Endovascular repair of aortic arch lesions in high-risk patients or after previous aortic surgery: Midterm results
Received 13 March 2009; received in revised form 30 July 2009; accepted 8 September 2009. published online 18 November 2009. Corrected Proof
Objective
The aim of this study was to assess the short- and midterm results after endovascular repair of the aortic arch in high-risk patients or after previous aortic surgery.
Methods
From November 1998 to November 2008, 57 thoracic stent grafts were implanted in 44 patients (sex ratio, 4.5; mean age, 66.5 ± 16.5 years) for aortic arch repair (zone 0 to 2 according to the arch map proposed by Ishimaru) of 19 degenerative aneurysms, 12 traumatic transections of the aorta, 8 complicated aortic dissections, 4 postcoarctectomy aortic pseudoaneurysms, and 1 penetrating atheromatous ulcer. All patients were considered to be at high surgical risk owing to serious comorbidities (American Society of Anesthesiologists score ≥ III [79.5 %]) or previous aortic surgery. Endovascular repair was performed in an emergency setting in 27.3% (n = 12) of the patients. Thirty-four underwent a hybrid technique with supra-aortic debranching and simultaneous or staged endovascular stent grafting. Debranching was performed to provide an adequate proximal aortic landing zone, in 28 patients by a cervical approach and in 6 patients by a sternotomy approach.
Results
The technical success rates for aortic zone 0 patients (n = 6), zone 1 patients (n = 4), and zone 2 patients (n = 34) were, respectively, 100%, 100%, and 97%. The 30-day mortality rate was 20.4%. The actuarial survival was 70% over a mean follow-up of 29.9 months. The rate of stroke was 6.8%. Two (4.5%) cases of paraplegia were observed, 1 of which was reversible after cerebrospinal fluid drainage. The rate of endoleak was 15.9% (n = 7): 3 type I, 3 type II, and 1 type III. There were no cases of device migration, but 1 stent-graft collapse occurred 20 days after exclusion of an aortic traumatic transection.
Conclusion
Hybrid endovascular aortic arch reconstructions, although some of these adjunctive procedures remain major operations, provide attractive alternatives for treating aortic arch lesions in high-risk patients who would otherwise be unsuitable for open repair, with acceptable primary results and encouraging midterm efficacy to prevent rupture.
Department of Vascular and Thoracic Surgery Arnaud de Villeneuve Hospital, Montpellier, France
Address for reprints: Pierre Alric, MD, PhD, Service de Chirurgie Vasculaire et Thoracique, Hôpital Arnaud de Villeneuve, 191 avenue du Doyen Gaston Giraud–34090–Montpellier, France.
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