Early and Long-term Results of Replacement of the Descending Aorta

Endovascular Repair For Thoracic Aortic Disease: Tertiary Single-center Experience In Northwestern Greece

The purpose of this article is to report the initial experience with endovascular repair of thoracic aortic disease in a single tertiary vascular unit in northwestern Greece.

Between 2003 and 2005, 16 patients were treated with endovascular techniques for various pathologies of the descending thoracic aorta. Twelve patients were treated electively and four emergently. Operative and follow-up data for a mean time of 18.4 months were retrospectively collected and analyzed.

Primary technical success was obtained in 14 (87.5%) cases. No early or late deaths occurred, and there was no major operation-related complication. No paraplegia was observed in our patients. Stent graft–related complications occurred in 18.75% (one type 2 and two type 3 endoleaks), but they all had a favorable outcome. No further problems have been reported in any of our patients.

Endovascular stent graft repair for diseases of the thoracic aorta seems to be a promising alternative to open surgery, especially for high-risk patients. Long-term results are needed to confirm the early benefit of this treatment option with regard to morbidity and mortality rates. The potential of this technique to be applicable even in relatively small, tertiary vascular centers might be of great benefit to patients.

Spinal cord injury following thoracic and thoracoabdominal aortic repairs

Objective

To discuss the currently available approaches to prevent spinal cord injury during thoracic and thoracoabdominal aortic repairs.

Methods

We carried out a PubMed search up to 2013 using the Medical Subject Headings: “aortic aneurysm/surgery” and “spinal cord ischemia”; “aortic aneurysm, thoracic/surgery” and “spinal cord ischemia”; “aneurysm/surgery” and “spinal cord ischemia/cerebrospinal fluid”; “aortic aneurysm/surgery” and “paraplegia”. All 190 original articles satisfying our inclusion criteria were analyzed for incidence, predictors, and other pertinent variables related to spinal cord injury, and we compared the results in recent publications with those in earlier reports.

Results

The mean age of the 38,491 patients was 65.3 ± 4.9 years. The overall incidence of paraplegia and/or paraparesis was 7.1% ± 6.1% (range 0%–32%). The incidence of spinal cord injury before 2000, from 2001 to 2007, and 2008–2013 was 9.0% ± 6.7%, 7.0% ± 6.1%, and 5.9% ± 5.2%, respectively ( p = 0.019). Various predictors of spinal cord injury were identified, extent of disease being the most common. Modification of surgical techniques, use of adjuncts, and better understanding of spinal cord perfusion physiology were attributed to the decrease in postoperative spinal cord injury in recent years.

Conclusions

Spinal cord injury after thoracic and thoracoabdominal aortic repair poses a real challenge to cardiovascular surgeons. However, with evolving surgical strategies, identification of predictors, and use of various adjuncts over the years, the incidence of spinal cord injury after thoracic/thoracoabdominal aortic repair has declined. Embracing a multimodality approach offers a good insight into combating this grave complication.

Emergency endovascular stent grafting in acute complicated type B dissection

OBJECTIVE

The objective of this study was to assess midterm results of emergency endovascular stent grafting for patients with life-threatening complications of acute type B aortic dissection.

METHODS

Between March 1999 and November 2011, 110 patients (86 men, 24 women) with complications of acute type B aortic dissection (mean age, 61 years; range, 19-87 years) were treated with thoracic endovascular aortic repair for malperfusion (55.5%) or aortic rupture (53.6%) in five major European referral centers and one U.S. referral center. Additional comorbidities included hypertension in 90 patients (82%), diabetes in 14 patients (13%), and chronic obstructive pulmonary disease in six patients (6%). Eleven patients (10%) had undergone previous aortic surgery.

RESULTS

Overall hospital mortality was 12% (n = 13), with 14 late deaths after hospital discharge. In-hospital complications occurred in 32 patients (36%); 10 patients developed postoperative renal failure, five patients experienced new permanent neurologic symptoms, and six patients (5.4%) experienced retrograde type A aortic dissection. Furthermore, nine patients (8%) developed an early type I endoleak. Actuarial survival at 1 and 5 years was 85% and 73%, respectively. Postprocedural computed tomography angiography showed complete or partial thrombosis of the false lumen at the stent graft level in 61% and 23% of all patients, respectively. Freedom from treatment failure according to the Stanford classification was 82%, 75%, and 59% at 1, 3, and 5 years.

CONCLUSIONS

Endovascular repair of complicated acute type B aortic dissection is proven to be a technically feasible and effective treatment modality in this relatively difficult patient cohort. Short-term and midterm results are persuasive; however, the long-term efficacy needs to be further evaluated.

Midterm results after endovascular treatment of acute, complicated type B aortic dissection

BACKGROUND

The purpose of this study was to assess the efficacy and midterm results of endovascular treatment of acute, complicated type B aortic dissection.

METHODS

Between January 2001 and February 2010, 32 patients (7 women, 25 men) with acute, complicated type B aortic dissection (mean age, 56 years; range, 35 to 83 years), defined as either aortic rupture, malperfusion, intractable pain, or uncontrolled hypertension, underwent endovascular stent graft placement with either the Gore Excluder/TAG device (n = 11), Medtronic Talent/Valiant device (n = 16), Bolton Relay (n = 2), or a combination of these stents (n = 3). Follow-up was 94% complete and averaged 26 ± 23 months.

RESULTS

Technical feasibility and success with deployment proximal to the entry tear was 87%, requiring partial or total coverage of the left subclavian artery (LSA) in 9 patients (28%). Hospital mortality was 12% ± 11% (95% confidence limit) with 2 late deaths (17 and 98 months after implant). Causes of hospital death included rupture in 2, retrograde type A dissection in 1, and multiorgan failure in 1 patient. Three patients (11%) experienced new neurologic complications (2 paraparesis and 1 hemiparesis). Six patients with malperfusion required branch vessel stenting. Furthermore, 2 had an early type Ia endoleak. Actuarial survival at 1 and 5 years was 81% and 76%, respectively. Freedom from treatment failure at 1 and 5 years (including reintervention, aortic rupture, device-related complication, and aortic related death) was 78% and 61%, respectively.

CONCLUSIONS

Endovascular stent-graft placement in acute, complicated type B aortic dissection proves to be a promising alternative therapeutic treatment modality in this relatively difficult patient cohort. Refinements, especially in stent design and application, may further improve the prognosis of patients in this life-threatening situation.

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.

Early outcomes after elective and emergent endovascular repair of the thoracic aorta

BACKGROUND

Endovascular treatment of thoracic aortic pathology has emerged as a viable alternative to open surgical repair in both the elective and emergent settings. The aim of this study was to evaluate preoperative work-up, intra-operative strategy, and outcomes of endovascular stent-grafting of the thoracic aorta in patients undergoing elective repair and those undergoing emergent repair.

METHODS

All patient information was obtained by a retrospective review of an established clinical database for all endovascular thoracic stent-graft cases. From October 1999 to August 2005, 70 patients were treated with endovascular stent-grafts for lesions of the thoracic aorta. Thirty-five patients had an elective endovascular procedure, and 35 patients had an emergent procedure.

RESULTS

Thirty-five patients in the endovascular (EL) group were treated for aneurysm (n = 34) and type B dissection (n = 1). Thirty-five patients in the emergent (EM) group were treated for aneurysm (n = 10), intramural hematoma (n = 10), type B dissection (n = 7), traumatic rupture (n = 7), and aortoesophageal fistula (n = 1). Preoperative angiography was performed in 94.3% (33/35) of EL patients but in only 45.7% (16/35) EM patients (P < .005). The EM procedures had significantly shorter operative times, used lower contrast volumes, used fewer stent-graft components (mode 2, range 1 to 5 vs mode 1, range 1 to 3; P = .02), and spinal cerebrospinal fluid drains were used significantly less often (82.9% vs 57.1%, P = .04). Both groups had similar 30-day morbidity, mortality (0/35 EL vs 1/35 [2.9%] EM, P = .99), postoperative endoleak (9/35 [25.7%] EL vs 7/35 [20.0%] EM, P = .78), endovascular failure (3/35 [8.6%] EL vs 5/35 [14.3%] EM, P = .71), and patient survival.

CONCLUSION

There are significant differences in the underlying pathology, preoperative evaluation, and operative course between elective and emergency treatment endovascular procedures for lesions of the thoracic aorta. Endovascular repair of thoracic aortic lesions can be accomplished with low perioperative mortality and morbidity rates, as well as acceptable endoleak and endovascular failure rates for both elective and emergency procedures.

Inflammatory Aneurysm of the Descending Aorta: A Case Report

We report a rare case of an inflammatory descending aneurysm. At surgery, the patient had multiple aneurysms on the descending aorta. Histology of the specimen demonstrated an infiltration of chronic inflammatory cells in the aortic media.