Fenestrated versus debranching TEVAR for endovascular treatment of distal aortic arch and descending aortic lesions

ABSTRACT Background Cervical debranching followed by thoracic endovascular aortic repair (TEVAR) is well-established for treating aortic arch lesions, but total endovascular repair with fenestrated endografts has not been adequately studied. This is a comparison of the two techniques. Methods This was a single-center, retrospective study comparing treatment of thoracic aortic lesions with custom-made fenestrated stent-grafts (fenestrated TEVAR) with a single fenestration for the left subclavian artery (LSA) and a scallop for the left carotid artery and hybrid repair with a thoracic stent-graft and cervical debranching of the LSA. Emergency cases were excluded. Results From 2012 to 2018, 19 patients (58% male) underwent elective fTEVAR (Group A) and 17 patients (82% male) underwent dTEVAR (Group B). Mean age ± SD in Group A was 65.8 ± 2 years and in Group B 68 ± 3 years. Left carotid-subclavian bypass was performed in 15/17 (88%) patients in Group B and transposition of the LSA in 2/17 (12%) patients. The two groups were comparable regarding comorbidities, except for peripheral arterial disease (PAD): 26% (5/19) of patients in Group A were suffering from PAD and none in Group B (p=0.049). Dissection or post-dissection aneurysm was the indication for treatment in 6/19 patients in the fTEVAR group and in 12/17 patients in the dTEVAR group (31.6% vs. 70.6%; p=0.04); the rest were for degenerative aortic aneurysms. Technical success was achieved in all cases but one dTEVAR due to Type Ia endoleak; mean endovascular operative time was 191 ± 120 minutes for fTEVAR and 130 ± 75 minutes for dTEVAR (p=ns), whereas mean operative time for the debranching procedure was 181 ± 97 minutes. There were no deaths or major strokes in the early postoperative period (30 days). 5/17 (29.4%) patients in Group B suffered a local complication related to the debranching operation. Mean follow-up was 14.6 ± 2 months for Group A and 17 ± 2 months for Group B. 2/19 (10.5%) patients in Group A and 6/17 (35.3%) patients in Group B received an unplanned re-intervention related to the thoracic stent-graft during the follow-up period (p=ns). Estimated freedom from unplanned re-intervention at 12 months was 86% for Group A and 81% for Group B. Primary patency of the LSA stent-graft or the carotid-subclavian bypass/transposition was 100% in both groups. Conclusion Both techniques showed excellent midterm patency rates for the target vessel and high technical success rate. Operation times were lower in the fenestrated-TEVAR group and complications related to the debranching procedure were avoided.