Endovascular treatment of thoracic aortic aneurysms: Results of the phase II multicenter trial of the GORE TAG thoracic endoprosthesis

Endovascular repair of an ascending aortic pseudoaneurysm with a septal occluder device: mid-term follow-up

Ascending pseudoaneurysm is an infrequent complication of ascending aortic surgery. Redo operations are often associated with a high surgical morbidity and mortality. Endovascular management of ascending aortic pathologies with endoluminal graft therapies are challenging due to short landing zones and the fear of flow obstruction to the coronaries and brachiocephalic circulation. We report mid-term follow-up of the management of an ascending aortic pseudoaneurysm using a an Amplatz septal occluder (AGA Medical Corp, Golden Valley, MN) in a 51-year-old man considered at high risk for conventional open surgical repair.

Management of neurologic complications of thoracic aortic surgery

Neurologic complications of thoracic aortic surgery are strongly associated with increased morbidity and mortality. Identifying preoperative risk factors for neurologic injury may enable us to refine our perioperative approach, and to lessen or avoid these complications. Methods to identify stroke and spinal ischemia intraoperatively such as neurophysiologic monitoring may enable us to improve outcomes in these patients by immediately instituting measures to improve brain and spine perfusion. The development of both protocols and therapies to treat these complications has allowed us to mitigate and, at times, reverse neurologic injury both intraoperatively and postoperatively.

Thoracic endovascular aortic repair for traumatic aortic transection

BACKGROUND

Traumatic transection of the thoracic aorta is a highly morbid injury. Treatment may be delayed while attention focuses on concomitant injuries. Thoracic endovascular aortic repair (TEVAR) is effective but remains controversial in these often-young patients. We reviewed our experience in acute and subacute treatment of these injuries with TEVAR.

METHODS

A retrospective analysis of five men and five women who underwent TEVAR for aortic transection from 1999 to 2007 was conducted. Procedures were performed with standard endovascular techniques. Follow-up included computed tomography at 1 month and yearly thereafter.

RESULTS

Mean age was 44 years (range, 20 to 84 years). Motor vehicle accidents accounted for 7 injuries, a snowmobile accident for 1, skydiving for 1, and balloon angioplasty of a coarctation for 1. Average diameter of the proximal landing zone was 25 mm (range, 23 to 29 mm). Mean external iliac size was 10 mm (range, 7 to 15 mm), and no conduits were required. Immediate technical success was 90%, with no 30-day mortality. Seven patients underwent repair acutely (< or =24 hours) and three patients subacutely (range, 4 days to 2 months) for pseudoaneurysm. Four patients had procedures for concomitant injuries before their transection was repaired (3 laparotomies and a fixation for open fracture). One endoleak was noted, which resolved by the 1-month follow-up. The lone device-related complication was an endograft collapse at 5 months managed by repeat endografting, which was complicated by aortoesophageal fistula requiring esophagectomy and open reconstruction. No iliac injuries occurred. At 20-months of mean follow-up (range, 2 to 70 months), all patients are alive and well.

CONCLUSIONS

TEVAR for traumatic aortic transection is feasible, with good initial success. Repair can be delayed in selected cases. Continued surveillance is necessary to ensure good long-term outcomes in these young patients. Care must be taken when performing TEVAR for this off-label indication because these devices are designed for the larger aortic diameters of aneurysm patients.

Risk factors for perioperative stroke after thoracic endovascular aortic repair

BACKGROUND

Stroke has emerged as an important complication of thoracic endovascular aortic repair (TEVAR). Identifying risk factors for stroke is important to define the risks of this procedure.

METHODS

All neurologic complications were analyzed in a prospective database of patients in thoracic aortic stent graft trials from 1999 to 2006. Serial neurological examination was performed. Stroke was defined as any new onset focal neurologic deficit.

RESULTS

The TEVAR was performed on 171 patients; 52 had lesions requiring coverage of the proximal descending thoracic aorta (extent A), 50 requiring coverage of the distal descending aorta (extent B), and 69 requiring coverage of the entire descending thoracic aorta (extent C). The incidence of stroke was 5.8%. Eighty-nine percent (8 of 9) of strokes occurred within 24 hours of operation. Stroke was associated with a 33% in-hospital mortality rate. Risk factors identified for stroke included prior stroke (odds ratio [OR] 9.4, confidence interval [CI] 2.3 to 38.1, p = 0.002) and extent A or C coverage (OR 5.5, CI 1.7-12.5, p = 0.001). The stroke rate in patients with both prior stroke and extent A or C coverage was 27.7%. Severe atheromatous disease involving the aortic arch by computed tomographic scan was strongly associated with perioperative stroke (OR = 14.8, CI 1.7 to 675.6, p = 0.0016). Transesophageal echocardiography demonstrated mobile atheroma in two patients with stroke.

CONCLUSIONS

Stroke after TEVAR was associated with a high mortality. The TEVAR of the proximal descending aorta (extent A or C) in patients with a history of stroke had the highest perioperative stroke rate. These risk factors, together with high grade aortic atheroma of the aortic arch, predicted a high probability for cerebral embolization and can be used to identify patients at high risk for stroke as a consequence of TEVAR.

An Extra Anatomic, Close Chest Approach to Manage an Aortic Arch Aneurysm in an 88-Year-Old Woman

Repair of thoracic arch aneurysms in the octogenarian is associated with a high morbidity and mortality. In this report we describe a minimally invasive approach to repair and arch aneurysm using an endoluminal graft with an extrathoracic, extra anatomic de-branching of the arch vessels. The advantage of this technique includes avoidance of a median sternotomy, cardiopulmonary bypass, and circulatory arrest with a rapid postoperative recovery.

Endovascular treatment of aortic aneurysms: techniques and clinical update

Open repair of abdominal and thoracic aortic aneurysms continues to be associated with considerable morbidity and mortality. Endovascular repair of abdominal and thoracic aortic aneurysms has evolved over the past few years and has significantly reduced the morbidity of aortic aneurysm repair compared with the standard open surgical procedures. Several devices have been approved for clinical use for this purpose. This has allowed the treatment of patients who are otherwise at high risk for open repair. This review paper aims to (1) describe the general principles of use for endovascular devices and review the radiographic features and clinical trials for the devices in current use, (2) present the results of the clinical trials that led to the approval and marketing of the current devices, and (3) review new techniques and approaches for the treatment of aortic aneurysms.

Early Results of Endovascular Treatment of the Thoracic Aorta Using the Valiant Endograft

Endovascular repair of the thoracic aorta has been adopted as the first-line therapy for much pathology. Initial results from the early-generation endografts have highlighted the potential of this technique. Newer-generation endografts have now been introduced into clinical practice and careful assessment of their performance should be mandatory. This study describes the initial experience with the Valiant endograft and makes comparisons with similar series documenting previous-generation endografts. Data were retrospectively collected on 180 patients treated with the Valiant endograft at seven European centers between March 2005 and October 2006. The patient cohort consisted of 66 patients with thoracic aneurysms, 22 with thoracoabdominal aneurysms, 19 with an acute aortic syndrome, 52 with aneurysmal degeneration of a chronic dissection, and 21 patients with traumatic aortic transection. The overall 30-day mortality for the series was 7.2%, with a stroke rate of 3.8% and a paraplegia rate of 3.3%. Subgroup analysis demonstrated that mortality differed significantly between different indications; thoracic aneurysms (6.1%), thoracoabdominal aneurysms (27.3%), acute aortic syndrome (10.5%), chronic dissections (1.9%), and acute transections (0%). Adjunctive surgical procedures were required in 63 patients, and 51% of patients had grafts deployed proximal to the left subclavian artery. Comparison with a series of earlier-generation grafts demonstrated a significant increase in complexity of procedure as assessed by graft implantation site, number of grafts and patient comorbidity. The data demonstrate acceptable results for a new-generation endograft in series of patients with diverse thoracic aortic pathology. Comparison of clinical outcomes between different endografts poses considerable challenges due to differing case complexity.

Etiology, pathogenesis and management of thoracic aortic aneurysm

Given the growing proportion of elderly people in Western societies and the increasing prevalence of chronic hypertension, the management of aneurysmal aortic disease is an ever growing challenge. Although degenerative changes in the aortic wall are common to thoracic aortic aneurysm (TAA) and to various types of dissection in general, TAA can result from specific heritable disorders of connective tissues. Today, increased awareness of vascular diseases and access to tomographic imaging equipment facilitate the diagnosis of TAA, even when asymptomatic. While most TAA cases with ascending aortic involvement are treated with surgical repair (primarily valve-preserving techniques), aneurysms of the distal arch and descending thoracic aorta are amenable to alternatives to classic open repair such as the emerging endovascular treatment techniques. In this Review, we provide a comprehensive overview of the etiology, pathophysiology and clinical management of patients with TAA, and discuss the most recent literature on the condition.

Role of interventional repair in the thoracic aorta

Endovascular treatment of chronic aneurysmatic diseases of the descending thoracic aorta has demonstrated encouraging peri-interventional mortality and morbidity and is accepted as a preferred strategy in experienced centers. The emergence of endovascular strategies for acute thoracic aortic pathologies is an even more exciting new territory for nonsurgical interventions considering the sobering results of open surgery. Although it is apparent that patients at high risk for open surgery will benefit from endovascular strategies, the exact role of stent-graft placement remains to be defined, as the community awaits solid long-term data and as devices and techniques continue to improve. While some indications and scenarios, such as acute type B dissection with associated malperfusion syndrome or imminent aortic rupture, have been shown to benefit from stent-graft treatment, others are less settled. The current paper discusses both the established and emerging indications, as well as technical and anatomical aspects of this fascinating therapeutic option.

Minimal Access Surgery of Ascending and Proximal Arch of the Aorta: A 9-Year Experience

BACKGROUND

Minimal access approaches are becoming readily accepted techniques for cardiac valve surgery. However, the safety or benefit of this approach for aortic surgery has not been well investigated.

METHODS

We retrospectively analyzed 128 consecutive patients who underwent ascending aortic replacement (n = 53), proximal aortic arch replacement (n = 7), aortic root replacement (n = 67), or sinus of Valsalva aneurysm repair (n = 1) through an upper hemisternotomy between August 1996 and May 2005. Using matched variables (age, type of procedure, redo operation, and use of circulatory arrest), we constructed two matched cohorts of 79 patients each: a minimally invasive (group A) and full sternotomy (group B) and compared outcomes.

RESULTS

The mean age for the minimally invasive group (n = 128) was 54 years (range, 25 to 83 years). There were six reoperations (4.7%), five (3.9%) urgent operations, and 16 (12.5%) deep hypothermic circulatory arrests. Operative mortality was zero, the median length of hospital stay was 5 days (range, 3 to 21 days), and 112 patients (82.4%) were discharged home. Actuarial survival at 5 years was 97.2%. On comparison between group A and B, there was no significant difference in operative times, mortality, and morbidity. However, group A had shorter median length of stay (5 versus 6 days, p = 0.020) and fewer median units of red blood cell transfusion than group B (2 versus 2.5, p = 0.020).

CONCLUSIONS

An upper hemisternotomy approach is safe and feasible for ascending aortic and proximal arch surgical procedures, with excellent early and late outcomes. This approach is associated with shorter hospital stay and less blood transfusion.

Endovascular treatment of thoracoabdominal aortic aneurysms

OBJECTIVE

To establish the safety and efficacy of endovascular repair of thoracoabdominal aortic aneurysms.

METHODS

Between May 2004 and February 2006, patients with thoracoabdominal aneurysms considered high risk for conventional surgery were enrolled in a prospective trial to evaluate a novel endovascular grafting system. Devices were custom designed for each patient using high-resolution computed tomography. Patient data included mortality, morbidity, procedural details, and surrogate end points for endovascular repair. These were collected at hospital discharge and at 1, 6, and 12 months.

RESULTS

Seventy-three patients underwent endovascular repair of thoracoabdominal aortic aneurysms for type I, II, or III (n = 28), or for type IV (n = 45) thoracoabdominal aneurysms. Mean aneurysm size was 7.1 cm (range 4.5-11.3 cm). General anesthesia was used in 47% of patients and regional anesthesia in 53%. There were no conversions to open surgery nor ruptures post-treatment. Technical success was achieved in 93% of patients (68/73). Thirty-day mortality was 5.5% (4/73). Major perioperative complications occurred in 11 (14%) patients and included paraplegia (2.7%, 2/73), new onset of dialysis (1.4%, 1/73), prolonged ventilator support (6.8%, 5/73), myocardial infarction (5.5%, 4/73), and minor hemorrhagic stroke (1.4%; 1/72). A majority of patients had no complications. Mean length of stay was 8.6 days. At follow-up, 6 deaths had occurred. There were no instances of stent migration nor aneurysmal growth.

CONCLUSIONS

Endovascular repair of aortic aneurysms involving the visceral segment in nonsurgical candidates is feasible. Known complications of repair are not eliminated, but morbidity and mortality appeared low relative to the high-risk population studied. Further refinement of device design, delivery technique, and patient selection is ongoing. Assessment of durability will require longer follow-up.

Endovascular treatment of atherosclerotic and other thoracic aortic aneurysms

The incidence of thoracic aortic aneurysms (TAAs) is increasing with the present rate of occurrence at 10.9 cases per 100,000 people per year. The estimated 5-year risk of rupture of a TAA with a diameter between 4 and 5.9 cm is 16%, but it rises to 31% for aneurysms ≥ 6 cm. Despite increasing awareness of the importance of early diagnosis and treatment options, there are no clear guidelines available at the time of writing. Nor is there any clear evidence for specific pharmacological treatment able to resolve or delay the disease progression. Endovascular treatment (EVT), proposed as an alternative to surgery, has been considered a therapeutic innovation, especially because it is minimally invasive, which allows treatment even in high surgical risk patients. Vascular imaging is crucial for patient selection, endoprosthesis choice, and planning of the treatment because not all aneurysms are suitable. Early and midterm results are encouraging, but long-term results are necessary to definitively assess reliability of stent-graft materials and improvement in patient survival. In the choice between surgical or endovascular repair of TAAs, many factors must be considered, including the clinical situation, comorbidities, anatomy, choice of equipment, and last, but not less important, experience of the clinical team.

Thoracic CT Findings Following Endovascular Stent-Graft Treatment for Thoracic Aortic Aneurysm

PURPOSE

To investigate the transient computed tomographic (CT) findings and morphological characteristics of the descending thoracic aorta following endovascular repair of thoracic aortic aneurysm (TAA).

METHODS

Of 50 TAAs repaired using custom-made endoprostheses between May 1997 and September 2005, 35 (25 men; mean age 67 years) were successfully treated and followed for >3 months by thoracic CT. The TAA etiologies were 22 degenerative/atherosclerotic, 7 dissection-related from intramural hematoma, 2 traumatic, 2 anastomotic, and 2 penetrating ulcers. The CT findings following stent-graft placement were retrospectively studied.

RESULTS

Over a mean follow-up of 27.0+/-25 months (range 3-92), periaortic changes were observed in 17 (48.6%) patients, and the amount of pleural effusion increased in 13 (37.1%). In all cases, these findings disappeared without specific treatment during the follow-up period. Late secondary endoleak was observed in 1 (2.9%) patient, and there was 1 (2.9%) caudal migration of the proximal end of the stent-graft. Five (14.3%) aneurysms increased in size. Two patients, both with dissection, showed aortic neck dilatation. There was a positive relationship between neck dilatation and dissection-related TAA etiology (p = 0.035).

CONCLUSION

Although aortic neck dilatation is less common after endovascular TAA repair than after abdominal repairs, patients with dissection-related TAA may be a subgroup prone to aneurysm neck dilatation.

Endovascular Repair of Localized Pathological Lesions of the Descending Thoracic Aorta: Midterm Results

The endoluminal stent-graft represents an attractive and a less invasive technique for treatment of various diseases of the descending thoracic aorta. The purpose of this study was to evaluate the Talent endovascular stent-graft for the treatment of various localized diseases of the descending thoracic aorta. Over a 3-year period, Talent thoracic endografts were placed in 40 patients with a high surgical risk, presenting a localized lesion of the descending thoracic aorta: degenerative aneurysm (n = 13), acute traumatic rupture (n = 11), acute Stanford type B aortic dissection (n = 6), false aneurysm (n = 7), and penetrating atherosclerotic ulcer (n = 3). Fifteen patients (37.5%) were treated as emergencies. The feasibility of endovascular treatment and sizing of the aorta and stent-grafts were determined preoperatively by magnetic resonance angiography (MRA) and intraoperative angiography. Immediate and mid-term technical and clinical success was assessed by clinical and MRA follow-up. Endovascular treatment was completed successfully in all 40 patients, with no conversion to open repair or intraoperative mortality. The mean operative time was 37.5 +/- 7 min. The overall 30-day mortality rate was 10% (n = 4), all in emergency cases, for causes not related to the endograft. The primary technical success was 92.5%. The mean follow-up period was 15 +/- 5 months. The survival rate was 95% (n = 35). Diminution of the aneurismal size was observed in 47.5% (n = 19). We conclude that endovascular treatment of the various localized diseases of the descending thoracic aorta is a promising, feasible, alternative technique to open surgery in well-selected patients.

Right thyrocervical trunk bronchial artery collateral: source of type II Endoleak after endovascular repair of thoracic aortic aneurysm

A patient with an enlarging thoracic aortic aneurysm (TAA) after endovascular repair showed a persistent endoleak on follow-up imaging at three and six months. He subsequently underwent angiography and transcatheter embolization of a right thyrocervical trunk bronchial collateral. Examination of potential anomalous or collateral thoracic pathways is mandatory when considering treatment of a Type II endoleak following endovascular TAA repair.

Anatomic factors associated with acute endograft collapse after Gore TAG treatment of thoracic aortic dissection or traumatic rupture

OBJECTIVE

The potentially devastating complication of total or near total thoracic endoprosthesis collapse has been described with the TAG device (W. L. Gore & Associates, Flagstaff, Ariz). This rare complication has resulted in a warning to clinicians and speculation about the etiology of this problem. This report evaluates potential causative anatomic factors that may increase the probability of endoprosthesis collapse in patients undergoing endovascular thoracic aneurysm repair (TEVAR).

METHODS

Preoperative and postoperative computed tomography scans were collected worldwide representing six patients who had experienced radiologically confirmed TAG endoprosthesis collapse. These were compared with a matched cohort of five patients with a TAG endoprosthesis in the same anatomic position in which no collapse occurred. Anatomic variables of aortic arch angulation, apposition, intraluminal lip length, proximal aortic diameter, distal aortic diameter, intragraft aortic diameter, percentage of oversizing, and angle of the proximal endograft to the aortic arch were compared between groups. Differences between groups were determined using the Student t test, with P < .05 considered significant.

RESULTS

The two groups (collapse vs no collapse) were evenly matched demographically, and all underwent endoluminal treatment with the TAG device, with no differences in gender, graft position in the aorta, operative indication, or age (P = NS). Distal sealing zone aortic diameter +/- standard deviation of 18.9 +/- 1.7 mm vs 22.7 +/- 2.7 mm and minimum aortic diameter within the endograft of 18.6 +/- 1.7 mm vs 22.4 +/- 3.1 mm predicted collapse (P < .05). Proximal aortic diameter, apposition, intraluminal lip length, aortic arch angle, and angle of proximal endograft to aortic arch did not predict collapse (P = NS).

CONCLUSION

Thoracic endograft collapse is an exceedingly rare event. In this series, endoprosthesis collapse occurred in patients who were treated outside the manufacturer's instructions for use for minimum required aortic diameter. Although distal aortic diameter and minimum intragraft aortic diameter predicted collapse, other variables may also influence this complication but were not significant owing to potential type II statistical errors. In the future, caution should be exercised when contemplating TEVAR in patients with small (<23 mm) aortic diameters.

The Midterm Results of Stent Graft Treatment of Thoracic Aortic Injuries

INTRODUCTION AND OBJECTIVES

Several publications document the technical feasibility of stent graft repair of aortic transection. We report our mid-term results of endovascular repair of thoracic aortic transections using covered stent grafts and compare this to a cohort undergoing open repair during the same time period to demonstrate the shift in practice pattern at our institution.

MATERIALS AND METHODS

A retrospective review of patients who sustained blunt thoracic transection was undertaken. Medical records were examined to identify the clinical outcome of the procedure, and follow-up CT scans were reviewed to document adequate treatment of the transection. Outcome measures include procedure-related mortality, neurological morbidity, and successful immediate and mid-term coverage of the thoracic false aneurysm and absence of graft migration or endoleak.

RESULTS

From July, 2000 to October, 2004, 27 patients were identified with descending thoracic aortic transection at our level I trauma center. Fourteen patients were managed nonoperatively, five patients underwent thoracotomy and direct aortic repair, and eight patients underwent endoluminal stent graft repair. Of the endovascular group (n=8), repairs were performed with stacked AneuRx aortic cuffs (Medtronic, Inc., Minneapolis, MN) (n = 6), a Gore thoracic aortic stent graft (Thoracic EXCLUDER; W.L. Gore, Flagstaff, AZ) (n=1), or a Medtronic Talent thoracic endograft (Medtronic, Inc.) (n=1). Access for stent graft deployment was the common femoral artery (n=2), iliac artery (n=4), or distal abdominal aorta (n=2). Completion arch aortography and postoperative CT scanning confirmed successful management of the aortic transection in each patient. There were no procedure-related deaths, paraplegia, or stroke. Postoperative complications included a brachial artery thrombosis in one patient as well as an external iliac artery dissection and acute renal failure in a second patient for a complication rate of 37.5%. Two patients died as a result of their injuries unrelated to the stent graft repair. Mean follow-up of 16.6 mo has shown no evidence of endoleak or stent graft migration. Of the open repair group (n=5), one patient died in the operating room during attempted aortic repair, and one patient had a postoperative stroke.

CONCLUSIONS

Due to technical success and absence of delayed complications including endoleak and graft migration, stent graft repair of traumatic aortic transection has replaced open aortic repair as the primary treatment modality in the multiply injured trauma patient at our institution. The postoperative complication rate observed in this small series tempers the success to some degree, but the severity of the complications compares favorably with those observed in the open repair group.

Endovascular stent-graft placement for vascular failure of the thoracic aorta

It still remains undetermined whether endovascular stent-graft placement (ESGP) is the optimal initial treatment for elective cases of thoracic aortic disease because of unknown long-term results. However, it is also recognized that ESGP contributes to better outcome as an initial treatment for aortic emergency, such as rupture, aortic injury, and complicated acute type B aortic dissection. Despite the fact that most patients are elderly, early mortality rates of ESGP are reportedly around 10% in cases of ruptured degenerative thoracic aortic aneurysm. Postoperative morbidity is also superior in ESGP compared with conventional open repair. Postoperative paraplegia has rarely occurred with ESGP. In cases of blunt aortic injury (BAI), other complications may also be present because of other serious injuries. ESGP has changed the surgical strategy for BAI and partially resolved some of the clinical dilemmas. Early mortality rate is almost zero when a stent graft can be placed before re-rupture. While BAI is a very good indication for ESGP, young patients need careful management and attention because of the unknown long-term outcome. In cases of complicated acute type B aortic dissection, the two main determinants of death, shock from rupture and visceral ischemia, could be managed by ESGP with or without conventional endovascular interventions. Recent reports disclosed less than 10% early mortality with ESGP for complicated acute aortic dissection. Even if the possibility of endotension remains, ESPG seems to be beneficial for these critical patients as the preferable initial treatment. The importance of close follow-up should be stressed to avoid some devastating late complications following ESGP.

Outcome after celiac artery coverage during endovascular thoracic aortic aneurysm repair: Preliminary results

BACKGROUND

Endovascular repair of descending thoracic aortic aneurysms has emerged as an alternative to open repair. Coverage of the left subclavian origin has been reported to expand the proximal sealing zone. We report the planned coverage of the celiac artery origin with a thoracic stent graft to achieve an adequate distal sealing zone.

METHODS

All patients undergoing endovascular aneurysm repair are prospectively entered into a computerized database. All patients who underwent thoracic endovascular aneurysm repair with coverage of the celiac artery origin were identified and retrospectively analyzed. End points for evaluation included indications for covering the celiac artery, anatomic features of the distal landing zone, demonstration of collateral circulation between the celiac artery and the superior mesenteric artery, technical success of the procedure, and presence of clinical ischemic symptoms after the procedure.

RESULTS

Between March 2005 and May 2006, 46 patients underwent endovascular repair of descending thoracic aortic aneurysms. Seven patients had planned celiac artery coverage with a thoracic stent graft to secure an adequate distal sealing zone. Six patients demonstrated collateral circulation through the gastroduodenal artery between the celiac and superior mesenteric arteries before deployment of the stent graft. One patient had a distal type I endoleak at the conclusion of the procedure related to inadequate sealing at the superior mesenteric artery origin. No type II endoleaks were evident at the final intraoperative angiogram or 30-day computed tomography scan. There were no postoperative deaths, no ischemic abdominal complications, and no clinical spinal cord ischemia. Short-term follow-up (1 to 10 months) has demonstrated no additional endoleaks (type I not fully assessed), no aneurysm growth, and no aneurysm ruptures.

CONCLUSION

This limited series supports the suitability, in selected patients, of covering the celiac artery origin for a distal landing zone when the distal sealing zone proximal to the celiac artery is inadequate. We recommend the angiographic evaluation of the collateral circulation between the celiac and superior mesenteric arteries when covering the celiac artery origin is being considered.

The Hybrid Aneurysm Repair: Extending the Landing Zone in the Thoracoabdominal Aorta

We present two cases of concomitant management of a type I thoracoabdominal aneurysm and an infrarenal aneurysm via laparotomy, open infrarenal aortic replacement, visceral bypasses from the infrarenal graft, and finally endovascular exclusion of the thoracoabdominal aneurysm. While there are other reports of hybrid procedures for patients with preexisting aortic grafts in place or with retrograde visceral perfusion from a native iliac artery for type II thoracoabdominal aneurysm, these are the first reported cases of concurrent management of a type I thoracoabdominal aneurysm and an infrarenal aneurysm using the infrarenal graft as a distal landing zone for the thoracoabdominal endograft.

Tratamento do aneurisma da aorta toracoabdominal com endoprótese ramificada para as artérias viscerais

Apresentamos um caso de aneurisma da aorta toracoabdominal (AATA) tratado, exclusivamente, pela técnica endovascular, utilizando uma endoprótese ramificada e customizada. Paciente do sexo feminino, 68 anos de idade, tabagista, hipertensa, portadora de extenso AATA e múltiplas comorbidades que restringiam a indicação de cirurgia convencional. O aneurisma iniciava-se na aorta torácica descendente, estendendo-se até a aorta abdominal infra-renal, envolvendo as emergências das artérias viscerais, tronco celíaco, artérias mesentérica superior e renais. O AATA foi tratado pela técnica endovascular com implante de uma endoprótese ramificada. Essa endoprótese ramificada foi customizada com base nas características anatômicas da aorta e no posicionamento dos ramos viscerais, obtidos em angiotomografia, objetivando excluir o aneurisma, mantendo a perfusão das artérias viscerais. O procedimento foi realizado em centro cirúrgico, sob anestesia combinada, regional e geral, antecedido de drenagem liquórica e sob orientação fluoroscópica. O acesso para o implante do corpo principal da endoprótese ramificada e o controle radiológico foram realizados através das artérias femorais, previamente dissecadas. Através das ramificações da endoprótese, foram implantadas extensões secundárias, com stents revestidos, para as respectivas artérias viscerais, cujo acesso foi realizado via artéria axilar esquerda. O tempo total do procedimento foi de 14 horas, com 4 horas e 30 minutos de fluoroscopia, e foram utilizados 120 mL de contraste iodado. No pós-operatório, a paciente apresentou instabilidade hemodinâmica. Ecocardiograma transesofágico mostrou dissecção retrógrada da aorta torácica, tipo A, seguida de trombose espontânea da falsa luz. A tomografia de controle mostrou exclusão do AATA e perviedade das pontes para os ramos viscerais, sem vazamentos. A alta ocorreu no 13º dia de pós-operatório. O tratamento endovascular do AATA com endoprótese ramificada é factível. A melhora dos recursos técnicos e da qualidade dos materiais poderá ampliar a indicação desse procedimento como alternativa à cirurgia aberta.

Proteinase systems and thoracic aortic aneurysm progression

Thoracic aortic aneurysms (TAAs) are a rare but potentially devastating condition. Current surgical treatment of TAAs usually involves a major operation, which conveys many risks to the patient. Better knowledge of the cellular events that lead to aneurysm formation may elucidate less morbid treatment options for this condition. A number of recent studies have identified that the relative abundance and activity of extracellular matrix (ECM) proteolytic systems are increased with TAAs. Specifically, the matrix metalloproteinases (MMPs) have been linked through numerous studies to TAA formation. MMPs comprise a family of ECM-degrading proteinases. Endogenous tissue inhibitors (TIMPs) normally regulate MMP activity, and the activation of MMPs is complex and tightly controlled. Aneurysm formation may be related to relative changes in the balance between MMP/TIMP abundance favoring proteolysis. Through ECM degradation, the medial layer will undergo structural remodeling and a loss of structural integrity, leading to TAA formation. The goals of this review are to examine the structure of the normal and aneurysmal thoracic aorta and to place the new findings regarding ECM proteolysis in perspective with regard to TAA formation and progression. Through an integration of basic and clinical studies regarding the underlying molecular basis for proteolysis of the thoracic aorta, improved diagnostic, prognostic, and therapeutic strategies for this disease process are likely to be realized.

Risk Factors of Neurologic Deficit After Thoracic Aortic Endografting

BACKGROUND

Stroke and spinal cord injury (SCI) remain the most devastating complications of thoracic endovascular aortic repair (TEVAR). The risk factors associated with these complications are poorly understood. The aim of this study was to analyze the risk factors associated with neurologic deficits after TEVAR.

METHODS

From 1998 to 2005, 153 patients underwent 184 TEVARs. Computed tomography scans, angiograms, and medical records were reviewed. TEVAR was completed in all but 3 patients. The underlying pathologies included descending thoracic aortic aneurysm in 91, acute type B aortic dissection in 25, chronic type B aortic dissection in 42, aortic transection in 12, and penetrating aortic ulcer in 14.

RESULTS

Stroke developed in 8 patients, and SCI developed in another 8 patients (4 immediate, 4 delayed paraplegia/paraparesis). The procedure-associated stroke and SCI rate was 4.3% (8/184). Univariate statistical analysis revealed increased postoperative stroke with obesity, significant intraoperative blood loss, and evidence of peripheral vascular embolization/thrombosis. Aneurysmal pathology, iliac conduit, and hypogastric artery coverage were highly associated with postoperative SCI after TEVAR. Early and late mortality were 9.8% (n = 18) and 19% (n = 35) in a 16-month average period of follow-up.

CONCLUSIONS

The incidence of stroke and SCI after TEVAR was 4.3% (8/184). The risk factors associated with postoperative stroke were obesity, intraoperative blood loss, and vascular embolization. Aneurysm as an underlying pathology, the use of an iliac conduit, and coverage of the hypogastric artery were all associated with SCI. These risk factors for SCI may be markers of tenuous collateral blood supply to the spinal cord.

Endovascular stent grafting versus open surgical repair of descending thoracic aortic aneurysms in low-risk patients: A multicenter comparative trial

OBJECTIVE

Results are presented from the first completed multicenter trial directed at gaining approval from the US Food and Drug Administration of endovascular versus open surgical repair of descending thoracic aortic aneurysms.

METHODS

Between September 1999 and May 2001, 140 patients with descending thoracic aneurysms were enrolled at 17 sites and evaluated for a Gore TAG Thoracic Endograft. An open surgical control cohort of 94 patients was identified by enrolling historical and concurrent subjects. Patients were assessed before treatment, at treatment, and at hospital discharge and returned for follow-up visits at 1 month, 6 months, and annually thereafter.

RESULTS

One hundred thirty-seven of 140 patients had successful implantation of the endograft. Perioperative mortality in the endograft versus open surgical control cohort was 2.1% (n = 3) versus 11.7% (n = 11, P < .001). Thirty-day analysis revealed a statistically significant lower incidence of the following complications in the endovascular cohort versus the surgical cohort: spinal cord ischemia (3% vs 14%), respiratory failure (4% vs 20%), and renal insufficiency (1% vs 13%). The endovascular group had a higher incidence of peripheral vascular complications (14% vs 4%). The mean lengths of intensive care unit stay (2.6 +/- 14.6 vs 5.2 +/- 7.2 days) and hospital stay (7.4 +/- 17.7 vs 14.4 +/- 12.8 days) were significantly shorter in the endovascular cohort. At 1 and 2 years' follow-up, the incidence of endoleaks was 6% and 9%, respectively. Through 2 years of follow-up, there were 3 reinterventions in the endograft cohort and none in the open surgical control cohort. Kaplan-Meier analysis revealed no difference in overall mortality at 2 years.

CONCLUSIONS

In this multicenter study early outcomes with descending aortic endovascular stent grafting were very encouraging when compared with those of a well-matched surgical cohort. However, at 2 years' follow-up, there is an incidence of endoleaks and reinterventions associated with endovascular versus open surgical repair. Continued vigilant surveillance of patients treated with an endograft is important.

Aortic Debranching for Descending Thoracic Aortic Aneurysm Repair by Stent Grafts

Endovascular repair of a descending thoracic aortic aneurysm may result in covering the ostia of the left carotid or left subclavian artery for proper proximal landing zones, and the celiac artery or superior mesenteric artery ostia in the abdomen for distal landing zones. To prevent possible complications of occluding the ostia of these vessels, the authors performed an innominate to left common carotid and left subclavian artery bypass as the first procedure in one patient. In the second patient they performed an aortoceliac and aortomesenteric bypass before stent graft placement. The stent graft repair of the descending thoracic aortic aneurysm was performed subsequently in both patients. This aortic debranching provides subsequent proper placement of thoracic stent grafts.

Degenerative aneurysm of the descending aorta. Endovascular treatment

The incidence of thoracic aortic aneurysms has a rate of occurrence of 10.9 cases per 100,000 person/year, with an estimated 5-year risk of rupture ranging from 16% (diameter between 4 and 5.9 cm) to 31% (6 cm or more). Despite increasing awareness of the important role of early diagnosis in treatment options, guidelines about therapeutic strategies are actually lacking, as well as definite evidence of pharmacological treatment able to resolve or delay the disease progression. Endovascular treatment proposed as alternative to surgery has been considered a therapeutic innovation, especially because of low invasiveness, which allows to treat even high surgical risk patients. The procedure is performed under general anesthesia, mechanical ventilation and blood pressure invasive monitoring (right radial artery cannulation). The common femoral artery or external iliac artery are used for access after surgical exposure. After exposition of the artery, a 6F sheath is inserted and 5000 UI of heparin administered. Angiography is then performed to identify the lesion, landing zones and its relation to side branches. Endovascular stent-graft is thus loaded on an extra-stiff guidewire and delivered, with induced hypotension, under fluoroscopic and transesophageal echo control. Post procedural angiography and echocardiography control are performed to reveal the final result.

Hybrid-procedures for the Treatment of Thoracoabdominal Aortic Aneurysms and Dissections

AIM

The conventional open repair of thoracoabdominal aneurysms and dissections remains complex and demanding and is associated with significant morbidity and mortality. We present our experience of hybrid open and endovascular treatment of thoracoabdominal aneurysms and dissections.

METHODS

Within an experience of 226 aortic stent-grafts between 1998 and April 2006, 6 of the patients (median age 60 years, range 35 to 68 years) with thoracoabdominal aneurysms (Crawford type I, II, III, and V) were treated with a combined endovascular and open surgical approach. Five men and one woman, with median aneurysm diameter of 75 mm (range 70-100 mm), received revascularization of the renal arteries, the superior mesenteric artery, and the coeliac trunk accomplished via transperitoneal bypass grafting. Aneurysmal exclusion was then performed by stent-graft deployment.

RESULTS

The entire procedure was technically successful in all patients. The patients were discharged a median of 9 days after the operation, while the postoperative studies revealed the patency of the vessels and no evidence of type I endoleak or secondary rupture of the aneurysm. During follow up (1 to 22 months) spiral-CT scanning revealed distinct shrinkage of the aneurysm, no graft migration or endoleak and patency of all revascularised vessels, except one renal artery in two patients. No patient experienced any temporary or permanent neurological deficit, and no dialysis was necessary.

CONCLUSION

The combined endovascular and open surgical approach is feasible, without cross clamping of the aorta and with minimized ischemia time for renal and visceral arteries, and seems to be an appropriate strategy for patients with a thoraco-abdominal aortic aneurysm or dissection.

Perioperative differences between endovascular repair of thoracic and abdominal aortic diseases

BACKGROUND

With the US Food and Drug Administration approval of the TAG thoracic device, more thoracic pathologies are being treated using endovascular techniques. Although endovascular abdominal and thoracic aortic repairs have some apparent similarities, there are substantive anatomic, pathologic, and technical differences that could impact perioperative outcomes. The purpose of this study is to identify these differences.

METHODS

During a 5-year period, 121 endovascular thoracic aortic repairs (TEVAR) and 450 abdominal aortic repairs (EVAR) were performed at a single institution. Preoperative, intraoperative, and early postoperative data were prospectively collected and retrospectively reviewed. Aggregate outcome measures were compared between the two cohorts, with statistical significance achieved at P < .05.

RESULTS

The mean age of patients undergoing EVAR was 72.8 +/- 8.3 compared with 68.3 +/- 13.9 for TEVAR (P = .02). More women underwent TEVAR (30.6% vs 11.1%, P < .001). Aneurysms undergoing TEVAR were larger than those for EVAR (62.0 mm vs 58.3 mm, P = .01). Intraoperatively, EVAR required 26.2 minutes of fluoroscopy compared with 22.1 minutes for TEVAR (P < .001). The amount of contrast used was higher in TEVAR (133.6 mL vs 93.6 mL, P < .001). The mean procedure times were 164 minutes for EVAR and 115 minutes for TEVAR (P < .001). Iliac conduits were required in 46 patients (10.2%) undergoing EVAR, and in 24 (19.8%) undergoing TEVAR (P = .007). The 30-day or in-hospital mortality was 2.0% for EVAR and 5.0% for TEVAR (P = NS). The median length of stay was longer for TEVAR (3 days vs 2 days, P =.034). There were 54 postoperative complications in 36 TEVAR patients (29.8%), including 13 neurologic (10.7%), 8 renal (6.6%), 7 pulmonary (5.8%), 6 ischemic (5.0), and 5 (4.1%) hemorrhagic events. Among the EVAR group, 136 (30.2%) patients had postoperative complications, which included 45 ischemic (10.0%), 34 wound (7.6%), 22 renal (4.9%), 12 cardiac (2.7%), 8 pulmonary (1.8%), 5 gastrointestinal (1.1%), and 4 neurologic (0.9%) events.

CONCLUSIONS

A relatively higher proportion of women underwent TEVAR than EVAR, and this was reflected in the greater need for iliac conduits to accommodate the larger delivery catheters of the thoracic devices. Intraoperative imaging techniques were also different, and TEVAR required higher contrast volumes despite shorter overall procedure times. The incidence of strokes and spinal cord ischemia was also higher during TEVAR. Despite apparent similarities of devices and techniques, EVAR and TEVAR are fundamentally different procedures with different perioperative outcomes.

Long-Term Results From a 12-Year Experience With Endovascular Therapy for Thoracic Aortic Disease

BACKGROUND

Endovascular approaches promise to revolutionize therapy for thoracic aortic disease. This study describes a long-term analysis of endovascular thoracic aortic repair.

METHODS

Seventy-three patients (mean age, 67.4 years) underwent endovascular thoracic aortic repair from 1993 to 2005. Indications for intervention included aneurysm (38%), dissection (23%), or penetrating ulcer or pseudoaneurysm (34%). Rupture was present in 16 patients (22%). Seventy-one percent were considered high risk for open surgery for reasons of age or comorbid conditions. Treated segments included ascending aorta (n = 1), distal arch (n = 24), and proximal (n = 50) or distal (n = 55) descending aorta. The total descending thoracic aorta was covered in 31 patients. Procedural success was achieved in 96%. Devices were delivered by femoral (79%), retroperitoneal iliac (18%), or carotid (2.7%) exposure. Devices used included Excluder (n = 30), Talent (n = 23), Zenith (n = 3), AneuRx (n = 5), and custom-fabricated (n = 14). Follow-up was 100% complete.

RESULTS

Thirty-day mortality was 5.5%. Significant morbidity included stroke (8.2%) and need for dialysis (4.1%). Although 3 patients had transient spinal cord ischemia (4.1%), none had permanent sequelae. Intervention for fusiform aneurysm was independently associated with a composite end point of 30-day mortality, need for dialysis, and stroke (p = 0.015). Eight patients (11%) had new or persistent endoleaks, and aortic reintervention was performed in 7 patients (9.6%). Mean survival for the entire cohort was 46.8 +/- 5.1 months. Intervention for penetrating ulcer or pseudoaneurysm (p = 0.045) was independently associated with long-term all-cause mortality.

CONCLUSIONS

An endovascular approach produces acceptable results for a broad range of thoracic aortic disease. However, the potential for endoleak or need for reintervention mandates continued close follow-up to achieve satisfactory long-term results.

Stent-graft versus open-surgical repair of the thoracic aorta: Mid-term results

OBJECTIVE

Pivotal and comparative trial data are emerging for stent graft (SG) vs open repair of the thoracic aorta. We reviewed procedure-related perioperative morbidity, mortality, and mid-term outcomes in a contemporary series of patients treated with SG of the thoracic aorta. The data were compared with those of a patient cohort concurrently treated with open surgical repair confined to the descending aorta.

METHODS

A review of patients undergoing SG procedures and open surgery of the thoracic aorta from January 1, 1996, to November 30, 2005, was performed from a prospectively compiled database. Study end points included perioperative complications, late survival, freedom from reinterventions, and graft-related complications. Multivariate methods were used to assess variables potentially associated with study end points; late outcomes were compared with actuarial methods.

RESULTS

In 105 patients (mean age, 70 years; 66 male [62.9%]) SG repairs were done for 68 degenerative aneurysms (64.7%), 12 penetrating ulcers (11.4%), 15 pseudoaneurysms (14.3%), 9 traumatic tears (8.6%), and 1 acute dissection (0.9%). Mean follow-up was 22 months (range, 0 to 101 months). Eighty-nine (84.8%) SG patients were asymptomatic at presentation and underwent elective repair, whereas 16 (15.2%) presented with acute conditions and underwent urgent repair. Perioperative mortality was 7.6% (8/105), and actuarial survival at 48 months was 54% +/- 7%. The perioperative mortality rate among SG patients treated for degenerative pathology was 10.4% (8/77). Seven (6.7%) of 105 patients experienced spinal cord ischemic complications, including 2 patients with transient paraparesis that resolved by the time of discharge. Reinterventions were performed in 10.5% of patients (11/105), with freedom from reintervention approaching 81% by 48 months. Over the same interval, 93 patients were treated with open-surgical repair for descending thoracic aneurysm (anastomosis cephalad to the celiac axis). Perioperative mortality in the open cohort was 15.1% (14/93; P = .09 vs SG repair), and the 48-month actuarial survival was 64% +/- 6%. The incidence of spinal cord ischemic complications was 8.6% (8/93), including 4 patients with transient paraparesis (P = .44 vs SG repair). Nine patients (9.7%) required surgical reintervention during the follow-up period, with 48-month freedom from reintervention approaching 79% (P = .73 vs SG repair).

CONCLUSIONS

Operative mortality was halved with SG, with similar late survival for both cohorts. Reinterventions were required at a nearly identical rate for open repair and SG, and both groups experienced similar rates of spinal cord ischemic complications.

Perioperative Management to Improve Neurologic Outcome in Thoracic or Thoracoabdominal Aortic Stent-Grafting

BACKGROUND

Thoracic or thoracoabdominal aortic stent-graft repair has shown a reduction in morbidity and mortality rates due to the procedure's advantages (no aortic cross-clamping, continuous distal aortic perfusion, no reperfusion injury). However, 3% to 12% of the patients are at risk of spinal cord ischemia. We investigated spinal cord protective measures with evoked potentials, cerebrospinal fluid drainage, and prevention of hypotension to minimize postoperative neurologic deficit.

METHODS

Between November 2000 and July 2005, vital parameters and spinal cord function were monitored, including cerebrospinal fluid pressure and transcranial motor-evoked and somatosensory-evoked potentials in 36 stent-graft procedures (31 patients) on the thoracic or thoracoabdominal aorta.

RESULTS

Stent-graft placement was technically successful in all patients. We achieved a survival rate of 100% without neurologic deficit after fast-track extubation. Eleven of 31 patients exhibited changes in evoked potentials during stent-graft deployment. In 12 of 31 patients (including the 11 with evoked potential alterations), cerebrospinal fluid pressure exceeded 15 mm Hg. Cerebrospinal fluid drainage and vital parameter adjustment were executed in those instances. We observed intraoperative evoked potential total recovery in 10 of 11 patients after these interventions.

CONCLUSIONS

Interventions to improve spinal cord perfusion led to total recovery of spinal function in most patients (10/11). Therefore, spinal cord protective measures with motor- and somatosensory-evoked potential monitoring, cerebrospinal fluid drainage, and prevention of hypotension can reduce the incidence of spinal cord ischemia and improve the neurologic outcome of patients undergoing endovascular thoracic or thoracoabdominal aortic repair.

Endovascular Treatment of Peripheral Vascular Disease

An estimated 10 million people in the U.S. have symptomatic peripheral arterial disease (PAD); 20 to 30 million have asymptomatic PAD. The prevalence of intermittent claudication increases with age, affecting >5% of patients over 70. The incidence of claudication doubles or triples in patients with diabetes. As people grow older, symptoms from peripheral vascular disease increasingly limit daily activity. Until recently, vascular surgical procedures were the only alternative to medical therapy in such patients. Today, advances in minimally invasive percutaneous interventions have made endovascular procedures the primary modality for revascularization in most patients. Compared with open surgical procedures, endovascular interventions offer comparable or superior long-term rates of success with very low rates for morbidity and mortality. Furthermore, most of these interventions are performed on an outpatient basis, reducing hospital stays considerably. In this monograph we discuss current endovascular interventions for treating occlusive PAD, aneurysmal arterial disease, and increasingly common venous occlusive diseases.

Stent-graft treatment of thoracoabdominal aortic aneurysms after complete visceral debranching

Complex thoracoabdominal aortic aneurysm repair remains a difficult problem from both open and endoluminal approaches. The reduced morbidity and mortality rates reported to be associated with aortic stent-graft procedures makes this option more attractive, but it is hampered by the need for adequate proximal and distal seal zones. While branched and fenestrated aortic stent-grafts are being refined, an alternative is a two-stage surgical and endoluminal approach that is particularly useful for aneurysms involving the aortic visceral segment. The present report describes stent-graft repair in two patients after complete visceral artery revascularization or "debranching."

Endoleaks after endovascular repair of thoracic aortic aneurysms

OBJECTIVE

Endoleaks are one of the unique complications seen after endovascular repair of thoracic aortic aneurysms (TEVAR). This investigation was performed to evaluate the incidence and determinants of endoleaks, as well as the outcomes of secondary interventions in patients with endoleaks, after TEVAR.

METHODS

Over a 6-year period, 105 patients underwent TEVAR in the context of pivotal Food and Drug Administration trials with the Medtronic Talent (n = 64) and Gore TAG (n = 41) devices. The medical and radiology records of these patients were reviewed for this retrospective study. Of these, 69 patients (30 women and 39 men) had follow-up longer than 1 month and were used for this analysis. The patients were evaluated for the presence of an endoleak, endoleak type, aneurysm expansion, and endoleak intervention.

RESULTS

The mean follow-up in this patient cohort was 17.3 +/- 14.7 months (range, 3-71 months). Endoleaks were detected in 29% (20/69) of patients, of which 40% (8/20) were type I, 35% (7/20) were type II, 20% (4/20) were type III, and 5% (1/20) had more than one type of endoleak. Patients without endoleaks experienced greater aneurysm sac regression than those with endoleaks (-2.89 +/- 9.1 mm vs -0.13 +/- 7.2 mm), although this difference was not statistically significant (P = .232). All but 2 endoleaks (90%; 18/20) were detected on the initial postoperative computed tomographic scan at 30 days. Two endoleaks (10%; 2/20) developed late. The endoleak group had more extensive aneurysms with significantly larger aneurysms at the time of intervention (69.4 +/- 10.5 mm vs 60.6 +/- 11.0 mm; P = .003). Factors predictive of endoleak included male sex (P = .016), larger aneurysm size (P = .003), the length of aorta treated by stent grafts (P = .0004), and an increasing number of stents used (P < .0001). No open conversions were performed for treatment of endoleaks. Four (50%) of the eight type I endoleaks were successfully repaired by using endovascular techniques. None of the type II endoleaks was treated by secondary intervention. During follow-up, the maximum aneurysm diameter in the type II endoleak patients increased a mean of 2.94 +/- 7.2 mm (range, -4.4 to 17 mm). Spontaneous thrombosis has occurred in 29% (2/7) of the type II endoleaks. Patients with type III endoleaks experienced a decrease in mean maximal aneurysm diameter of 0.78 +/- 3.1 mm during follow-up.

CONCLUSIONS

Endoleaks are not uncommon after TEVAR. Many type I endoleaks may be treated successfully by endovascular means. Short-term follow-up suggests that observational management of type II endoleaks is associated with continued sac expansion, and these patients should be monitored closely.

Hybrid approach to complex thoracic aortic aneurysms in high-risk patients: surgical challenges and clinical outcomes

BACKGROUND

Endovascular therapy is a less invasive alternative treatment for high-risk patients with thoracic aortic aneurysms. However, this technology alone is often not applicable to complex aneurysmal morphology. The purpose of this study was to evaluate the utility of hybrid strategies in high-risk patients who are otherwise unsuitable for endovascular therapy alone.

METHODS

During an 18-month period, 31 high-risk patients (mean age, 69 years; range, 52-89 years) underwent combined open and endovascular approaches for complex aneurysms, including 16 patients with ascending and arch aneurysms and 15 patients with aneurysms involving visceral vessels. Among them, 11 patients had histories of aneurysm repairs. To overcome the anatomic limitations of endovascular repairs, various adjunctive surgical maneuvers were used, including aortic arch reconstruction in 3 patients, supra-aortic trunk debranching in 13 patients (including 8 patients who required aortas as inflow sources), and visceral vessel bypasses in 15 patients (including 10 patients who required bypasses to all 3 visceral branches). Additionally, carotid artery access was obtained in 1 patient, and iliac artery conduits were created in 12 patients.

RESULTS

Technical success was achieved in all patients. There was one perioperative death (3.2%) due to postoperative bleeding. Two patients (6.4%) had immediate type II endoleaks, which were resolved by the 1-month follow-up. Other procedure-related complications occurred in three patients (9.6%), including renal bypass thromboses in two patients and retroperitoneal hematoma, which was successfully managed conservatively, in one patient. During a mean follow-up of 16 months, two patients died of unrelated causes, whereas the remainder of patients were asymptomatic, without aneurysm enlargement.

CONCLUSIONS

Our study highlights how hybrid strategies incorporating surgical and endovascular approaches can be used successfully in treating patients with complex thoracic aortic aneurysms. This combined approach potentially expands the field of endovascular stent grafting and is an attractive solution for patients with poor cardiopulmonary reserves.

Contemporary results of open surgical repair of descending thoracic aortic aneurysms

Considerable progress has been made in the refinement of operative strategies to repair descending thoracic aortic aneurysms (TAA). While no single strategy has totally eliminated the postoperative morbidities of renovisceral and spinal cord ischemic complications, contemporary reports from centers of excellence detail admirable rates of overall risk in the 5-10% range. Balancing these risks represents a clinical dilemma for the aortic surgeon and a thoughtful, logical risk analysis of the individual patient presentation is clearly warranted before TAA repair. In this article, we review surgical approaches to TAA and adjunctive methods, examine the reports from centers of excellence, and elucidate the challenges yet to be overcome in the management of patients with aneurysms of the descending thoracic aorta.