Stroke Rates With Single-branch Endovascular System
Paul X. Hayes.
University of Cambridge, Cambridge, United Kingdom.
BACKGROUND: Neurological complications after aortic arch repair are one of the most profound sources of post-operative morbidity. Conventional aortic arch replacement is associated with a high mortality (14.5%: 131/906 cases PMID:29395709). Alternatives such as frozen elephant trunk (FET) have reduced mortality but a recent review of 3154 FET cases found a 4.7% spinal cord ischemia and a 7.6% permanent stroke rate (PMID:31757456). Endovascular approaches avoid prolonged distal aortic occlusion/hypotension and are associated with lower rates of spinal cord ischemia (1.1%: 1/89 cases PMID:28583734). Unfortunately, current endovascular devices continue to report stroke rates in excess of 10% (PMID:29153441 & 33956958). The high stroke rates seen currently may be due to cerebral vessel trauma caused by the need to directly puncture the carotid arteries, and the associated passage of wires and sheaths. A new, single branch off-the-shelf endovascular device avoids dangerous carotid trauma during implantation and so has the potential to lower strokes rates. METHODS: The single branch system is deployed over a femoro-right subclavian wire into the innominate artery, avoiding the need for carotid manipulation. Surgical debranching/parallel graft insertion was performed to provide LCCA/LSCA flow. The system has dual-flush ports to maximize air bubble removal, which are associated with silent brain infarction. Prospective data collection using structured case report forms was used for all cases.
RESULTS: 28 patients were treated with complete follow up to 3 years. The composite freedom from mortality/disabling stroke or paraplegia rate at 30 days was 92.9%. There were no late strokes or paraplegias, or any device related deaths over 3 years of follow up. There were no type 1a endoleaks throughout the study period and only a single type 1b leak (3.8%) was present at 3-year scanning. The brachiocephalic trunk branch remained patent in 100% of cases at 3-year follow up. CONCLUSIONS: This new system demonstrates a high success rate with excellent 3-year outcomes and very low rates of neurological complications. The unique design of the system may help overcome one of the last significant barriers in the management of aortic arch pathologies.
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