Thoracic aortic aneurysm repair with an endovascular stent graft: the "first generation"

Stent-Graft Repair Versus Open Surgery for the Descending Aorta:A Case-Control Study

PURPOSE

To compare the clinical outcomes of open surgery versus endovascular repair in patients with pathologies of the descending thoracic aorta (DTA).

METHODS

This retrospective study included 44 patients (28 men; mean age 68+/-12 years, range 37-86) treated for DTA pathologies between 1995 and 2003. Twenty-two patients (15 men; mean age 68+/-13 years, range 37-86) undergoing stent-graft implantation were matched for sex, age, emergency operation, and comorbidities (coronary artery disease, chronic obstructive pulmonary disease) with a 22-patient contemporaneous surgical cohort (13 men; mean age 69+/-11 years, range 41-80).

RESULTS

Thirty-day mortality was 5% in the stent-graft group and 27% in the open surgery group (p=0.047). The incidences of postoperative stroke and paraplegia were both 5% in the stent-graft group and 9%, respectively, in the open surgery cohort. One patient required a second stent-graft due to an endoleak during the same hospital stay, and 2 reoperations were performed in the standard operation group (p = NS). Lengths of stay in the intensive care unit (ICU) and hospital were 4.3+/-5.4 and 11.9+/-15.0 days, respectively, in the stent-graft group and 10.0+/-7.4 and 21.5+/-17.4 days, respectively, in the open surgery group (p<0.006).

CONCLUSIONS

Stent-graft repair was associated with lower 30-day mortality and comparable complication rates in older patients with significant comorbidities and a high percentage of emergency operations compared to open surgery. Stent-graft implantation shortens ICU and hospital stays significantly. In the future, subgroups of patients who may experience the greatest benefit from stent-graft repair in the long term should be defined.

Mid-term Results after Endovascular Repair of the Atherosclerotic Descending Thoracic Aortic Aneurysm

INTRODUCTION

Thoracic aortic aneurysms (TAA) are the most common condition of the thoracic aorta requiring surgical treatment. Despite significant improvement in anesthetic, surgical techniques and postoperative care, the mortality and morbidity rate in TAA-repair remains high. The aim of this study was to assess the morbidity and mortality rate after endovascular stent-graft treatment of atherosclerotic (non-dissecting) TAAs.

METHODS

Thirty-one patients, ASA-classification III-IV, with symptomatic or expanding atherosclerotic TAAs underwent endovascular stent-graft repair between May 1997 and August 2003. Procedures were performed on an emergency basis in 13 patients and elective in 18 patients. Patients were assessed postoperatively by routine CT-scan within 48 h. Further follow up investigations were performed after 3, 6, 12 months and annually thereafter.

RESULTS

Stent-graft placement was successful in all but one patient in whom the stent-graft procedure had to be postponed due severe hemodynamic instability. Perioperative mortality rate was 19% including three haemorrhages, two cardiac events and one respiratory failure (6/31). Technical success rate was 55% (17/31). Completion CT scans performed in 30 patients within 2 days of stent-graft procedure showed type I leaks in seven patients (23%), type II leaks in four patients (13%) and type III leaks in two patients (6%). Further complications included one stroke, one paralysis, one spinalis anterior syndrome and five relevant access related complications. New onset endoleaks, all type I, were observed in seven patients (23%) occurring after 3, 4, 7, 8, 17, 25 and 26 months. Mean follow-up was 15 months (range 2-69 months).

CONCLUSION

Thoracic aortic atherosclerotic aneurysm stent-grafting is feasible but not without significant morbidity and mortality.

Upper and lower spinal cord blood supply: the continuity of the anterior spinal artery and the relevance of the lumbar arteries

OBJECTIVE

Thoracic and thoracoabdominal aortic repair are still complicated by spinal cord ischemia and paraplegia. The aim of the present article is to present the results of an anatomical study conducted by means of both postmortem injection of the vertebral artery and perfusion of the abdominal aorta.

METHODS

The spinal cord blood supply was investigated in 51 Caucasian cadavers: in 40 cases a methylene blue solution was hand-injected into the vertebral artery, whereas in the remaining 11 cases the abdominal aorta was perfused with a methylene blue solution by means of a roller pump. The level and side of the arteria radicularis magna and the continuity of the anterior spinal artery were recorded.

RESULTS

The anterior spinal artery was a continuous vessel without interruptions along the spinal cord in all 51 cases. The arteria radicularis magna level was variable, ranging from T9 to L5. The arteria radicularis magna arose from a lumbar artery in 36 cases (70.5%) and it was left-sided in 32 cases (62.7%).

CONCLUSIONS

The anterior spinal artery constitutes an uninterrupted pathway between the vertebral arteries, the arteria radicularis magna, and the posterior intercostal and lumbar arteries. Moreover, the arteria radicularis magna arises from a lumbar artery in most of cases. Therefore, the sacrifice of the intercostal arteries during a thoracic aorta repair could be justified, at least from an anatomical standpoint. However, if an extended thoracoabdominal aortic repair is planned, it may be prudent to preserve the blood flow from the lumbar arteries.

Thoracovisceral segment aneurysm repair after previous infrarenal abdominal aortic aneurysm surgery

OBJECTIVE

Repair of thoracovisceral aortic aneurysms (TVAA) after previous open repair of an infrarenal abdominal aortic aneurysm (AAA) poses significant challenges. We sought to better characterize such recurrent aneurysms and to evaluate their operative outcome.

METHODS

We reviewed the records and radiographs of 49 patients who underwent repair of TVAAs between 1988 and 2002 after previous repair of an AAA. Visceral artery reconstructions were completed with combinations of beveled anastomoses, inclusion patches, and side arm grafts. In 14 patients visceral endarterectomy was required to treat associated occlusive disease. Sixteen patients had cerebrospinal fluid drainage, and 10 patients had distal perfusion during cross-clamping.

RESULTS

Patient mean age was 72 years, and 80% were men. Fifty-one percent of patients had symptomatic disease, and average TVAA diameter was 6.2 cm. Mean time between AAA and TVAA repair was 77 months. Twenty-six percent of aneurysms were restricted to the lower visceral aortic segment, 35% extended to the diaphragm, another 35% extended to the distal or middle thoracic aorta, and 4% involved the entire remaining visceral and thoracic aorta. The 30-day operative mortality rate was 4.1% in patients with nonruptured aneurysms and 50% in patients with ruptured aneurysms, for an overall mortality rate of 8.2%. Fifteen patients (30.6%) had major morbidity, including paresis in two patients and dialysis-dependent renal failure in five patients. At late follow-up, three patients required further aortic operations to treat additional aneurysms, and four patients had fatal aortic ruptures. Two-year and 5-year cumulative survival rates were 61% (+/-7.5%) and 37% (+/-7.8%), respectively. At univariate analysis, operative blood loss was the sole significant predictor of major morbidity (P <.023), and rupture (P <.030, P <.0001) and aneurysm extent (P <.0007, P <.0001) correlated with both operative death and long-term survival. Only aneurysm extent (P <.010, relative risk 37.3) remained a significant predictor of long-term survival at multivariate analysis.

CONCLUSION

Elective repair of TVAAs after previous AAA repair can be performed with an acceptable level of operative mortality, though with considerable operative morbidity. Limited long-term survival mandates careful patient selection, and the high mortality associated with ruptured TVAA underscores the need for post-AAA surveillance.

Endovascular treatment of an iatrogenic thoracic aortic injury after spinal instrumentation: case report

Iatrogenic aortic injuries after spinal surgery have been described, but are rare. We describe a case of a 77-year-old woman who underwent surgical correction of a debilitating spinal deformity at an outside institution. Postoperative thoracic spine radiographs and computed tomography scans revealed a misplaced pedicle screw at T5, which was impinging on the descending thoracic aortic wall. The patient was brought to the operating room, where a thoracic stent graft was deployed under fluoroscopic guidance as the malpositioned screw was manually retracted. The patient had an uneventful postoperative course, and was discharged within 24 hours. This case represents a rare but potentially morbid vascular complication of spinal instrumentation surgery that was successfully treated without the need for thoracotomy.

Endovascular Stent-Graft Treatment for Thoracic Aortic Aneurysms: Short- to Midterm Results

PURPOSE

To evaluate short- and midterm results of the endovascular repair of thoracic aortic aneurysm (TAA) with the use of custom-made stent-grafts.

MATERIALS AND METHODS

Between May 1997 and May 2003, 40 patients with TAA (26 degenerative/atherosclerotic, seven dissection-related, three traumatic, two mycotic, one anastomotic, and one penetrating ulcer) underwent endovascular stent-graft placement. The mean age of the patients (29 male and 11 female) was 67.2 years. Twenty-four of the 40 patients (60%) were judged not to be good candidates for conventional open repair. Stent-graft placement was performed in the angiography suite with general anesthesia and transient cardiac arrest or induced hypotension. Custom-made stent-grafts were used in all patients. Four of the 40 patients (10%) underwent preliminary extra-anatomic bypass surgery to provide a sufficiently long landing zone. The mean follow-up period was 16.7 months (range, 1-65 months).

RESULTS

The technical success rate was 97.5% and the early mortality rate was 2.5% (one out of 40 patients). There were four late deaths (two procedure-related). Survival rates were 84.2%+/-6.6% at 1 year and 84.2%+/-6.6% at 2 years. Survival rates were not significantly different between surgical candidates and non-surgical candidates (P =.423). Intraprocedural complications included access artery complications in nine patients and bleeding in three patients. Postoperative complications included early aneurysmal expansion in one patient, pneumonia in one patient, wound infection in one patient, stroke in three patients, paraplegia in one patient, respiratory insufficiency in two patients, aortoesophageal fistula in one patient, and late aneurysmal expansion in three patients. The rates of freedom from first additional intervention were 91.0%+/-6.7% at 1 year and 74.5%+/-11.9% at 2 years. The rates of freedom from second additional intervention was 100% at 2 years. The rates of freedom from treatment failure were 84.7%+/-7.6% at 1 year and 69.3%+/-11.6% at 2 years.

CONCLUSION

Endovascular repair of TAA with a custom-made stent-graft is a safe and effective alternative to open repair and continues to play an important role. However, careful follow-up is mandatory to manage complications.

Transoesophageal Echocardiogram Identifying the Source of Endoleak After Combined Open/Endovascular Repair of a Type 3 Thoracoabdominal Aortic Aneurysm

Open repair of thoracic aortic aneurysms is associated with significant morbidity and mortality. The introduction of endovascular repair has reduced both the morbidity and mortality. However, endovascular stent repair can be complicated by endoleaks. We report here the successful treatment of a type 2 endoleak following endovascular repair of a thoracoabdominal aortic aneurysm, using transesophageal echocardiography to assist in the localization of the thoracic endoleak.

Predictors of Cardiac Morbidity And Mortality in Patients Undergoing Endovascular Repair of the Thoracic Aorta

The aim of this study was to determine predictors of cardiac morbidity and mortality in patients undergoing endovascular repair of the thoracic aorta. This was a retrospective cohort study that took place in a University-affiliated county hospital. Preoperative and intraoperative variables were collected from a consecutive series of patients who underwent repair of the thoracic aorta at our institution between 1998 and 2003. Perioperative complications and mortality were identified for each patient. Fifty-nine patients underwent endovascular repair of the thoracic aorta. The endografts were successfully deployed in 58 (98%) patients. Nine (15%) died perioperatively, 4 (7%) from cardiac causes. There were 12 (20%) perioperative cardiac events. A history of myocardial infarction (MI) was the only preoperative risk factor that was predictive of a cardiac event (p = 0.001). The cardiac event rate was 29% for patients who did not receive perioperative beta-blockade vs. 8% in patients who did (p = 0.04). Intraoperative predictors of MI were estimated blood loss (2480 cc vs. 680 cc, p = 0.01), intravenous (i.v.) fluids (2955 cc vs. 2010 cc, p =0.02), and length of operation (269 min vs. 178 min, p = 0.02). From these results we concluded that mortality associated with endovascular repair of thoracic aorta remains significant. Patients with a history of MI had a higher perioperative cardiac event rate. Intraoperative predictors of perioperative cardiac events included blood loss, i.v. fluid requirement, and length of operation. Perioperative beta-blockade is important in endovascular thoracic surgery as a protection against postoperative cardiac events.

Surgical repair of a distal arch aneurysm with a stent-graft

This study evaluates the effectiveness and potential complications of stent-grafting for the treatment of distal arch aneurysms using profound hypothermia and circulatory arrest with retrograde cerebral perfusion. Between December 1998 and December 2001, 9 consecutive patients with a distal arch aneurysm (6 men and 3 women, mean age 71 years) underwent surgical repair using a stent-graft. Profound hypothermic circulatory arrest and retrograde cerebral perfusion were performed in all patients. Endovascular leakage was screened postoperatively using three-dimensional computerized tomography. The mean follow-up period was 27.4 months. Thirty day mortality was 0%. One patient died 3 months after stent-grafting due to proximal leakage into her aneurysm. The mean postoperative extubation period was 2.1 days. No patients suffered cerebral infarction or paraplegia. Although preliminary outcomes using this technique were good, endovascular leakage is a concern. We suggest that, if major proximal leakage is recognized postoperatively, re-intervention should be performed as soon as possible. Endovascular stent-grafting appears to be a good alternative treatment for distal arch aneurysms, although longer follow-up is necessary to more comprehensively evaluate this procedure.

Endovascular treatment of the thoracic aorta

Open surgical repair has been considered the mainstay of therapy for thoracic aortic aneurysms, both elective and emergency procedures alike. Recent advances in endovascular technology have made endovascular stentgraft placement a therapeutic modality that is minimally invasive and potentially a safer treatment for aneurysmal disease of the descending thoracic aorta. Moreover, this technology may be appropriate for other diseases of the thoracic aorta, including traumatic disruptions and dissections. There appears to be an increase in the diagnosis, and therefore incidence, of these various thoracic aortic pathologies, owing both to improvement in imaging capabilities and longer life expectancies. In distinction to endovascular repair of infrarenal aortic aneurysms, the evolution of thoracic stentgrafts has progressed more slowly as there has yet to exist a clinically proven device after 10 years of clinical trials. However, the enthusiasm for this technology persists, for it may indeed hold the potential for the greatest patient benefit as conventional open surgical repair continues to offer serious morbidity and mortality rates. This paper reviews the current status of thoracic aortic stentgrafts, including recent clinical studies, device failures and refinements, and future directions.

The Importance of Intraoperative Transesophageal Echocardiography in Endovascular Repair of Thoracic Aortic Aneurysms

Endovascular repair of the aorta (EVAR) is a promising alternative to open repair. Transesophageal echocardiography (TEE) is a sensitive imaging modality for aortic disease. We reviewed our experience with TEE in thoracic EVAR. Seven patients underwent thoracic EVAR under general anesthesia. Intraoperative angiography and TEE were used to identify the extent of the aneurysm and guide placement of the stent. Doppler color flow was used to supplement angiography to detect flow within the aneurysmal sac after stent placement. The endograft was successfully deployed in six patients. Endoleak was identified by TEE in three patients and confirmed by angiography in two of them. EVAR was abandoned in one patient on the basis of TEE findings of extensive aortic dissection. We found TEE to be a valuable intraoperative tool for 1) identifying aortic pathology, 2) confirming that the guidewire is in the true lumen, 3) aiding stent graft positioning, and 4) supplementing angiography for detecting endoleaks. TEE can supplement information obtained by angiography to enhance the accuracy of EVAR and potentially improve outcomes. The anesthesiologist is ideally positioned to provide the endovascular team with vital information regarding stent positioning, endoleaks, and cardiac performance with a single imaging modality.

IMPLICATIONS

Endovascular repair is an emerging alternative to open surgery for aortic aneurysms. We found transesophageal echocardiography to be a valuable imaging tool for guiding placement of the endograft, detecting leaks around the endograft, and supplementing information derived from angiography during endograft deployment.

Endovascular Treatment of the Descending Thoracic Aorta

OBJECTIVES

to report our initial experience with endovascular stent graft repair of a variety of thoracic aortic pathology.

DESIGN

retrospective single center study.

MATERIAL AND METHODS

between February 2000 and January 2002, endovascular stent graft repair was performed in 26 patients: traumatic aortic isthmus rupture (n=3), Type B dissection (n=11) and descending thoracic aortic aneurysm (n=12). The deployed stent graft systems were AneuRx-Medtronic (n=1), Talent-Medtronic (n=13) and Excluder-Gore (n=12).

RESULTS

successful deployment of the stent grafts in the intended position was achieved in all patients. No hospital mortality neither paraplegia were observed. Late, non procedure related, death occurred in four patients (15%). Access artery complications with rupture of the iliac artery occurred in two patients and were managed by iliac-femoral bypass. The left subclavian artery was overstented in seven patients (27%). Only the first patient received a carotido-subclavian bypass. The mean maximal aortic diameter decreased significantly in patients treated for descending thoracic aneurysm. Only one patient had an endoleak type II after 6 months without enlargement of the aneurysm. Complete thrombosis of the thoracic false lumen occurred in all but one patient treated for Type B dissection 6 months postoperatively. Two patients underwent a consecutive stent graft placement, due to a large re-entry tear distal to the first stent graft.

CONCLUSIONS

endovascular stent graft repair for Type B dissection, descending thoracic aneurysm and aortic isthmus rupture is a promising less-invasive alternative to surgical repair. Further studies are mandatory to determine its long-term efficacy.

Descending thoracic aortic diseases: stent-graft repair

PURPOSE

To evaluate endovascular treatment of descending thoracic aorta with commercially available self-expanding stent-grafts.

MATERIALS AND METHODS

Seventy patients with aortic dissection, intramural hemorrhage, degenerative and posttraumatic aneurysm, penetrating atherosclerotic ulcer, and pseudoaneurysm underwent endovascular treatment. Eleven patients had impending rupture and were treated on an emergency basis. Stent-grafts were customized or selected on the basis of spiral computed tomographic (CT) or magnetic resonance (MR) imaging measurements. Preprocedure diagnostic angiography was performed in patients with aortic dissection and in other selected patients. All procedures were performed in an operating room and monitored with digital subtraction angiography (DSA) and transesophageal echocardiography (TEE). Follow-up was at 1, 3, 6, and 12 months after treatment and yearly thereafter.

RESULTS

Stent positioning was technically successful in 68 cases. At DSA and TEE, complete aneurysm or false-lumen exclusion was achieved in 66 (97%) cases. No intraoperative mortality or complications occurred. In-hospital complications included transient monoparesis (one patient) and extension of dissection into ascending aorta (one patient) that was repaired surgically. Early endoleak was observed in five (7%) patients: In three (type 2), endoleak resolved spontaneously; in one (type 1), it was persistent; and in one (type 1), treatment was converted to surgery. At long term, one (1%) patient died of aortic rupture; another, of respiratory insufficiency. Five (7%) late endoleak (type 1, one caused by migration of the stent) cases were observed. In three (4%), endovascular treatment was successful; in two (3%), surgery was performed. In one patient with persistent postimplantation syndrome, treatment was converted to surgery after successful aneurysm sealing. Procedure failure (ie, aortic disease-related mortality or conversion to surgery) occurred in six (9%) patients.

CONCLUSION

Endovascular stent-graft repair is less invasive in patients with chronic and acute descending thoracic aortic aneurysm and dissection.

Treatment of descending thoracic aneurysms by endovascular stent grafting

PURPOSE

Endovascular stent-graft treatment for true aneurysms of the descending thoracic aorta is a valid and effective alternative to conventional surgery. A review of our experience with 21 consecutive patients is reported and technical considerations are discussed.

METHODS

Twenty-one patients (mean age 73 years) with true aneurysms of the descending thoracic aorta (n = 14) or contained rupture (n = 7) were treated between October 1999 and July 2001. Seven patients (33%) underwent emergency endovascular procedure. Postoperatively, the patients were followed with CT scans at 1, 3, 6, and 12 months. Follow-up, which averaged 17 months, was 100% complete. THIRTY-DAY RESULTS: No conversions to open repair were necessary. Two patients died (10%), one of acute intestinal ischemia and the other because of multiorgan failure. Four patients showed endoleaks immediately after stenting. Two patients required new endovascular stentgrafts, while the remaining two were treated conservatively. Besides endoleaks, eight major complications occurred in six patients (two stroke, two paraplegia, two respiratory insufficiency, and one renal failure). MID-TERM RESULTS: Three more patients died during the follow-up period. One patient died of heart failure after a complicated postoperative course, 91 days after stenting. The second patient died because of aortic rupture, 139 days after stenting. The third patient died of heart failure, 15 months after the endovascular procedure. The remaining 16 patients are alive and have been regularly controlled by CT scans. No late migration or endoleaks have been detected. In all the survivors, the size of the aneurysm was unchanged or diminished.

CONCLUSIONS

Treatment of descending thoracic aortic aneurysms by endovascular stentgraft devices has good early and mid-term results. More accurate selection of patients may further reduce mortality and morbidity.

Endovascular treatment of thoracic aortic aneurysms

Endovascular repair of thoracic aortic aneurysms is a promising modality that may someday replace open surgical repair. While stent grafts have been used with moderate success in small to moderate-sized retrospective series, there have been no completed multicenter clinical trials directed at gaining approval from the U.S. Food and Drug Administration. The available data suggest that morbidity and mortality of the procedure may be lowered with endovascular techniques. Paraplegia occurs, but despite the inability to maintain perfusion of intercostal vessels, the rate is at least as low as that associated with open repair. Similar to the minimally invasive repair of infrarenal aneurysms, the trade-off between the open and endovascular approach rests in the necessity to follow patients closely with after endovascular repair. The long-term durability of available devices is unproved, and serial imaging studies must be followed in order to detect device failure prior to the development of devastating clinical sequelae.

Endografting of the thoracic aorta:

BACKGROUND

Thoracic aortic dissections, ruptures, fistulae, and aneurysms pose a unique surgical challenge. Traditional repair of thoracic aortic aneurysms involves thoracotomy with graft interposition. Despite advances in perioperative care and both total and partial cardiopulmonary bypass, conventional surgery carries a significant morbidity and mortality. Principal complications include bleeding, paraplegia, stroke, cardiac events, pulmonary insufficiency, and renal failure. Recent enthusiasm for innovative endovascular therapies to treat aortic disease has spurred many centers to investigate endoluminal grafting of the thoracic aorta. Early reports on endovascular repair using custom made "first generation devices" demonstrated the technique to be feasible with a mortality and morbidity comparable to open repair.

METHODS AND RESULTS

From February 2000 to February 2001, endovascular stent graft repair of the thoracic aorta was performed in 46 patients (mean age 70; 29 male and 17 female) using the Gore Excluder. Twenty-three patients (50%) had atherosclerotic aneurysms, fourteen patients (30%) had dissections, three patients (7%) had aortobronochial fistulas, three patients (7%) had pseudoaneurysms, two patients (4%) had traumatic ruptures, and one patient (2%) had a ruptured aortic ulcer. Patient characteristics, procedural variables, outcomes, and complications were recorded. All patients were followed with chest CT scans at 1, 3, 6, and 12 months. Mean follow up was 9 months ranging from 1 to 15 months. All procedures were technically successful. There were no conversions. Average duration of the procedure was 120 minutes. Average length of stay was 6 days, but most patients left the hospital within 4 days (64%) after endoluminal grafting. Overall morbidity was 23%. Two patients (4%) had endoleaks that required a second procedure for successful repair. Two patients (4%) died in the immediate postoperative period. There were no cases of paraplegia. At follow-up, one patient had an endoleak found the day after the procedure and another patient had an endoleak 6 moths post procedure. Both were treated successfully with additional stent grafts. There were no cases of migration. One patient died of a myocardial infarction 6 months after graft placement. The Gore Excluder device was voluntarily recalled on February 26, 2001. Therefore, from June 2000 to January 2001, 37 patients underwent endovascular stent graft repair of the thoracic aorta for various disease entities using our customized thoracic graft (Endomed). Twenty-seven patients (73%) had aneurysms, six (16%) had dissections, two (5%) had pseudoaneurysms, one (2%) had a traumatic transection, and one patient (2%) had an embolizing ulcer. Patients were followed with CT scans at 1, 3, 6, and 12 months. All procedures were technically successful. There were no conversions. The average age was 68 years.(17-87). And the male and female ratio was 24/13. One patient died in the operating room from iliac rupture and one died from embolization/stroke in the immediate postoperative period. Two patients died within 30 days from comorbid factors. The total 30-day mortality was 10%. Two patients had endoleaks. One returned to the operating room and needed an additional cuff. The other had a small leak in a proximal dissection that is being followed. There were no cases of paraplegia.

CONCLUSION

Thoracic endoluminal grafting is a safe and feasible alternative to open graft repair and can be performed successfully with good results. Early data suggest that an endoluminal approach to these disease entities maybe favorable to open resection and graft replacement. Technical details of Endoluminal stent grafting of the thoracic aorta for different disease entities have been discussed at length.

Aortoesophageal fistula: value of in situ aortic allograft replacement

PURPOSE

The purpose of this report is to describe our experience in management of aortoesophageal fistulas (AEF) with special emphasis on the value of in situ aortic allograft replacement.

PATIENTS

Nine patients presenting with AEF were observed between May 1988 and April 2002. There were 4 men and 5 women with a mean age of 54.3 years (range, 32-77 years). Six patients presented secondary AEF after aortic repair. Two patients presented primary AEF after rupture of an atherosclerotic aneurysm into the esophagus. In the remaining patient, AEF was caused by swallowing a fishbone. In 6 cases involving true AEF with a direct communication between the aorta and esophagus, massive exsanguinating hematemesis occurred. It was usually preceded by minor sentinel bleeding. Two patients presented esophagoparaprosthetic fistula (EPPF). One patient presented primary AEF that was contained by a large thrombus in the communication. The clinical picture in these 3 patients involved severe sepsis without hemorrhage.

RESULTS

Two patients died as a result of massive hemorrhage before assessment and surgical treatment could be undertaken. One 77-year-old woman presenting EPPF refused to undergo surgery and died because of infection. The remaining 6 patients underwent surgical treatment with various outcomes. One man died during thoracotomy caused by exsanguinating hemorrhage. One woman presenting EPPF was treated by exclusion followed by ascending aorta to abdominal aorta bypass grafting, removal of the prosthesis, esophageal exclusion, and directed esophageal fistula. She died of infection. The other 4 patients were treated by in situ aortic allograft replacement. The damaged esophagus was repaired by using the Thal technique in 1 patient. In the remaining 3 cases subtotal esophagectomy was performed in association with cervical esophagostomy, ligation of the abdominal esophagus, gastrostomy, and jejunostomy. One patient died of sepsis during the first 24 hours after the operation. The other 3 patients underwent secondary esophagoplasty and survived with no further sign of infection. Mean duration of follow-up in the survivor group was 53 months (range, 15-95 months). Overall 6 patients, including 3 that did not undergo surgical treatment, died and 3 patients survived.

CONCLUSION

Our experience confirms that AEF is a rare but catastrophic disorder. In situ allograft replacement usually in association with subtotal esophagectomy appears to be an excellent salvage modality whenever emergency surgery is feasible.

Endovascular exclusion of thoracic aortic aneurysms: mid-term results of elective treatment and in contained rupture

PURPOSE

The purpose is to present results of endovascular exclusion (stent-graft treatment) of aneurysms of the descending thoracic aorta both in elective cases and in emergencies.

METHODS

Indications for stent-graft treatment were dependent on multislice angio-CT evaluation revealing a proximal neck of at least 10 mm between the left common carotid artery and the onset of aneurysm. All stent grafts were inserted in the operating room; 43 transfemoral, 2 transiliac. The stent grafts used were Corvita, Stenford, Vanguard, AneuRx, Talent, and Excluder. Deployment was achieved under fluoroscopic control, endoleaks were checked for with D S A on the operating table and postoperatively by angio-CT. Long-term follow-up consisted of evaluation with angio-CT after 6 and 12 months, and from there on once a year and with plain chest X-rays. Follow-up was achieved in all patients.

RESULTS

Mean follow-up is 21 months (1-66); 30-day mortality is 3/45, no permanent neurologic deficit. Thirty patients were treated electively, 15 with contained rupture. Left subclavian artery overstenting proved to be necessary in 12 patients for proper proximal sealing of the aneurysm, type I endoleaks were observed in 10 patients, one early conversion, 7 proximal extension cuffs, one sealed spontaneously, one still at risk. Among patients where LSA had been overstented only one wanted a transposition, all others did well without left-hand ischemia or subclavian steal syndrome.

CONCLUSION

Endovascular treatment is less invasive and has reasonable mortality and morbidity but is limited to well-defined morphologies. Mid-term results are promising but it has to be observed whether these will translate into long-term durability.

Midterm outcomes of thoracic aortic stent-grafts: complications and imaging techniques

PURPOSE

To evaluate the midterm outcomes of thoracic aortic stent-grafting and the performance of computed tomographic angiography (CTA), radiography, and magnetic resonance angiography (MRA) in endograft surveillance.

METHODS

Forty-seven patients with traumatic thoracic aortic ruptures (n=16), aneurysms (n=14), false aneurysms (n=3), penetrating ulcers (n=3), and dissections (n=11) treated with stent-grafts were monitored in follow-up using chest radiography and CTA in all patients and MRA in 23 patients. Two perpendicular maximal aortic diameters, the sum of these diameters, and the elliptical cross-sectional area were determined and compared to baseline for the entire group and in subgroup analyses according to lesion type. CTA, MRA, and radiography were compared for their ability to detect endoleak, monitor stent-graft configuration, and measure aortic diameters.

RESULTS

The mortality rate was 8.5%. Severe complications were observed in 14.8% (6% neurological complications); 12 (25.5%) patients had primary endoleaks. Over a mean 11-month follow-up (range 0.25-46 months), the aortic diameters decreased for all patients without endoleak (p<0.001). In the diameter/area subgroup analyses, only the traumatic rupture cohort demonstrated significant decreases in all 4 measurements. CTA and MRA measurements correlated well, but chest radiography was superior to both for visualizing stent-graft shape. In terms of endoleak detection, MRA missed only 1 (12.5%) endoleak (type II) seen on CTA; there were no false positive results with MRA.

CONCLUSIONS

Morbidity and mortality observed after thoracic stent-grafting are acceptable. Radiography is better for monitoring stent-graft conformation, while CTA provides the best overall morphological information. The performance of MRA in endoleak detection is encouraging.

Acute retrograde aortic dissection during endovascular repair of a thoracic aortic aneurysm

Endovascular aneurysm exclusion represents a valuable alternative treatment for descending thoracic aortic aneurysms. Although the minimally invasive character of this procedure is obvious, major complications are possible. We report a 77-year-old male who developed acute retrograde dissection of the aortic arch and ascending aorta during endovascular stent-grafting of a descending aortic aneurysm. Emergent open surgical repair provided a successful outcome.

Endovascular treatment of thoracic aortic pathology: feasibility and mid-term results

OBJECTIVE

to report our experience with 21 consecutive patients treated with a thoracic stent-graft.

DESIGN

retrospective analysis.

MATERIALS AND METHODS

Between October 1998 and February 2002, 21 patients (12 male), mean age 55.6 years (range 19-86 years), were treated for aorticortic pathology localized to the descending aorta (18 patients), the aortic arch (2 patients) and the ascending aorta (1 patient) and comprising true aneurysms (8 patients), false aneurysms (6 patients), traumatic rupture (4 patients), mycotic aneurysms (2 patients), and ruptured aneurysm (1 patient). Plain chest X-rays and computed tomography was performed at 3, 6 and 12 months postoperatively and then annually.

RESULTS

the median (range) operation time was 85min (50-305min), hospital stay 6 days (3-63 days) and follow-up 24 months (5-44 months). Complications occurred in 5 patients and comprised intraoperative migration (1), type I endoleak (1), type II endoleak (1), ischemic myelopathy (1), pneumonia (2), suture granuloma (1) and common femoral artery dissection (1).

CONCLUSIONS

stent-grafting can be successfully employed to treat a wide range of thoracic aortic pathologies with a mortality, morbidity and resource utilization that is considerably less than that associated with conventional surgery. However, long term follow-up on safety and efficacy is needed.

Endoluminal repair of mycotic thoracic aneurysms

PURPOSE

To report a series of endoluminally repaired mycotic thoracic aneurysms.

CASE REPORTS

Four patients with presumed mycotic aneurysms of the thoracic aorta were treated with endovascular grafts owing to overly high risk for open repair. All aneurysms were successfully excluded at the initial intervention. In one case, which required endograft fenestrations for the superior mesenteric and renal arteries, the patient died 53 days after the procedure, following graft migration and occlusion of major branch vessels. The other 3 patients remain alive and well at a mean follow-up of 16 months with no signs of ongoing sepsis.

CONCLUSIONS

Endoluminal repair of thoracic mycotic aneurysms is technically feasible and, in association with long-term antibiotics, offers at least temporary protection against imminent rupture.

Type A aortic dissection developing during endovascular repair of an acute type B dissection

PURPOSE

To describe an extension of type B dissection into type A during endoluminal treatment of acute type B dissection.

CASE REPORT

A 57-year-old man with acute type B dissection underwent endovascular repair using 2 Excluder stent-grafts. Before releasing the second stent-graft, the patient complained of mild central chest pain, headache, and visual flashes, but no hemodynamic changes were noticed. An angiogram, performed soon afterwards, showed a retrograde extension of the dissection through the aortic arch involving both the left carotid artery and the ascending aorta. The procedure was completed, and the patient was transported to the operating room where the proximal ascending aorta was replaced. Spiral computed tomographic angiography performed 2 weeks after the procedure showed complete exclusion of the primary entry tear. At 6-month follow-up, the patient was asymptomatic; the left carotid artery dissection had disappeared.

CONCLUSIONS

Endovascular repair of acute type B dissection is technically feasible, but longer experience will help prevent technical complications.

Elective endovascular stent-graft repair of atherosclerotic thoracic aortic aneurysms: clinical results and midterm follow-up

OBJECTIVE

The purpose of this study was to evaluate the clinical and midterm results after endovascular treatment of atherosclerotic thoracic aortic aneurysms.

MATERIALS AND METHODS

Twenty-eight consecutive patients who were 53-82 years old (mean age, 71.6 years) were treated with a commercially available endoprosthesis. Subclavian transposition or bypass surgery was performed before the procedure in eight patients. Size dynamics of the aneurysms were analyzed on the basis of diameter and thrombus volume measurements obtained on three-dimensional CT reconstructions before hospital discharge (n = 22) and at the 1-year (n = 22), 2-year (n = 12), and 3-year (n = 5) follow-ups.

RESULTS

The technical success rate was 100%. There was no 30-day mortality. None of the patients had symptoms due to spinal cord ischemia. The survival rate at 1, 2, and 3 years was 96.1%, 90.9%, and 80.2%, respectively. During the perioperative period, patients presented with leukocytosis (37%), fever (36%), elevated C-reactive protein value (92%), pleural effusion (50%), and periaortic atelectasis (41%). Three early type I endoleaks sealed spontaneously. Three early type II endoleaks persisted over time, and one late type II endoleak was detected. In patients with type II endoleaks, thrombus volume of the aneurysms was constant (n = 2) or increased (n = 2). In patients without endoleaks, mean thrombus volume decreased (-53.2 +/- 56.8 mL, -40%) significantly (p = 0.001) during the first year. There was no significant interval decrease between the 1- and 2-year follow-ups (mean, -2.4 mL, p = 0.92) and between the 2- and 3-year follow-ups (mean, -0.4 mL, p = 0.68).

CONCLUSION

Endovascular treatment of atherosclerotic thoracic aortic aneurysms may result in a substantial reduction of the aneurysm sac in patients without endoleaks.

Clinical application of a curved nitinol stent-graft for thoracic aortic aneurysms

PURPOSE

To evaluate the clinical efficacy of a curved nitinol stent-graft for repair of thoracic aortic aneurysms.

METHODS

The Matsui-Kitamura stent-graft (MKSG), composed of a self-expanding nitinol stent and polyester fabric, was shaped to match the aortic curvature of 11 patients (6 men; mean age 72.6 years, range 33-90) with 6 true and 5 false aneurysms of the distal arch or proximal descending aorta. The delivery system was an 18 or 20-F J-shaped sheath combined with a preloader-type introducer. The original mean proximal neck length was 16.4 mm, but 4 patients received an axilloaxillary bypass to lengthen the neck. Although the mean corrected proximal neck length was 21.9 mm (overall), 5 cases still had proximal necks <15 mm long.

RESULTS

All curved MKSGs were successfully deployed in the correct position and fitted to the curvature of the aortic arch, achieving complete aneurysm exclusion in 8 (73%) cases. The other 3 repairs displayed early endoleaks; 1 received an additional MKSG, but the other 2 are being observed. Thirty-day mortality was 0%. One patient developed transient renal failure requiring hemodialysis; no neurological complications were observed.

CONCLUSIONS

Endovascular repair of thoracic aortic aneurysms using curved MKSGs appears to be feasible and clinically effective. A tighter fit of the device to the curvature of the aortic arch may exclude distal arch aneurysms despite a short proximal neck.

Endovascular treatment in diseases of the descending thoracic aorta: 6-year results of a single center

OBJECTIVE

The purpose of this study was to evaluate endovascular treatment in diseases of the descending thoracic aorta.

MATERIAL AND METHODS

This study was designed as a single center's (university hospital) experience. Over a 6-year period (1995 to 2001), thoracic endografts were placed in 74 patients with a diseased descending thoracic aorta who were at high risk for conventional open surgical repair: 34 had atherosclerotic aneurysms, six had posttraumatic aneurysms, 14 had type B dissection with aneurysmal dilatation of the false lumen, 12 had isthmic transections from blunt trauma, five had thoracoabdominal aneurysms (treated with a combined procedure), two had aortic coarctation, and one had an aortobronchial fistula. Twenty-six procedures (35.1%) were conducted as emergencies, and 48 (64.9%) were elective. The feasibility of endovascular treatment and sizing of stent grafts were determined with preoperative spiral computed tomography and intraoperative angiography.

RESULTS

Endovascular operations were completed successfully in all 74 patients; postprocedural conversion to open repair was necessary in three cases. The overall 30-day mortality rate was 9.5% (seven deaths). Temporary neurologic deficits developed in two patients; not one patient had permanent paraplegia. The primary endoleak rate was 20.3% (15 patients). The mean follow-up period was 22 months (range, 3 to 72 months). Five deaths occurred in the follow-up period, and three patients needed secondary conversion to open repair 2, 3, and 14 months after initial endografting.

CONCLUSION

Endoluminal treatment in diseases of the thoracic descending aorta is feasible and may offer results as good as the open method.

Endograft therapy for diseases of the descending thoracic aorta: results in 43 high-risk patients

PURPOSE

To report an initial experience with endovascular stent-graft implantation for diseases of the descending thoracic aorta in high-risk patients.

METHODS

Forty-three patients (28 men; mean age 67 years, range 17-82) with 16 descending thoracic aortic dissections, 14 aneurysms, 7 contained ruptures, 3 mycotic aneurysms, 2 posttraumatic pseudoaneurysms, and an aneurysm of an anomalous right subclavian artery were treated between June 1999 and July 2001. Twenty-three (53%) patients were treated emergently.

RESULTS

There were no conversions to open repair, but 3 (7%) patients died during the first 30 days (pneumonia, multiorgan failure, and acute bowel ischemia). Thirteen (30%) patients suffered 18 major complications (8 strokes, paraplegia in 3, respiratory insufficiency in 6, and 1 renal failure). Of 7 (16%) endoleaks detected in the early postoperative period, 3 required additional stents, while the other 4 were treated conservatively. Follow-up, which averaged 19 +/- 6 months (median: 13; range 0-34), was 100% complete. Five (12%) patients died: 3 of aortic rupture at 34, 47, and 139 days, respectively, and 2 from heart failure at 3 and 15 months, respectively. No late migration or endoleaks have been detected in the remaining 35 patients; however, 1 (2%) patient showed progressive aortic dissection proximal to the stent-graft. In all other cases, the size of the aneurysm or the false lumen was unchanged or diminished.

CONCLUSIONS

Treatment of descending thoracic aortic diseases with an endovascular approach has acceptable early mortality and morbidity in high-risk patients. In selected cases, stent-grafts may afford the best therapy.

Complications after endovascular repair of type B aortic dissection

PURPOSE

To outline the complications encountered after endoluminal treatment in patients with type B aortic dissection.

METHODS

Between 1999 and 2001, 14 patients (12 men; mean age 60.3 years, range 39-79) with isolated type B aortic dissection (13 chronic, 1 acute) underwent aortic stent-grafting. Three patients with chronic dissection presented an acute clinical picture and were managed emergently. The left subclavian artery was intentionally covered by the prosthesis in 9 patients. Follow-up studies were performed at 6-month intervals.

RESULTS

Stent-graft implantation was technically successful in all patients, but incomplete sealing (endoleak) of the entry site required additional proximal stent-graft implantation in 4. The left subclavian artery remained patent in 5 patients. Secondary conversion was required in 3 patients: 2 for acute type A dissection resulting from injury to the aortic arch by Talent endografts and a sustained hemorrhage (left hemothorax). In another patient, a secondary intramural hematoma subsided spontaneously. Anterior spinal artery syndrome in 1 patient persisted at 1 month. No bypass was necessary for the 9 patients with the covered left subclavian arteries. Mean follow-up was 14 months (range 1-23).

CONCLUSIONS

Stent-grafting is feasible in patients with type B aortic dissection, although it is associated with a considerable rate of complications. Frank reporting of these sequelae for a variety of stent-grafts is of paramount importance to clarifying the limitations of the method.

Thoracic aortic stents: a combined solution for complex cases

OBJECTIVES

The combination of endovascular and standard surgical techniques may facilitate the management of complex aortic disease although the long-term durability of this approach needs to be confirmed.

DESIGN

A retrospective review of our experience in the treatment of patients with complex aortic pathology using a combined endovascular and surgical approach.

MATERIALS AND METHODS

Between 1998 and 2001, 27 patients with thoracic aortic aneurysm underwent stent-graft implantation. Eight required combined endovascular and surgical procedure because of complex pathology. In 3 cases, combined repair was carried out for a concomitant abdominal aortic aneurysm or aorto-iliac-femoral occlusive disease. In the other 5 cases, vessel relocation was performed to obtain safe landing zones: left subclavian artery to left carotid artery translocation in 3 patients, celiac trunk to superior mesenteric artery translocation in one and aorto-celiac-mesenteric bypass grafting in one.

RESULTS

One of the 8 patients died on 12th post-operative day of intestinal bleeding and bowel infarction. No neurological sequelae were reported. The other patients are currently well at 11 months mean follow-up time.

CONCLUSIONS

Simultaneous surgical and endovascular procedure is a feasible and may be a valuable adjunct to the treatment of complex aortic and peripheral vessel anatomy.

Endovascular repair of traumatic descending aortic transection

PURPOSE

To present the results of endovascular repair of acute traumatic descending aortic transection.

METHODS

Among 66 thoracic stent-graft repairs performed between 1995 and 2001, 11 patients (9 men; mean age 34 years, range 12-73) underwent emergent endovascular repair of acute traumatic descending aortic transection following traffic accidents. Immediate treatment of aortic rupture was indicated in all patients because of a marked fresh hematoma with hemothorax; the spiral computed tomographic (CT) scans showed circular or semicircular descending thoracic aortic injuries. The devices used included 11 thoracic Excluders and 1 Talent stent-graft.

RESULTS

No patient required conversion to an open transthoracic operation. No patient developed temporary or permanent neurological deficit after endovascular treatment. Two type I endoleaks required periprocedural treatment: a second stent-graft was deployed in one and the existing stent-graft was balloon dilated in the other. Two patients underwent secondary procedures (iliac access complication and revascularization of the left subclavian artery). One patient died 22 days postoperatively secondary to injuries unrelated to the aortic repair. Over a mean 14-month follow-up (range 1-26), the surveillance CT scans have shown the stent-graft to be correctly positioned in all patients.

CONCLUSIONS

The treatment of acute traumatic descending aortic transection with an endovascular approach is feasible and safe and may offer the best means of therapy. Mortality and the risk of neurological deficit are low compared with open operations.

Indications for, timing of, and results of catheter-based treatment of traumatic injury to the aorta

OBJECTIVE

The optimal treatment for and timing of surgery to repair traumatic aortic injury are still controversial. Endovascular treatment is a viable option in patients with both acute and chronic aortic trauma. However, appropriate patient selection criteria, treatment timing, and long-term durability of endovascular repair remain to be defined. We sought to identify appropriate selection criteria and optimal timing of treatment as well as to assess the long-term durability of endovascular repair.

SUBJECTS AND METHODS

From July 1997 to December 2001, 19 patients with traumatic aortic injury (11 patients with acute and eight with chronic injuries) were selected for endovascular treatment. In all patients, the lesions were sited at the proximal segment of the descending aorta at a distance of 10 +/- 17 mm (mean +/- SD) from the left subclavian artery. Nine of the patients with acute injuries were treated after clinical stabilization of other severe associated lesions, whereas two patients, in whom hemodynamic and imaging findings suggested an impending rupture, received emergency treatment. Single-detector helical CT or MR imaging was used for patient selection and stent-graft customization before treatment and for evaluation of patients during the follow-up period.

RESULTS

Endovascular stent positioning was successful in all patients. None of the patients developed complications. Aneurysm exclusion and shrinkage were confirmed at followup examinations. A partial covering of the subclavian artery occurred in six patients without interrupting the blood flow. All patients remain asymptomatic after a mean follow-up period of 20 months (range, 1-56 months).

CONCLUSION

Endovascular repair represents an alternative, minimally invasive treatment, particularly suitable for use in patients with traumatic aortic injuries. The decision of whether to provide immediate emergency treatment or to delay treatment should be based on the lesion characteristics on imaging and clinical findings. The durability of treatment seems to be related to the absence of alteration to the aortic wall at the extremities.

Combined surgical and endovascular treatment of acute aortic dissection type A: preliminary results

BACKGROUND

The established treatment modality of acute Stanford type A dissection includes repair of the ascending aorta and various portions of the aortic arch, whereas the descending aorta is left untreated. We report a simultaneous approach of open repair of the ascending aorta with transluminal stent grafting of the descending aorta to minimize the consequences of an untreated descending aorta.

METHODS

From April 2001 to February 2002, 8 consecutive patients (3 women [37.5%] and 5 men [62.5%]) with a mean age of 55.7 years (range, 45 to 70 years) were intended to be treated with the combined method of surgical repair of the ascending aorta and transluminal stent grafting into the descending aorta during the period of deep hypothermic circulatory arrest. Circulatory arrest time ranged between 30 and 67 minutes (average, 38.8 minutes). Specially designed Talent stent grafts (32 to 40 mm in diameter, length 13 cm) were inserted under direct vision and deployed with the proximal end at the origin of the left subclavian artery.

RESULTS

Intraoperative stent graft placement was successful in 7 patients (87.5%). Because of severe kinking of the distal arch, stent insertion failed in 1 patient (12.5%). One patient with a history of preoperative stroke in the middle cerebral artery died because of intracerebral bleeding on postoperative day 2, resulting in an in-hospital mortality of 12.5%. Mean intensive care unit stay was 6.4 days (range, 2 to 21 days) and overall hospital stay was 18.2 days (range, 7 to 33 days). Completion computed tomographic scans revealed complete thrombosis of the false lumen in 2 patients and partial thrombosis in 4 patients. Follow-up was complete and ranged from 1 to 9 months (mean, 5.4 months).

CONCLUSIONS

This preliminary study shows that combined surgical and endovascular treatment of acute type A dissection is feasible, and at least partial thrombosis of the false lumen can be achieved, potentially minimizing the risk of further dilatation or rupture. Additionally, the stent graft expands the otherwise sickle-shaped true lumen, thereby ameliorating distal aortic perfusion. Long-term results are warranted to demonstrate the effectiveness of this new combined treatment modality.

Evolving experience with thoracic aortic stent graft repair

PURPOSE

We reviewed our initial thoracic aorta (TA) stent graft experience in 28 patients from the perspective of treatment with homemade devices (Dacron over Gianturco Z stents; 14 cases) and a commercial device (Excluder; W.L. Gore Co, Flagstaff, Ariz; 14 cases).

METHODS

From November 1996 to August 2001, 28 patients with a spectrum of disease (degenerative aneurysm, n = 18; chronic dissection, n = 4; pseudoaneurysm, n = 3, with 1 trauma and 2 anastomotic; intramural hematoma, n = 2; and coarctation, n = 1) underwent TA stent grafting. Clinical parameters included a mean age of 71 years, 12 female (43%) and 16 male (57%) patients, 14 of 28 patients (50%) with major comorbidities that prohibited open repair, and nine of 28 patients (32%) with urgent or ruptured conditions. Seven patients (25%) needed open surgical access to the aorta or iliac artery for either concomitant abdominal aortic aneurysm repair (n = 3) or device deployment (n = 4), and six of 28 patients (21%) needed left subclavian-carotid transposition to provide for an adequate proximal fixation site. Focal (<15 cm) grafts were used in 19 patients, and the remaining patients had at least two thirds of their descending aorta excluded.

RESULTS

The procedural mortality rate was 3.5% (1/28 patients); three additional deaths, (1 device-related) occurred during the mean follow-up period of 17 months. Access artery complications occurred in six of 28 patients (21%), with one fatal. No immediate or late open conversions were performed. One patient needed urgent dilation and stenting of a collapsed stent graft 3 weeks after deployment. Serious systemic complications included temporary dialysis (n = 1), congestive heart failure (n = 1), and unstable angina (n = 1). Complete exclusion of the TA lesion was noted in 27 of 28 cases (96%). No cases of spinal cord ischemia were noted. Ease and accuracy of deployment was superior for the second generation (commercial) device.

CONCLUSION

TA stent graft repair, although in evolution, appears to be a safe and effective alternative to open repair for many patients with a spectrum of TA disease. Prospective trials for individual diseases will be necessary to define its ultimate role.

Endoluminal stent grafting of the thoracic aorta: initial experience with the Gore Excluder

PURPOSE

The purpose of this study was to describe our experience with endoluminal graft repair of a variety of thoracic aorta pathologies with a commercially developed device currently under investigation. Our patient population included patients eligible for open surgical repair and those with prohibitive surgical risk.

METHODS

From February 2000 to February 2001, endovascular stent-graft repair of the thoracic aorta was performed in 46 patients (mean age, 70 years; 29 male and 17 female patients) with the Gore Excluder. Twenty-three patients (50%) had atherosclerotic aneurysms, 14 patients (30%) had dissections, three patients (7%) had aortobronchial fistulas, three patients (7%) had pseudoaneurysms, two patients (4%) had traumatic ruptures, and one patient (2%) had a ruptured aortic ulcer. Patient characteristics, procedural variables, outcome, and complications were recorded. All patients were followed with chest computed tomographic scans at 1, 3, 6, and 12 months. Follow-up period ranged from 1 month to 15 months, with a mean of 8.5 months.

RESULTS

All the procedures were technically successful. There were no conversions. Average duration of the procedure was 120 minutes. Average length of stay was 6 days, but most patients (64%) left the hospital within 4 days after endoluminal grafting. The overall morbidity rate was 23%. Two patients (4%) had endoleaks that necessitated a second procedure for successful repair. Two patients (4%) died in the immediate postoperative period. There were no cases of paraplegia. At follow-up examination, one patient had an endoleak found the day after the procedure and another patient had an endoleak 6 months after the procedure. Both cases were treated successfully with additional stent-grafts. There were no cases of migration. One patient died of a myocardial infarction 6 months after graft placement. In patients treated for aneurysm (n = 23), the aneurysm diameter ranged from 5.0 to 9.5 cm (mean, 6.8 cm). Residual sac measurements were obtained at 1, 6, and 12 months, with mean sac reductions of 0.59 cm, 0.77 cm, and 0.85 cm, respectively. In three cases, the sac remained unchanged, without evidence of endoleak.

CONCLUSION

Thoracic endoluminal grafting with the Gore Excluder is a safe and feasible alternative to open graft repair and can be performed successfully with good results. Early data suggest an endoluminal approach to these disease entities may be favorable over classical resection and graft replacement.

Predicting spinal cord ischemia before endovascular thoracoabdominal aneurysm repair: monitoring somatosensory evoked potentials

PURPOSE

To present a method of predicting spinal cord ischemia before deployment of an endograft in the thoracoabdominal aorta.

CASE REPORT

A 76-year-old high-risk patient presented with an aneurysm of the distal thoracic and proximal abdominal aorta. An endovascular treatment was scheduled, but before deployment of the endograft, occlusion of the aneurysmal segment was monitored for 15 minutes using multilevel somatosensory evoked potentials (SEP). An external axillofemoral bypass was necessary during the test period to prevent distal ischemia; transesophageal echocardiography verified the absence of flow inside the aneurysm during occlusion. Because no SEP changes occurred during the 15-minute test, a 20-cm-long endograft was deployed. No postoperative neurological event was encountered, and the aneurysm has remained successfully excluded with shrinkage of the sac diameter by 1 cm at 6 months.

CONCLUSIONS

An occlusion test to detect spinal cord ischemia before deployment of an endograft could be useful in lowering the risk of paraplegia associated with endovascular treatment of thoracoabdominal aneurysm.

Acute traumatic rupture of the thoracic aorta treated with endoluminal stent grafts

BACKGROUND

Endovascular technologies provide a new therapeutic option in the treatment for acute traumatic rupture of the thoracic aorta. We report our experience with endoluminal stent graft repair of thoracic aortic ruptures.

METHODS

Five patients underwent repair of the thoracic aorta with an endoluminal stent graft for acute traumatic rupture. Data from patient history, the procedure, hospital course, and follow-up were analyzed.

RESULTS

All patient were involved in motor vehicle crashes. The mean Injury Severity Score was 51.8 +/- 6.38. All procedures were technically successful. Mean operating room time was 111 minutes and mean estimated blood loss was 200 mL. There were no cases of postprocedural endoleaks or conversions. There were no procedural complications, paraplegia, or deaths. Average follow-up was 20.2 months.

CONCLUSION

Five cases of successful endograft repair of thoracic aortic rupture have been demonstrated. This should encourage future studies to determine whether endovascular repair of thoracic aortic ruptures is a safe and feasible alternative to conventional open repair.