Long-term results of endoluminal grafting for descending thoracic aortic aneurysms

The surgical strategy for multilevel massive ossification of the posterior longitudinal ligaments

Purpose

Creating enough decompression, favorable outcome, less complication, and maintain adequate lordosis and stability in the patients with cervical myelopathy due to multilevel massive ossification of the posterior longitudinal ligament (OPLL) still poses a challenge for surgeons. The aim of our study is to retrospectively evaluate our patients and try to seek a better surgical strategy.

Methods

Between 2015 and 2019, 55 consecutive patients with multilevel massive OPLL underwent surgical treatment. Among these, 40 patients were treated with cervical laminectomy and then anterior decompression, fusion, and fixation (ADF), which was defined as group 1, and 15 patients were treated with cervical laminectomy and fixation simultaneously, which was defined as group 2. The patient's radiographic characteristics and postoperative outcomes were evaluated.

Results

Better postoperative cervical sagittal lordosis and less long-term axial pain was achieved in group 1 (p < 0.001), though the functional outcome had no significant difference. In the multivariable analysis, anterior fixation accounts for independent factors for better cervical sagittal alignment (p < 0.001). No complications directly associated with cervical laminectomy were observed.

Conclusion

In patients with cervical multilevel massive OPLL, laminectomy at compression level and then ADF depended on the severity and range of compression, but corpectomy of not more than two vertebral bodies is suggested, except K-line (+) and long-segment massive OPLL majorly involving the C2 and posterior laminectomy above and below the OPLL-affected levels with posterior fixation simultaneously.

Endovascular repair of nonruptured thoracic aortic aneurysms: systematic review

Thoracic aortic aneurysms represent a major health problem. Untreated thoracic aortic aneurysms may rupture, which has a dismal outcome. The standard treatment for thoracic aneurysms is open surgical repair, but it is associated with high mortality and morbidity. Endovascular repair provides a less invasive and safer alternative. A systematic review was performed of all published literature on the above subject. Our primary objective was to measure 30-day mortality for nonruptured thoracic aortic aneurysms. Studies describing other pathologies, such as aortic dissection, mycotic aneurysms, penetrating ulcers, traumatic transactions, and pseudoaneurysms, and studies from which independent data for thoracic aortic aneurysm could not be separately extracted were excluded. Case series describing less than 10 patients and all case series describing ruptures or concealed ruptures were excluded as well. Twenty-six case series and one comparative study were identified. This formed a cohort of 1,038 patients. Technical success was possible in more than 97% of patients. The 30-day mortality was calculated to be 5.1% even though the group under study was mostly those who were refused surgery by a surgeon or had a higher surgical risk. The incidence of paraplegia and stroke was 3.1% and 4.7%, respectively. Early endoleak was seen in 16.7% of patients, whereas 11.7% of patients developed late endoleak, but most did not require any additional procedure. The rate of reintervention was 14.9%. The 12-month mortality rate was 14.2%. Endovascular repair shows encouraging short-term results. It is associated with significantly less mortality and morbidity, but long-term results need to be further investigated.

Vascular Graft Replacement of the Ascending and Descending Aorta: Do Dacron Grafts Grow?

BACKGROUND

The tendency of Dacron vascular grafts to expand after placement in the ascending and descending thoracic aorta has been noted, but never described in detail.

METHODS

From 1986 to 2005, two or more computed tomography studies were obtained as part of routine postoperative surveillance in patients with Dacron grafts implanted to replace diseased aortic segments. Scans were digitized to evaluate the entire thoracic aorta. The median diameters of 547 grafts (18 to 34 mm) in the ascending (349) and descending (198) aorta were calculated from more than 2,000 postoperative computed tomography scans.

RESULTS

In scans obtained 7 or fewer days after implantation, the median graft diameters increased from the manufacturer's measurement by 17% in the ascending aorta (n = 169; interquartile range, 11% to 21%; p < 0.0001) and 21% in the descending aorta (n = 63; interquartile range, 12% to 25%; p < 0.0001). From an initial scan within 30 days to at least one other within 18 months after implantation, ascending aorta grafts dilated further, at a median rate of 2.8% per year (n = 143; interquartile range, -2.2% to +6.9%; p = 0.0001). Descending grafts dilated less markedly: 1.1% per year (n = 80; interquartile range, -4.0% to +6.1%; p = 0.14). After 18 months, median graft expansion gradually diminished to less than 1% per year.

CONCLUSIONS

Significant initial expansion and early growth of woven vascular Dacron grafts occurs; it is slightly different in the ascending and descending aorta. Graft expansion should be anticipated when selecting grafts for aortic valve-sparing procedures to prevent development of regurgitation, and, for endoluminal repair of thoracoabdominal aneurysms, to prevent development of type III endoleaks in the projected landing zone.