Total Endovascular Treatment of Chronic Aortic Dissection with Fenestrated and Branched Stent-Grafts

ABSTRACT Introduction Chronic aortic dissection with aneurysm development that includes the aortic arch and/or thoraco-abdominal aorta (TAAA) is traditionally treated with open or hybrid surgery. Total endovascular treatment with fenestrated and branched stent grafts (F/B-EVAR) has recently been introduced as a less invasive alternative. The aim was to report short- and mid-term outcome from a single tertiary vascular center. Methods All patients with chronic aortic dissection treated with F/B-EVAR 2010-2019 at Uppsala University Hospital were identified. Peri and postoperative parameters were analyzed, with focus on short- ( Results F/B-EVAR was performed on 26 patients (median age 63 years (range 33-87), 18 men, median aortic diameter 70mm (range 50-98)); median follow up 23 months (range 0.5-118). One patient underwent both arch and TAAA repair. Overall, 13 arch repairs (arch group) following type A (n=8) and type B (n=5) dissection (all elective) were performed, and 14 TAAA repairs (TAAA group) following type A (n=5) and type B (n=9) dissection (one rupture). A total of 72 aortic branches were targeted (22 arch, 50 TAAA). Short-term results: Technical success was achieved in 24/27 (89%) procedures. Failures were related to one intraoperative retrograde type A dissection (RTAD) requiring open conversion (arch group); one persistent type Ic endoleak on completion angiography (arch group), one persistent type III endoleak (TAAA group). Mortality was 4% (n=1) at 30 days; related to a second RTAD, that occurred after discharge and was found on autopsy. Both RTADs occurred in patients with chronic type B dissection undergoing fenestrated arch repair (arch-FEVAR). Paraplegia occurred in three cases (2 arch, 1 TAAA) (11%), none permanent, and stroke in three cases (2 arch, 1 TAAA) (11%), one permanent. Mid-term results: Endoleaks were detected in 12 patients (44%); persistent false lumen flow (n=3), type Ib (n=1), type Ic (n=3), type II (n=7) and type IIIc (n=2). Three-year survival (Kaplan-Meier) arch: 75%, TAAA 93%. Freedom-from-reintervention at 3 years were arch: 100% and TAAA: 48%. In patients with FU>6 months (n=23) all had stable or decreased aortic diameters, and complete false lumen thrombosis at level of stent-graft was present in 65% (n=15). Conclusion Endovascular treatment of post-dissection aneurysms is feasible, with acceptable short- and mid-term outcome. RTAD following fenestrated and branched endovascular arch repair warrants caution when performed on patients with native ascending aortas, and re-interventions are frequent in TAAA repair.