Current status of endovascular (branch graft) treatment of the aortic arch
Dr. T. Kölbel
Voorzitter(s): dr. L.C. van Dijk, interventieradioloog, HagaZiekenhuis, Den Haag & dr. J.A. van Herwaarden, vaatchirurg, UMC Utrecht
11:30 - 11:50u
in Atrium zaal
Thoracic endovascular aortic repair (TEVAR) has evolved rapidly as the standard-treatment for lesions of the descending aorta including landing zones 2-4 according to the Ishimaru-classification. For Lesions of the aortic arch that include the innominate artery (IA) and the left common carotid artery (LCCA) open aortic arch replacement including cardiopulmonary bypass (CPB) and cardiac arrest is still the gold standard, but limited to young and relatively fit patiënts due to its operative mortality and morbidity. Major advancements in perioperative management, surgical techniques with antegrade cerebral perfusion, and introduction of hybrid-techniques such as the frozen elephant trunk technique (FET) have led to recent improvements in open arch surgery, but especially patiënts with older age, severe comorbidities and previous cardiac surgery are today preferably managed by hybrid aortic techniques with debranching of the aortic arch-vessels and TEVAR in landing zones 0-1 obviating the need for aortic cross-clamping and CPB. However, these less invasive hybrid-techniques still require extensive open surgery including sternotomy for zone 0 with relevant morbidity and an in-hospital mortality rate up to 8%. Branched and fenestrated endografts, produced as custom-made devices, have the ability to avoid these extensive debranching operations and have shown acceptable results in small case series. Access-problems limit these new endovascular techniques in a considerable number of patiënts with narrow or tortuous iliac vessels or kinked aortic segments. Alternative transcardiac access routes may help to overcome these problems and have shown promising results in selected patiënts.
