The Modified Arch Landing Areas Nomenclature identifies hostile zones for endograft deployment: a confirmatory biomechanical study in patients treated by thoracic endovascular aortic repair†

Marrocco-Trischitta, Massimiliano M.; Romarowski, Rodrigo M.; Beaufort, Hector W. de; Conti, Michele; Vitale, Renato; Secchi, Francesco; Auricchio, Ferdinando; Trimarchi, Santi

doi:10.1093/ejcts/ezy409

Cited by 14 publications

(21 citation statements)

References 25 publications

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“…Experimental studies based on in silico endograft virtual deployment 41 may represent a feasible and cutting edge first step to address this issue. Also, as previously suggested, 7 the potential causative effect of the magnitude and orientation of the displacement forces exerted in the different proximal landing zones of the arch should be investigated by specific computational fluid dynamics studies.…”

Section: Resultsmentioning

confidence: 98%

“…This finding implies that the magnitude of the hemodynamic disturbances induced by the misalignment of the endograft, consistent with previous functional studies specifically performed in trauma patients, 12 may not per se induce complete endograft failure. Yet, displacement forces are greater in aneurysmal aortas compared with healthy aortas (ie, nondilated aortas such as in trauma patients) in zone 3, 7 and therefore clinical outcomes may vary based on the indication for TEVAR and the choice of the proximal landing zone. Among the potential determinants of the BBC analyzed in the literature, specific anatomic risk factors are the ones most consistently reported, namely proximal landing zones 2 and 3 1,2,9,19,22 and aortic angulation.…”

Section: Discussionmentioning

confidence: 99%

“…33 In the descending thoracic aorta, TEVAR can currently be regarded as the treatment of choice on the basis of remarkable long-term clinical success rates. 34 TEVAR of the aortic arch, in contrast, remains challenging due to its peculiar geometries 35 and hemodynamic environment, 6,7 which may lead to an increased risk of endograft failure. 32,36,37 Also, concerns persist regarding the long-term durability of endovascular treatment in the view of continuous remodeling of the arch induced by the endograft.…”

Section: Discussionmentioning

confidence: 99%

“…Indeed, the advent of new devices specifically designed to conform with the arch geometry have improved the TEVAR results. 8,9 The issue of the biomechanical interaction between the endograft and the aortic arch wall, however, remains largely unaddressed, 7,9 and the incidence of the postoperative bird-beak configuration (BBC) has been reduced but remains anything but eliminated. 9,10 Of note, a surrogate of the BBC (ie, the distance between the proximal end of the endograft and the inner curvature of the arch), was employed as a conformability index in the European Gore C-TAG registry.…”

Section: Introductionmentioning

confidence: 99%

“…4 The protrusion of the endograft in the aortic lumen may cause relevant hemodynamic disturbances. 5 The high pulsatile forces acting on the aortic arch wall 6 are transmitted as displacement forces on the terminal fixation sites of the endograft after its release, 7 and this also may cause an endoleak or even the collapse of the device 5 and a consequent fatal aortic occlusion.…”

Section: Introductionmentioning

confidence: 99%

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Impact of the Bird-Beak Configuration on Postoperative Outcome After Thoracic Endovascular Aortic Repair: A Meta-analysis

et al. 2019

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Purpose: To investigate the association between the bird-beak configuration (BBC), a wedge-shaped gap between the undersurface of a thoracic endograft and the lesser curvature of the arch after thoracic endovascular aortic repair (TEVAR), and postoperative outcome after TEVAR. Methods: The study was performed according to the PRISMA guidelines. The PubMed, EMBASE, and Cochrane databases were searched to identify all case series reporting BBC after TEVAR between 2006 and April 2018. Data analysis was performed considering the difference in the risk of complications for presence vs absence of BBC. After screening 1633 articles, 21 studies were identified that matched the selection criteria; 12 of these reported detailed information to investigate the postoperative outcome using proportion meta-analysis with a random effects model. The pooled risk difference is reported with the 95% confidence interval (CI). Heterogeneity of the included studies was assessed with the I2 statistic (low 25%, medium 50%, high 75%). Results: Complications occurred within a range of 0 to 72 months in 14.7% (95% CI 7.4% to 27.3%) of patients with BBC and in 6.3% (95% CI 2.5% to 15.4%) of patients without BBC. A cumulative incidence could not be assessed. The summary risk difference was 11.1% (95% CI −0.1% to 22.3%, p=0.052). There was significant heterogeneity ( I2=85.6%). The Egger test did not show evidence of publication bias (p=0.975). When specifically considering type Ia endoleak and endograft migration, the risk difference between BBC and non-BBC patients was 8.2% (95% CI 0.3% to 16.1%, p=0.042; I2=69.0%). The specific risk difference for endograft collapse/infolding and thrombosis was 3.7% (95% CI −3.5% to 11.1%, p=0.308; I2=10.2%). Conclusion: At present the literature does not provide statistical evidence to establish an overall prognostic value of the BBC. Nevertheless, the BBC appears to be associated with a high risk of type Ia endoleak and endograft migration, which warrants specific and long-term surveillance. Clinically relevant values for BBC grading should be established to perhaps define indications for preemptive treatment based on the presence of BBC only.

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Section: Resultsmentioning

confidence: 98%