Antegrade Endograft Deployment with Supra-Aortic Debranching to Treat Arch and Descending Thoracic Aortic Lesions. A Single-Center Experience.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) is a widely used procedure that has drastically changed the management of thoracic aortic diseases. We assess the effectiveness of supra-aortic debranching during antegrade TEVAR procedures with a retrospective analysis of our clinical experience. METHODS: Between December 2005 and April 2017, 55 patients underwent 64 TEVAR procedures. Among them, there were 8 male patients, mean age 72, who underwent hybrid antegrade stent-graft deployment. Particularly, for degenerative aneurysms of the aortic arch, 3 patients for aneurysm of descending thoracic aorta 3, for post-traumatic pseudoaneurysm 1, and for penetrating aortic ulcer 1 which had resulted in an aortoesophageal fistula. Proximal landing zones were Z0:1, Z1:3 and Z2:4. Type I hybrid aortic arch repair was performed in 1 case, carotid-carotid bypass in 2, carotid-subclavian in 5 and aorto-carotid in 1. RESULTS: The 30-day postoperative mortality was 12.5%. One patient suffered a temporary right hemiplegia which resolved after left aorto-carotid bypass. No endoleaks were observed postoperatively and in follow-up period. In the long term and a mean follow-up of 4.9 years, there were no deaths related to the stent-graft implantation or to revascularization procedures. Regarding the aortic arch rerouting procedure, there were no pseudoaneurysm or other anastomotic events. CONCLUSIONS: Antegrade delivery of the endograft, combined with hybrid and revascularization procedures of the supra-aortic vessels is a safe treatment modality, in complex hostile anatomies. However, further improvements are recommended due to the presence of neurologic complications and reinterventions.

Antegrade Hybrid Chimney TEVAR Endograft in a Patient with Blunt Aortic Injury: A Challenging Case with Technical Success but Unfavorable Result.

Thoracic Endovascular Aortic Repair (TEVAR) has modified aortic medicine, particularly in patients with traumatic aortic injury (TAI). Conventional repair of TAI in the aortic arch is technically demanding as it requires cardiopulmonary bypass and deep hypothermic arrest with still a significant number of complications. Despite recent improvements in endovascular techniques, many patients have been excluded from endovascular repair due to unfavorable anatomy. To increase the feasibility of endovascular repair, adjunctive open extra-anatomical bypasses may be required to provide an adequate proximal landing zone. Several methods, for instance, chimney technique, hybrid technique, and fenestrated or branched stent-grafts, have been proposed as options to preserve the supra-aortic branches, each with its own advantages and disadvantages. We herein present a patient with complex anatomical features and blunt aortic injury, who underwent antegrade chimney stent-graft deployment through the ascending aorta, not otherwise amenable to standard retrograde delivery because of severe peripheral artery disease. The remarkable aspect, in this case, is that both stents were placed antegrade, through the ascending aorta.

First Use of GORE TAG Thoracic Endograft with Active Control System in Traumatic Aortic Rupture.

Patients after a high-velocity motor vehicle collision with rapid deceleration are at a significant risk of blunt aortic injury, a life-threatening condition that usually occurs in the aortic isthmus. Aortic transection is the second leading cause of death behind head injury for individuals aged 4 to 34. During the last two decades, there has been a shift from open towards the endovascular repair. Significant progress has been made recently in terms of the design of both the stent graft and the delivery system. We herein present the case of a female patient under dual antiplatelet therapy for coronary artery disease, with type IV blunt aortic injury (rupture) that was successfully repaired with Conformable Thoracic Endograft with Active Control System. This new device provides an intermediate deployment step at 50% and optional angulation control of the proximal part of the stent graft. These improvements are beneficial providing accurate device placement and maximum seal length in anatomies where the distal, as well as a proximal landing zone, is critical.

Diagnostic and Therapeutic Approach in a Patient with Buerger's and Coronary Artery Disease.

Occlusive coronary artery disease coexisting with Buerger's disease has rarely been reported. Potential difficulties regarding diagnostic workup and therapeutic management in this group of patients are discussed through this case report. We present an interesting case of a 52-year-old patient suffering from Buerger's disease, with a history of generalized peripheral occlusive arteriopathy, who presented with acute coronary syndrome. A difficulty in accessing and performing coronary angiography was evident due to the vascular status of the patient. Diagnosis was performed by computed tomography (CT) of the coronary arteries. It showed 80-90% obstruction of the LAD, and since percutaneous coronary intervention was impossible, a single aortocoronary bypass grafting was performed with the off-pump technique. Coronary artery disease coexisting with Burger's disease is a rare entity, and CT angiography is a useful diagnostic tool, when the classic angiography could not be performed. In addition, off-pump coronary artery bypass should be the therapeutic option of choice in this high risk group of patients. The uncomplicated postoperative course of the patient and his hitherto good condition showed that both diagnostic and therapeutic procedures were the best possible.