Mid-term results from an analysis of a series of hybrid aortic arch reconstructions utilizing overlapping single thoracic branch endoprostheses in a dual-branch configuration showed the technique to be safe and versatile.
Delivered at the 2024 Western Vascular Society (WVS) annual meeting in Colorado Springs, Colorado (Sept. 7–10), the paper was the winner of the WVS Rapid Fire Competition.
Presenter Evan R. Brownie, MD, a vascular surgeon at Intermountain Health in Murray, Utah, characterized use of the procedure following the commercial launch and subsequent widespread use of the Gore Tag thoracic branch endoprosthesis (TBE). Despite this, Brownie said, “we believe there is still a role for a versatile multiple-branched arch option.”
Brownie and colleagues performed their first 49 TBE deployments in 44 patients from October 2022 to December 2023, five of which involved the dual-TBE configuration in question. Median follow-up was six months, and up to 12 months.
“All of these patients had at least one prior sternotomy with an existing ascending aortic stent graft, some sort of systolic heart failure and one of the five patients had a prior recurrent laryngeal nerve injury at the time of their index procedure, henceforth why—even though we do an equal number of zone 0 deployments off a single branch—we are trying to minimize risk for this patient population and the discrepancies that can be seen with a single branch perfusing all of the great vessels,” he explained.
Three of the five underwent a dual brachiocephalic configuration with a left carotid-to-subclavian transposition through a left cervical incision, Brownie said. The other two had a left-common-carotid-to-right-common-carotid transposition, he added, explaining that “we do a separate arteriotomy in the right carotid artery to maintain cerebral perfusion throughout the case.”
For the endovascular portion of the procedure, he continued, “we obtained bilateral percutaneous femoral and bilateral percutaneous arm access. We do a zone 2 thoracic branch stent graft, put in an oversized Viabahn (Gore) stent graft in position, then extend proximally with our zone 0 stent graft and deploy it. So, we are gaining the overlap seal between the devices, as well as the parallel seal zone, just to maintain perfusion to the subclavian limb.”
Procedures were typically staged, Brownie said, with the transposition performed two days prior to the endovascular repair. Following transposition, there were no strokes, cranial nerve injuries or early thrombosis, he told WVS 2024. Similarly, following endovascular repair, there were no cases of spinal cord, renal or bowel ischemia.
Furthermore, one patient was returned to the operating room for an access site complication, one had a stroke, and there were no type I or II endoleaks, nor gutter leaks. Sixty percent of these patients have already demonstrated sac regression, Brownie added.
“An appropriate trial design and regulatory application could bridge the gap until we have a dedicated arch graft available,” he concluded. “And, of course, this will largely be dependent on compensation and reimbursement for such procedures.”
