title: Stacked proximal aortic cuffs: an "off-the-shelf" solution for treating focal thoracic aortic pathology.
abstract: OBJECTIVE
  To report our early experience with the endovascular placement of stacked Zenith main body extensions (cuffs) in the treatment of focal thoracic aortic pathology in high-risk patients.
  
  
  METHODS
  Between January 2003 and May 2004, 6 patients (3 men; mean age 59 years, range 37-82) with focal aortic pathology underwent endovascular repair using stacked 30 and 32-mm-diameter Zenith main body extensions. The setting was a university tertiary referral center for vascular disease. Indication for treatment included 2 descending thoracic aneurysms and individual cases of traumatic thoracic tear, diverticulum of Kommerell, thoracic pseudoaneurysm, and aortoesophageal fistula.
  
  
  RESULTS
  All procedures were performed successfully, with a mean of 3 cuffs used. The patient with an aortoesophageal fistula expired after successful cuff placement due to sequela of massive pretreatment hemorrhage; fistula coverage was confirmed at autopsy. There were no type I endoleaks. Morbidity included an occluded right subclavian artery from traumatic passage of the device through the artery. No left subclavian arteries were covered. No neurological deficits or paraplegia was observed. The cuffs were patent in all surviving patients at an average follow-up of 7 months (range 3-12). Computed tomography in all survivors confirmed adequate cuff placement, absence of endoleak, and lack of cuff migration. Based on this experience, the following technical recommendations are offered: (1) right subclavian cutdown when needed to reach a lesion beyond the range of the sheath, (2) Dacron chimney placement, (3) stiff guidewire usage, (4) wire placement from the right subclavian artery through the common femoral artery if necessary to ease a sharp bend in the arch, and (5) cuff overlap of 25% to 50%.
  
  
  CONCLUSIONS
  In high-risk patients, focal aortic pathology can be successfully treated with off-the-shelf commercially available cuffs using a stacking technique with acceptable mortality, morbidity, and short-term durability.
authors.affiliation: Center for Vascular Disease, University of Rochester, New York 14642, USA.
authors.forename: Heather Y
authors.initials: HY
authors.lastname: Wolford
authors.forename: Scott M
authors.initials: SM
authors.lastname: Surowiec
authors.forename: Jeffrey H
authors.initials: JH
authors.lastname: Hsu
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Rhodes
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Singh
authors.forename: Cynthia K
authors.initials: CK
authors.lastname: Shortell
authors.forename: Karl A
authors.initials: KA
authors.lastname: Illig
authors.forename: Richard M
authors.initials: RM
authors.lastname: Green
authors.forename: David L
authors.initials: DL
authors.lastname: Waldman
authors.forename: Mark G
authors.initials: MG
authors.lastname: Davies
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017541:Aneurysm, False / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000295:instrumentation / Q000379:methods; D004240:Diverticulum / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery; D004937:Esophageal Fistula / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery; D005260:Female; D005263:Femoral Artery / Q000000981:diagnostic imaging / Q000473:pathology / Q000503:physiopathology / Q000601:surgery; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality; D011474:Prosthesis Design; D012189:Retrospective Studies; D015607:Stents; D013348:Subclavian Artery / Q000000981:diagnostic imaging / Q000473:pathology / Q000503:physiopathology / Q000601:surgery; D015996:Survival Rate; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014654:Vascular Patency / Q000502:physiology