Endovascular Outcomes in Aortic Arch Repair with Double and Triple Parallel Stent Grafts
How do early and midterm outcomes of patients with thoracic aortic aneurysm (TAA) or aortic dissection (AD) involving zones 0 or 1 compare when treated with double versus triple parallel stent grafts (PSGs)?
Patients who underwent TPSG repair had increased incidence of adverse events without increase in mortality or need for secondary procedures than patients who underwent DPSG repair.
Guo B, Guo D, Chen B, et al. Endovascular Outcomes in Aortic Arch Repair with Double and Triple Parallel Stent Grafts. J Vasc Interv Radiol. 2020;31(12):1984-1992.e1.
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Retrospective cohort study
Sponsored by the Shanghai Sailing Program (18YF1404000), National Natural Science Foundation of China (81770474, 81770508), and Excellent Young Talents Fund Program of Zhongshan Hospital Fudan University (2019ZSYQ26).
Zhongshan Hospital, Shanghai, China.
Figure 2. Technical conduct and follow-up outcome of TEVAR with DPSGs for non-A, non-B aortic dissection. (a, b) Preoperative CT scan (a) and angiogram (b) showing the proximal entry tear located in the ostium of the LSA, with retrograde dissection extending into zone 0. (c, d) Two anterograde PSGs in the innominate artery and left common carotid artery had been delivered through the bilateral common carotid arteries and placed in parallel with each other after some adjustments with the wires and catheters. (e) Both PSGs were simultaneously deployed following implantation of the aortic endograft. Typically, 2 coaxial stent grafts without crossing are deployed because of concerns about durability in this configuration. (f) In this case, the LSA was planned to be covered without embolization or revascularization, and the angiogram indicated no endoleak on completion. (g) CT scan at 3 months after TEVAR demonstrated a slight type II endoleak. (h) The endoleak had sealed completely after 27 months.
Thoracic endovascular aortic repair (TEVAR), a minimally-invasive technique for the treatment of aortic disease, often requires augmentation when supra-aortic branches are involved. One of these augmentation techniques, the chimney technique, encompasses the use of parallel stent grafts (PSGs) to maintain communication between the aorta and supra-aortic branches. While originally used to rescue the left subclavian artery after inadvertent covering during TEVAR, the technique has been progressively adopted as a technique for proximal aortic disease. Long-term data on the techniques’ efficacy, however, is lacking.
In this retrospective cohort study, all patients with aortic dissection or thoracic aortic aneurysm who had underwent endovascular repair over a 7-year period were evaluated. Of these 1806 patients, 31 had underwent TEVAR with multiple PSGs for zone 0 or 1 disease. Of these 20 were treated with double parallel stent grafts (DPSGs) and 11 were treated with triple parallel stent grafts (TPSGs). Follow-up consisted of surveillance imaging at 1, 6, and 12 months as well as annually after the first year, in addition to additional imaging as warranted by new symptoms or adverse events. Outcome variables assessed included all-cause mortality, major adverse events including aortic rupture, endoleaks, endograft migration, retrograde type A aortic dissection, PSG stenosis or occlusion, and stroke.
48.4% of patients underwent urgent/emergent TEVAR for symptomatic or acute aortic disease. 61.3% of patients underwent repair for zone 0 disease. In terms of outcomes within 30 days of the procedure, type Ia endoleak occurred in 30% of DPSG repair and 45.5% of TPSG repairs (p=0.45). No endograft migrations were observed. One interoperative death occurred in a patient undergoing DPSG repair. No additional deaths were reported within 30 days of the procedures. Technical and clinical success was achieved in 70% of DPSG repairs and 45.5% of TPSG repairs. Minor strokes were reported in 36.4% of TPSG repairs versus 5% of DPSG repairs (p=0.042, 16.1% of all patients). There were no differences in length of hospital or ICU admissions between the two cohorts.
Mean follow-up was 28.9 months with a range of 4.8 to 68.6 months. No cases were lost to follow-up. Overall mortality was 12.9% and aorta-related mortality was 6.5%. There were no significant differences in all-cause mortality between cohorts. 41.9% of patients experienced major adverse events, which occurred in 72.7% of TPSG cases and 25% of DPSG cases (p=0.021). Most common major adverse events were endoleaks (12.9%), endograft migration (9.7%), PSG stenosis/occlusion (6.5%), retrograde dissection (6.5%), and stroke (3.2%). All endograft migrations occurred in the TPSG cohort. There was no significant difference in secondary interventions or need for additional interventions between cohorts. Overall mortality was 16.1% over the perioperative and follow-up period without significant differences between cohorts.
This study provides a comparison between repairs using both DPSGs and TPSGs in TEVAR for aortic disease involving zone 0 and 1. It demonstrated a statistically-significant increase in major adverse events, including 30-day minor stroke and endograft migration, in the TPSG group. This study is limited, however, for multiple reasons including small sample size, lack of comparison to single PSG repair or open surgical repair, as well as analysis of differences between different variations in PSG technique (e.g. landing zones). While patient capture is likely difficult and there is a significant selection bias involved is choice of number of PSGs placed based on case-specific details, larger multicenter studies will allow for more robust statistical comparison and subgroup analysis in order to draw more concrete conclusions.
Jared Edwards, MD
General Surgery Intern (PGY-1)
Department of General Surgery
Naval Medical Center San Diego, San Diego, CA