Total endovascular aortic arch repair: is it for everyone and where is its evidence?

Abstract

Open total arch replacement (TAR) remains the mainstay management strategy for thoracic aortic diseases involving the aortic arch. TAR evolved from the 2-stage conventional elephant trunk (CET) technique to the hybrid frozen elephant trunk (FET) which combined open surgical repair (OSR) with thoracic endovascular aortic repair (TEVAR) into a 1-stage procedure. Although FET has been able to achieve superior results to CET, including excellent survival, it still carries a risk of certain complications that may even require secondary reintervention. The era of elephant trunk is being overtaken by the new generation of TEVAR devices being used for total endovascular aortic arch (or endoarch) repair. Total endoarch repair (TER) is currently indicated in patients deemed high-risk for open surgery; however, it has shown strong potential for becoming the gold stand treatment for aortic arch pathologies. Despite the minimally-invasive nature of TER providing an obvious advantage over OSR in certain cases, TER remains associated with comparable mortality rates and key complications such as technical failure, neurological injury, need for reintervention, and loss of or failure to achieve target vessel patency. Upon comprehensively searching the literature, the technical success of TER ranged from 91%-100%, mortality 0%-19%, stroke 0%-16.7% and reintervention 0%-30.3%, using different commercially available endografts. Given its novelty, further studies with larger cohorts and longer follow-up periods are necessary to solidify the evidence on TER, taking into account the significant learning curve associated with TEVAR. In addition, studies directly comparing arch OSR to TER are warranted to determine superiority. This review aimed to highlight the evolution of aortic arch repair, focusing on TER device development, intervention criteria and clinical outcomes.

Keywords

Thoracic aortic disease / aortic arch / endovascular / endoarch / TEVAR

References

[1] Di Eusanio M,Cefarelli M.Long-term outcomes after aortic arch surgery: results of a study involving 623 patients.Eur J Cardiothorac Surg2015;48:483-90

[2] Tsilimparis N,Kolbel T. Endovascular aortic arch repair - endovascular today. 2015. Available from: https://evtoday.com/articles/2015-nov-supplement/endovascular-aortic-arch-repair [Last accessed on 10 March 2022]

[3] Antoniou GA,Bicknell CD.Hybrid repair of the aortic arch in patients with extensive aortic disease.Eur J Vasc Endovasc Surg2010;40:715-21

[4] Chiesa R,Tshomba Y.Ten years of endovascular aortic arch repair.J Endovasc Ther2010;17:1-11

[5] Preventza O,Cooley DA.Total aortic arch replacement: a comparative study of zone 0 hybrid arch exclusion vs. traditional open repair.J Thorac Cardiovasc Surg2015;150:1591-8; discussion 1598

[6] Shrestha M,Krüger H.Total aortic arch replacement with the elephant trunk technique: single-centre 30-year results.Eur J Cardiothorac Surg2014;45:289-95; discussion 295

[7] Shrestha M,Krueger H.The elephant trunk is freezing: the hannover experience.J Thorac Cardiovasc Surg2015;149:1286-93

[8] Di Eusanio M,Murana G.Frozen elephant trunk surgery-the Bologna’s experience.Ann Cardiothorac Surg2013;2:597-605 PMCID:PMC3791204

[9] LeMaire SA,Coselli JS.The elephant trunk technique for staged repair of complex aneurysms of the entire thoracic aorta.Ann Thorac Surg2006;81:1561-9; discussion 1569

[10] Svensson LG,Blackstone EH.Elephant trunk procedure: newer indications and uses.Ann Thorac Surg2004;78:109-16; discussion 109

[11] Safi HJ,Estrera AL.Optimization of aortic arch replacement: two-stage approach.Ann Thorac Surg2007;83:S815-8; discussion S824

[12] Schepens MA,Morshuis WJ,Heijmen RH.The elephant trunk technique: operative results in 100 consecutive patients.Eur J Cardiothorac Surg2002;21:276-81

[13] Jakob H,Tossios P.Combining classic surgery with descending stent grafting for acute DeBakey type I dissection.Ann Thorac Surg2008;86:95-101

[14] Di Bartolomeo R,Berretta P.Frozen elephant trunk surgery in acute aortic dissection.J Thorac Cardiovasc Surg2015;149:S105-9

[15] Geragotellis A,Jubouri M.Endovascular reintervention after frozen elephant trunk: where is the evidence?.J Cardiovasc Surg2022;63:425-33

[16] Preventza O,Olive JK.Neurologic complications after the frozen elephant trunk procedure: a meta-analysis of more than 3000 patients.J Thorac Cardiovasc Surg2020;160:20-33.e4

[17] Di Bartolomeo R,Di Marco L.Frozen vs. conventional elephant trunk technique: application in clinical practice.Eur J Cardiothorac Surg2017;51:i20-8

[18] Mousavizadeh M,Jubouri M.Zone proximalization in frozen elephant trunk: what is the optimal zone for open intervention?.J Cardiovasc Surg2022;63:265-74

[19] Fiorentino M,Sonker U.Thoraflex hybrid as frozen elephant trunk in chronic, residual type A and chronic type B aortic dissection.Interact Cardiovasc Thorac Surg2021;32:566-72 PMCID:PMC8906721

[20] Leone A,Martens A.Total aortic arch replacement with frozen elephant trunk technique: Results from two European institutes.J Thorac Cardiovasc Surg2020;159:1201-11

[21] Ho JYK,Kwok MWT,Wong RHL.Total aortic arch replacement and frozen elephant trunk.Semin Thorac Cardiovasc Surg2021;33:656-62

[22] Jubouri M,Saha P.Incidence of distal stent graft induced new entry vs. aortic remodeling associated with frozen elephant trunk.Front Cardiovasc Med2022;9:875078 PMCID:PMC8960270

[23] Kayali F,Tan SZ,Bashir M.Aortic remodeling in aortic dissection after frozen elephant trunk: overcoming the challenges.J Cardiovasc Surg2022;63:434-8

[24] Kayali F,Jubouri M,Tan SZCP.Kinking of frozen elephant trunk hybrid prostheses: incidence, mechanism, and management.Front Cardiovasc Med2022;9:912071 PMCID:PMC9091648

[25] Bavaria JE,Makaroun MS.Endovascular stent grafting vs. open surgical repair of descending thoracic aortic aneurysms in low-risk patients: a multicenter comparative trial.J Thorac Cardiovasc Surg2007;133:369-77

[26] Makaroun MS,Kee ST.Endovascular treatment of thoracic aortic aneurysms: results of the phase II multicenter trial of the GORE TAG thoracic endoprosthesis.J Vasc Surg2005;41:1-9

[27] Kölbel T,Larena-Avellaneda A,Franzen O.An externalized transseptal guidewire technique to facilitate guidewire stabilization and stent-graft passage in the aortic arch.J Endovasc Ther2010;17:744-9

[28] Nordon IM,Morgan R,Jahangiri M.Progress in endovascular management of type A dissection.Eur J Vasc Endovasc Surg2012;44:406-10

[29] Nienaber CA,Rehders TC.Rapid pacing for better placing: comparison of techniques for precise deployment of endografts in the thoracic aorta.J Endovasc Ther2007;14:506-12

[30] Czerny M,Morlock J.Orthotopic branched endovascular aortic arch repair in patients who cannot undergo classical surgery.Eur J Cardiothorac Surg2018;53:1007-12

[31] Bradshaw RJ,Powell O.Left subclavian artery revascularization in zone 2 thoracic endovascular aortic repair is associated with lower stroke risk across all aortic diseases.J Vasc Surg2017;65:1270-9

[32] Yuan X,Mozalbat D.Alternative management of proximal aortic dissection: concept and application.Indian J Thorac Cardiovasc Surg2022;38:183-92 PMCID:PMC8980987

[33] Yokoi Y,Yamazaki K.Advantage of a precurved fenestrated endograft for aortic arch disease: simplified arch aneurysm treatment in Japan 2010 and 2011.J Thorac Cardiovasc Surg2013;145:S103-9

[34] Tsilimparis N,von Kodolitsch Y.Branched vs. fenestrated endografts for endovascular repair of aortic arch lesions.J Vasc Surg2016;64:592-9

[35] Hagan PG,Isselbacher EM.The international registry of acute aortic dissection (IRAD): new insights into an old disease.JAMA2000;283:897-903

[36] Preventza O,Amarasekara HS.In the endovascular era, is elective open aortic arch surgery in elderly patients still justified?.J Thorac Cardiovasc Surg2019;158:973-9

[37] Iafrancesco M,Dronavalli V.Open aortic arch replacement in high-risk patients: the gold standard.Eur J Cardiothorac Surg2016;49:646-51; discussion 651

[38] Spear R,Ohki T.Editor’s choice - subsequent results for arch aneurysm repair with inner branched endografts.Eur J Vasc Endovasc Surg2016;51:380-5

[39] Tan GWL,Tan BP.Early experience and lessons learnt with customized fenestrated thoracic endovascular aortic reconstruction for aortic arch pathology in an asian population.Cardiovasc Intervent Radiol2018;41:544-53

[40] Singh S,Tan SZCP.RELAY (TM) branched-international results of vessel patency and reintervention.Front Cardiovasc Med2022;9:962884 PMCID:PMC9277010

[41] Alsafi A,Rudarakanchana N.Endovascular treatment of thoracic aortic aneurysms with a short proximal landing zone using scalloped endografts.J Vasc Surg2014;60:1499-506

[42] Azuma T,Yamazaki K.The next generation of fenestrated endografts: results of a clinical trial to support an expanded indication for aortic arch aneurysm treatment.Eur J Cardiothorac Surg2013;44:e156-63; discussion e163

[43] Sato H,Tamiya Y.Long-term clinical outcomes of thoracic endovascular aortic repair for arch aneurysms with the najuta thoracic stent-graft system.Ann Vasc Dis2020;13:384-9 PMCID:PMC7758573

[44] Iwakoshi S,Itoh H.Clinical outcomes of thoracic endovascular aneurysm repair using commercially available fenestrated stent graft (Najuta endograft).J Vasc Surg2015;62:1473-8

[45] Roselli EE,Thompson MM.Results of the valiant mona LSA early feasibility study for descending thoracic aneurysms.J Vasc Surg2015;62:1465-71.e3

[46] Fujimura N,Motoki M.Anatomical analysis and feasibility study of next-generation fenestrated or branched stent-grafts for the treatment of arch aneurysms.J Endovasc Ther2020;27:777-84

[47] Riambau V,Coppi G.Final operative and midterm results of the European experience in the RELAY Endovascular Registry for Thoracic Disease (RESTORE) study.J Vasc Surg2011;53:565-73

[48] Zipfel B,Riambau V.Worldwide results from the RESTORE II on elective endografting of thoracic aneurysms and dissections.J Vasc Surg2016;63:1466-75

[49] O’Callaghan A,Greenberg RK,Bena J.Outcomes for supra-aortic branch vessel stenting in the treatment of thoracic aortic disease.J Vasc Surg2014;60:914-20

[50] Gutsche JT,McGarvey ML.Risk factors for perioperative stroke after thoracic endovascular aortic repair.Ann Thorac Surg2007;84:1195-200; discussion 1200

[51] Jiang SM,Nguyen G.Zone 0 frozen elephant trunk for type A retrograde acute aortic dissection following endovascular stenting of the arch.J Card Surg2021;36:2124-6

[52] Potter BJ.Subclavian steal syndrome.Circulation2014;129:2320-3

[53] Tan SZCP,Singh S.Favorable neurological outcomes in thoracic endovascular aortic repair with RELAY™ branched-An international perspective.J Card Surg2022;37:3556-63