Emergency Use of Branched Thoracic Endovascular Repair in the Treatment of Aortic Arch Pathologies

Background: Branched thoracic endovascular aortic repair (b-TEVAR) has revolutionized the treatment of aortic arch pathologies. However, b-TEVAR requires custom design and time for manufacturing, which limits its use in emergency situation.

Methods: We retrospectively studied a series of 11 patients, who underwent emergency b-TEVAR in our institution. Stent grafts were either already available for the patient or from another patient with similar anatomy. Study endpoints were technical success, 30-day mortality, perioperative complications, early reinterventions, and subsequent image follow-up.

Results: Between December 2012 and December 2017, 11 patients (5 male; age 67 ± 14 years) were treated emergently with b-TEVAR for type A dissection (n = 2), peripheral malperfusion despite ascending repair in type A dissection (n = 1), contained ruptured ascending aortic pseudoaneurysm (n = 2), symptomatic arch aneurysm (n = 4), and ruptured subclavian aneurysm (n = 2). Three patients received their personal custom-made endografts but were hospitalized and treated urgently because of new symptom onset; the remaining 8 patients were treated with endografts from other patients. Technical success was 100%. Thirty-day mortality was 9% (1 of 11). Perioperative complications included one major stroke (9%), one sepsis (9%), two respiratory failures (18%), one acute renal injury (9%), and one retroperitoneal hematoma (9%). There were five (45%) early reinterventions. With median 6 months (range, 1 to 28) of follow-up, 2 patients had persistent false lumen perfusion, whereas all supraaortic branches remained patent.

Conclusions: Our experience provided an early insight to the feasibility and safety of b-TEVAR in an emergency situation, although the early reintervention rate was not negligible. The endograft was versatile, with potential off-the-shelf use in future.