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Case Series: A Novel Approach To Thoracic Endovascular Aortic Repair Using A “Zone 1.5” Deployment Of Thoracic Branched Endoprosthesis Device
Keyuree Satam, MD, Sabina Sorondo, MD, Arash Fereydooni, MD, Pauline Berens, Jason T. Lee, MD.
Stanford, Palo Alto, CA, USA.
DEMOGRAPHICS: Zone 2 TEVAR traditionally requires a carotid-subclavian bypass. Newly FDA-approved, Gore’s Thoracic Branched Endoprosthesis offers complete endovascular Zone 2 repair with LSCA branch stent, or Zone 1 repair with left carotid branching and carotid-subclavian bypass. Inadequate distance (<20 mm) between arch branches can force proximal branch coverage when planning TBE for Zone 2 or Zone 1. Of 53 patients in our prospectively maintained complex TEVAR registry who had undergone TBE, three had anatomy unsuitable for standard Zone 2 or Zone 1 repair. Patient 1 was a 74-yo Asian male with hypertension and a current smoker. Patient 2 was an 80-yo Asian male with AFib, hypertension, ESRD on dialysis, and a former smoker. Patient 3 was a 73-yo white male with AFib, hypertension, hyperlipidemia, CKD 4, and a current smoker.
HISTORY: Patient 1 presented for urgent repair of an acute type B dissection with malperfusion to his lower extremities. Patient 2 presented with aneurysmal degeneration of his chronic type B dissection. Patient 3 presented with a saccular aneurysm in Zone 2 from a penetrating aortic ulcer. Landing zones from LSCA to carotid were 13.9, 18.8 and 9.6 mm respectively. Landing zones from innominate to left carotid were 13, 18.5, and 14.7 mm respectively.
PLAN: All patients underwent a “Zone 1.5” configuration repair: coverage up to the innominate, LSCA branch stent, and subclavian-carotid bypass. Centerline measurements and anatomy were determined using TeraRecon. All cases were performed in a hybrid OR suite with Cydar fusion imaging. Patients 1 and 3 underwent subclavian-carotid bypass, and Patient 2 underwent transposition. All had left radial and right CFA access, and delivery of 40, 40, and 34-mm TBEs with branch stents of 12,17, and 15mm respectively. Postoperatively, Patient 3 had an MCA stroke requiring thrombectomy; he required three device turns in the arch to orient the TBE. He also developed transient post-operative AKI. On 1-month follow-up, all had stable or reduced aneurysms with partial or complete false-lumen thrombosis. (Figure)
DISCUSSION: Zone 1.5 TBE with left subclavian-carotid bypass is effective for patients with inadequate proximal neck lengths for standard Zone 2 or Zone 1 repair.
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