Early clinical outcomes of retrograde in situ branched stent grafting for complex aortic arch aneurysms

Objective: To evaluate the early outcomes of retrograde in situ branched stent grafting (RIBS) using the gutter balloon technique for complex aortic arch aneurysms (CAAs). Methods: The RIBS technique is an in situ needle fenestration procedure during thoracic endovascular aortic repair with the reconstruction of cervical branches. The double RIBS (D-RIBS) for the reconstruction of the left common carotid artery and the brachiocephalic artery using the gutter balloon technique was performed in 30 high-risk patients. We describe the early clinical results of the D-RIBS technique for CAAs. Primary end points were technical success and 30-day mortality. Secondary end points were postoperative complications, rates of endoleaks, overall survival, aneurysm-related death, and reinterventions. Results: The mean age was 77.1 +/- 6.6 years, and the mean maximum minor-axis aneurysmal diameter was 65.9 +/- 8.9 mm. Twenty-six patients underwent D-RIBS for elective arch aortic aneurysm, and four patients were for reintervention after zone 2 thoracic endovascular aortic repair failure. Stent graft puncture was performed 60 times from the common carotid arteries, and technical success was achieved in all cases (100%). Postoperative complications included cerebral infarction in two patients (6.7%) and recurrent nerve palsy in one patient (3.3%). The 30-day mortality was 0%. During the median follow-up period of 14 months (6-56 months), overall survival at 12 months was 92.3% without any aneurysm-related death. Type 1 b and type 2 endoleaks were observed in one each, and no reintervention was encountered. Conclusions: Early clinical outcomes of the D-RIBS for high-risk patients with CAAs are acceptable. The gutter balloon method enables safe and reliable fenestration. Further studies and dedicated devices are warranted.