Lengthening Proximal and Distal Landing Zones to Facilitate Endovascular Thoracic Aortic Stentgraft Placement

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Manish Mehta, MD, MPH, R. Clement Darling, III, MD, Philip SK Paty, MD, Yaron Sternbach, MD, Stephanie Saltzberg, MD, Sean P. Roddy, MD, John B. Taggert, MD, Paul B. Kreienberg, MD, Kathleen J. Ozsvath, MD, Benjamin B. Chang, MD.
Albany Medical College, Albany, NY, USA.

Purpose: We report our experience of thoracic stentgraft coverage of arch branch vessles and visceral arteries to lengthen the proximal and distal landing zones during thoracic endovascular aneurysm repair (TEVAR).
Methods: From 2004 to 2007, 145 patients underwent elective (n=67, 46%) and emergent (n=78, 54%) endovascular thoracic aortic stentgraft placement for TAA (n=113, 78%), symptomatic ulceration (n=13, 9%), pseudoaneurysms (n=6, 4%) and traumatic aortic transections (n=13, 9%). Data was prospectively collected in our vascular registry and outcomes of interrupting arch and visceral vessels were analyzed.
Results: Of 145 TEVAR patients, 63 (43%) required interruption of at lease one arch or visceral artery during repair. The stentgraft covered the left subclavian artery (SA) in 44 (30%) patients; 26 (59%) underwent carotid-subclavian bypass. The common carotid artery (CCA) was partially covered in 14 (10%) patients; all underwent proximal CCA stenting during TEVAR; on follow-up, 3 (21%) patients developed proximal CCA stenosis, 2 underwent in-stent angioplasty, and 1 required carotid-carotid bypass. Two patients underwent complete arch debranching procedure during TEVAR. The distal aspect of the stentgraft covered the celiac artery in 17 (12%) patients that had documented superior mesenteric artery (SMA) collaterals; 1 (6%) required emergent revascularization for shock liver. The SMA was partially covered in 6 (4%) patients; all underwent SMA stenting during TEVAR, and none developed symptoms of mesenteric ischemia. There were no proximal type I endoleaks, and 2 patients with distal type I endoleak were successfully treated by catheter directed thoracic aneurysm sac embolization. Overall, 4 (8%) patients had stroke, and 1 (2%) patient had spinal cord ischemia with full recovery following cerebral spinal fluid drainage, and 3 died (2 with ruptured TAA, and 1 elective TAA).
Conclusions: Our preliminary data would suggest that the proximal and distal thoracic aortic landing zones can be lengthened by coverage of thoracic arch and visceral arteries. However, these maneuvers might be associated with a considerable incidence of stroke and the need for recurrent procedures for in-stent stenosis.

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