Atsushi Kitagawa1, Roy K. Greenberg1, Matthew J. Eagleton1, Tara M. Mastracci1, Eric Roselli2
1The Cleveland Clinic Department of Vascular Surgery, Cleveland, OH; 2The Cleveland Clinic Department of Thoracic Surgery, Cleveland, OH.
OBJECTIVES: Treatment of patients with arch, TAAA and chronic dissection is challenging. We report the results of FEVAR of such aneurysms.
METHODS: A single center prospective FEVAR trial enrolled 356 patients (2006-11), of which 29 had chronic dissections with arch and/or TAAA. Patients were divided into a group with extensive dissections from the arch through the visceral segment (Group A, n=15, mean age 57y), and a group with focal dissections (Group B, n=14, mean age 73y).Customized grafts were implanted into the true lumen, from which all supra-aortic trunk (arch branch devices) and visceral vessels were supplied. Patients were followed annually with imaging and laboratory studies. Outcome analyses included survival, rupture, spinal cord ischemia, endoleak, morbidity (cardiac, renal, pulmonary), secondary interventions, dissection and aneurysm growth.
RESULTS: Mean time between dissection and FEVAR was 10.6 years, and aneurysm size was 61mm. Follow-up averaged 1.7 years. There were no perioperative mortalities, and one aortic related death at 90 days due to progression of pre-existing untreated arch dissection. No ruptures, cardiac, renal, paraplegia or pulmonary complications occurred. Despite narrow true lumen dimensions, stent grafts expanded to their nominal diameters in all cases without graft compression. Post FEVAR growth was noted in two cases (one Marfan/one LDS), related to type II endoleaks. Sac regression was similar (-7.5 mm vs. -10.1 mm).Early secondary interventions were more common in group A, occurring in 7 patients (all endovascular).Younger patients, and those with a defined connective tissue disease(Marfan’s/LDS) were more commonly in Group A (p<0.001).
CONCLUSIONS: FEVAR is feasible for patients with chronic dissections with arch and TAAA. Visceral vessel access and graft compression resulting from narrow true lumen diameters were not problems in this select population. Favorable sac and lumen morphologic changes coupled with low mortality and complication risk makes this an attractive treatment option.
AUTHOR DISCLOSURES: M. J. Eagleton, Cook Medical, Consulting fees or other remuneration (payment), Bolton Medical, Consulting fees or other remuneration (payment); R. K. Greenberg, Cook Medical, Consulting fees or other remuneration (payment); A. Kitagawa, Nothing to disclose; T. M. Mastracci, Cook Medical, Consulting fees or other remuneration (payment); E. Roselli, Cook Medical, Consulting fees or other remuneration (payment), Medtronic, Consulting fees or other remuneration (payment).
Posted April 2012