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TEVAR in the Aortic Arch: Results with Branch Vessel Stenting Instead of De-branching

Frank J. Criado.
Union Memorial Hospital, Baltimore, Md.
 
OBJECTIVES: De-branching of the aortic arch is frequently necessary to facilitate or enable TEVAR. Percutaneous retrograde stenting of the left subclavian (LSA) and left common carotid (LCCA) arteries can achieve the same objectives but obviating the need for additional surgical procedures.

METHODS: In a 5-year period (ending 12/31/07), 14 patients underwent stenting of the LSA (n=6) or LCCA (n=8) during thoracic repair involving complete or partial endograft coverage/exclusion of such vessels. TEVAR was performed for treatment of thoracic aneurysms (n=12) or aortic dissection (n=2). The LCCA procedures consisted of direct retrograde catheterization of the carotid artery in the neck with placement of a 6F sheath. Balloon angioplasty was followed by deployment of an appropriate-size balloon-expandable stent. The proximal 1/3 of the device was placed into the aortic lumen, parallel and outside the thoracic endograft, breaking the seal to the aortic wall in that focal area. Normal antegrade flow into the LCCA could thus be re-established. The LSA procedure was done much in the same way, via catheterization of the left brachial artery [Figure 1].

RESULTS: all procedures were completed successfully. There were no complications attributable to the branch stenting component of the intervention. Patient follow-up ranged from 6 to 54 months, mean 23. All stented vessels (n=14) have remained patent, but 1 patient was lost to follow-up at 6 months, and another died 6 weeks post-TEVAR. Evidence of a hemodynamically significant in-stent stenosis (in the LCCA) was detected by duplex in 1 patient. No patient has developed symptoms, endoleaks, or endograft-related complications that would be related to the branch stenting procedure.

CONCLUSIONS: Arch branch preservation by stenting of the LCCA and/or the LSA is feasible. The technique offers a non-surgical alternative to surgical bypasses and transpositions generally used to create or optimize the proximal endograft fixation site within the aortic arch. However, widespread adoption may not be warranted until more definitive information becomes available on unanswered questions, such as the potential for creating proximal endoleaks, possible device interaction-related complications, and long-term patency.

AUTHOR DISCLOSURES: F.J. Criado, None.

Figure 1.