Experience with the Ankura Thoracic Stent Graft and In-situ Fenestration for the Left Subclavian Artery with the Fu-Through Needle - a Technical Overview and Comparison to Similar Endovascular Techniques

Abstract

Thoracic endovascular aortic repair (TEVAR) is a widespread minimally invasive procedure prevalently used to treat thoracic aortic pathologies. However, when the left subclavian artery (LSA) is involved in the pathology, a more complex surgical approach is required to guarantee the perfusion of the vertebral and brachial arteries. In fact, coverage of the LSA has been proven to be associated with a higher risk of stroke, spinal cord ischemia, and arm ischemia.

Historically, carotid-subclavian bypass or subclavian transposition has been the only treatment options to restore the perfusion of the LSA. For the past 10 years, different endovascular techniques have been implemented in the endovascular armamentarium to reduce the risk of complications related to surgical treatment such as infection, bleeding, and chylothorax.

Currently, physician-modified grafts, in situ fenestration, chimneys, and branched or fenestrated devices are available. The aim of this overview is to describe the technique with the Ankura thoracic stent graft and in situ fenestration with the Futhrough needle and thus to shed light on the different approaches by comparing their pros and cons.

Zusammenfassung

Die thorakale endovaskuläre Aortenreparatur (TEVAR) ist ein weit verbreitetes minimalinvasives Verfahren, das häufig zur Behandlung von Pathologien der thorakalen Aorta eingesetzt wird. Wenn die linke Schlüsselbeinarterie in die Pathologie involviert ist, ist jedoch ein komplexerer chirurgischer Ansatz erforderlich, um die Perfusion der Hals- und Armarterien zu gewährleisten. Es wurde festgestellt, dass die Abdeckung der linken Schlüsselbeinarterie mit einem höheren Risiko für Schlaganfälle, Rückenmarksischämien und Armischämien verbunden ist.

Historisch gesehen waren die Karotis-Subclavia-Bypass- oder Subclavia-Transpositionsverfahren die einzigen Behandlungsoptionen zur Wiederherstellung der Perfusion der linken Schlüsselbeinarterie. In den letzten 10 Jahren wurden jedoch verschiedene endovaskuläre Techniken in das endovaskuläre Arsenal aufgenommen, um das Risiko von Komplikationen im Zusammenhang mit chirurgischer Behandlung wie Infektionen, Blutungen und Chylothorax zu reduzieren.

Derzeit stehen modifizierte Grafts, In-situ-Fenestration, „Chimneys“ und gebranchte oder fenestrierte Prothesen zur Verfügung. Das Ziel dieses Überblicks ist es, die Technik mit dem Ankura Thorax-Stentgraft und der In-situ-Fenestration mit dem Futhrough Needle zu beschreiben und somit die verschiedenen Ansätze zu beleuchten, indem ihre Vor- und Nachteile verglichen werden.

Schlüsselwörter

Aortenaneurysma - A. thoracalis - Aortenchirurgie - Aortenstentprothese - Endoleak - Endograft

Keywords

aortic aneurysm - aortic surgery - aortic stent prosthesis - endoprosthesis - endovascular treatment

• References

• 1 Sayed H, Ramlawi B. The current status of endovascular repair of thoracic aortic aneurysms (TEVAR). Methodist Debakey Cardiovasc J 2011; 7: 15-19
• 2 Bradshaw RJ, Ahanchi SS, Powell O. et al. Left subclavian artery revascularization in zone 2 thoracic endovascular aortic repair is associated with lower stroke risk across all aortic diseases. J Vasc Surg 2017; 65: 1270-1279
• 3 Youssef A, Ghazy T, Kersting S. et al. Management of the left subclavian artery during TEVAR – complications and mid-term follow-up. Vasa 2018; 47: 387-392
• 4 Bertoglio L, Salvati S, Fittipaldi A. et al. Carotid to subclavian bypass and Amplatzer vascular plug subclavian endovascular occlusion before thoracic open or endovascular repair. J Vasc Surg 2020; 71: 1480-1488.e1
• 5 Lin J, Parikh N, Udgiri N. et al. Laser Fenestration of Aortic Stent-Grafts Followed by Noncompliant vs Cutting Balloon Dilation: A Scanning Electron Microscopy Study. J Endovasc Ther 2018; 25: 397-407
• 6 Li X, Zhang L, Song C. et al. Outcomes of Total Endovascular Aortic Arch Repair with Surgeon-Modified Fenestrated Stent-Grafts on Zone 0 Landing for Aortic Arch Pathologies. J Endovasc Ther 2022; 29: 109-116
• 7 Crawford SA, Osman E, Doyle MG. et al. Impact of fenestrated stent graft misalignment on patient outcomes. J Vasc Surg 2019; 70: 1056-1064
• 8 Tsilimparis N, Debus ES, von Kodolitsch Y. et al. Branched versus fenestrated endografts for endovascular repair of aortic arch lesions. J Vasc Surg 2016; 64: 592-599
• 9 Xie W, Xue Y, Li S. et al. Left subclavian artery revascularization in thoracic endovascular aortic repair: single center’s clinical experiences from 171 patients. J Cardiothorac Surg 2021; 16: 207
• 10 Hogendoorn W, Schlösser FJ, Moll FL. et al. Thoracic endovascular aortic repair with the chimney graft technique. J Vasc Surg 2013; 58: 502-511
• 11 Wu X, Li Y, Zhao Y. et al. Efficacy of left subclavian artery revascularization strategies during thoracic endovascular aortic repair in patients with type B dissection: A single-center experience of 105 patients. Front Cardiovasc Med 2023; 10: 1084851
• 12 Crawford SA, Sanford RM, Forbes TL. et al. Clinical outcomes and material properties ofin situfenestration of endovascular stent grafts. J Vasc Surg 2016; 64: 244-250
• 13 Li J, Xue Y, Li S. et al. Outcomes of thoracic endovascular aortic repair with chimney technique for aortic arch diseases. Front Cardiovasc Med 2022; 9: 868457
• 14 Pecoraro F, Veith FJ, Puippe G. et al. Mid- and Longer-term Follow up of Chimney and/or Periscope Grafts and Risk Factors for Failure. Eur J Vasc Endovasc Surg 2016; 51: 664-673