The Role of the Nexus Aortic Arch System in Reducing Neurological Events after Aortic Arch Repair

 

Objectives: Neurological complications after aortic arch repair are one of the most profound sources of post-operative morbidity. Conventional aortic arch replacement is associated with a high mortality (14.5%: 131/906 cases).¹ Alternatives such as frozen elephant trunk (FET) have reduced mortality but a recent review of 3,154 FET cases found a 4.7% spinal cord ischemia and a 7.6% permanent stroke rate.² Endovascular approaches avoid prolonged distal aortic occlusion/hypotension and are associated with lower rates of spinal cord ischaemia (1.1%: 1/89 cases)³.

Unfortunately, current endovascular devices continue to report stroke rates in excess of 10%.^4,5 The high stroke rates seen currently may be due to cerebral vessel trauma caused by the need to directly puncture the carotid arteries, and the associated passage of wires and sheaths. The NEXUS Aortic Arch Stent Graft System avoids uncontrolled carotid trauma during implantation and so has the potential to lower strokes rates.

Methods: The single branch of the NEXUS system is deployed over a femoro-right subclavian wire into the innominate artery, avoiding the need for carotid manipulation. Surgical debranching/parallel graft insertion was performed to provide LCCA/LSCA flow. The system has dual-flush ports to maximize air bubbles removal, which are associated with silent brain infarction. Prospective data collection using structured case report forms was used for all cases.

Results: Twenty-eight patients were treated with the Nexus system with a complete follow-up to 3 years. Hundred percent of the cases had their proximal sealing zone in Zone 0. The median total procedure time was 185 minutes [IQR 148–254], with 19/28 patients undergoing a totally percutaneous procedure. The median length of hospital stay was 8.5 [7.0–14.7] days, with a median ICU stay of only 1.0 [1.0–3.0] days.

The composite freedom from mortality/disabling stroke or paraplegia rate at 30 days was 92.9%. There were no late strokes or paraplegias, or any device related deaths over 3 years of follow-up. There were no type 1a endoleaks throughout the study period and only a single type 1b leak (3.8%) was present at 3 year scanning. The brachiocephalic trunk branch remained patent in 100% of cases at 3-year follow-up

Conclusion: The NEXUS Aortic Arch System demonstrates a high success rate with excellent 3-year outcomes and very low rates of neurological complications. The unique design of the system may help overcome one of the last significant barriers in the management of aortic arch pathologies.

References

1. Hanif H, Dubois L, Ouzounian M, et al; Canadian Thoracic Aortic Collaborative (CTAC) Investigators. Aortic arch reconstructive surgery with conventional techniques vs frozen elephant trunk: a systematic review and meta-analysis. Can J Cardiol 2018;34(3):262–273 PubMed

2. Preventza O, Liao JL, Olive JK, et al. Neurologic complications after the frozen elephant trunk procedure: a meta-analysis of more than 3000 patients. J Thorac Cardiovasc Surg 2020;160(1):20–33.e4 PubMed

3. Tazaki J, Inoue K, Higami H, et al. Thoracic endovascular aortic repair with branched inoue stent graft for arch aortic aneurysms. J Vasc Surg 2017;66(5):1340–1348.e5 PubMed

4. Spear R, Hertault A, Van Calster K, et al. Complex endovascular repair of postdissection arch and thoracoabdominal aneurysms. J Vasc Surg 2018;67(3):685–693 PubMed

5. Czerny M, Berger T, Kondov S, et al. Results of endovascular aortic arch repair using the Relay Branch system. Eur J Cardiothorac Surg 2021;60(3):662–668 PubMed

Publication History

Article published online:
10 June 2022

© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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