Branched versus fenestrated endografts for endovascular repair of aortic arch lesions.
OBJECTIVE
Endovascular repair of the aortic arch represents a formidable challenge because of aortic diameter, angulation, elasticity, and greater distance to the femoral access vessels. Whereas both fenestrated and branched endografts have been customized to accommodate complex pathologic processes of the arch, no data comparing the techniques are available. The aim of this study was to compare the outcomes of custom-made fenestrated vs branched thoracic endovascular aortic repair (fTEVAR vs bTEVAR).


METHODS
This was a single-center, retrospective comparative study of all consecutive patients treated with fTEVAR and bTEVAR for aortic arch diseases. All patients were considered unsuitable for open surgical therapy and treated with customized stent grafts (Cook Medical, Bloomington, Ind).


RESULTS
Within 42 months, 29 patients underwent fTEVAR and bTEVAR (66 ± 9 years; nine female patients). The fTEVAR patients (n = 15) had no differences in comorbidities compared with the bTEVAR patients (n = 14). Dissection or postdissection aneurysm was the indication in 6 of 15 fTEVARs and 5 of 14 bTEVARs (40% vs 36%; P = NS); the remaining procedures were performed for aneurysms. Six (40%) fTEVAR patients underwent previous cervical debranching compared with all bTEVAR patients. In all patients with bTEVAR, two arch vessels were targeted (innominate, 13; left carotid artery, 14; left subclavian artery, 1), whereas fTEVAR targeted 1.6 ± 0.5 arch vessels (bovine trunk, 4; innominate artery, 1; left carotid artery, 10; left subclavian artery, 9). Technical success was achieved in all but one case of a fenestrated endograft that was displaced, resulting in major stroke and death of the patient. Strokes occurred in two fTEVAR patients and one bTEVAR patient (P = NS). The 30-day mortality was 20% in the fTEVAR patients (n = 3) vs 0% in the bTEVAR patients (P = NS). The causes of early mortality were major stroke (n = 1), access complication (n = 1), and myocardial infarction (n = 1). Mean follow-up was 8 (1-35) and 10 (2-22) months for fTEVAR and bTEVAR, respectively. No branch occlusions occurred, and two patients underwent coil embolization for endoleaks (P = NS). One patient was readmitted with infected branched endograft 4 months after intervention and has so far been successfully treated with aneurysm sac drainage and antibiotics. There was one late nonaneurysm-related death in each group.


CONCLUSIONS
Both fTEVAR and bTEVAR are feasible for the treatment of aortic arch diseases in high-risk patients. Results are promising, although fTEVAR was associated with higher mortality in this early experience. bTEVAR was more commonly used in Ishimaru zone 0.
Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany. Electronic address: n.tsilimparis@uke.de.
Nikolaos
N
Tsilimparis
Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany.
E Sebastian
ES
Debus
Department of Cardiology, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany.
Yskert
Y
von Kodolitsch
Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany.
Sabine
S
Wipper
Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany.
Fiona
F
Rohlffs
Department of Cardiac Surgery, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany.
Christian
C
Detter
Cook Medical, Bloomington, Ind.
Blayne
B
Roeder
Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany.
Tilo
T
Kölbel
D000368:Aged; D000784:Aortic Dissection / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001013:Aorta, Thoracic / Q000000981:diagnostic imaging / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D000072226:Computed Tomography Angiography; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D005260:Female; D005858:Germany; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology / Q000628:therapy; D011474:Prosthesis Design; D019233:Retreatment; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome