Prograde and Retrograde Stenting of Aortic Arch Branches During or After Thoracic Endografting: Useful Techniques in the Thoracic Endovascular Era

Christopher M. Chambers, MD, Luis A. Sanchez, MD, Brian G. Rubin, MD, Patrick J. Geraghty, Marc R. Moon, MD and Gregorio A. Sicard, MD
Vascular Surgery, Washington University School of Medicine, St. Louis, MO

Objectives: Proper use of thoracic endografts requires at least a 2cm proximal and distal landing zones for attachment and seal. Often, the device has to be deployed at the edge/partially across an arch vessel to obtain optimal seal. Prograde or retrograde stenting techniques can be useful to preserve arterial perfusion of critical aortic arch branch vessels which have been partially or totally covered during thoracic endografting, avoiding emergent arterial reconstructions. We reviewed our experience with arterial stenting associated with thoracic endografting to better understand its safety and efficacy.
Methods: Over the past 6 years(March 2000-2006), 89 patients were treated at our institution with thoracic endografts for aneurysms(62), traumatic lesions(20), penetrating ulcers(5), and dissections(2). Sixty patients were treated using the TAG(40), Talent(19), and TX2(1) grafts while 29 patients were treated with abdominal components. Arch vessels required stenting due to graft misplacement in 2 patients, while 2 stent procedures were a planned intervention. Secondary endovascular interventions unrelated to aortic arch branch vessel stenting were performed in 3 patients (Type I & III endoleaks, endograft collapse) for a total of 92 procedures.
Results: During or after deployment of the aortic endografts, 4 patients underwent retrograde(3) or prograde(1) stenting of the left carotid(3) or subclavian(1) arteries (for preservation of hemodialysis access). All procedures were performed without complications. The stents and endografts are patent at mean follow-up of 20 months.
Conclusions: Retrograde and prograde stenting of aortic arch branches is an extremely useful technique that must be part of the interventionalist’s armamentarium. These techniques allow salvage of critical situations that can occur during endograft misplacement and can be used to protect arch branches during endograft deployment at or partially across a branch, obtaining the best seal in the aortic arch.