Outcomes of Surgically Assisted SDRNP for Three-Fenestration Stent Grafts in Treatment of Aortic Arch Pathologies

Summary

The reconstruction of aortic arch vessels is one of the most important and difficult processes in treating aortic arch diseases. This article presents the application of surgically assisted short-distance retrograde needle puncture technique for three-fenestration stent grafts in treating aortic aneurysm, dissection or penetrating ulcers involving aortic arch.

Abstract

Thoracic endovascular aortic repair (TEVAR) has become the preferred method in the treatment of aortic arch diseases by now. Due to the complex anatomical structure and reconstruction techniques, it is difficult to perform total endovascular aortic arch treatment for patients with aortic arch lesions. Our team initiates the reconstruction of aortic arch vessels using the surgically assisted short-distance retrograde needle puncture (SDRNP) technique for three-fenestration stent grafts. This article aims to demonstrate the feasibility and safety of performing the SDRNP technique for three-fenestration stent grafts in treating aortic aneurysm, dissection, or penetrating ulcer involving the aortic arch. A retrospective review was performed on 12 patients with aortic arch diseases, who underwent surgically assisted SDRNP technique for three-fenestration stent grafts to revascularize supra-arch branches. The overall technical success rate was 100.0% (12/12). The average operative time and intraoperative bleeding were 228.5 ± 69.6 min and 74.5 ± 26.9 mL, respectively. Complications consisted of 1 stroke, 1 acute myocardial infarction, and 2 endoleaks (1 type III and 1 type I). The patient with type III endoleaks improved after coil embolization after re-intervention. There were no aorta-related deaths during the average follow-up of 10.3 ± 2.8 months. All of the bridging stents were patent, with no migration. The three-fenestration stent grafts using the surgically assisted SDRNP technique offer a great advance for the treatment of aortic arch diseases, which might be an ideal operation process for aortic arch vessels.

Introduction

Total arch replacement was considered a conventional surgical treatment. Previous studies showed that despite improvements in the surgical techniques, the trauma and risks associated with total arch replacement remained relatively high^1,2. The current strategies of thoracic endovascular repair (TEVAR) with the reconstruction of branch vessels, including TEVAR + DeBranching, TEVAR + Chimney /in situ fenestration technology, and so on, have some limitations, such as the aortic tortuosity and inadequate landing zone^3,4. Due to the complex anatomy of the aortic arch and the limitations of current devices, total endovascular treatment of aortic arch lesions remains a surgical challenge. Therefore, up to date, it was required to develop an optimal method for treating aortic arch lesions.

In situ fenestration (ISF) has been reported to preserve blood flow in supra-aortic branches as much as possible^5,6. Compared with the chimney technique, the endoleaks and compression of branch stents in the ISF technique were much lower, and this technique was widely accepted⁷. Some studies showed that there were many methods for fenestration of supra-aortic branches, including radio frequency, laser, and puncture. These fenestration methods involved long distances for the radio-frequency catheter, laser catheter, or puncture needle to reach the targeted locations in supra-aortic branches^8,9. Moreover, the distortion of targeted vessels would make it difficult to adjust the angle of the tips in catheters, which would lead to difficulty reaching the desired position. These would often lead to failure of the puncture to the membrane or even injuries to blood vessels, resulting in complications such as hemorrhage, especially for the large angle of supra-aortic branches or type III aortic arch¹⁰. Additionally, the cautery of stent membranes from laser or radiofrequency in situ fenestration during TEVAR might produce debris, which could cause the risk of debris dislodgement, resulting in distal infarction¹¹.

 In order to improve the success rate of puncture and reduce trauma, this study innovatively proposed a new approach based on the previous fenestration methods¹². In our center, we developed in situ fenestration of aortic arch vessels using the surgically assisted short-distance retrograde needle puncture (SDRNP) technique for three-fenestration stent grafts. In this technique, a puncture needle, also called a sonoguide percutaneous transhepatic cholangiography (PTC) needle, and a 10Fr developing short sheath were quickly used for short-distance in situ fenestration, and the femoral artery-common carotid artery bypass system was used to maintain the blood flow of the carotid artery and cerebral perfusion. This approach could significantly reduce the puncture distance from the puncture needle to the stent membrane, better control the puncture force, and easily adjust the puncture angle. In this study, the data of 12 patients with aortic arch lesions using this technique were analyzed in order to investigate the application values of surgically assisted SDRNP in situ fenestration in TEVAR. The results of this study would provide an experimental basis and foundation for the surgically assisted (SDRNP) technique for three-fenestration stent grafts treating aortic arch diseases.

Protocol

This study retrospectively analyzed the data from 12 patients with aortic arch lesions admitted to our center from March 2021 to March 2024, who were treated with TEVAR combined with the surgically assisted (SDRNP) technique for three-fenestration stent grafts. This study was permitted by the Ethics Committee of the Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine (2021-N-17). Informed consent was obtained from all patients for this study.

Patient selection

For this study, the patients included were aged >18 years with aortic arch lesions (Figure 1) such as retrograde type A aortic dissection, type B aortic dissection, aortic arch aneurysms, and penetrating aortic ulcers of the arch, undergoing TEVAR combined with the surgically assisted (SDRNP) technique for three-fenestration stent grafts. arch lesions involving the ascending aorta with ≤ 20 mm from the coronary ostia or the proximal anchoring zone diameter ≥ 45 mm cores of American society of anesthesiologists with more than grade III left vertebral artery dominanceoriginating from the aortic archardiac and lung pathologiesenal insufficiency; and incomplete clinical data

Preoperative preparation

Patients were asked to fast, starting at 6 h before the operation for fluid and 8 h for solid food. A 14G intravenous cannula was placed in a peripheral vein as well as in the central venous line. Monitoring of electrocardiogram, oxygen saturation and capnograph, arterial pressure (cannulation of right radial artery and dorsal artery of left foot), urinary volumes, pulse oximetry, and body temperature was done. The patient was given general anesthesia (inhalation and intravenous anesthesia) through tracheal intubation in the supine position. Prophylactic antibiotics with second-generation cephalosporins were administered 30 min before surgery.

Left subclavian artery (LSA) isolation

A 4 cm transverse incision by the round knife was performed in the left supraclavicular region. The tissues were dissected to expose the anterior oblique muscle, paying attention to recurrent laryngeal nerve protection. To enable retrograde access for SDRNP fenestration of the LSA, the second segment of the left subclavian artery was exposed through transecting the anterior oblique muscle.

Left common carotid artery (LCCA) isolation

The tissues were dissected to expose the internal jugular vein in a left supraclavicular transverse incision. To enable retrograde access for SDRNP fenestration of the LCCA, the LCCA was isolated on the inside of internal jugular vein, paying attention to vagus nerve protection.

Right common carotid artery (RCCA) separation

A 3 cm longitudinal incision was performed using the round knife in the right neck. To enable retrograde access for SDRNP fenestration of the RCCA and femoro-carotid bypass, the tissues were dissected to separate the RCCA.

Artery puncture

To begin with, 62.5 U of heparin sodium/kg body weight was administered before artery puncture. Then, one purse suture was performed in LSA and LCCA, or two purse sutures in RCCA, using 5-0 polypropylene suture. Next, the developing short 10Fr sheath was placed in the purse sutures of LSA, LCCA, and RCCA by retrograde puncture, respectively (Figure 2A). Ensure that the tips of the sheath reach the aortic arch. The short 11Fr sheath was placed in the purse sutures of RCCA by anterograde puncture, preparing for femoral artery-right common carotid artery bypass (Figure 2A). The right common femoral artery approach was selected if there were no abnormalities after assessing the risk factors. The left common femoral artery approach was preferred if the right iliofemoral artery approach was thin or involved the dissection lesions. The vessel suture instruments were reserved in the common femoral artery for blocking the puncture points. The short 11Fr sheath was placed in the common femoral artery.

Thoracic endovascular aortic repair (TEVAR) operation

The location of fenestration and stent specifications were determined based on preoperative computed tomography angiography (CTA) and pathological features. Ensure that the proximal anchorage zone of TEVAR (more than 1.5 cm) was sufficient, allowing a sufficient proximal fenestration area for SDRNP. The proximal end of the first stent was placed against the LSA ostia in the descending aorta. The proximal end of the second stent (c-TAG aortic covered stent) was anchored in the ascending aorta, approximately 3-4 cm above the coronary artery ostia, and the distal end of the second stent overlapped with the first stent in the descending thoracic aorta. A pre-prepared temporary system of right femoral artery-right common carotid artery bypass was performed immediately (Figure 2B), maintaining the blood flow in the right common carotid artery and keeping the cerebral perfusion.

SDRNP fenestration of LCCA

The pre-curved cerebral suction tube was inserted through the developing short 10Fr sheath (Figure 2C). The position and angle of the cerebral suction tube, as well as the tip of the developing short 10Fr sheath, were adjusted under the condition of the perspective positioner (Figure 2D), reaching the larger curved side of the covered stent. The cerebral suction tube directly contacting the stent and the minimum angulation through the normal position and lateral projection were identified. The puncture needle was inserted through the cerebral suction tube. The covered stent was punctured by a slight sensation of breakthrough, and the puncture needle was confirmed to enter the covered stent. The Supercore wire was inserted into the ascending aorta through the puncture needle tube, and then the cerebral suction tube and the puncture needle were withdrawn. The hole of fenestration was dilated via introducing a high-pressure balloon using 16 standard atmospheric pressure, with a 2 mm smaller than the target vessel. A covered stent was implanted 1 to 2 mm larger than the target vessel. The post-stenotic dilation was performed by the same diameter of balloon. It was sure that no stenosis existed in the stent and the contrast entered into the aortic arch by the digital subtraction angiography from the short vascular sheath of LCCA.

SDRNP fenestration of brachiocephalic trunk (BCT)

The temporary system of right femoral artery-right common carotid artery bypass was withdrawn. The BCT fenestration was performed using the same method as LCCA fenestration. A covered stent was implanted after the balloon dilatation (Figure 2E). The morphology of the covered stent and blood flow was assessed by digital subtraction angiography from a short sheath of BCT.

SDRNP fenestration of LSA

The LSA fenestration was conducted using the method as the same as LCCA fenestration. A covered stent was inserted after the balloon dilatation. The conditions of stents were re-checked by the digital subtraction angiography from short vascular sheath of LSA.

End of procedure

The ascending aortic angiography was performed to identify the patency and absence of endoleaks in BCT, LCCA, and LSA (Figure 2F). All the short vascular sheaths were withdrawn, and all incisions were closed.

Observed indicators

The technical success rate was defined as follows: In situ fenestration and stent implantation were intraoperatively successful in patients who underwent TEVAR. The angiogram showed that stents in the aortic arch had good morphology, with normal blood flow and no incidence of endoleaks. Moreover, Other indicators such as the operative time, postoperative complications, 30-day mortality, and the conditions of endoleaks during the follow-up were also included (Figure 3).

Statistical analysis

The data collection was performed through the SPSS software. The measurement data were presented as Mean ± standard deviation (SD), and the enumeration data were expressed as case/percentage [n(%)].

Results

Between March 2021 and March 2024, 12 patients underwent successful TEVAR combined with the surgically assisted (SDRNP) technique for three-fenestration stent grafts (Table 1). The stents for the fenestration of aortic arch vessels were c-TAG-covered stents. Ankura stent was considered to be implanted according to the distal lesions of the descending aorta. The average age was 62.1 ± 9.5 years and the average follow-up was 10.3 ± 2.8 months.

None were converted to open surgery...

Discussion

In the TEVAR technique, at least a 15 mm proximal landing zone is needed to treat the aortic arch diseases, because the coverage of supra-arch vessels is necessary to get an adequate seal. TEVAR + DeBranching technique could be applied without concern for the proximal landing zone. Compared with total arch replacement, this approach was less traumatic but still showed a certain incidence of cerebral infarction and mortality¹³. Among the endovascular reconstruction methods of aortic supra-arch vess...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Ankura stent	LifeTech Scientific Corporation, China	XJZDZ3026160
Balloon-expandable covered stent	BARD HEALTHCARE SCIENCE CO., LTD., China	LSM0801038
C-TAG covered stent	Gore Company, USA	TGU373720
High-pressure balloon	Boston Scientific Corporation, USA	H74939171100810
Lunderquist Wire	Cook Medical Trading Co., LTD, USA	TSMG-35-260-LES
Polypropylene suture (5-0)	PROLENE ETHICON, Johnson & Johnson Corporation, USA	EPH8710
Puncture needle	Hakko Co, LTD, Japan	18G*150mm
SPSS software	International Business Machines Corporation, USA	Version 22.0
Supercore wire	Abbott Laboratories, USA	No.100270302
Vascular sheath	Terumo Corporation, Japan	RS*A10K10SQ
Vessel suture instruments	Perclose ProGlide Suture-Mediated Closure System, Abbott Laboratories, USA	No.12673