graft placement. In the majority of patients, stent graft insertion was performed using a percutaneous approach, after preclosing vascular access sites using suture-mediated closure devices (PercloseÔ; Abbott Lab., Menlo Park, CA, USA).11 Surgical exposure of the access vessel was required in one patient with severely tortuous and calcified CFAs, and prophylactic cerebrospinal fluid drainage was performed in patients who required coverage of the distal descending thoracic aorta with stent grafts. In most cases, lowering blood pressure was not necessary for stent graft implantation, but when necessary, especially for zone 0 aortic arch disease, rapid ventricular pacing was performed during deployment of the stent graft. To achieve satisfactory sealing, stent grafts were oversized by 10e15% for aortic dissections (proximal implantation side) and by 15e20% for aortic aneurysms. Definitions, study endpoints, and follow up The EuroSCORE II system was used to assess operative risks (http://www.euroscore.org/calc.html). Outcome criteria and definitions for hybrid endovascular repair were based on recommended reporting standards for endovascular aortic aneurysm repair issued by the Ad Hoc Committee for Standardized Reporting Practices in Vascular Surgery.12
Comparison of Total Arch and Partial Arch Transposition
Primary success was defined as stent graft implantation without surgical conversion, mortality or type I or III endoleak. All 53 patients underwent contrast enhanced computed tomographic angiography (CTA) scans before discharge, and all complied with a follow up surveillance protocol requiring a CTA scan and outpatient clinic review at 6 and 12 months during the first year, and annually thereafter. The primary study endpoints were peri-operative (30 day) mortality and stroke rates. Secondary endpoints were type I endoleak, re-interventions, survival rates, and post-procedural complications. Statistical analysis Quantitative data are presented as means and standard errors and the significance of intergroup differences was determined using the Student t test. Qualitative data are expressed in absolute numbers and percentages, and were analyzed using the chi-square test or Fisher’s exact test. The KaplaneMeier method was used to determine event free survival rates with respect to death and re-intervention. The analysis was performed using a computer based statistical software package (Statistical Package for Social Sciences [SPSS], Ver. 20 for Windows; SPSS, Chicago, IL, USA). Two sided p-values of <.05 were considered to be statistically significant. RESULTS Patient characteristics Of the 53 patients, 20 received TAT and 33 PAT. No intergroup differences were found for gender, age, or comorbidities, including EuroSCORE II results, or between aortic arch type distributions. PAD was more common in the TAT group than in the PAT group (5.0% vs. 21.2%). In terms of underlying aortic diseases, aneurysm was more common in the TAT group (85.0% vs. 72.7%) and aortic dissection was more common in the PAT group (10.0% vs. 15.2), but both were without statistical significance (Table 1). Hybrid endovascular repair Arch transposition was performed successfully prior to endovascular repair and stent graft implantation was achieved in all 53 study patients (Table 2). In most (77.4%), a staged procedure was performed (TAT group, 85.0%; PAT group, 72.7%, p¼.500), and the median time between arch transposition and endovascular repair was longer in the TAT group (13 days vs. 4 days, p¼.012). Three different stent grafts were used: Seal (S & G Biotech, Seoul), Valiant (Medtronic, Santa Rosa, CA), and TX2 Pro-Form (Cook Inc, Bloomington, IN). The Seal thoracic stent graft was more commonly used in the TAT group and the other two devices were more common in the PAT group (p¼.016). A single device was used in 11 (55.0%) and 23 patients (69.7%) in the TAT and PAT groups respectively, and multiple devices were implanted in the other 9 and 10 patients respectively, who had extensive thoracic lesions. LSCA embolization using a vascular plug was more common in the TAT group
175 Table 1. Baseline characteristics. TAT (n¼20) PAT (n¼33) p-value Age, years 65.416.3 64.815.8 .888 Male, n (%) 16 (80.0) 25 (75.8) .721 Hypertension, n (%) 12 (60.0) 23 (69.7) .470 DM, n (%) 4 (20.0) 5 (15.2) .715 Dyslipidemia, n (%) 6 (30.0) 14 (42.4) .399 Smoker, n (%) 10 (50.0) 15 (43.5) .950 CAD, n (%) 8 (40.0) 20 (60.6) .168 PAD, n (%) 1 (5.0) 7 (21.2) .234 COPD, n (%) 4 (20.0) 8 (24.2) 1.000 CRF, n (%) 4 (20.0) 5 (15.2) .715 Prior aortic surgery, n (%) 1 (5.0) 1 (3.0) 1.000 EuroSCORE II (%) 4.84.6 4.85.4 .989 Type of aortic arch, n (%) .639 I 3 (15.0) 6 (18.2) II 3 (15.0) 8 (24.2) III 14 (70.0) 19 (57.6) Dominance of vertebral 1.000 artery, n (%) Right 7 (35) 12 (36.4) Left 5 (25) 8 (24.2) No dominance 8 (40) 13 (39.4) Indication for intervention, .559 n (%) Aneurysm 17 (85.0) 24 (72.7) Aortic dissection 2 (10.0) 5 (15.2) Pseudoaneurysm 1 (5.0) 4 (12.1) DM ¼ diabetes mellitus; CAD ¼ coronary artery disease; PAD ¼ peripheral artery disease; COPD ¼ chronic obstructive pulmonary disease; CRF ¼ chronic renal failure (GFR <30 mL/min).
Table 2. Procedural data. Success rate of supra-aortic vessel transposition, n (%) Median time from supra-aortic transposition to endovascular repair (days) Proximal landing zone length, mm Staged procedure, n (%) Stent graft, n (%) Seal thoracic Valiant TX2 Pro-Form Number of stent grafts, n (%) 1 2 Maximal diameter of stent graft, mm LSCA revascularization, n (%) LSCA embolization with vascular plug, n (%) Percutaneous approach, n (%) Primary success, n (%) Type I endoleak, n (%) LSCA ¼ left subclavian artery.
TAT (n¼20) PAT (n¼33) p-value 20 (100) 33 (100) 1.000 13 (0e133) 4 (0e45)
.012
35.715.0 28.39.0
.159
17 (85.0)
24 (72.7)
.500 .016
12 (60.0) 4 (20.0) 4 (20.0)
7 (21.2) 15 (45.5) 11 (33.3) .480
11 (55.0) 9 (45.0) 38.04.9
23 (69.7) 10 (30.3) 38.44.8
.785
20 (100) 13 (65.0)
33 (100) 9 (27.3)
1.000 .007
19 (95.0) 16 (80.0) 4 (20.0)
32 (97.0) 23 (69.7) 9 (27.3)
1.000 .527 .744
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W.C. Kang et al.
(65.0% vs. 27.3%, p¼.007). Stent grafts were implanted using a percutaneous approach in 51 of the study patients (96%). The primary success rate was non-significantly higher in the TAT group (80.0% vs. 69.7%, p¼.527). Type I endoleak rates were 20.0% and 27.3% in the TAT and PAT groups, also not significant. Peri-operative mortality and morbidity Peri-operative death occurred in one patient (5.0%) in the TAT group and in three patients (9.1%) in the PAT group (p ¼ 1.000). The single death in the TAT group was caused by aortic rupture on the day after surgery. In the PAT group, two patients died of intra-operative stroke, and one succumbed to intracranial hemorrhage 25 days postoperatively. Peri-operative morbidities were observed in 10 patients in the TAT group and in eight patients in the PAT group. Stroke was more common in the TAT group, but there was no statistical significance (10.0% vs. 6.1%, p¼0.627). No significant intergroup difference was observed for spinal cord ischemia, retrograde dissection, renal failure, bleeding, or vascular injury (Table 3). Late outcomes during follow up The mean follow up duration was 36.9 months. Overall survival was similar in the TAT and PAT groups (89.7% vs 87.4% at 1 year and 89.7% vs 79.3% at 3 years; p¼.375; Fig. 1). In the TAT group, two patients died of aortic rupture 10 (untreated type I endoleak) and 76 months (progression of retrograde aortic dissection) post-operatively, and one patient died from sepsis and multi-organ failure 46 months post-operatively. In the PAT group, one patient died of aortic rupture (untreated type I endoleak) 9 months postoperatively, one died of sepsis at 17 months, and another of pneumonia at 19 months. So the mortality related type I endoleak occurred in one patient in each group. Group reintervention free survival rates were also similar (78.6% vs. 92.0% at 1 year; 72.0% vs. 62.2% at 3 years, p¼.872; Fig. 2).
Figure 1. KaplaneMeier death free survival rate curves.
In the TAT group, three patients required re-intervention for a type I endoleak (n¼2) or endotension (n¼1); all three were treated by additional stent graft implantation. In addition, one patient with intra-operative retrograde dissection was treated by open surgical repair 7 days postoperatively, and another with de novo type B aortic dissection in the proximal descending thoracic aorta was treated with a stent graft at 2 months. In the PAT group, six patients required re-intervention. Patients with a type I endoleak (n¼2) or endotension (n¼1) were treated by additional stent graft implantation. One patient with retrograde dissection was treated by open surgical repair 8 months post-operatively. Another with de novo aortic dissection at the distal portion of the previously placed stent graft was treated with an additional stent graft at 28
Table 3. Peri-operative (30 day) and follow up clinical outcomes. TAT (n¼20) PAT (n¼33) p-value Peri-operative outcomes Death or stroke, n (%) Death, n (%) Stroke, n (%) Spinal cord ischemia, n (%) Retrograde dissection, n (%) Renal failure, n (%) Bleeding, n (%) Vascular injury, n (%) Pneumonia, n (%) Wound infection, n (%) Follow up outcomes Death, n (%) Stroke, n (%) Re-intervention, n (%) Chronic renal failure, n (%)
3 1 2 0 2 2 1 3 0 0 4 3 5 2
(15.0) (5.0) (10.0) (10.0) (10.0) (5.0) (15.0)
(20.0) (15.0) (26.3) (10.0)
3 3 2 0 1 2 1 1 1 0
(9.1) (9.1) (6.1)
.661 1.000 .627
(3.0) (6.1) (3.0) (3.0) (3.0)
.549 .627 1.000 .145 1.000
6 (18.2) 2 (6.1) 6 (19.4) 0
1.000 .354 .727 .149 Figure 2. KaplaneMeier re-intervention free survival rate curves.
Comparison of Total Arch and Partial Arch Transposition
months. The remaining patient had endovascular therapy for confined aortic rupture detected by follow up CT 11 months post-operatively. Morphologic analysis of the follow up CTA findings of surviving patients (n¼49) showed shrinkage of aortic diameter more than 5 mm or no interval change in 78.9% (15/19) in the TAT group and 77.5% (23/ 30) in the PAT group (p¼1.000). There was no stent graft migration in either group. DISCUSSION Main findings A recent report compared data between hybrid endovascular and open surgical repair for aortic arch disease involving zones 0 and 1.13 The present study focused on data for hybrid endovascular repair and compared perioperative and long-term outcomes after hybrid endovascular repair with TAT (for zone 0) or PAT (for zone 1 or 2). Results obtained were as follows. First, peri-operative mortality (5.0% vs. 9.1%, p¼1.000) and stroke (10.0% vs. 6.1%, p¼.627) rates were no different between the TAT and PAT groups. Second, although proximal landing zone length was longer in the TAT group, type I endoleak incidences were not significantly different between the groups (20.0% vs. 27.3%, p¼.744). Third, overall survival and reintervention free rates at 1 and 3 years post-operatively were not different between groups. Mortality and stroke Generally, it is believed that TAT is associated with a significantly greater operative risk, and that this results in higher peri-operative mortality. Furthermore, several studies have reported higher mortality rates for zone 0 than zone 1 patients.6e10 Nonetheless, debate continues on the comparative merits of hybrid endovascular repair with complete arch reconstruction or with partial arch reconstruction on a background of aortic arch disease. In the present study, mortality rates were similar between the two study groups, and EuroSCORE II results showed that operative risks were similar. These findings suggest a sternotomy for complete arch reconstruction does not carry a higher operative risk than re-routing for partial reconstruction. However, it should be noted that the present study is prone to selection bias, because TAT is often reserved for optimal patients based on considerations of operative risk. On the other hand, proximal extent of repair has been reported to be significantly associated with a higher incidence of stroke,12,14 which is probably the case when stent graft implantation into the aortic arch is compared with implantation into the descending thoracic aorta, because of wire and device manipulation within the ascending aorta and aortic arch. But in the present study, no difference was found between the two study groups in terms of the incidence or severity of strokes with a more proximal stent graft implantation. Interestingly, all strokes occurred in patients with a type III aortic arch which means the vertical distance from the origin of the BA to the top of the arch is
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>2 diameters of the LCCA, and two deaths in the PAT group were related to massive stroke after procedures, which indicates that stent graft manipulation in the ascending aorta might increase stroke risk regardless of aortic arch reconstruction type. Unlike the present study, previous studies focused mainly on comparisons of zone 0 and zone 1,7,15 and thus, little information is available regarding hybrid endovascular repair with PAT for zone 2. To the authors’ knowledge, this is the first comparative study on hybrid endovascular repair using TAT or PAT for aortic arch disease to include zone 2 repair. Type I endoleak and re-intervention Hybrid endovascular repair with PAT has a significant risk of technical failure mainly because of type I endoleak. This phenomenon is considered to be the main drawback of hybrid endovascular repair for arch disease because of its anatomic complexity and the limitations of current devices.10,15,16 A shorter proximal landing zone and acute angulation of the aortic arch in zone 1 may lead to inadequate stent graft attachment, and thus, a high type I endoleak rate in zone 1. A previous meta-analysis reported a significantly lower primary success rate for stent graft implantation into zone 1 of the aortic arch than for stent graft implantation after TAT in zone 0,10 and as a result, a higher re-intervention rate in zone 1 than in zone 0. However, in the present study, despite a longer mean proximal landing zone length in the TAT group, type I endoleak and re-intervention rates during follow up were no different between the two groups. Based on data regarding endovascular repair of abdominal aortic aneurysms, a landing zone of 20 mm was considered to be optimal for proximal sealing, but the incidence of type I endoleak in the present study was relatively high and it was the most common cause of primary failure. A recent study lends support to the high rate of type I endoleak after arch endovascular repair. In the study, it was found that a landing zone <24 mm in length independently predicted primary failure for hybrid endovascular arch repair, and it was suggested that this might be related to a diseased and angulated proximal landing zone in the aortic arch.17 Precise placement of a stent graft in the proximal landing zone after arch vessel transposition is not easy, even for a highly experienced operator. In a comparative study on endovascular repair between aortic arch and descending aorta, the type I endoleak rate was high for zone 3 endovascular repairs and for the complex areas in the arch, which reflected the limitations of the current devices used to treat thoracic aortic disease.18 Dedicated stent grafts for the aortic arch continue to evolve, but precise stent graft placement without losing the proximal landing zone in the hostile aortic arch remains unfeasible, with the devices currently available. Limitations The major limitation of the present study is its retrospective study design and its small study population, which did not
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allow full assessment of confounders or minor outcomes. Nevertheless, the comparison of zone 0 and zone 1/2 repairs does provide new outcome data. In addition, heterogeneities of aortic pathologies in both study groups, the use of three stent graft types, the lack of use of risk stratifications systems, and the short follow up are limitations. CONCLUSIONS Morbidity and mortality were high within the first year of hybrid endovascular therapy for aortic arch disease, which means candidates for hybrid procedures must be selected carefully. Peri-operative mortality/stroke and long-term survival were found to be similar for hybrid endovascular repair with TAT or PAT, so it is concluded that hybrid endovascular therapy for aortic arch disease could be considered irrespective of arch reconstruction type, when it is clinically indicated. CONFLICT OF INTEREST None. FUNDING None. REFERENCES 1 Okita Y, Okada K, Omura A, Kano H, Minami H, Inoue T, et al. Total arch replacement using antegrade cerebral perfusion. J Thorac Cardiovasc Surg 2013;145:S63e71. 2 Patel HJ, Nguyen C, Diener AC, Passow MC, Salata D, Deeb GM. Open arch reconstruction in the endovascular era: analysis of 721 patients over 17 years. J Thorac Cardiovasc Surg 2011;141: 1417e23. 3 Kang WC, Shin EK, Park CH, Kang JM, Ko YG, Choi D, et al. Hybrid endovascular repair for aortic arch pathology: intermediate outcomes and complications: a retrospective analysis. Catheter Cardiovasc Interv 2013;82:275e82. 4 Gottardi R, Seitelberger R, Zimpfer D, Lammer J, Wolner E, Grimm M, et al. An alternative approach in treating an aortic arch aneurysm with an anatomic variant by supraaortic reconstruction and stent graft placement. J Vasc Surg 2005;42: 357e60. 5 De Rango P, Cao P, Ferrer C, Simonte G, Coscarella C, Cieri E, et al. Aortic arch debranching and thoracic endovascular repair. J Vasc Surg 2014;59:107e14.
W.C. Kang et al. 6 Cao P, De Rango P, Czerny M, Evangelista A, Fattori R, Nienaber C, et al. Systematic review of clinical outcomes in hybrid procedures for aortic arch dissections and other arch diseases. J Thorac Cardiovasc Surg 2012;144:1286e300. 7 Schumacher H, Von Tengg-Kobligk H, Ostovic M, Henninger V, Ockert S, Böckler D, et al. Hybrid aortic procedures for endoluminal arch replacement in thoracic aneurysms and type B dissections. J Cardiovasc Surg 2006;47:509e17. 8 Antoniou GA, El Sakka K, Hamady M, Wolfe JH. Hybrid treatment of complex aortic arch disease with supra-aortic debranching and endovascular stent graft repair. Eur J Vasc Endovasc Surg 2010;39:683e90. 9 Vallejo N, Rodriguez-Lopez JA, Heidari P, Wheatley G, Caparrelli D, Ramaiah V, et al. Hybrid repair of thoracic aortic lesions for zone 0 and 1 in high risk patients. J Vasc Surg 2012;55:318e25. 10 Kotelis D, Geisbüsch P, Attigah N, Hinz U, Hyhlik-Dürr A, Böckler D. Total vs hemi-aortic arch transposition for hybrid aortic arch repair. J Vasc Surg 2011;54:1182e6. 11 Lee WA, Brown MP, Nelson PR, Huber TS, Seeger JM. Midterm outcomes of femoral arteries after percutaneous endovascular aortic repair using the Preclose technique. J Vasc Surg 2008;47: 919e23. 12 Chaikof EL, Blankensteijn JD, Harris PL, White GH, Zarins CK, Bernhard VM, et al. Reporting standards for endovascular aortic aneurysm repair. J Vasc Surg 2002;35:1048e60. 13 Kang WC, Ko YG, Shin EK, Park CH, Choi D, Youn YN, et al. Comparison of hybrid endovascular and open surgical repair for proximal aortic arch diseases. Int J Cardiol 2016;203:975e9. 14 Feezor RJ, Martin TD, Hess PJ, Klodell CT, Beaver TM, Huber TS, et al. Risk factors for peri-operative stroke during thoracic endovascular aortic repairs (TEVAR). J Endovasc Ther 2007;14: 568e73. 15 Anderson ND, Williams JB, Hanna JM, Shah AA, McCann RL, Hughes GC. Results with an algorithmic approach to hybrid repair of the aortic arch. J Vasc Surg 2013;57:655e67. 16 Lotfi S, Clough RE, Ali T, Salter R, Young CP, Bell R, et al. Hybrid repair of complex thoracic aortic arch pathology: long term outcomes of extra-anatomic bypass grafting of the supra-aortic trunk. Cardiovasc Intervent Radiol 2013;36:46e55. 17 Boufi M, Aouini F, Guivier-Curien C, Dona B, Loundou AD, Deplano V, et al. Examination of factors in type I endoleak development after thoracic endovascular repair. J Vasc Surg 2015;61:317e23. 18 Kwolek CJ, Fairman R. Update on thoracic aortic endovascular grafting using the medtronic talent device. Semin Vasc Surg 2006;19:25e31.
Comparison of Total Arch and Partial Arch Transposition During Hybrid Endovascular Repair for Aortic Arch Disease W.C. Kang a, Y.-G. Ko
b,*
, P.C. Oh a, E.K. Shin a, C.-H. Park c, D. Choi b, Y.N. Youn d, D.Y. Lee
e
a
Cardiology, Gachon University Gil Medical Center, Incheon, Republic of Korea Cardiothoracic Surgery, Gachon University Gil Medical Center, Incheon, Republic of Korea Cardiology, Severance Cardiovascular Hospital, Yonsei University, Seoul, Republic of Korea d Cardiothoracic Surgery, Severance Cardiovascular Hospital, Yonsei University, Seoul, Republic of Korea e Radiology, Severance Cardiovascular Hospital, Yonsei University, Seoul, Republic of Korea b c
WHAT THIS PAPER ADDS To the authors’ knowledge, this is the first comparative study on hybrid endovascular repair using TAT or PAT for aortic arch disease to include zone 2 repair. Previous studies have focused mainly on comparisons between zone 0 and zone 1. In the present study, it was noted that morbidity and mortality were high within the first year of hybrid endovascular repair for aortic arch disease, and peri-operative mortality/stroke and long-term survival were found to be similar for hybrid endovascular repair with TAT or PAT. It was concluded that hybrid endovascular therapy for aortic arch disease could be considered irrespective of arch reconstruction type, when it is clinically indicated.
Objective: Total arch transposition (TAT) during hybrid endovascular repair for aortic arch disease is believed to allow a better landing zone, but also to be associated with higher peri-operative mortality than partial arch transposition (PAT). Information on this issue is limited. Method: This study was a retrospective analysis. All 53 consecutive patients with aortic arch disease (41 males, mean age 65.0 years) who underwent hybrid endovascular repair with TAT (zone 0, n¼20) or PAT (zone 1 or 2, n¼33) from 2008 to 2014 were analyzed retrospectively. The peri-operative and late outcomes of these two groups were compared. Results: Baseline characteristics, including EuroSCORE II results, were similar in the two groups. After procedures, peri-operative mortalities and stroke rates were similar in the two groups (5.0% vs. 9.1%, p¼1.000, and 10.0% vs. 6.1%, p¼.627). Interestingly, all four strokes occurred in patients with a type III aortic arch irrespective of transposition type. Primary success rates (80.0% vs. 69.7%, p¼.527) and type I endoleak incidences (20.0% vs. 27.3%, p¼.744) were not significantly different. During follow up (mean duration 36.9 months), overall survival (89.7% vs. 87.4% at 1 year and 89.7% vs. 79.3% at 3 years; p¼.375) and re-intervention free survival rates (78.6% vs. 92.0% at 1 year; 72.0% vs. 62.2% at 3 years, p¼.872) were similar in the two groups. Conclusion: Morbidity and mortality were high within the first year of hybrid endovascular therapy for aortic arch disease, implying that candidates for hybrid procedures need to be selected carefully. Hybrid endovascular repair with TAT was found to have peri-operative mortality, stroke, and long-term survival rates comparable with PAT, so hybrid endovascular repair may be considered, irrespective of type of arch reconstruction, when clinically indicated. Ó 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. Article history: Received 28 January 2016, Accepted 1 June 2016, Available online 23 June 2016 Keywords: Hybrid endovascular repair, Total arch transposition, Partial arch transposition, Stent graft, Mortality, Re-intervention
INTRODUCTION
* Corresponding author. Cardiology, Severance Cardiovascular Hospital, Yonsei University, 50e1 Yonsei-ro, Seodaemun-gu, Seoul 120e752, Republic of Korea. E-mail address: [email protected] (Y.-G. Ko). 1078-5884/Ó 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejvs.2016.06.001
Open surgical repair for aortic arch disease carries a high risk of significant morbidity and mortality.1,2 Although endovascular repair represents a significant advance in the management of aortic disease, the aortic arch presents specific challenges because of acute arch angulation, its branches, high blood flow, and the pulsatile nature of the proximal aorta. Hybrid endovascular repair involves extraanatomic, supra-aortic vessel transposition to provide an
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adequate proximal landing zone and to maintain cerebral perfusion before endovascular repair, and has emerged as an alternative to open surgical repair of aortic arch diseases. Furthermore, several early reports have described favorable clinical outcomes.3e5 The choice of arch transposition for hybrid endovascular repair depends on the morphologic features of the aortic arch and the extent of aortic disease. Total arch transposition (TAT) allows for a better landing zone, but is believed to have a higher peri-operative mortality rate than the less invasive partial arch transposition (PAT). Nevertheless, the type of arch vessel transposition that minimizes procedural invasiveness without losing effectiveness and long-term durability remains a subject of debate.6e10 The purpose of this study was to compare the outcomes of TAT and PAT during hybrid endovascular repair for aortic arch disease. MATERIALS AND METHODS Study design and patient population This retrospective analysis was performed on 53 consecutive patients who underwent hybrid endovascular repair for aortic arch diseases at the Gachon University Gil Medical Center and Yonsei University Severance Cardiovascular Hospital. Patients for hybrid endovascular repair were selected from patients unsuitable for open surgical repair because of a coexisting condition or conventional endovascular repair because of extensive disease involvement of the aortic arch. The indications for hybrid endovascular repair were as follows: (1) maximum aortic diameter 55 mm; (2) rapid aortic enlargement (10 mm per year). The type of arch transposition was decided by multidisciplinary teams of cardiovascular surgeons, interventional cardiologists, and radiologists. An aortic arch segment of diameter <42 mm and length >20 mm was considered to be a suitable proximal landing zone for implantation of a stent graft during hybrid endovascular repair. Medical records and radiographic data were reviewed. The institutional review boards of the two study institutions approved this study and waived the requirement for informed consent because of the retrospective nature of the analysis.
Analysis of pre-procedural CT angiography Analysis of aortic diameter and distance between each branch was performed on a three dimensional workstation (AquariusWS; Terarecon, San Francisco, CA, USA). A flow centerline was generated using the semi-automated centerline algorithms on the workstation. The calculated centerline was confirmed manually by scrolling through the images in axial, coronal, and sagittal planes to ensure that it accurately reflected the center point of the arterial lumen. Reconstructions perpendicular to the centerline of flow were then displayed in a two-dimensional format from which diameter and length measurements were measured.
W.C. Kang et al.
Hybrid endovascular repair Arch transposition. All arch transposition operations were performed in an operation room or hybrid angiography suite located in an operation room. The type of arch transposition was based on considerations of aortic arch disease extent and morphologic appearance of the proximal landing zone for the stent graft. For treatment of zone 0 arch disease, through a sternotomy approach, an anastomosis is performed between the proximal portion of the prosthesis and the ascending aorta. Then, an end to end anastomosis is performed between the first branch of the prosthesis and the brachiocephalic artery (BA). Afterward, an end to end anastomosis is performed between the second branch of the prosthesis and the left subclavian artery (LSCA). Finally, the left common carotid artery (LCCA) is reinserted into the branch to the LSCA. For treatment of zone 1 arch disease, a carotid-carotid crossover bypass using a retro-esophageal route is routine. After exposure of all supra-aortic branches, an end to side anastomosis is performed between the LCCA and the BA. Next, an end to side anastomosis between the LSCA and the LCCA finalizes the procedure. Treatment of zone 2 arch disease is done by a standard approach through a skin incision parallel to the left clavicle. The LSCA is divided at its origin at the level of the aortic arch. The vessel is guided dorsal to the left jugular vein, and an end to side anastomosis is performed between the LSCA and the LCCA.3 The LSCA is ligated proximally when possible, and when not possible vascular plugs are used to achieve subclavian occlusion. Stent graft placement. All endovascular procedures were performed in an angiography suite. The common femoral artery (CFA) was used for access in all cases for stent graft placement. In the majority of patients, stent graft insertion was performed using a percutaneous approach, after preclosing vascular access sites using suture-mediated closure devices (PercloseÔ; Abbott Lab., Menlo Park, CA, USA).11 Surgical exposure of the access vessel was required in one patient with severely tortuous and calcified CFAs, and prophylactic cerebrospinal fluid drainage was performed in patients who required coverage of the distal descending thoracic aorta with stent grafts. In most cases, lowering blood pressure was not necessary for stent graft implantation, but when necessary, especially for zone 0 aortic arch disease, rapid ventricular pacing was performed during deployment of the stent graft. To achieve satisfactory sealing, stent grafts were oversized by 10e15% for aortic dissections (proximal implantation side) and by 15e20% for aortic aneurysms. Definitions, study endpoints, and follow up The EuroSCORE II system was used to assess operative risks (http://www.euroscore.org/calc.html). Outcome criteria and definitions for hybrid endovascular repair were based on recommended reporting standards for endovascular aortic aneurysm repair issued by the Ad Hoc Committee for Standardized Reporting Practices in Vascular Surgery.12
Comparison of Total Arch and Partial Arch Transposition
Primary success was defined as stent graft implantation without surgical conversion, mortality or type I or III endoleak. All 53 patients underwent contrast enhanced computed tomographic angiography (CTA) scans before discharge, and all complied with a follow up surveillance protocol requiring a CTA scan and outpatient clinic review at 6 and 12 months during the first year, and annually thereafter. The primary study endpoints were peri-operative (30 day) mortality and stroke rates. Secondary endpoints were type I endoleak, re-interventions, survival rates, and post-procedural complications. Statistical analysis Quantitative data are presented as means and standard errors and the significance of intergroup differences was determined using the Student t test. Qualitative data are expressed in absolute numbers and percentages, and were analyzed using the chi-square test or Fisher’s exact test. The KaplaneMeier method was used to determine event free survival rates with respect to death and re-intervention. The analysis was performed using a computer based statistical software package (Statistical Package for Social Sciences [SPSS], Ver. 20 for Windows; SPSS, Chicago, IL, USA). Two sided p-values of <.05 were considered to be statistically significant. RESULTS Patient characteristics Of the 53 patients, 20 received TAT and 33 PAT. No intergroup differences were found for gender, age, or comorbidities, including EuroSCORE II results, or between aortic arch type distributions. PAD was more common in the TAT group than in the PAT group (5.0% vs. 21.2%). In terms of underlying aortic diseases, aneurysm was more common in the TAT group (85.0% vs. 72.7%) and aortic dissection was more common in the PAT group (10.0% vs. 15.2), but both were without statistical significance (Table 1). Hybrid endovascular repair Arch transposition was performed successfully prior to endovascular repair and stent graft implantation was achieved in all 53 study patients (Table 2). In most (77.4%), a staged procedure was performed (TAT group, 85.0%; PAT group, 72.7%, p¼.500), and the median time between arch transposition and endovascular repair was longer in the TAT group (13 days vs. 4 days, p¼.012). Three different stent grafts were used: Seal (S & G Biotech, Seoul), Valiant (Medtronic, Santa Rosa, CA), and TX2 Pro-Form (Cook Inc, Bloomington, IN). The Seal thoracic stent graft was more commonly used in the TAT group and the other two devices were more common in the PAT group (p¼.016). A single device was used in 11 (55.0%) and 23 patients (69.7%) in the TAT and PAT groups respectively, and multiple devices were implanted in the other 9 and 10 patients respectively, who had extensive thoracic lesions. LSCA embolization using a vascular plug was more common in the TAT group
175 Table 1. Baseline characteristics. TAT (n¼20) PAT (n¼33) p-value Age, years 65.416.3 64.815.8 .888 Male, n (%) 16 (80.0) 25 (75.8) .721 Hypertension, n (%) 12 (60.0) 23 (69.7) .470 DM, n (%) 4 (20.0) 5 (15.2) .715 Dyslipidemia, n (%) 6 (30.0) 14 (42.4) .399 Smoker, n (%) 10 (50.0) 15 (43.5) .950 CAD, n (%) 8 (40.0) 20 (60.6) .168 PAD, n (%) 1 (5.0) 7 (21.2) .234 COPD, n (%) 4 (20.0) 8 (24.2) 1.000 CRF, n (%) 4 (20.0) 5 (15.2) .715 Prior aortic surgery, n (%) 1 (5.0) 1 (3.0) 1.000 EuroSCORE II (%) 4.84.6 4.85.4 .989 Type of aortic arch, n (%) .639 I 3 (15.0) 6 (18.2) II 3 (15.0) 8 (24.2) III 14 (70.0) 19 (57.6) Dominance of vertebral 1.000 artery, n (%) Right 7 (35) 12 (36.4) Left 5 (25) 8 (24.2) No dominance 8 (40) 13 (39.4) Indication for intervention, .559 n (%) Aneurysm 17 (85.0) 24 (72.7) Aortic dissection 2 (10.0) 5 (15.2) Pseudoaneurysm 1 (5.0) 4 (12.1) DM ¼ diabetes mellitus; CAD ¼ coronary artery disease; PAD ¼ peripheral artery disease; COPD ¼ chronic obstructive pulmonary disease; CRF ¼ chronic renal failure (GFR <30 mL/min).
Table 2. Procedural data. Success rate of supra-aortic vessel transposition, n (%) Median time from supra-aortic transposition to endovascular repair (days) Proximal landing zone length, mm Staged procedure, n (%) Stent graft, n (%) Seal thoracic Valiant TX2 Pro-Form Number of stent grafts, n (%) 1 2 Maximal diameter of stent graft, mm LSCA revascularization, n (%) LSCA embolization with vascular plug, n (%) Percutaneous approach, n (%) Primary success, n (%) Type I endoleak, n (%) LSCA ¼ left subclavian artery.
TAT (n¼20) PAT (n¼33) p-value 20 (100) 33 (100) 1.000 13 (0e133) 4 (0e45)
.012
35.715.0 28.39.0
.159
17 (85.0)
24 (72.7)
.500 .016
12 (60.0) 4 (20.0) 4 (20.0)
7 (21.2) 15 (45.5) 11 (33.3) .480
11 (55.0) 9 (45.0) 38.04.9
23 (69.7) 10 (30.3) 38.44.8
.785
20 (100) 13 (65.0)
33 (100) 9 (27.3)
1.000 .007
19 (95.0) 16 (80.0) 4 (20.0)
32 (97.0) 23 (69.7) 9 (27.3)
1.000 .527 .744
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(65.0% vs. 27.3%, p¼.007). Stent grafts were implanted using a percutaneous approach in 51 of the study patients (96%). The primary success rate was non-significantly higher in the TAT group (80.0% vs. 69.7%, p¼.527). Type I endoleak rates were 20.0% and 27.3% in the TAT and PAT groups, also not significant. Peri-operative mortality and morbidity Peri-operative death occurred in one patient (5.0%) in the TAT group and in three patients (9.1%) in the PAT group (p ¼ 1.000). The single death in the TAT group was caused by aortic rupture on the day after surgery. In the PAT group, two patients died of intra-operative stroke, and one succumbed to intracranial hemorrhage 25 days postoperatively. Peri-operative morbidities were observed in 10 patients in the TAT group and in eight patients in the PAT group. Stroke was more common in the TAT group, but there was no statistical significance (10.0% vs. 6.1%, p¼0.627). No significant intergroup difference was observed for spinal cord ischemia, retrograde dissection, renal failure, bleeding, or vascular injury (Table 3). Late outcomes during follow up The mean follow up duration was 36.9 months. Overall survival was similar in the TAT and PAT groups (89.7% vs 87.4% at 1 year and 89.7% vs 79.3% at 3 years; p¼.375; Fig. 1). In the TAT group, two patients died of aortic rupture 10 (untreated type I endoleak) and 76 months (progression of retrograde aortic dissection) post-operatively, and one patient died from sepsis and multi-organ failure 46 months post-operatively. In the PAT group, one patient died of aortic rupture (untreated type I endoleak) 9 months postoperatively, one died of sepsis at 17 months, and another of pneumonia at 19 months. So the mortality related type I endoleak occurred in one patient in each group. Group reintervention free survival rates were also similar (78.6% vs. 92.0% at 1 year; 72.0% vs. 62.2% at 3 years, p¼.872; Fig. 2).
Figure 1. KaplaneMeier death free survival rate curves.
In the TAT group, three patients required re-intervention for a type I endoleak (n¼2) or endotension (n¼1); all three were treated by additional stent graft implantation. In addition, one patient with intra-operative retrograde dissection was treated by open surgical repair 7 days postoperatively, and another with de novo type B aortic dissection in the proximal descending thoracic aorta was treated with a stent graft at 2 months. In the PAT group, six patients required re-intervention. Patients with a type I endoleak (n¼2) or endotension (n¼1) were treated by additional stent graft implantation. One patient with retrograde dissection was treated by open surgical repair 8 months post-operatively. Another with de novo aortic dissection at the distal portion of the previously placed stent graft was treated with an additional stent graft at 28
Table 3. Peri-operative (30 day) and follow up clinical outcomes. TAT (n¼20) PAT (n¼33) p-value Peri-operative outcomes Death or stroke, n (%) Death, n (%) Stroke, n (%) Spinal cord ischemia, n (%) Retrograde dissection, n (%) Renal failure, n (%) Bleeding, n (%) Vascular injury, n (%) Pneumonia, n (%) Wound infection, n (%) Follow up outcomes Death, n (%) Stroke, n (%) Re-intervention, n (%) Chronic renal failure, n (%)
3 1 2 0 2 2 1 3 0 0 4 3 5 2
(15.0) (5.0) (10.0) (10.0) (10.0) (5.0) (15.0)
(20.0) (15.0) (26.3) (10.0)
3 3 2 0 1 2 1 1 1 0
(9.1) (9.1) (6.1)
.661 1.000 .627
(3.0) (6.1) (3.0) (3.0) (3.0)
.549 .627 1.000 .145 1.000
6 (18.2) 2 (6.1) 6 (19.4) 0
1.000 .354 .727 .149 Figure 2. KaplaneMeier re-intervention free survival rate curves.
Comparison of Total Arch and Partial Arch Transposition
months. The remaining patient had endovascular therapy for confined aortic rupture detected by follow up CT 11 months post-operatively. Morphologic analysis of the follow up CTA findings of surviving patients (n¼49) showed shrinkage of aortic diameter more than 5 mm or no interval change in 78.9% (15/19) in the TAT group and 77.5% (23/ 30) in the PAT group (p¼1.000). There was no stent graft migration in either group. DISCUSSION Main findings A recent report compared data between hybrid endovascular and open surgical repair for aortic arch disease involving zones 0 and 1.13 The present study focused on data for hybrid endovascular repair and compared perioperative and long-term outcomes after hybrid endovascular repair with TAT (for zone 0) or PAT (for zone 1 or 2). Results obtained were as follows. First, peri-operative mortality (5.0% vs. 9.1%, p¼1.000) and stroke (10.0% vs. 6.1%, p¼.627) rates were no different between the TAT and PAT groups. Second, although proximal landing zone length was longer in the TAT group, type I endoleak incidences were not significantly different between the groups (20.0% vs. 27.3%, p¼.744). Third, overall survival and reintervention free rates at 1 and 3 years post-operatively were not different between groups. Mortality and stroke Generally, it is believed that TAT is associated with a significantly greater operative risk, and that this results in higher peri-operative mortality. Furthermore, several studies have reported higher mortality rates for zone 0 than zone 1 patients.6e10 Nonetheless, debate continues on the comparative merits of hybrid endovascular repair with complete arch reconstruction or with partial arch reconstruction on a background of aortic arch disease. In the present study, mortality rates were similar between the two study groups, and EuroSCORE II results showed that operative risks were similar. These findings suggest a sternotomy for complete arch reconstruction does not carry a higher operative risk than re-routing for partial reconstruction. However, it should be noted that the present study is prone to selection bias, because TAT is often reserved for optimal patients based on considerations of operative risk. On the other hand, proximal extent of repair has been reported to be significantly associated with a higher incidence of stroke,12,14 which is probably the case when stent graft implantation into the aortic arch is compared with implantation into the descending thoracic aorta, because of wire and device manipulation within the ascending aorta and aortic arch. But in the present study, no difference was found between the two study groups in terms of the incidence or severity of strokes with a more proximal stent graft implantation. Interestingly, all strokes occurred in patients with a type III aortic arch which means the vertical distance from the origin of the BA to the top of the arch is
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>2 diameters of the LCCA, and two deaths in the PAT group were related to massive stroke after procedures, which indicates that stent graft manipulation in the ascending aorta might increase stroke risk regardless of aortic arch reconstruction type. Unlike the present study, previous studies focused mainly on comparisons of zone 0 and zone 1,7,15 and thus, little information is available regarding hybrid endovascular repair with PAT for zone 2. To the authors’ knowledge, this is the first comparative study on hybrid endovascular repair using TAT or PAT for aortic arch disease to include zone 2 repair. Type I endoleak and re-intervention Hybrid endovascular repair with PAT has a significant risk of technical failure mainly because of type I endoleak. This phenomenon is considered to be the main drawback of hybrid endovascular repair for arch disease because of its anatomic complexity and the limitations of current devices.10,15,16 A shorter proximal landing zone and acute angulation of the aortic arch in zone 1 may lead to inadequate stent graft attachment, and thus, a high type I endoleak rate in zone 1. A previous meta-analysis reported a significantly lower primary success rate for stent graft implantation into zone 1 of the aortic arch than for stent graft implantation after TAT in zone 0,10 and as a result, a higher re-intervention rate in zone 1 than in zone 0. However, in the present study, despite a longer mean proximal landing zone length in the TAT group, type I endoleak and re-intervention rates during follow up were no different between the two groups. Based on data regarding endovascular repair of abdominal aortic aneurysms, a landing zone of 20 mm was considered to be optimal for proximal sealing, but the incidence of type I endoleak in the present study was relatively high and it was the most common cause of primary failure. A recent study lends support to the high rate of type I endoleak after arch endovascular repair. In the study, it was found that a landing zone <24 mm in length independently predicted primary failure for hybrid endovascular arch repair, and it was suggested that this might be related to a diseased and angulated proximal landing zone in the aortic arch.17 Precise placement of a stent graft in the proximal landing zone after arch vessel transposition is not easy, even for a highly experienced operator. In a comparative study on endovascular repair between aortic arch and descending aorta, the type I endoleak rate was high for zone 3 endovascular repairs and for the complex areas in the arch, which reflected the limitations of the current devices used to treat thoracic aortic disease.18 Dedicated stent grafts for the aortic arch continue to evolve, but precise stent graft placement without losing the proximal landing zone in the hostile aortic arch remains unfeasible, with the devices currently available. Limitations The major limitation of the present study is its retrospective study design and its small study population, which did not
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allow full assessment of confounders or minor outcomes. Nevertheless, the comparison of zone 0 and zone 1/2 repairs does provide new outcome data. In addition, heterogeneities of aortic pathologies in both study groups, the use of three stent graft types, the lack of use of risk stratifications systems, and the short follow up are limitations. CONCLUSIONS Morbidity and mortality were high within the first year of hybrid endovascular therapy for aortic arch disease, which means candidates for hybrid procedures must be selected carefully. Peri-operative mortality/stroke and long-term survival were found to be similar for hybrid endovascular repair with TAT or PAT, so it is concluded that hybrid endovascular therapy for aortic arch disease could be considered irrespective of arch reconstruction type, when it is clinically indicated. CONFLICT OF INTEREST None. FUNDING None. REFERENCES 1 Okita Y, Okada K, Omura A, Kano H, Minami H, Inoue T, et al. Total arch replacement using antegrade cerebral perfusion. J Thorac Cardiovasc Surg 2013;145:S63e71. 2 Patel HJ, Nguyen C, Diener AC, Passow MC, Salata D, Deeb GM. Open arch reconstruction in the endovascular era: analysis of 721 patients over 17 years. J Thorac Cardiovasc Surg 2011;141: 1417e23. 3 Kang WC, Shin EK, Park CH, Kang JM, Ko YG, Choi D, et al. Hybrid endovascular repair for aortic arch pathology: intermediate outcomes and complications: a retrospective analysis. Catheter Cardiovasc Interv 2013;82:275e82. 4 Gottardi R, Seitelberger R, Zimpfer D, Lammer J, Wolner E, Grimm M, et al. An alternative approach in treating an aortic arch aneurysm with an anatomic variant by supraaortic reconstruction and stent graft placement. J Vasc Surg 2005;42: 357e60. 5 De Rango P, Cao P, Ferrer C, Simonte G, Coscarella C, Cieri E, et al. Aortic arch debranching and thoracic endovascular repair. J Vasc Surg 2014;59:107e14.
W.C. Kang et al. 6 Cao P, De Rango P, Czerny M, Evangelista A, Fattori R, Nienaber C, et al. Systematic review of clinical outcomes in hybrid procedures for aortic arch dissections and other arch diseases. J Thorac Cardiovasc Surg 2012;144:1286e300. 7 Schumacher H, Von Tengg-Kobligk H, Ostovic M, Henninger V, Ockert S, Böckler D, et al. Hybrid aortic procedures for endoluminal arch replacement in thoracic aneurysms and type B dissections. J Cardiovasc Surg 2006;47:509e17. 8 Antoniou GA, El Sakka K, Hamady M, Wolfe JH. Hybrid treatment of complex aortic arch disease with supra-aortic debranching and endovascular stent graft repair. Eur J Vasc Endovasc Surg 2010;39:683e90. 9 Vallejo N, Rodriguez-Lopez JA, Heidari P, Wheatley G, Caparrelli D, Ramaiah V, et al. Hybrid repair of thoracic aortic lesions for zone 0 and 1 in high risk patients. J Vasc Surg 2012;55:318e25. 10 Kotelis D, Geisbüsch P, Attigah N, Hinz U, Hyhlik-Dürr A, Böckler D. Total vs hemi-aortic arch transposition for hybrid aortic arch repair. J Vasc Surg 2011;54:1182e6. 11 Lee WA, Brown MP, Nelson PR, Huber TS, Seeger JM. Midterm outcomes of femoral arteries after percutaneous endovascular aortic repair using the Preclose technique. J Vasc Surg 2008;47: 919e23. 12 Chaikof EL, Blankensteijn JD, Harris PL, White GH, Zarins CK, Bernhard VM, et al. Reporting standards for endovascular aortic aneurysm repair. J Vasc Surg 2002;35:1048e60. 13 Kang WC, Ko YG, Shin EK, Park CH, Choi D, Youn YN, et al. Comparison of hybrid endovascular and open surgical repair for proximal aortic arch diseases. Int J Cardiol 2016;203:975e9. 14 Feezor RJ, Martin TD, Hess PJ, Klodell CT, Beaver TM, Huber TS, et al. Risk factors for peri-operative stroke during thoracic endovascular aortic repairs (TEVAR). J Endovasc Ther 2007;14: 568e73. 15 Anderson ND, Williams JB, Hanna JM, Shah AA, McCann RL, Hughes GC. Results with an algorithmic approach to hybrid repair of the aortic arch. J Vasc Surg 2013;57:655e67. 16 Lotfi S, Clough RE, Ali T, Salter R, Young CP, Bell R, et al. Hybrid repair of complex thoracic aortic arch pathology: long term outcomes of extra-anatomic bypass grafting of the supra-aortic trunk. Cardiovasc Intervent Radiol 2013;36:46e55. 17 Boufi M, Aouini F, Guivier-Curien C, Dona B, Loundou AD, Deplano V, et al. Examination of factors in type I endoleak development after thoracic endovascular repair. J Vasc Surg 2015;61:317e23. 18 Kwolek CJ, Fairman R. Update on thoracic aortic endovascular grafting using the medtronic talent device. Semin Vasc Surg 2006;19:25e31.