Early Outcomes of a Curvature-Guided Strategy for Dual-Branch Revascularization in Zone 1 TEVAR.

Objective

To evaluate the feasibility and early outcomes of a curvature-guided strategy that guides dual-branch revascularization during Zone 1 Thoracic Endovascular Aortic Repair (TEVAR) based on whether the aortic pathology is predominantly located on the greater or lesser curvature of the arch.

Methods

In this retrospective, descriptive study (February 2023-June 2024), 43 consecutive patients were included under a predefined anatomical protocol. Of these, 3 patients (7.0%) were lost to follow-up and were included in the analysis of baseline characteristics and perioperative outcomes. The remaining 40 patients constituted the per-protocol follow-up cohort. Pathologies predominantly on the aortic arch's greater curvature (n = 21) were managed with a Castor single-branched stent-graft for the left subclavian artery (LSA) and a left common carotid artery (LCCA) chimney stent. Those on the lesser curvature (n = 22) received a physician-modified endograft (PMEG). The primary outcome was technical success; secondary outcomes included safety, branch patency, and reintervention.

Results

The overall technical success rate was 97.7% (100% in the Castor-chimney cohort [21/21] vs. 95.5% in the PMEG cohort [21/22]). No perioperative stroke, spinal cord ischemia, or retrograde type A dissection occurred in either cohort. Two type II endoleaks were observed: one intraoperative in the Castor-chimney cohort and one during follow-up in the PMEG cohort. Among the 40 patients (20 per cohort) who completed a median follow-up of 22.5 months, freedom from aortic-related reintervention was 95% (38/40), with one reintervention occurring in each cohort. Branch patency was 100% (20/20) in the PMEG cohort, whereas it was 95% (one asymptomatic LSA occlusion) in the Castor-chimney cohort.

Conclusions

The implementation of a curvature-guided protocol, which rationally matches endograft techniques to arch anatomy, suggests acceptable early safety and efficacy for complex Zone 1 TEVAR. This anatomy-driven framework offers a potential personalized approach to dual-branch revascularization and warrants prospective validation.