Thoracic endovascular aneurysm repair in Japan: Experience with fenestrated stent grafts in the treatment of distal arch aneurysms

Objectives

In the West, stent grafts for endovascular repair of thoracic aortic aneurysms have been commercially available for several years, whereas in Japan, a manufactured stent graft was not approved for this application until March 2008. Nevertheless, endovascular thoracic intervention began to be performed in Japan in the early 1990s, with homemade devices used in most cases. Many researchers have continued to develop homemade devices. We have participated in joint design and assessment efforts with a stent graft manufacturer, focusing primarily on fenestrated stent grafts used in repairs at the distal arch, a site especially prone to aneurysm.

Methods

From 1995 to February 2008, we performed about 1100 endovascular procedures to treat thoracic aortic aneurysms and 682 cases were performed at Tokyo Medical University. In 435 out of 682 the aneurysm was located in the area from the distal arch to the proximal descending aorta. Fenestrated stent grafts were inserted in 288 cases. Computed tomography scans were performed at 3, 6, and 12 months postoperatively and annually thereafter.

Results

The initial success rate in the entire series was 95.2%. Complications included 26 cerebral infarctions (3.8%), six of which (0.9%) resulted in serious paralysis and changes in consciousness. Among patients who received fenestrated stent grafts, paraplegia occurred in 2.6%, aortic injury in 1.2%, and iliofemoral artery injury in 6.0%. No complications resulted from occlusion of aortic arch branches. At ≥2 years after intervention, aneurysm diameter was reduced in 62% of patients, 33% had no change, and 5% had a diameter enlargement. The stent graft complication rate during follow-up was 8.4%, the device fracture rate was 1.4%, and the device migration rate was 7%. The 5-year survival rate was 62.4%, with follow-up in 96.8% of the patients.

Conclusion

Endovascular repair has promising results in the descending thoracic aortic region, although some stent grafts and their delivery systems can still be improved. Additional commercial developments and available stent grafts designed for use in the distal arch are urgently needed.