Results of endografting of the aortic arch in different landing zones

Abstract Introduction: Endovascular approach to the aortic arch is an appealing solution for selected patients. Aim of this study is to compare the technical and clinical success recorded in the different anatomical settings of endografting for aortic arch disease. Methods: Between June 1999 and October 2006, among 178 patients treated at our Institution for thoracic aorta disease with a stent-graft, the aortic arch was involved in 64 cases. According to the classification proposed by Ishimaru, aortic "zone 0" was involved in 14 cases, "zone 1" in 12 cases and "zone 2" in 38 cases. A hybrid surgical procedure of supraortic debranching and revascularization was performed in 37 cases to obtain an adequate proximal aortic landing zone. Results: "Zone 0" (14 cases). Proximal neck length: 44 ± 6 mm. Initial clinical success 78.6%: 2 deaths (stroke), 1 type Ia endoleak. At a mean follow-up of 16.4 ± 11 months the midterm clinical success was 85.7%. "Zone 1" (12 cases). Proximal neck length: 28 ± 5 mm. Initial clinical success 66.7%: 0 deaths, 4 type Ia endoleaks. At a mean follow-up of 16.9 ± 17.2 months the midterm clinical success was 75.0%. "Zone 2" (38 cases) Proximal neck length: 30 ± 5 mm. Initial clinical success 84.2%: 2 deaths (1 cardiac arrest, 1 multiorgan embolization), 3 type Ia endoleaks, 1 case of open conversion. Two cases of delayed transitory paraparesis/paraplegia were observed. At a mean follow-up of 28.0 ± 17.2 months the midterm clinical success was 89.5%. Conclusions: Total debranching of the arch for "zone 0" aneurysms allowed to obtain a longer proximal aortic landing zone with lower incidence of endoleak, however a higher risk of cerebrovascular accident was observed. The relatively high incidence of adverse events in "zone 1" could be associated to a shorter proximal neck, therefore this landing zone is reserved for patients unfit for sternotomy. In case of endoleak, discovered after a satisfactorily positioned endograft in the arch, the rate of spontaneous resolution within the first 6 months is high.