Pre-curved Fenestrated Endovascular Repair Versus Total Arch Replacement for Aortic Arch Aneurysm Repair

Abstract

Background:

This study compares the outcomes of endovascular repair using pre-curved fenestrated endografts and open surgery with total arch replacement for aortic arch aneurysm repair.

Methods:

Patients who underwent aortic arch aneurysm repair with fenestrated endograft or total arch replacement between 2009 and 2021 were retrospectively analyzed. Subjects were limited to true aortic arch aneurysms, and cases with a history of thoracic aortic surgery, connective tissue disorder, or concomitant procedure were excluded. The Kaplan–Meier method was used to calculate cumulative survival and freedom from aorta-related death, and the Fine and Grey methods were used for re-intervention rates.

Results:

A total of 106 cases were included, with fenestrated endografts (F group, n=58) and total arch replacement (T group, n=48). The median follow-up times were 48.0 (25.5, 94.8) and 62.5 (46.0, 110.8) months (p=0.038) in the F and T group, respectively. The median age (76.5 [71.3, 80.0] vs 71.5 [66.0, 77.0], p<0.001) and European System for Cardiac Operative Risk Evaluation II (11.0 [10.0, 14.0] vs 8.5 [6.0, 11.0], p<0.001) were higher in the F group. Intraoperative blood transfusions (19 [32.8%] vs 48 [100%], p<0.001), operative times (145.0 [113.3, 191.0] vs 464.5 [413.8, 531.5], p<0.001), postoperative intubation times (0 [0, 0] vs 68.0 [20.0, 150.0], p<0.001), intensive care unit stays (1.0 [1.0, 2.0] vs 6.5 [5.0, 11.0], p<0.001) and in-hospital stays (10.0 [8.0, 12.0] vs 27.0 [22.0, 41.3], p<0.001) were significantly reduced in the F group. In-hospital mortality (2.0 [3.5%] vs 0 [0%], p=0.50), perioperative cerebral infarction (2 [3.5%] vs 3 [6.3%], p=0.66), and spinal cord injury (1 [1.7%] vs 0 [0%], p>1) were comparable between the 2 groups. The 5-year survival rates were 68.9% (standard error [SE]=6.85) and 81.5% (SE=6.00) in the F and T groups, respectively (p=0.003); however, freedom from aorta-related death rate (100% vs 100%, p=0.32) and the re-intervention rates (19.0% vs 6.30%, p=0.08) at 5-year showed no significant difference.

Conclusions:

Fenestrated endovascular aortic repair reduces operative time, postoperative intubation, intensive care unit and in-hospital stays, and blood transfusions. The 5-year freedom from aorta-related death and re-intervention rates were comparable to those of total arch replacement.

Clinical Impact

Pre-curved fenestrated endografts provide a less-invasive yet effective option for aortic arch aneurysm repair, compared to total arch replacement. They offer shorter operative and intubation times, reduced transfusion rate, and shorter ICU stays, without increasing aorta-related mortality or reintervention during follow-up. This approach expands treatment opportunities for elderly and high-risk patients who previously could not undergo conventional arch repair.

Visual Abstract

Keywords

aortic arch aneurysm fenestrated endograft endovascular repair Najuta endograft total arch replacement

Get full access to this article

View all access options for this article.

References

Yiu

Cheng

. Natural history and risk factors for rupture of thoracic aortic arch aneurysms. J Vasc Surg. 2016;63(5):1189–1194.

Czerny

Schmidli

Adler

, et al. 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) and the European Society for Vascular Surgery (ESVS). Eur J Cardiothorac Surg. 2019;55(1):133–162.

El-Sayed Ahmad

Papadopoulos

Risteski

, et al. The standardized concept of moderate–to–mild (≥28°C) systemic hypothermia during selective antegrade cerebral perfusion for all–comers in aortic arch surgery: single–center experience in 587 consecutive patients over a 15–year period. Ann Thorac Surg. 2017;104(1):49–55.

Suzuki

Asai

Nota

, et al. Selective cerebral perfusion with mild hypothermic lower body circulatory arrest is safe for aortic arch surgery. Eur J Cardiothorac Surg. 2013;43(4):e94–e98.

Zierer

El-Sayed Ahmad

Papadopoulos

, et al. Selective antegrade cerebral perfusion and mild (28°C–30°C) systemic hypothermic circulatory arrest for aortic arch replacement: results from 1002 patients. J Thorac Cardiovasc Surg. 2012;144(5):1042–1049.

Hachiro

Kinoshita

Suzuki

, et al. Total arch replacement in octogenarians. Interact Cardiovasc Thorac Surg. 2022;34(2):283–290.

Jones

Loubani

Grant

, et al. Cardiac surgery in older patients: hospital outcomes during a 15–year period from a complete national series. Interact Cardiovasc Thorac Surg. 2022;34(4):532–539.

United Nations Department of Economic and Social Affairs. World population ageing 2019-highlights. https://www.un.org/en/development/desa/population/publications/pdf/ageing/WorldPopulationAgeing2019-Highlights.pdf. Accessed October 30, 2024.

Seike

Fukuda

Yokawa

, et al. Differences of mid-term outcomes in debranching thoracic endovascular aortic repair between zone 0 and zone 1-2 landing. Gen Thorac Cardiovasc Surg. 2023;71(1):59–66.

10.

Yokoi

Azuma

Yamazaki

. Advantage of a precurved fenestrated endograft for aortic arch disease: simplified arch aneurysm treatment in Japan 2010 and 2011. J Thorac Cardiovasc Surg. 2013;145(suppl 3):S103–S109.

11.

Azuma

Yokoi

Yamazaki

. The next generation of fenestrated endografts: results of a clinical trial to support an expanded indication for aortic arch aneurysm treatment. Eur J Cardiothorac Surg. 2013;44(2):e156–e163.

12.

Furuta

Azuma

Yokoi

, et al. The midterm results of thoracic endovascular aortic repair with a precurved fenestrated endograft in zone 0–1. Eur J Cardiothorac Surg. 2020;58(4):722–729.

13.

Azuma

Yokoi

Hayakawa

, et al. Multibranched endovascular repair using a modified endograft with hydrogel–reinforced fenestrations. Eur J Cardiothorac Surg. 2022;62(1):ezac042.

14.

Nakamae

Azuma

Yokoi

, et al. Total endovascular repair of a mycotic thoracic aortic aneurysm in a patient with an aberrant right subclavian artery. Eur J Cardiothorac Surg. 2021;59(4):914–916.

15.

De Cocker

Messaoudi

Stockman

, et al. Preoperative prediction of intensive care unit stay following cardiac surgery. Eur J Cardiothorac Surg. 2011;39(1):60–67.

16.

Almashrafi

Alsabti

Mukaddirov

, et al. Factors associated with prolonged length of stay following cardiac surgery in a major referral hospital in Oman: a retrospective observational study. BMJ Open. 2016;6(6):e010764.

17.

Cacciatore

Belluomo Anello

Ferrara

, et al. Determinants of prolonged intensive care unit stay after cardiac surgery in the elderly. Aging Clin Exp Res. 2012;24(6):627–634.

18.

Arrowsmith

Grocott

Reves

, et al. Central nervous system complications of cardiac surgery. Br J Anaesth. 2000;84(3):378–393.

19.

Miao

Song

Sun

, et al. Meta–analysis of open surgical repair versus hybrid arch repair for aortic arch aneurysm. Interact Cardiovasc Thorac Surg. 2017;24(1):34–40.

20.

Moulakakis

Mylonas

Markatis

, et al. A systematic review and meta–analysis of hybrid aortic arch replacement. Ann Cardiothorac Surg. 2013;2(3):247–260.

21.

Yoshitake

Okamoto

Yamazaki

, et al. Comparison of aortic arch repair using the endovascular technique, total arch replacement and staged surgery. Eur J Cardiothorac Surg. 2017;51(6):1142–1148.

22.

Kang

Shin

, et al. Comparison of hybrid endovascular and open surgical repair for proximal aortic arch diseases. Int J Cardiol. 2016;203:975–979.

23.

Hori

Okamura

Yamamoto

, et al. Early and mid–term outcomes of endovascular and open surgical repair of non–dissected aortic arch aneurysm. Interact Cardiovasc Thorac Surg. 2017;24(6):944–950.

24.

Steinlauf

Hazan Shenberger

Halak

, et al. Aortic arch aneurysm repair—unsteady hemodynamics and perfusion at different heart rates. J Biomech. 2021;121:110351.