The Visceral Hybrid Repair of Thoraco-abdominal Aortic Aneurysms – A Collaborative Approach

Mycotic Thoracic Aortic Aneurysm: Epidemiology, Pathophysiology, Diagnosis, and Management

Mycotic thoracic aortic aneurysm (MTAA) is an aneurysm of the aorta caused by infection of the vessel tissue through microbial inoculation of the diseased aortic endothelium. It is most commonly caused by bacteria. Rarely, it can be caused by fungi. However, viral aortic aneurysm has never been reported. Depending on the area and time period investigated, the infections organism discovered may vary significantly. Little is known about the natural history of MTAA due to its rarity. It is not known if they follow the same pattern as other TAAs. However, it is unclear whether MTAA follows a similar clinical course. The combination of clinical presentation, laboratory results, and radiographic results are used to make the diagnosis of MTAA. Treatment of MTAA is complex since patients frequently present at a late stage, frequently with fulminant sepsis, as well as concomitant complications such as aneurysm rupture. While medical treatment, including antibiotics, is recommended, surgery is still the mainstay of management. Surgery to treat MTAA is complicated and carries a high risk of morbidity and mortality and includes both open repairs and endovascular ones. In this review, we explore the etiology, pathogenesis, clinical presentations, diagnostic modalities as well as treatment management available for MTAA.

Single Stem Visceral Debranching for Complex Aortic Disease

Objective

The treatment of complex aortic disease has been described with various retrograde visceral bypass techniques. An original technique with a single stem retrograde visceral graft (SSRVG) is presented.

Methods

This was a single centre retrospective study including 16 patients between 2015 and 2019. Patients were treated for aortic dissection (AD; type A and acute or chronic type B), thoraco-abdominal aortic aneurysms (TAAAs), and visceral occlusive disease. Surgery consisted of visceral vessel debranching from the native infrarenal aorta or from an aortic graft. In the case of AD, surgical fenestration was performed. Additional thoracic endovascular aneurysm repair (TEVAR) completed the treatment when indicated, during the same procedure or later. Patient outcomes and reconstruction patency were studied.

Results

The mean patient age was 64 years (median 68 ± 12.6). Ten (62%) patients were treated for AD, three (19%) for TAAA, and three (19%) for occlusive disease. Sixty-nine target vessels were debranched with this SSRVG technique. Aortic surgical fenestration was performed in eight cases and TEVAR in four. During their hospital stay, three (19%) TAAA patients died, seven cases of renal insufficiency (44%), four cases of pneumonia (25%), and three colonic ischaemia cases (19%) were noted. After a mean follow up of 21 months, no other deaths occurred. All vessels (except two inferior mesenteric arteries) were patent and no endoleak was noted.

Conclusion

The SSRVG technique can be offered in various complex aortic diseases. The use of a single graft is feasible and reduces the volume of multiple branch assembly in the retroperitoneal space. The observed patency rate is high.

•

Not all patients with complex aortic disease are amenable to open surgery or total endovascular repair.

•

Hybrid surgery with visceral vessel debranching may represent an alternative.

•

Various techniques using several grafts to debranch visceral vessels have been published.

•

The use of a single conduit for total visceral debranching is relatively straightforward and provides excellent patency results.

Total abdominal debranching hybrid thoracoabdominal aortic aneurysm repair versus chimneys and snorkels

Open thoracoabdominal aortic aneurysm (TAAA) repair remains a surgical challenge. Hybrid and total endovascular repair have emerged as alternatives in treating TAAA. Total endovascular TAAA repair may be best performed with branched/fenestrated stent grafts. However, these technologies are not yet widely available. Thus, currently total endovascular TAAA repair using the chimney/snorkel techniques is considered a viable option in many centers.

In this article, we briefly review 2 readily available techniques with off-the-shelf devices, hybrid procedure using total abdominal debranching, and total endovascular repair using chimney/snorkel procedures. The hybrid TAAA repair avoids thoracotomy but requires laparotomy and carries high morbidity and mortality (eg, operative mortality, 4%-26% and renal failure, 4%-26%), comparable to traditional open repair. The staged hybrid approach has been proposed to minimize the invasiveness of the procedure, whereas the associated risk of interval aortic deaths is not negligible. Total endovascular repair reduces the morbidity and mortality after TAAA repair (eg, operative mortality, 3%-20% and renal failure, 0%-20%). However, it is technically demanding and the risks of future reinterventions—and need for repetitive surveillance—is inevitable (eg, immediate type I endoleak, 7%-16% and 1-year branch patency, 93%-98%). Currently, there are not enough data to determine which less-invasive option for open repair in patients with TAAA is superior. These alternatives should complement each other and be applied to carefully selected populations as a part of the overall toolbox in treating TAAA.

Isolated Ruptured Paravisceral Penetrating Aortic Ulcers

BACKGROUND

The goal of this study is to investigate the clinical presentation, treatment options, and outcomes of the patients with isolated ruptured paravisceral penetrating aortic ulcers (PV-PAU).

METHODS

All patients presenting with acute aortic syndrome from 2015 to 2020 were screened, of which patients with isolated ruptured PV-PAU were included in this retrospective study. Study endpoints were the assessment of treatment options, technical success, and clinical outcome. Outcome measures included major perioperative complications and mortality.

RESULTS

Sixteen patients (11 men; median age 68; IQR 60 - 75 years) presented with isolated ruptured PV-PAU were included in this study. The median follow-up was 25 months (range 1 - 51). Ruptured PV-PAUs represented 12.3% of the ruptured aortic aneurysms in all locations. PV-PAUs were found in segment A (n = 8, 50%), segment B (n = 5, 31%), and segment C (n = 3, 19%). PV-PAUs showed a mean protrusion distance of 27±10 mm, a mean neck diameter of 21 ± 7 mm, and maximal aortic diameter of 50 ± 11 mm. Five patients (31%) showed hemodynamic instability on admission and needed intense fluid resuscitation. Of those, 2 patients needed urgent laparotomy with a fast transabdominal supraceliac aortic clamping, one needed an aortic balloon occlusion to obtain rapid aortic control. The open aortic repair was the most frequently performed surgery (11/16, 69%), followed by hybrid procedures (3/16) and parallel graft chimney technique (2/16). Two patients died during the follow-up, calculating for in-hospital and 1-year mortality rates of 6 - 12%, respectively. The postoperative morbidity rate was 31%. Postoperative complications included acute renal failure (31%), pneumonia (25%), and 1case of ischemic colitis (6%). No spinal cord ischemia was reported.

CONCLUSIONS

Ruptured PV-PAU is a rare and challenging diagnostic and therapeutic entity. Open aortic repair seems to be a reliable option in treating patients with isolated ruptured PV-PAUs. Hybrid procedures and parallel stent-graft techniques can only be used in selected patients.

[Visceral debranching in hybrid surgery of thoracoabdominal aortic aneurysms]

Presented herein is a review of the literature dedicated to the method of visceral debranching, i. e., switching of the visceral and renal branches of the abdominal aorta to its intact portion, using synthetic vascular prostheses as the first stage of hybrid surgical treatment of thoracoabdominal aortic aneurysms prior to endovascular aortic aneurysm repair. This is accompanied and followed by describing the history of the problem, operative technique, results of studies, as well as the data from registries and meta-analyses. Also discussed are the main complications of the method and measures of their prevention. We conclude that hybrid surgery of the thoracoabdominal portion of the aorta is a promising method in a particular cohort of patients, especially those at high surgical risk of 'open' aortic surgery.

Parallel Grafting Should Be Considered as a Viable Alternative to Open Repair in High-Risk Patients With Paravisceral Aortic Aneurysms

BACKGROUND

Parallel grafting presents a viable method for treating patients with complex aortic aneurysms. The current literature is limited to mostly pararenal configurations. We examined our results in patients with SMA and/or Celiac artery involvement.

METHODS

A retrospective analysis was performed for all patients undergoing parallel grafting during the period of 2014 to 2018 at a single institution. All patients had at least SMA with and/or without Celiac artery parallel grafting.

RESULTS

Seventy-nine patients (65% male, median age 74) were treated with 208 parallel grafts. Median ASA score is 4. Forty-nine cases were elective, 22 urgent, and 8 emergent. Mean pre-operative aneurysm diameter was 7.1 cm (4.6-15 cm). Self-expanding covered stents were used for the renal arteries (mean 6.3mm), and balloon-expandable covered stents were used for the SMA and Celiac (mean SMA 8.6 mm, mean celiac 8.3 mm). Axillary exposure was the choice of access in 68 patients (86%). Technical success was achieved in all cases. We defined this as aneurysm sac exclusion with patent visceral stent grafts, and absent to mild gutter leaks. Mean aortic graft proximal seal achieved was 48mm. Coverage extended above the celiac artery in 75% (10% stented and 65% covered). Median contrast volume was 145ml, operative duration was 4 hours, fluoroscopy time was 56 min, and EBL was 250 ml. Perioperative mortality was 6.1%. 4.5%, and 25%, for the elective, urgent, and emergent groups, respectively. There was no incidence of spinal cord ischemia. Axillary access was complicated in 4 patients, requiring patch closure of the axillary artery. One patient developed postprocedural ESRD from a rupture and ATN despite patent renal stents. Of those patients with a patent GDA and celiac coverage, 2 required a cholecystectomy. Nine patients had a persistent gutter leak at the conclusion of the procedure. Median follow-up was 12 months. On follow-up imaging, all SMA and Celiac stents were patent. Six renal stents were occluded and 2 patients progressed to ESRD, both solitary renal periscope configurations at the index procedure. Only 4 patients had persistent gutter leaks with 2 requiring reintervention. Ninety-five percent of patients demonstrated sac regression or stabilization with a mean sac size of 6.5 cm.

CONCLUSIONS

Parallel grafting presents a safe, efficacious and off the shelf alternative to conventional repair of complex aortic aneurysms involving the visceral aorta.

Comparison of Clinical Outcomes Following One versus Two Stage Hybrid Repair of Thoraco-Abdominal Aortic Aneurysms: A Comprehensive Meta-Analysis

OBJECTIVE

For thoraco-abdominal aortic aneurysms (TAAA), it is unclear whether it is better to perform hybrid repair in one (single) or two stages (staged). This study aimed to compare the clinical outcomes of single vs. staged hybrid repair of TAAA.

METHODS

The Medline, Embase, and Cochrane Databases (1 January 1994 to 11 May 2020) were searched for studies on hybrid repair of TAAA. Cohort studies and case series reporting outcomes of single and staged hybrid repair of TAAA were eligible for inclusion. The Newcastle-Ottawa scale and an 18 item tool were used to assess the risk of bias. The primary outcome was 30 day mortality, and the secondary outcomes included post-operative complications, overall survival, and other mid term events. A random effects model was used to calculate pooled estimates.

RESULTS

A total of 37 studies was included in the meta-analysis. The quality assessment of the included studies suggested low or moderate risk of bias. The pooled estimates for aneurysm rupture and death during stage interval were 2% (95% CI 0%-4%, I² = 0%) and 4% (95% CI 2%-7%, I² = 0%), respectively. Single repair was associated with a significantly higher 30 day risk of death when compared with patients who completed staged procedures successfully (OR 2.64, 95% CI 1.36-5.12, I² = 0%). Staged repair also had lower incidence of major adverse cardiac events (MACE) (single: 10%, 95% CI 5%-16%; staged: 2%, 95% CI 0%-5%) and intestinal complications (single: 15%, 95% CI 8%-25%; staged: 3%, 95% CI 1%-6%). For mid term outcomes, single and staged repair had comparable 12 month overall survival, aneurysm related mortality, rate of re-intervention, and graft patency.

CONCLUSION

Two stage hybrid repair may represent a better choice for patients with controlled risk of aneurysm rupture, because it can provide lower 30 day mortality risks, MACE, and intestinal complications, as well as comparable mid term outcomes. Randomised controlled trials are needed to ascertain the effect of repair staging in patients for elective TAAA.

Ten-year experience of the thoraco-abdominal aortic aneurysm treatment using a hybrid thoracic endovascular aortic repair

OBJECTIVES

The treatment of thoraco-abdominal aortic aneurysm continues to have a high mortality and paraplegia rate. In superaging societies, the methods of performing less invasive operations remain a major issue. We reviewed our 10-year experience in the treatment of thoraco-abdominal aortic aneurysm using a hybrid procedure of combined visceral reconstruction and thoracic endovascular aortic repair.

METHODS

Sixty patients underwent a hybrid repair for the treatment of the thoraco-abdominal aortic aneurysm between 2007 and 2016. The mean age was 72.7 years. A true aneurysm was found in 43 (72%) patients and a chronic dissection in 17 (28%) patients. The standard operative procedure involved replacing the abdominal aorta with an artificial graft, and the visceral arteries were reconstructed using a quadrifurcated graft. Renovisceral debranching and stent grafting were performed as a 2-stage procedure.

RESULTS

The hospital mortality rate was 5%. Two (3%) patients died due to an aneurysmal rupture in the hospital just after renovisceral debranching. The other 2 patients died due to an aneurysmal rupture in the long-term period after preventive renovisceral debranching. Two (3%) patients experienced spinal cord ischaemia after the stenting procedure. Four (7%) patients required additional treatment during the follow-up period. The overall survival was 75.9% at 2 years, 65.2% at 5 years and 43.5% at 8 years. The rates of freedom from aorta-related events were 92.9% at 2 years, 80.5% at 5 years and 72.5% at 8 years.

CONCLUSIONS

The hybrid repair is considered to be a good option for elderly and high-risk patients. Further long-term follow-up is necessary to extend the indication in younger patients.

Precise plan of hybrid treatment for thoracoabdominal aortic aneurysm: Hemodynamics of retrograde reconstruction visceral arteries from the iliac artery

Hybrid visceral-renal debranching procedures with endovascular repair have been proposed as a less invasive alternative to conventional thoracoabdominal aortic aneurysm or dissection (TAAA or TAAD) surgery. Up to now, there has been no information about the hemodynamic effects of retrograde visceral reconstruction (RVR) for Crawford type II/III/IV TAAA patients undergoing hybrid treatment. The aim is to provide insights in the abnormal hemodynamics of RVR from unilateral or bilateral common iliac arteries (CIAs). Idealized three-dimensional AAs with RVR from unilateral CIA or bilateral CIAs were generated and computationally simulated. The results show that RVRs from CIA lead to a dramatic decrease in flow to the visceral organs compared with a healthy AA and that the anastomosis region is most dangerous to graft occlusion and the initiation of an aneurysm. In addition, compared with a quar-furcated graft, the employment of bilateral bi-furcated grafts have better performance in terms of the wall shear stress (WSS) and flow filed but result in less flow to the celiac and mesenteric arteries. This study has revealed the potential risks after an RVR operation, and points out the advantages and disadvantages of different approaches for the visceral reconstruction, which the vascular surgeons are not fully aware of. According to our results, bilateral bi-furcated grafts are recommended to the TAAA patients when the CIAs are unique inflow sites for visceral reconstruction. A precise plan with patient specific for TAAA or TAAD will be designed for better long-term outcome.

Outcomes Following Non-operative Management of Thoracic and Thoracoabdominal Aneurysms

BACKGROUND

Surgical decision making remains difficult in several patients with aneurysmal disease of the descending thoracic (DT) or thoracoabdominal (TA) aorta. Despite previous studies that have investigated aneurysms treated non-operatively using a prospective growth analysis, completeness and accuracy of follow-up were inconsistent. We aim to describe the survival and freedom from adverse aortic events in patients with DT and TA who did not undergo operative repair.

METHODS

This is a single-center retrospective analysis of all patients with either a descending degenerative atherosclerotic or dissection-related DT or TA aortic lesion who were treated non-operatively from April 2002 to December 2016. We studied patients who did not undergo operative repair of descending degenerative atherosclerotic or dissection-related DT or TA aortic lesion. Primary end points were overall survival and freedom from aortic-related mortality (ARM).

RESULTS

Of the 315 patients diagnosed with DT or TA disease, 56 (18%) did not undergo surgical repair. Mean aneurysm diameter was 65 mm ± 15 (range 50-120; IQR 5.4-7.15). Extent of the aortic aneurysms was DT in 36 (11%) patients and TA in 20 (6%). Median duration of follow-up was 12 months (range 1-108; IQR 3-36). Over the course of the study, 41 (73%) patients died for an overall survival rate of 53% ± 7 at 1 year (95% CI 40-65) and 23% ± 7 at 3 year (95% CI 17-42.5). Aortic-related mortality was 27% (n = 15), significantly higher in patients with aneurysms ≥ 60 mm [n = 13, (39%) vs. n = 2, (9%); P = 0.025; OR = 5.04]. Overall, estimated freedom from ARM was 81% ± 5.5 at 1 year (95% CI 68-89) and 66.5% ± 9 at 3 year (95% CI 48-81). Only TA extent was independently associated with freedom from ARM during the follow-up (P = 0.005; HR: 5.74; 95% CI 1.711-19.729).

CONCLUSIONS

Thoracoabdominal extent of the aneurysmal aortic disease is the most important predictor of ARM in unrepaired DT or TA aortic diseases. Mortality from aortic-related events was significantly more premature than mortality from non-aortic-related mortality.

Infrarenal aortic repair with or without false lumen intentional placement of endografts for hybrid management of complex aortic dissection

OBJECTIVE

Aortic dissection (AD) often involves the infrarenal aorta. We review our experience with open infrarenal aortic repair with or without false lumen intentional placement (FLIP) of endografts in the proximal dissected aorta as part of a hybrid strategy to treat complex AD.

METHODS

A prospectively maintained database of patients undergoing intervention for AD was reviewed. Data regarding diagnosis, imaging features, nature of the infrarenal repair (one- vs two-stage procedure), endoleaks, need for additional interventions, morbidity, and mortality were collected.

RESULTS

Between 2006 and 2017, there were 16 patients with AD with thoracoabdominal aortic aneurysm (TAAA), malperfusion, or both who underwent open infrarenal aortic repair or replacement combined with endovascular repair in a single- or multiple-stage procedure. Fifteen patients had a chronic AD and one patient had an acute AD. The most common indication for intervention was absolute size or rapid growth of the abdominal, thoracic, or thoracoabdominal aortic aneurysm (65%). In four patients with AD, the infrarenal replacement surgical graft was used as a common distal seal zone, allowing FLIP of an endograft to treat the proximal AD. Ten (62%) cases were done in two or more stages. Three patients had infrarenal aortic replacement with debranching only. In two of these patients, the proximal dissected aorta has remained stable without aneurysmal degeneration. One patient died as a result of rupture of his aneurysm while awaiting the second stage (perioperative mortality, 6%). Patients were observed from 1 month to 7 years. One patient had a stable type II endoleak, and one patient required subsequent replacement of ascending aortic arch for aneurysmal disease. One patient died of unrelated causes on follow-up.

CONCLUSIONS

Hybrid infrarenal aortic repair for treatment of complex AD can be performed with low morbidity and mortality and excellent medium-term results. This strategy can resolve malperfusion while simultaneously creating a landing zone using the false lumen as the conduit for the stent graft (FLIP) in selected patients. The FLIP technique allows full expansion of the endograft, potential preservation of lumbar and intercostal artery flow, and exclusion of the weaker false lumen while, in some cases, decompressing and thus stabilizing the proximal dissected aorta.

[Staged approach for hybrid thoracoabdominal aortic replacement]

AIM

To generalize our experience of step-by-step hybrid thoracoabdominal aortic replacement.

MATERIAL AND METHODS

Twenty-three patients were enrolled who underwent staged hybrid treatment of thoracoabdominal aortic aneurysm. There were 5 (21.7%) women and 18 (78.3%) men aged 61.4±8.3 years (37-74 years). The first stage was proximal debranching, the second - distal (abdominal) procedure and the third - stenting of the thoracoabdominal aorta.

RESULTS

There were no any complications after proximal debranching and aortic stenting. Abdominal debranching was followed by lethal outcome in 3 (13.0%) patients and early postoperative occlusion of the prosthesis brunch in 3 out of 87 cases.

CONCLUSION

Staged approach for hybrid surgical treatment is optimal solution, especially in high risk patients. In our opinion no necessity for cardiopulmonary bypass is the main advantage of this technique.

Debranching aortic surgery

Conventional open surgery still remains as the gold standard of care for aortic arch and thoracoabdominal pathology. In centers of excellence, open repair of the arch has been performed with 5% immediate mortality and a low rate of complications; however overall mortality rates are around 15%, being up to 40% of all patients rejected for treatment due to their age or comorbidities. For thoracoabdominal aortic pathology, data reported from centers of excellence show immediate mortality rates from 5% to 19%, spinal cord ischemia from 2.7% to 13.2%, and renal failure needing dialysis from 4.6% to 5.6%. For these reasons, different alternatives that use endovascular techniques, including debranching procedures, have been developed. The reported results for hybrid debranching procedures are controversial and difficult to interpret because series are retrospective, heterogenic and including a small number of patients. Clearly, an important selection bias exists: debranching procedures are performed in elderly patients with more comorbidities and with thoracoabdominal aortic aneurysms that have more complex and extensive disease. Considering this fact, debranching procedures still remain a useful alternative: for aortic arch pathology debranching techniques can avoid or reduce the time of extracorporeal circulation (ECC) or cardiac arrest which may be beneficial in high-risk patients that otherwise would be rejected for treatment. And compared to pure endovascular techniques, they can be used in emergency cases with applicability in a wide range of anatomies. For thoracoabdominal aortic aneurysms, they are mainly useful when other lesser invasive endovascular options are not feasible due to anatomical limitations or when they are not available in cases where delaying the intervention is not an option.

Review of Treatment for Thoracoabdominal Aortic Aneurysm, and the Modern Experience of Multi-Branched Endograft in Taiwan

Thoracoabdominal aortic aneurysm (TAAA) is a complicated aortic disease. Most treatments for other aortic aneurysms have already shifted from conventional open surgery to endovascular operation; but for TAAA, open surgery remains the gold standard treatment. Several alternative treatments such as hybrid operation as well as endovascular techniques are utilized for the treatment of TAAA. Some of the procedures combine off-the-shelf devices such as the chimney procedure. Some other procedures required custom-made specialized stent grafts. A new off-the-shelf multi-branched endograft, T-branch graft, was released in late 2012, though it was not introduced into Taiwan until 2015. Ultimately, also we plan to report the experience of multi-branched endograft in Taiwan.

One-Year Follow-Up After Hybrid Thoracoabdominal Aortic Repair

Background:

Compared to open thoracoabdominal aortic aneurysm (TAAA) repair, hybrid repair is thought to be less invasive with better perioperative outcomes. Due to the extent of the operation and long recovery period, studying perioperative results may not be sufficient for evaluation of the true treatment effect. The aim of this study is to evaluate 1-year mortality and morbidity in patients with TAAA undergoing hybrid repair.

Methods:

In a retrospective cohort study, all medical records of patients undergoing hybrid repair for TAAA at the Erasmus University Medical Center between January 2007 and January 2015 were studied. Primary outcome measures were 30-day and 1-year mortality. Secondary outcome measures included major in-hospital postoperative complications.

Results:

A total of 15 patients were included. All-cause mortality was 33% (5 of the 15) at 30 days and 60% (9 of the 15) at 1 year. Aneurysm-related mortality was 33% (5 of the 15) and 53% (8 of the 15) at 30-day and 1-year follow-up, respectively, with colon ischemia being the most common cause of death. Major complication rate was high: myocardial infarction in 2 (13%) cases, acute kidney failure in 5 (33%) cases, bowel ischemia in 3 (20%) cases, and spinal cord ischemia in 1 (7%) case.

Conclusion:

The presumed less invasive nature of hybrid TAAA repair does not seem to result in lower complication rates. The high mortality rate at 30 days continues to rise dramatically thereafter, suggesting that 1-year mortality is a more useful clinical parameter to use in preoperative decision-making for this kind of repair.

Complementary roles of open and hybrid approaches to thoracoabdominal aortic aneurysm repair

OBJECTIVE

Thoracoabdominal aortic aneurysm (TAAA) repair remains a significant challenge with considerable perioperative morbidity and mortality. A hybrid approach utilizing visceral debranching with endovascular aneurysm exclusion has been used to treat high-risk patients and therefore allow repair in more patients. Limited data exist regarding long-term outcomes with this procedure as well as comparison to conventional open repair. This study describes our institutional algorithmic approach to TAAA repair using both open and hybrid techniques.

METHODS

Hybrid and open TAAA repairs performed between July 2005 and August 2015 were identified from a prospectively maintained institutional aortic surgery database. Perioperative morbidity and mortality, freedom from reintervention, and long-term and aorta-specific survival were calculated and compared between the two groups.

RESULTS

During the study period, 165 consecutive TAAA repairs were performed, including 84 open repairs and 81 hybrid repairs. Patients in the hybrid repair group were significantly older, were more frequently female, and had a generally greater comorbid disease burden, including significantly more chronic kidney disease. Despite the older and sicker cohort, there was no difference in in-hospital mortality between the two groups (9.9% hybrid vs 7.1% open; P = .59). Major morbidity rates differed by procedure, with patients undergoing open repair having a significantly higher rate of postoperative stroke (9.5% open vs 0% hybrid; P = .017), whereas patients undergoing hybrid repair had a higher rate of new permanent dialysis (14.8% hybrid vs 3.6% open; P = .043). There was no difference between groups in the rate of postoperative permanent paraplegia/paresis (8.3% open vs 7.4% hybrid; P = .294). There was a significantly increased rate of reintervention in the hybrid repair group (12.3% hybrid vs 1.2% open, P = .004), with all hybrid reinterventions performed because of endoleak. One-year survival was similar between groups at 69% in hybrid repairs vs 77% in open repairs. Long-term survival was worse in the hybrid group (5-year survival, 32% hybrid vs 56% open), although late survival appeared to be influenced mainly by comorbid disease burden, given the similar long-term aorta-specific survival between groups.

CONCLUSIONS

Use of an algorithmic approach whereby higher risk patients with TAAA are treated by a hybrid approach and lower risk patients with conventional open repair yields satisfactory short- and long-term outcomes. The availability of multiple options for TAAA repair within a single center likely allows repair in more patients with consequent decrease in the risk of aorta-related death, at the expense of increased reinterventions for endoleak.

Multibranched Stent-Grafts for the Treatment of Thoracoabdominal Aortic Aneurysms

Purpose: To evaluate the available literature on endovascular repair of thoracoabdominal (TAAA) and pararenal aortic aneurysms (PRAA) using multibranched stent-grafts. Methods: MEDLINE, EMBASE, and Cochrane databases were searched between January 2001 and June 2015 to identify articles related to the use of multibranched stent-grafts for the treatment of TAAA and PRAA. Articles with <4 cases and those on juxtarenal aortic aneurysms were excluded. Meta-analyses were conducted to evaluate 30-day mortality, all-cause mortality, spinal cord ischemia, renal insufficiency, endoleak, target vessel patency, and reintervention. Of 370 articles screened, only 4 articles encompassing 185 patients (mean age 71.1 years; 137 men) were aligned with the inclusion criteria. There were 23 PRAAs; the mean aneurysm diameter was 64.5 mm. The Crawford TAAA classification was 10 type I, 47 type II, 37 type III, 58 type IV, and 9 type V; there was 1 Stanford type B dissection in association with a large TAAA. Results of the meta-analyses are reported as proportions and 95% confidence interval (CI). Results: Pooled analysis indicated a technical success rate of 98.9%. As study heterogeneity was significant, random effects models were used for meta-analysis. The rate for 30-day mortality was 9% (95% CI 3% to 19%), for all-cause mortality 27% (95% CI 17% to 38%), endoleaks 10% (95% CI 1% to 25%), target vessel patency 98% (95% CI 95% to 99%), SCI 17% (95% CI 1% to 26%), irreversible SCI 6% (95% CI 3% to 10%), renal insufficiency 15% (95% CI 0.8% to 41%), and reinterventions 21% (95% CI 4% to 47%). Conclusion: Use of multibranched stent-grafts in the treatment of TAAAs and PRAAs appears to be feasible and safe based on satisfactory early outcomes in the limited literature available to date. Long-term surveillance and further studies are essential to determine the durability of this technique.

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.

["Debranching" -- a new surgical option for the aortic arch and thoracoabdominal aorta hybrid interventions]

INTRODUCTION

Endovascular techniques in vascular surgery are frequently applied to treat aortic diseases. These minimally invasive procedures changed aortic interventions remarkably. We have to be familiar with new terminology and methods.

METHOD

New and old surgical procedures gained new role in preparation of endograft implantations. Transforming anatomy of aortic branches - "debranching" - is aimed to create a sufficient fixation of the endografts at safe "landing zones".

CONCLUSIONS

Knowing the option of hybrid procedures is a fundamental requirement for the vascular surgeon. Equally important is to know the biomechanical characteristics of the available endografts, the possible complications during and after implantation and the treatment options. We have to be aware of the limitations of these new methods and the role of traditional open surgery in the new era. Our intention in this paper is to summarize methods of debranching.

Total endovascular repair of thoracoabdominal aortic aneurysms with non-customized stent grafts

BACKGROUND

Total endovascular repair of thoracoabdominal aortic aneurysms with customized branched or fenestrated endografts could be technically challenging outside large-volume centers. This study aims to describe a new endovascular strategy for use of both noncustomized stent grafts and flow-diverting stents in treating complicated thoracoabdominal aortic aneurysms.

METHODS

Patients diagnosed with thoracoabdominal aortic aneurysms and deemed unfit for open surgical repair were recruited. The aim of the procedure was to cover the renovisceral segment of the aorta with flow-diverting uncovered stents, while covering the remaining aneurysm with stent grafts. Aneurysm morphologic evolution and the patency of the visceral branches were assessed at follow-up.

RESULTS

Between February 2012 and August 2013, 6 selective patients (4 men, mean age 58 years) underwent the novel joint procedure. During mean follow-up of 14 months, aneurysm shrinkage (maximum diameter decrease ＞5 mm) was demonstrated in 4 patients and aneurysm stabilization (maximum diameter decrease ＜5 mm) was observed in 2 patients. No aneurysm expansion was observed in any participants. Mean aneurysm diameter decreased from 65.0±8.8 mm to 58.5±12.2 mm (p=0.054), with a significant increase in average sac thrombus deposition volume (sac thrombosis ratio increased from 23.3%±7.4% to 98.0%±3.3%, p＜0.001). The majority of side branches (23 of 24) were successfully preserved.

CONCLUSIONS

Complete endovascular repair of thoracoabdominal aortic aneurysms with this novel joint procedure may be a feasible alternative in high surgical risk patients. Further validation of this technique is required to substantiate these results.

Thoracoabdominal aortic aneurysm repair: current endovascular perspectives

Thoracoabdominal aneurysms account for roughly 3% of identified aneurysms annually in the United States. Advancements in endovascular techniques and devices have broadened their application to these complex surgical problems. This paper will focus on the current state of endovascular thoracoabdominal aneurysm repair, including specific considerations in patient selection, operative planning, and perioperative complications. Both total endovascular and hybrid options will be considered.

Left retroperitoneal aortic aneurysm repair in patients unsuitable for endovascular treatment

BACKGROUND

This study aims to evaluate the contemporary outcome of left open retroperitoneal (RP) abdominal aortic surgery over a 7-year time period in patients with difficult anatomy unsuitable for endovascular aneurysm repair (EVAR).

METHODS

Eighty-four consecutive patients unsuitable for EVAR/FEVAR underwent left RP open aortic surgery. Of these, 44 (52%) required an infrarenal cross-clamp, 17 (20%) a suprarenal cross-clamp and 15 (18%) a supracoeliac cross-clamp. Eight (10%) were thoracoabdominal aneurysms.

RESULTS

There were four mortalities within 30 days (4.8%). Two occurred in patients with a supracoeliac cross-clamp, one in a suprarenal cross-clamp (total suprarenal mortality 10%) and one in an infrarenal cross-clamp. Four patients required prolonged ventilatory support (>10 days). Three patients (9%) from the suprarenal group developed post-operative renal dysfunction, one of these required permanent dialysis. Paralytic ileus occured in two patients (2%) and was secondary to ischaemia in both cases.

CONCLUSION

There will always remain a small group of patients best treated by open aortic surgery. By definition, these are complex, difficult cases and are decreasing in number. However, in vascular units regularly performing the RP approach, excellent results can be obtained. This series provides further evidence for centralization of vascular services.

Combined open and endovascular treatment of thoracoabdominal aortic pathologies: a systematic review and meta-analysis

BACKGROUND

A combined open-endovascular technique has emerged as an alternative treatment option for thoracoabdominal pathologies. However, reported experiences from various medical centers have been contradictory and heterogeneous. The aim of this study is to assess the mortality rate and various complication rates associated with this approach.

METHODS

An electronic health database search was performed on all articles published up to March of 2012 describing combined open-endovascular repair of thoracoabdominal pathologies. Studies were included in the meta-analysis if they had ≥10 patients and reported the basic outcome criteria. End points of the meta-analysis were defined as primary technical success, endoprosthesis related complications, 30-day/in-hospital mortality, symptoms of spinal cord ischemia (SCI) and irreversible paraplegia, permanent renal function impairment, and other major complications.

RESULTS

Fourteen studies were deemed eligible for this meta-analysis with a total of 528 patients (68.0% male, mean age 70.5 years). The mean follow-up period was 34.2 months. The pooled estimate for primary technical success and visceral graft patency was 95.4% and 96.5% respectively. An endoleak developed in 106 (21.1%) patients in whom both stages had been completed. The pooled rate for symptomatic SCI was 7.0% and for irreversible paraplegia 4.4%. The pooled proportion for permanent renal failure was 7.0% and for mesenteric ischemia 4.5%. Prolonged respiratory support and cardiac complications were observed in a pooled rate of 7.8% and 4.6% respectively. The meta-analysis for 30-day/in-hospital mortality revealed a pooled rate of 14.3%.

CONCLUSIONS

Although the hybrid technique for thoracoabdominal aortic pathology provides a less invasive approach, the technique is still associated with a considerable morbidity and mortality rates. High risk patients unfit to withstand open repair, are equally likely to suffer significant complications with the hybrid procedure. The choice of the optimal treatment strategy for thoracoabdominal pathologies should be carefully made on a patient to patient basis, assessing the clinical fitness and the anatomical suitability of each patient. The hybrid approach should be reserved for high volume centers with accumulated experience and high standards of perioperative management.

Clinical outcomes of single versus staged hybrid repair for thoracoabdominal aortic aneurysm

OBJECTIVE

We investigated the outcomes of hybrid repair of thoracoabdominal aortic aneurysms and performed meta-analyses and meta-regressions to assess whether the number of stages during hybrid repair is associated with mortality.

METHODS

Review methods were according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The primary outcome was 30-day mortality. Secondary outcomes of procedural and clinical success were reported descriptively. Meta-analyses, meta-regressions, and logistic regressions were performed to estimate the odds ratio (OR) describing the association between the staging of the operation and in-hospital death.

RESULTS

We included 19 studies of 660 patients. Procedures were single-staged in 288 patients and staged in 372. Perioperative mortality ranged from 0% to 44.4%, and spinal cord ischemia ranged from 0% to 15.3%. After a mean follow-up of 26 months (range, 6-88.5 months), the overall mortality was 20.8%. The meta-regression of all studies' summary data (OR, 0.64; 95% confidence interval [CI], 0.19-2.16; P = .45; I(2) = 0.42) and a meta-regression where mortality rates in four studies were stratified by operative staging (OR, 0.57; 95% CI, 0.24-1.36; P = .19; I(2) = 0.38) supported a two-stage procedure but failed to reach statistical significance. Logistic regressions of individual patient data from a single center demonstrated evidence that a staged procedure was safer (adjusted OR, 0.04; 95% CI, 0.00-0.96; P < .05).

CONCLUSIONS

Hybrid repair of thoracoabdominal aortic aneurysms may reduce early morbidity and mortality even in a group considered high risk for open surgery but still carries risks of perioperative complications. This study suggested advantages to a staged procedure, but statistically significant evidence is lacking. Prospective data are still needed to optimize hybrid repair and best define its role.

Endovascular repair of thoracoabdominal aortic aneurysm (TAAA): early experience

BACKGROUND

Repair of thoracoabdominal aortic aneurysms (TAAA) represents a considerable technical challenge. Since its first description in 1955, open repair of TAAA has been considered the gold standard of repair. Despite improvements in surgical techniques, spinal cord protection and post-operative critical care support, patients who undergo open repair are faced with a mortality rate of 5-35 %. We report the first Irish experience of endovascular management of TAAAs.

RESULTS

To date five patients have undergone endovascular repair; four had hybrid repair and one a fenestrated graft. The mean age of the patients was 66.8 ± 3.4 and the mean aneurysm diameter was 6.74 ± 0.6 cm. All patients were ASA III. Two-stage hybrid repair was associated with an increased risk of complications, prolonged intensive care unit and overall hospital stay. One patient died in the perioperative period due to rupture of their aneurysm between the two stages of their hybrid repair.

CONCLUSION

The role of endovascular techniques in the treatment of TAAA continues to evolve. Hybrid and complete endovascular repairs do not replace conventional repair, but provide an alternative for high-risk patients who might otherwise be denied treatment.

Predictors and outcomes of acute kidney injury after thoracic aortic endograft repair

BACKGROUND

This study analyzed the incidence and the predictive factors of postoperative acute kidney injury (AKI) after thoracic endovascular aortic repair (TEVAR) and evaluated the effect of AKI on postoperative survival.

METHODS

Between November 2000 and April 2011, all consecutive patients undergoing TEVAR of the descending thoracic or thoracoabdominal aorta were enrolled at four teaching hospitals. Estimated glomerular filtration rate (eGFR) was evaluated during the entire hospitalization. AKI was defined by the RIFLE (Risk, Injury, Failure, Loss of function, End-stage renal disease) consensus criteria.

RESULTS

The study included 171 patients (80% men) who were a mean age of 69±14 years (range, 18-87 years). AKI occurred in 24 patients (14%). Independent predictors of postoperative AKI were preoperative depressed eGFR, thoracoabdominal extent, and postoperative transfusion. Patients with AKI experienced major postoperative complications (P=.001), longer hospitalization (P=.008), and higher hospital mortality (29% vs 4%; P<.001). Kaplan-Meier analysis showed a survival of 82%, 51%, and 51% at 1, 3, and 5 years for patients who developed AKI, which was significantly worse than the 99%, 89%, and 80% for patients who did not experience AKI (P=.001).

CONCLUSIONS

Preoperative poor renal function, blood transfusions, and the thoracoabdominal extent of the aortic disease were the most important predictors for AKI.

Chimney technique in the endovascular management of complex aortic disease

The objective of this study was to systematically review the literature reporting on the chimney technique and perform an analysis of the outcomes. A search of electronic databases was undertaken to identify all studies reporting on the outcome of the chimney technique. The selected articles were divided into those reporting on the treatment of aortic pathology involving the visceral and those involving the supra-aortic branches. Twenty-one articles reporting on the treatment of juxta/supra-renal aorta and aortic arch disease in 102 and 37 patients, respectively, were identified. In the visceral group, an overall technical success rate of 91% was achieved, the perioperative major morbidity and mortality rates were 17 and 5%, respectively, and an early type I endoleak developed in 13 patients (13%). During follow-up, one patient died of intestinal ischemia. In the supra-aortic group, the technical success rate was recorded in 95%, and three patients (8%) developed an early type I endoleak. Three patients (13%) required conversion to open surgery during follow-up. In conclusion, this technique may be viewed as a complementary technique in high-surgical-risk patients.

Staged total abdominal debranching and thoracic endovascular aortic repair for thoracoabdominal aneurysm

OBJECTIVE

Thoracoabdominal aortic aneurysms (TAAAs) occur most commonly in elderly individuals, who are often suboptimal candidates for open repair because of significant comorbidities. The availability of a hybrid option, including open visceral debranching with endovascular aneurysm exclusion, may have advantages in these patients who are at high-risk for conventional repair. This report details the evolution of our technique and results with complete visceral debranching and endovascular aneurysm exclusion for TAAA repair in high-risk patients.

METHODS

Between March 2005 and June 2011, 47 patients (51% women) underwent extra-anatomic debranching of all visceral vessels, followed by aneurysm exclusion by endovascular means at a single institution. A median of four visceral vessels were bypassed. The debranching procedure was initially performed through a partial right medial visceral rotation approach, leaving the left kidney posterior in the first 22 patients, and in the last 25 by a direct anterior approach to the visceral vessels. The debranching and endovascular portions of the procedure were performed in a single operation in the initial 33 patients and as a staged procedure during a single hospital stay in the most recent 14.

RESULTS

Median patient age was 71.0 ± 9.8 years. All had significant comorbidity and were considered suboptimal candidates for conventional repair: 55% had undergone previous aortic surgery, 40% were American Society of Anesthesiologists (ASA) class 4, and baseline serum creatinine was 1.5 ± 1.3 mg/dL. The 30-day/in-hospital rates of death, stroke, and permanent paraparesis/plegia were 8.5%, 0%, and 4.3%, respectively, but 0% in the most recent 14 patients undergoing staged repair. These patients had significantly shorter combined operative times (314 vs 373 minutes), decreased intraoperative red blood cell transfusions (350 vs 1400 mL), and were more likely to be extubated in the operating room (50% vs 12%) compared with patients undergoing simultaneous repair. Over a median follow-up of 19.3 ± 18.5 months, visceral graft patency was 97%; all occluded limbs were to renal vessels and clinically silent. There have been no type I or III endoleaks or reinterventions. Kaplan-Meier overall survival is 70.7% at 2 years and 57.9% at 5 years.

CONCLUSIONS

Hybrid TAAA repair through complete visceral debranching and endovascular aneurysm exclusion is a good option for elderly high-risk patients less suited to conventional repair in centers with the requisite surgical expertise with visceral revascularization. A staged approach to debranching and endovascular aneurysm exclusion during a single hospitalization appears to yield optimal results.