Selective Supra-Aortic Trunk Stenting During Endovascular Total Aortic Arch Repair in Patients With Residual Chronic Type A Dissection Treated With Double-Fenestrated Physician-Modified Endografts

Abstract

Objective:

To assess the impact of selective supra-aortic trunk (SAT) stenting on aortic remodeling in patients with chronic type A aortic dissection (cTAAD).

Methods:

Patients treated from 2017 to 2024 with aortic arch repair using double-fenestrated physician-modified endografts (PMEGs) for cTAAD were retrospectively analyzed. The objectives are to compare aortic treatment and remodeling, SAT evolution, and overall outcomes according to SAT dissection status (before and after), total aortic arch repair using a double-fenestrated PMEG.

Results:

Among 42 cTAAD patients treated, 30 had SAT dissection. Thirty-five patients received a standard PMEG, while 7 underwent additional selective SAT stenting (3 LCCA, 1 brachiocephalic trunk (BT), 4 right subclavian artery (RSA), and 3 right common carotid artery (RCCA)). Technical success was 100%. At 30 days, 1 patient died from stroke, 1 from pneumonia post-discharge. During a median follow-up of 18.5 months (IQR: 38.8), no type Ia endoleaks occurred. Six type Ic endoleaks were observed; 3 patients underwent reintervention, while the remaining 3 were monitored with follow-up CT scans showing no evidence of aortic growth. Complete SAT dissection resolution occurred in 12 patients (40%), including 9 with standard PMEG. Positive aortic remodeling was seen in 32 patients (76%) with a median diameter reduction of −1% (IQR: 5.5%). Five patients died during mid-term follow-up, with no deaths related to the procedure. Positive aortic remodeling rates are 73% vs. 83% (p=0.7) between patients with and without initial SAT dissection, 83% vs 92% (p=1) between patients with initially no SAT dissection and those who healed, 61% vs 88% (p=0.07) between patients with persistent SAT dissection and the others. Patients on curative anticoagulation or dual antiplatelet therapy showed reduced positive remodeling.

Conclusion:

Double-fenestrated PMEGs are effective for treating residual cTAADs, with high SAT healing and favorable remodeling. Persistent SAT dissection may hinder remodeling and require additional intervention.

Clinical Impact

Aortic arch repair using fenestrated physician-modified endografts without systematic SAT stenting reduces SAT manipulation and may lower stroke risk, while promoting a high rate of SAT and aortic dissection healing. In cases where SAT dissection persists and aortic growth is reported, secondary complementary SAT intervention can be performed to enhance aortic remodeling.