title: Strategies for managing the insufficiency of the proximal landing zone during endovascular thoracic aortic repair.
abstract: BACKGROUND
  The insufficiency of the proximal landing zone (PLZ) is a frequent factor challenging the applicability and efficacy of endovascular repair (EVR) for thoracic aortic disorders. This study discusses two strategies for conquering this challenge.
  
  
  METHODS
  Ten patients underwent EVR for thoracic aortic diseases during a one-year period ending June 30, 2004. Nine patients had DeBakey type III dissecting aortic aneurysm (DAA), and one had descending thoracic aortic aneurysm (DTAA). The PLZ, defined as the distance from the origin of the left subclavian artery (LSA) to the primary entry tear of the dissection or to the proximal aspect of DTAA, was less than 15 mm in all instances. EVR with intentional coverage of the LSA without any supportive bypass was employed in 6 patients with DAA, and the preliminary right-left carotid and left carotid-subclavian bypass combined with EVR in the DTAA and other 3 DAA cases.
  
  
  RESULTS
  Technical success was achieved in all the patients. The patient with DTAA died from hemispheric cerebral infarction and subsequent multiple system organ failure following an uneventful recovery from the cervical reconstruction performed 1 week previously. In cases receiving the EVR with intentional coverage of the LSA, in two patients dizziness occurred, which noticeably resolved after intravenous administration of mannitol for 4 to 5 days, and a drop in blood pressure of the left arm was noted in all the cases, but remained clinically silent. No neurological deficits or limb ischaemia developed perioperatively or during the followup, ranging from 3 to 12 months, and complete thrombosis of the thoracic aortic false lumen was revealed on CT at 3 months in the 9 patients with DAA.
  
  
  CONCLUSIONS
  Both the intentional bypass absent coverage of the LSA and the adjunctive surgical bypass appear to be feasible and effective in managing the insufficiency of the PLZ during the endovascular thoracic aortic repair.
authors.affiliation: Division of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China.
authors.forename: Wei-guo
authors.initials: WG
authors.lastname: Fu
authors.forename: Zhi-hui
authors.initials: ZH
authors.lastname: Dong
authors.forename: Yu-qi
authors.initials: YQ
authors.lastname: Wang
authors.forename: Da-qiao
authors.initials: DQ
authors.lastname: Guo
authors.forename: Xin
authors.initials: X
authors.lastname: Xu
authors.forename: Bin
authors.initials: B
authors.lastname: Chen
authors.forename: Jun-hao
authors.initials: JH
authors.lastname: Jiang
authors.forename: Jue
authors.initials: J
authors.lastname: Yang
authors.forename: Zheng-yu
authors.initials: ZY
authors.lastname: Shi
mesh_terms: D000328:Adult; D001013:Aorta, Thoracic / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D014656:Vascular Surgical Procedures