Branched Endovascular Therapy of the Distal Aortic Arch: Preliminary Results of the Feasibility Multicenter Trial of the Gore Thoracic Branch Endoprosthesis

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Presentation transcript:

Branched Endovascular Therapy of the Distal Aortic Arch: Preliminary Results of the Feasibility Multicenter Trial of the Gore Thoracic Branch Endoprosthesis Himanshu J. Patel, MD, Michael D. Dake, MD, Joseph E. Bavaria, MD, Michael J. Singh, MD, Mark Filinger, MD, Michael P. Fischbein, MD, PhD, David M. Williams, MD, Jon S. Matsumura, MD, Gustavo Oderich, MD The Annals of Thoracic Surgery Volume 102, Issue 4, Pages 1190-1198 (October 2016) DOI: 10.1016/j.athoracsur.2016.03.091 Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Device configuration and deployment. (A) The Gore Thoracic Branch Endoprosthesis (TBE, WL Gore, Flagstaff, AZ) is a nitinol-based expanded polytetrafluoroethylene stent graft that has a single side branch located 20 to 40 mm distal to the partially uncovered proximal stents. It is currently available with 21- to 53-mm diameters and 10-cm lengths. The target treatment range is 16 to 4 8 mm. (B) The side branch is a tapered, heparin-coated (CBAS Heparin Surface, Carmeda, WL Gore) stent graft that exits an internal portal in the main aortic component and is oriented in a retrograde manner. The three segments are a distal branch sealing segment, a proximal segment that is positioned within the internal portal, and a tapered segment that maintains luminal diameter when oriented in a retrograde configuration. (C) There is also an aortic extender cuff available for placement proximal to the main aortic component, with a 3.6- 5.6-cm length. (D) Deployment occurs with the aortic component device cannulated with two wires, one positioned within the proximal aorta and the other residing in the branch vessel. The aortic component is deployed, the side branch introducer sheath is advanced into the branch vessel and the branch component is deployed. (Courtesy WL Gore, Flagstaff, AZ.) The Annals of Thoracic Surgery 2016 102, 1190-1198DOI: (10.1016/j.athoracsur.2016.03.091) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Example of treated arch anatomy. (A) This 84-year-old woman presented with a 52-mm saccular aneurysm, a horizontal aortic arch, and a kink in her vertically oriented left subclavian artery. She was treated with a single 31-mm diameter, 10-cm length main aortic component and a 10-mm distal branch diameter, 6-cm length side branch device. The aortic component was oversized at 8%, and she had an intraoperative proximal type I endoleak that was expected to resolve given the lack of outflow into the aneurysm sac. (B) Her imaging study at 1 month revealed a patent side branch and a resolved type I endoleak. The left-to-right brachial artery index was unchanged from the preoperative value. The Annals of Thoracic Surgery 2016 102, 1190-1198DOI: (10.1016/j.athoracsur.2016.03.091) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Kaplan-Meier survival curve. In this study, 1 patient died at 4 months of a concomitant ascending aortic aneurysm rupture, thus yielding a 6-month Kaplan-Meier estimated survival of 94.7%. The Annals of Thoracic Surgery 2016 102, 1190-1198DOI: (10.1016/j.athoracsur.2016.03.091) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Analysis of a patient who died. (A) This 73-year-old patient with a maternal family history of thoracic aneurysm had a stable 5.3-cm ascending aneurysm and a 7.2-cm growing descending aortic aneurysm. She underwent thoracic branch endoprosthesis implantation through an infrarenal conduit using through and through access for side branch portal delivery. The operative plan consisted of placement of the main thoracic branch endoprosthesis and side branch components followed by distal extension conformable TAG (CTAG) devices to the distal landing zone. During side branch balloon angioplasty, the main component was noted to displace distally. The distal CTAG devices were then placed to stabilize the distal landing zone, and then aortic extenders were advanced into position. Invagination of the extender was noted during proximal landing zone balloon aortoplasty. (B) Because of this invagination (arrow), only the endograft is visualized on the 1-week computed tomography scan. Given the difficulty with the procedure, the procedure was terminated with the intent to plan early ascending repair to stabilize the landing zone and eliminate the observed proximal type I endoleak. (C) Although both type I and type III endoleaks (arrow) were seen at 1 week, none was identified at 1 month. The patient then presented with a ruptured ascending aortic aneurysm without dissection on postoperative day 113. (D) At autopsy, the aorta is opened on the greater curvature, and a longitudinal tear not extending to the proximal landing zone is seen along the lesser curvature. (E) The aortic arch with the invaginated endograft and the presence of thrombus within the gutter is shown in a roentgenogram of the device within the removed aorta (arrow) and at the superior proximal edge of the device on the explanted aorta itself. (F) The histologic examination of thrombus is shown. The Annals of Thoracic Surgery 2016 102, 1190-1198DOI: (10.1016/j.athoracsur.2016.03.091) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Analysis of a patient who died. (A) This 73-year-old patient with a maternal family history of thoracic aneurysm had a stable 5.3-cm ascending aneurysm and a 7.2-cm growing descending aortic aneurysm. She underwent thoracic branch endoprosthesis implantation through an infrarenal conduit using through and through access for side branch portal delivery. The operative plan consisted of placement of the main thoracic branch endoprosthesis and side branch components followed by distal extension conformable TAG (CTAG) devices to the distal landing zone. During side branch balloon angioplasty, the main component was noted to displace distally. The distal CTAG devices were then placed to stabilize the distal landing zone, and then aortic extenders were advanced into position. Invagination of the extender was noted during proximal landing zone balloon aortoplasty. (B) Because of this invagination (arrow), only the endograft is visualized on the 1-week computed tomography scan. Given the difficulty with the procedure, the procedure was terminated with the intent to plan early ascending repair to stabilize the landing zone and eliminate the observed proximal type I endoleak. (C) Although both type I and type III endoleaks (arrow) were seen at 1 week, none was identified at 1 month. The patient then presented with a ruptured ascending aortic aneurysm without dissection on postoperative day 113. (D) At autopsy, the aorta is opened on the greater curvature, and a longitudinal tear not extending to the proximal landing zone is seen along the lesser curvature. (E) The aortic arch with the invaginated endograft and the presence of thrombus within the gutter is shown in a roentgenogram of the device within the removed aorta (arrow) and at the superior proximal edge of the device on the explanted aorta itself. (F) The histologic examination of thrombus is shown. The Annals of Thoracic Surgery 2016 102, 1190-1198DOI: (10.1016/j.athoracsur.2016.03.091) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions