Endovascular Repair of Penetrating Thoracic Aortic Ulcers Using Tubular Stent Grafts Versus Stent Grafts With a Proximal Scallop

Abstract

Purpose:

In penetrating aortic ulcers (PAUs), limited data support tubular thoracic endovascular aortic repair (TEVAR) as a viable treatment option. For treatment of more proximal PAUs, hybrid approaches and—more recently—scalloped TEVAR (scTEVAR) have been advocated. Outcomes of scTEVAR specifically for PAUs have not yet been reported. This study reports long-term outcomes for tubular and scTEVAR in PAUs and compares the safety profile in both cohorts regarding the significantly more proximal landing zone (LZ) for scTEVAR.

Materials and Methods:

This single-center retrospective cohort study includes all nonacute patients treated for complicated PAU with scTEVAR and tubular TEVAR. Patient and PAU characteristics as well as procedural success, complication and reintervention rates, and all-cause and aortic mortality were analyzed.

Results:

Of 212 TEVAR procedures reviewed, 21 patients with tubular TEVAR and 19 patients with scTEVAR were included. Patient and PAU characteristics were similar, and LZ was significantly more proximal in the scTEVAR cohort (p=0.0001), with similar number and types of supra-aortic revascularization procedures. Clinical success was reached in all 40 patients (100%), and reintervention rate was 2/21 (9.5%) and 1/19 (5.3%), respectively. Over the mean follow-up of 63 (TEVAR) and 53 (scTEVAR) months, clinical success was stable in all patients with one (abdominal) aortic-related mortality in the scTEVAR cohort.

Conclusion:

Treatment of complicated PAUs with TEVAR as well as scTEVAR provides excellent and similar clinical success, stability of clinical success, and aortic survival with acceptable complication and reintervention rates. Scalloped TEVAR safely lengthens the proximal sealing zone to address more proximal pathologies.

Clinical Impact

Treatment of asymptomatic complicated penetrating aortic ulcers (PAUs) with thoracic endovascular aortic repair (TEVAR) provides excellent clinical success and acceptable complication and reintervention rates. More patients become amenable to endovascular treatment by including scalloped TEVAR (scTEVAR) as a means to safely lengthen the proximal sealing zone to address more proximal pathologies.

Keywords

aortic arch thoracic endovascular aortic repair penetrating aortic ulcer scallop stent graft

Get full access to this article

View all access options for this article.

References

Coady

Rizzo

Elefteriades

JA.

Pathologic variants of thoracic aortic dissections. Penetrating atherosclerotic ulcers and intramural hematomas. Cardiol Clin. 1999;17(4):637–657. doi:10.1016/s0733-8651(05)70106-5.

Piffaretti

Fontana

Tadiello

, et al. Arch and access vessel complications in penetrating aortic ulcer managed with thoracic endovascular aortic repair. Ann Cardiothorac Surg. 2019;8(4):471–482. doi:10.21037/acs.2019.06.07.

Eggebrecht

Plicht

Kahlert

, et al. Intramural hematoma and penetrating ulcers: indications to endovascular treatment. Eur J Vasc Endovasc Surg. 2009;38(6):659–665. doi:10.1016/j.ejvs.2009.09.001.

D’Annoville

Ozdemir

Alric

, et al. Thoracic endovascular aortic repair for penetrating aortic ulcer: literature review. Ann Thorac Surg. 2016;101(6):2272–2278. doi:10.1016/j.athoracsur.2015.12.036.

Geisbüsch

Kotelis

Weber

, et al. Early and midterm results after endovascular stent graft repair of penetrating aortic ulcers. J Vasc Surg. 2008;48(6):1361–1368. doi:10.1016/j.jvs.2008.07.058.

Aidinian

Massimiano

Speir

, et al. Endovascular stent-graft repair of penetrating descending thoracic aortic ulcer. Vasc Endovascular Surg. 2007;41(1):83–86. doi:10.1177/1084713806296075.

Jiang

Pan

Zou

, et al. Outcomes of endovascular stent graft repair for penetrating aortic ulcers with or without intramural hematoma. J Vasc Surg. 2021;73(5):1541–1548. doi:10.1016/j.jvs.2020.10.022.

JÃ¡nosi

Gorla

Tsagakis

, et al. Thoracic endovascular repair of complicated penetrating aortic ulcer: an 11-year single-center experience. J Endovasc Ther. 2016;23(1):150–159. doi:10.1177/1526602815613790.

Czerny

Schmidli

Adler

, et al. Editor’s choice—current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2019;57(2):165–198. doi:10.1016/j.ejvs.2018.09.016.

10.

Funovics

Blum

Langenberger

, et al. Endovascular repair of the descending aorta and the aortic arch with the Relay stent graft. Ann Thorac Surg. 2009;88(2):637–640. doi:10.1016/j.athoracsur.2008.12.078.

11.

Anwar

Hamady

Various endoluminal approaches available for treating pathologies of the aortic arch. Cardiovasc Intervent Radiol. 2020;43(12):1756–1769. doi:10.1007/s00270-020-02561-y.

12.

Fernández-Alonso

Fernández Alonso

Martínez Aguilar

, et al. Fenestrated and scalloped endovascular grafts in zone 0 and zone 1 for aortic arch disease. Ann Vasc Surg. 2020;69:360–365. doi:10.1016/j.avsg.2020.06.009.

13.

Oderich

Kärkkäinen

Reed

, et al. Penetrating aortic ulcer and intramural hematoma. Cardiovasc Intervent Radiol. 2019;42(3):321–334. doi:10.1007/s00270-018-2114-x.

14.

Rokosh

Rockman

Patel

, et al. Thoracic endovascular aortic repair for symptomatic penetrating aortic ulcers and intramural hematomas is associated with poor outcomes. J Vasc Surg. 2021;74(1):63–70.e1. doi:10.1016/j.jvs.2020.11.045.

15.

Riambau

Böckler

Brunkwall

, et al. Editor’s choice-management of descending thoracic aorta diseases: clinical practice guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2017;53(1):4–52. doi:10.1016/j.ejvs.2016.06.005.

16.

Evangelista

Moral

Penetrating atherosclerotic ulcer. Curr Opin Cardiol. 2020;35(6):620–626. doi:10.1097/HCO.0000000000000782.

17.

Stanson

Kazmier

Hollier

, et al. Penetrating atherosclerotic ulcers of the thoracic aorta: natural history and clinicopathologic correlations. Ann Vasc Surg. 1986;1(1):15–23. doi:10.1016/S0890-5096(06)60697-3.

18.

Ganaha

Miller

Sugimoto

, et al. Prognosis of aortic intramural hematoma with and without penetrating atherosclerotic ulcer: a clinical and radiological analysis. Circulation. 2002;106(3):342–348. doi:10.1161/01.cir.0000022164.26075.5a.

19.

Evangelista

Czerny

Nienaber

, et al. Interdisciplinary expert consensus on management of type B intramural haematoma and penetrating aortic ulcer. Eur J Cardiothorac Surg. 2015;47(2):209–217. doi:10.1093/ejcts/ezu386.

20.

Fillinger

Greenberg

McKinsey

, et al. Reporting standards for thoracic endovascular aortic repair (TEVAR). J Vasc Surg. 2010;52(4):1022–1033, 1033.e15. doi:10.1016/j.jvs.2010.07.008.

21.

Lansky

Messé

Brickman

, et al. Proposed standardized neurological endpoints for cardiovascular clinical trials: an academic research consortium initiative. Eur Heart J. 2018;39(19):1687–1697. doi:10.1093/eurheartj/ehx037.

22.

Hanna

Abdullah

Kashef

, et al. Four-year results of the Bolton relay proximal scallop endograft in the management of thoracic and thoracoabdominal aortic pathology with unfavorable proximal landing zone. J Vasc Surg. 2021;74(5):1447–1455. doi:10.1016/j.jvs.2021.04.027.

23.

Cao

De Rango

Czerny

, et al. Systematic review of clinical outcomes in hybrid procedures for aortic arch dissections and other arch diseases. J Thorac Cardiovasc Surg. 2012;144(6):1286–1300.e2. doi:10.1016/j.jtcvs.2012.06.013.

24.

Martin

Riga

Gibbs

, et al. Short- and long-term results of hybrid arch and proximal descending thoracic aortic repair: a benchmark for new technologies. J Endovasc Ther. 2016;23(5):783–790. doi:10.1177/1526602816655446.

25.

Verscheure

Haulon

Tsilimparis

, et al. Endovascular treatment of post type A chronic aortic arch dissection with a branched endograft: early results from a retrospective international multicenter study. Ann Surg. 2021;273(5):997–1003. doi:10.1097/SLA.0000000000003310.

26.

Czerny

Berger

Kondov

, et al. Results of endovascular aortic arch repair using the Relay Branch system. Eur J Cardiothorac Surg. 2021;60(3):662–668. doi:10.1093/ejcts/ezab160.

27.

Chen

Zhang

Liu

, et al. Retrograde type A aortic dissection after thoracic endovascular aortic repair: a systematic review and meta-analysis. J Am Heart Assoc. 2017;6(9):e004649. doi:10.1161/JAHA.116.004649.

28.

Yoon

Mell

MW.

Outcome comparison of thoracic endovascular aortic repair performed outside versus inside proximal landing zone length recommendation. J Vasc Surg. 2020;72(6):1883–1890. doi:10.1016/j.jvs.2020.03.033.

29.

Holt

Johnson

Hinchliffe

, et al. Outcomes of the endovascular management of aortic arch aneurysm: implications for management of the left subclavian artery. J Vasc Surg. 2010;51(6):1329–1338. doi:10.1016/j.jvs.2009.10.131.

30.

Weigang

Parker

Czerny

, et al. Should intentional endovascular stent-graft coverage of the left subclavian artery be preceded by prophylactic revascularisation. Eur J Cardiothorac Surg. 2011;40(4):858–868. doi:0.1016/j.ejcts.2011.01.046.

31.

Chung

Kasirajan

Veeraswamy

, et al. Left subclavian artery coverage during thoracic endovascular aortic repair and risk of perioperative stroke or death. J Vasc Surg. 2011;54(4):979–984. doi:10.1016/j.jvs.2011.03.270.

32.

Wojciechowski

Znaniecki

Bury

, et al. Thoracic endovascular aortic repair with left subclavian artery coverage without prophylactic revascularisation-early and midterm results. Langenbecks Arch Surg. 2014;399(5):619–627. doi:10.1007/s00423-014-1186-6.

33.

DeCarlo

Latz

Boitano

, et al. Prognostication of asymptomatic penetrating aortic ulcers: a modern approach. Circulation. 2021;144(14):1091–1101. doi:10.1161/CIRCULATIONAHA.121.054710.