Long-term results of thoracic endovascular aortic repair in atherosclerotic aneurysms involving the descending aorta

Predictors for reintervention and survival during long-term follow-up after thoracic endovascular aortic repair for descending thoracic aortic aneurysm

BACKGROUND

Several studies have reported short- and intermediate-term outcomes after thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm (DTAA); however, reports on long-term (10 years) outcomes are sparse. Therefore, the aim of this study was to analyze predictors impacting long-term outcome after TEVAR for DTAA.

METHODS

Databases from four academic institutions were reviewed and consecutive cases of TEVAR for DTAA between 1999 and 2021 were included in this retrospective multicenter study (case series). Ethical approval from the institutional review board was obtained and patient demographics and treatment data, as well as follow-up information were retrieved and analyzed.

RESULTS

We identified 305 patients (mean age, 72 ± 10 years) who were treated with TEVAR for degenerative DTAA with a mean aortic diameter of 64 mm. Altogether 445 endografts were implanted via femoral access (93%) with a technical success of 94%. Operative mortality, stroke rate, and rate of spinal cord ischemia were 6% (5% for intact, 12% for ruptured DTAA), 4%, and 3%, respectively. Kaplan-Meier estimates for overall survival rates were 76%, 59% and 34% at 1, 5 and 10 years and freedom from reintervention rates were 84%, 73% and 58% at 1, 5 and 10 years, respectively. In multivariate analysis, American Society of Anesthesiologists grade 3 to 5 and nonelective case were identified as predictors for death, whereas as fusiform DTAA, proximal landing zone 2, and hypertension, but not device generation, were predictive for reintervention.

CONCLUSIONS

This study is, to date, the largest reporting long-term (10 years) outcome on TEVAR for DTAA. We found acceptable rates for long-term survival and freedom from reintervention that were independent of endovascular device generation.

Learning Curve and Long-Term Outcomes of Thoracic Endovascular Repair With the Relay Stent-Graft

PURPOSE

To define the learning curve of a widely employed stent-graft for thoracic endovascular repair (TEVAR) by analyzing procedural variables and their impact on long-term outcomes.

MATERIALS AND METHODS

Standard TEVARs for each major aortic thoracic disease were included excluding procedures using thoracoabdominal, arch fenestrated/branched devices and/or chimneys. The primary outcome was the learning curve analysis using the cumulative sum chart method. The secondary outcomes, presented as early (Q1-Q2) versus latest (Q3-Q4) quartiles of experience, were 30-day major adverse events (MAEs); procedural details (additional maneuvers, operative and fluoroscopy time, and contrast volume); 30-day clinical success; endoleak; aorta-related reintervention; and overall and aorta-related survival.

RESULTS

Between November 2005 and September 2021, 220 consecutive TEVAR procedures involving the Relay endograft (Terumo Aortic, Sunrise, FL, USA) were performed and included in the present analysis. The mean follow-up was 4.5 ± 3.9 years. The learning curve was reached after 10 patients. Secondary outcomes improved significantly over experience. Thirty-day MAE occurrence was 14.5% versus 11.8% (p=0.550). Additional maneuvers (p=0.009), access-vessel additional maneuvers (p=0.010), operative time (p=0.004), Relay Plus (p=0.001), and implantation of multiple stent-grafts (p=0.034) were independent risk markers for MAEs. Operative time (125.9 ± 66.7 vs 86.7 ± 48.5 minutes, p<0.001), contrast volume (185.4 ± 112.8 vs 140.5 ± 88.2 mL, p=0.003), and fluoroscopy time (12.4 ± 12.7 vs 8.8 ± 7.5 minutes, p=0.017) decreased significantly. Late endoleak occurrence was 19.5% with a nonsignificant reduction (21.8% vs 17.3%, p=0.395). Fluoroscopy time (hazard ratio [HR]=1.0; 95% confidence interval [CI]=1.0-1.1; p=0.008), contrast volume (HR=1.0; 95% CI=1.0-1.1; p=0.018), and type III aortic arch (HR=3.3; 95% CI=1.7-6.4; p<0.001) were independent risk markers for endoleak. Fluoroscopy time (HR=1.0; 95% CI=1.0-1.1; p=0.032) and type III aortic arch (HR=3.6; 95% CI=1.7-7.4; p=0.001) confirmed their significant association in a multivariable analysis.

CONCLUSION

In a high-volume center with a consistent previous endovascular experience, the Relay graft presented satisfactory long-term results with a short learning curve supporting its reliability.

CLINICAL IMPACT

The manuscript addresses the understanding of how many TEVAR procedures with a currently implanted device have been required to reach the learning curve for an endovascular skilled center. Our TEVAR experience with the Relay stent-graft (Terumo Aortic) demonstrated that ten implantations were required to achieve the device-related learning curve. The fifteen-year analyzed period showed that intraoperative learning-related variables were associated with long-term clinical outcomes and both improved over time. The Relay stent-graft presented satisfactory long-term results along with a short learning curve in a high-volume endovascular center supporting its ongoing implantation.

Thoracic aortic emergencies involving the aortic arch: An integrated cardiovascular surgical treatment approach

Thoracic aortic emergencies involving the aortic arch are potentially fatal conditions that require the entire surgical repertoire of conventional surgery, such as complete aortic arch replacement using the frozen-elephant-trunk technique, through hybrid procedures, to full surgical endovascular options with conventional or delivered/fenestrated stent-grafts. An interdisciplinary aortic team should choose the optimal treatment of the pathologies of the aortic arch, considering the morphology of the entire aorta, from the root to beyond the bifurcation, as well as the clinical comorbidities. The treatment goal is a complication-free postoperative result and lasting freedom from aortic reinterventions. Irrespective of the selected therapy method, patients should then be connected to a specialized aortic outpatient clinic. The aim of this review was to provide an overview of pathophysiology and current treatment options in emergencies of the thoracic aorta, also involving the aortic arch. We wanted to summarize the preoperative considerations, intraoperative settings, and strategies, as well the postoperative follow-up.

Endoleak outcomes with different stent-graft generations in a 25-years thoracic endovascular aortic repair experience

INTRODUCTION

To compare endoleak outcomes after thoracic endovascular aneurysm repair (TEVAR) with different stent-graft generations into long-term follow-up.

DESIGN

retrospective, observational, and single-center cohort study.

METHODS

TEVAR procedures performed between November 1995 and December 2020 were analyzed. The primary endpoint of this study was the freedom from endoleak (type I/III) in four stent-graft generations during the follow-up period. The first generation (GEN1) included: Vanguard; AneuRx and Talent; Stentor; Excluder; Endologix; EndoFit. The second generation (GEN2) included: TAG and TX. The third (GEN3) included: Relay Plus; Valiant Captivia; Zenith Alpha and custom-made. The fourth (GEN4) included: Relay Pro; Conformable C-TAG; Navion; E-Vita; Najuta; Nexus; standard and custom-made thoraco-abdominal devices. Nonaortic and aorta-related survival was considered as secondary outcome.

RESULTS

A total of 509 TEVAR were included with a 44.3 ± 42.5 months mean follow-up. Freedom from endoleak at 5 years was 65.6%, 61.4%, 76.2%, and 69.1% for GEN1, GEN2, GEN3, and GEN4, respectively (p = 0.368). The first two generations demonstrated a higher endoleak rate when compared with the two most recent ones (27.2 vs 18.2%, respectively; p = 0.043). GEN1 was an independent risk factor (p = 0.014) and GEN4 was an independent protective factor (p = 0.001) for endoleak. GEN1 was found to be a risk factor for type-Ia endoleak (p = 0.059). GEN4 demonstrated a protective association regarding type-Ib endoleak (p = 0.012). Overall survival was 75.3%, 44.4%, 27.2%, and 17.6% at 1, 5, 10, and 15 years, respectively. Survival distinguished as non-related versus aortic-related was 86.7% vs 23.5%, 52.7% vs 9.8%, 32.9% vs 2.0%, 21.2% vs 0% at 1, 5, 10, and 15 years, respectively (p< 0.000).

CONCLUSION

Endoleak occurred in a non-negligible percentage of TEVAR patients. A significant reduction of endoleak incidence over evolving stent-grafts generations was registered. Newer stent-graft generations demonstrated better long-term endoleak. Data about long-term outcomes require ongoing updates to prove both the reliability and the durability of newer stent-graft generations.

Endovascular Stent-Graft Repair of the Ascending Aorta: Assessment of a Specific Novel Stent-Graft Design in Phantom, Cadaveric, and Clinical Application

Purpose

To test a stent-graft specifically designed for the ascending aorta in phantom, cadaver, and clinical application, and to measure deployment accuracy to overcome limitations of existing devices.

Methods

A stent-graft has been designed with support wires to fixate the apices toward the inner curvature, thereby eliminating the forward movement of the proximal end which can happen with circumferential tip capture systems. The device was deployed in three aortic phantoms, and in four cadavers, deployment precision was measured. Subsequently, the device was implanted in a patient to exclude a pseudoaneurysm originating from the distal anastomosis after ascending aortic replacement.

Results

The stent-grafts were successfully deployed in all phantoms and cadavers. Deployment accuracy of the proximal end of the stent-graft was within 1 mm proximally and 14 mm distally to the intended landing zone on the inner curvature, and 2–8 mm distal to the intended landing zone on the outer curvature. In clinical application, the pseudoaneurysm could be successfully excluded without complications.

Conclusion

The novel stent-graft design promises accurate placement in the ascending aorta. The differential deployment of the apices at the inner and outer curvatures allows deployment perpendicular to the aortic axis.

Level of Evidence

No level of evidence.

Blunt thoracic aorta injuries, an Australian single centre's perspective

BACKGROUND

Blunt thoracic aortic injuries (BTAI) are potentially life-threatening emergencies. The management paradigm has shifted from open repair to a predominantly endovascular approach. We evaluated the trends in managing BTAI at our centre over the last decade and compared them to current international guidelines.

METHODS

We retrospectively reviewed all patients who presented with BTAI to our level one trauma centre, Westmead Hospital, New South Wales, Australia between 1 January 2010 and 31 December 2019. Patient demographics, injury grade and location, imaging features, management details and outcomes were analysed.

RESULTS

BTAI is rare, with 39 patients identified at our institute over the last 10 years. Of these, seven died in the emergency department from their associated injuries (17.9%). Of the 32 survivors, 27 underwent surgical management with an endovascular stent-graft placement, and the remaining five patients were treated non-operatively. No patients were treated via an open surgical approach. All patients were diagnosed via computed tomography angiography. There were one death and two endoleaks amongst patients who underwent Thoracic endovascular aortic repair (TEVAR). The death occurred secondary to severe traumatic brain injury. Two patients illustrated neurological changes however these were associated with the original injury. No patients failed non-operative management.

CONCLUSION

This study demonstrates that at our level one trauma centre, patients with BTAI are managed in accordance with international guidelines. All patients underwent computed tomography angiography for diagnosis and grading of injury. All patients requiring surgical management underwent TEVAR. Furthermore, our data support that select patients with grade I injuries can safely be managed non-operatively.

Aortic Arch Anatomy Pattern in Patients Treated Using Double Homemade Fenestrated Stent-Grafts for Total Endovascular Aortic Arch Repair

Purpose: To analyze the structural variation of the aortic arch and the supra-aortic arteries and establish an average spatial configuration that would be a pattern for a “universal double fenestration” design for physician-modified endovascular grafts (PMEGs) used in total thoracic endovascular aortic repair (TEVAR). Materials and Methods: Aortic arch morphology was retrospectively analyzed by reviewing the preoperative thoracic computed tomography angiography scans in 33 consecutive patients (mean age 68 years; 27 men) treated between January 2017 and March 2019 using double-fenestrated PMEGs for zone 0 TEVAR. Image analysis was completed according to a standardized technique on a vascular workstation with center lumen line reconstruction for all measurements. Variations in branching pattern of the aortic arch were classified into 8 types. Results: The arch trunk configuration was type I in 26 patients (79%), type II in 5 (15%), type III in 1, and type IV in 1. Mean aortic diameters at the level of mid ascending aorta, innominate artery (IA), left common carotid artery (LCCA), and left subclavian artery (LSA) were 35.7±3.7, 34.2±4.5, 33.3±6.7, and 33.7±4.7 mm, respectively. Mean diameters of the trunk were 12.2±1.7, 7.5±1.4, and 8.0±0.8 mm, respectively. Mean longitudinal center to center lengths were 15.9±2.5 mm between the LSA and LCCA and 12.1±3.0 mm between the LCCA and IA. Mean clock positions using the LSA as reference were 12:50 for the IA and 12:05 for the LCCA. In 32 patients (97%) all the supra-aortic branch vessels fit perfectly inside two delimited areas defined by a proximal common square area of 30×30 mm for the IA and LCCA and a second distal 8-mm-diameter circle for the LSA. Conclusion: Variations of the aortic arch anatomy are numerous and common. A general morphological pattern is described that delimits the aortic area where these variations occur. This information can be utilized for the design of an off-the-shelf double-fenestrated stent-graft for zone 0 TEVAR.

Replacement of the descending thoracic aortic aneurysm with partial cardiopulmonary bypass in the era of endovascular repair

OBJECTIVES

Although the advent of thoracic endovascular aortic repair (TEVAR) has provided an alternative treatment option for descending thoracic aortic aneurysm (DTAA), open repair still plays a crucial role in DTAA repair. The purpose of this study was to re-evaluate the operative and long-term outcomes of open repair with partial cardiopulmonary bypass, compared to the results of TEVAR with a proximal landing zone of 3 or 4.

METHODS

Between 2007 and 2017, open repair was performed for 44 patients and TEVAR for 282 patients. Acute aortic dissection and open proximal anastomosis under circulatory arrest were excluded. Perioperative and long-term follow-up data were analyzed.

RESULTS

In-hospital mortality rate (4.5% vs 3.2%, p = 0.42), and frequencies of spinal cord injury and neurological deficit showed no significant differences between the open repair and TEVAR groups (p = 0.41, 0.25, respectively). The propensity score-matched analysis showed similar cumulative survival (p = 0.23), but significantly higher reintervention rates for the repaired segment in the TEVAR group than in the open repair group (p = 0.0054). Twenty-two (7.8%) TEVAR patients required re-interventions for the repaired segment. Of those, 17 patients underwent additional TEVAR and 5 patients needed open conversion surgery with partial cardiopulmonary bypass. Reintervention rates for the repaired segment were significantly higher in the TEVAR group than in the open repair group (p = 0.012).

CONCLUSIONS

Open repair DTAA using partial cardiopulmonary bypass showed operative outcomes comparable to TEVAR and lower reintervention rates, and thus remains an acceptable procedure for selected patients in this era of endovascular repair.

The Society for Vascular Surgery practice guidelines on follow-up after vascular surgery arterial procedures

Although follow-up after open surgical and endovascular procedures is generally regarded as an important part of the care provided by vascular surgeons, there are no detailed or comprehensive guidelines that specify the optimal approaches with regard to testing methods, indications for reintervention, and follow-up intervals. To provide guidance to the vascular surgeon, the Clinical Practice Council of the Society for Vascular Surgery appointed an expert panel and a methodologist to review the current clinical evidence and to develop recommendations for follow-up after vascular surgery procedures. For those procedures for which high-quality evidence was not available, recommendations were based on observational studies, committee consensus, and indirect evidence. Recognizing that there are numerous published reports on the role of duplex ultrasound for surveillance of infrainguinal vein bypass grafts, the Society commissioned a systematic review and meta-analysis on this topic. The panel classified the strength of each recommendation and the corresponding quality of evidence on the basis of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system: recommendations were graded either strong or weak, and the quality of evidence was graded high, moderate, or low. The resulting recommendations represent a wide variety of open surgical and endovascular procedures involving the extracranial carotid artery, thoracic and abdominal aorta, mesenteric and renal arteries, and lower extremity arterial revascularization. The panel also identified many areas in which there was a lack of high-quality evidence to support their recommendations. This suggests that there are opportunities for further clinical research on testing methods, threshold criteria, and the role of surveillance as well as on the modes of failure and indications for reintervention after vascular surgery procedures.

Thoracic endovascular aortic repair for uncomplicated type B aortic dissection

PURPOSE OF REVIEW

Type B aortic dissection has largely been regarded as the nice dissection with regard to its natural course, especially when compared with type A aortic dissection. However, a more thorough look into the natural course of the disease has shown that a high number of patients with type B aortic dissection will experience complications and will require therapy, sooner or later.

RECENT FINDINGS

Reasons and timepoints are different, being malperfusion, contained rupture and retrograde propagation of the disease into the aortic arch or into the ascending aorta in the early phase and being mainly aneurysmal formation in the chronic phase of the disease.

SUMMARY

This article provides the interested reader with detailed knowledge regarding the natural course of the disease and is meant as a companion to anticipate the right timepoint for therapy and finally as a guide to do the right things when advancing to treatment.

Late-onset aortoesophageal fistula after treatment of a chronic type B aortic dissection with a three-step approach

Aortoesophageal fistula is a rare but lethal complication after thoracic endovascular repair for thoracic aortic diseases. Extensive treatment is reserved for patients fit for surgery. Various technical approaches have been described; however, mortality rates are still high. Herein, we report a case of a 76-year-old woman with aortoesophageal fistula treated by a three-step treatment approach, with close collaboration between cardiothoracic and general surgery specialists. The patient required tracheostomy after the first procedure, but this was closed at 15 days. She subsequently recovered and is doing well at 3 months after surgery. Staged treatment aims to shorten operative times, to reduce the risk of anesthesia complications, and to provide the patients the time to recover after each procedure.

Type B Aortic Dissections: Current Guidelines for Treatment

Stanford type B aortic dissections (TBADs) involve the descending aorta and can present with complications, including malperfusion syndrome or aortic rupture, which are associated with significant morbidity and mortality if left untreated. Clinical diagnosis is straightforward, typically confirmed using CT angiography. Treatment begins with immediate anti-impulse medical therapy. Acute TBAD with complications should be repaired with emergent thoracic endovascular aortic repair (TEVAR). Uncomplicated TBAD with high-risk features should undergo TEVAR in the subacute phase. Open surgical repair is seldom required and reserved only for select cases. It is critical to follow these patients clinically and radiographically in the outpatient setting.

Successful Repair of Type I Endoleak Using the Frozen Elephant Trunk Technique

Thoracic endovascular aortic repair (TEVAR) has emerged as an effective therapy for a variety of thoracic aortic pathologies. However, various types of endoleak remain a major concern, and its treatment is often challenging. We report a case of type I endoleak occurring 19 months after zone II hybrid TEVAR. The endoleak was successfully repaired by the frozen elephant trunk technique, without removal of a previous stent graft, combined with ascending aorta and total arch replacement.

Update in the management of type B aortic dissection

Stanford type B aortic dissection (TBAD) is a life-threatening aortic disease. The initial management goal is to prevent aortic rupture, propagation of the dissection, and symptoms by reducing the heart rate and blood pressure. Uncomplicated TBAD patients require prompt medical management to prevent aortic dilatation or rupture during subsequent follow-up. Complicated TBAD patients require immediate invasive management to prevent death or injury caused by rupture or malperfusion. Recent developments in diagnosis and management have reduced mortality related to TBAD considerably. In particular, the introduction of thoracic stent-grafts has shifted the management from surgical to endovascular repair, contributing to a fourfold increase in early survival in complicated TBAD. Furthermore, endovascular repair is now considered in some uncomplicated TBAD patients in addition to optimal medical therapy. For more challenging aortic dissection patients with involvement of the aortic arch, hybrid approaches, combining open and endovascular repair, have had promising results. Regardless of the chosen management strategy, strict antihypertensive control should be administered to all TBAD patients in addition to close imaging surveillance. Future developments in stent-graft design, medical therapy, surgical and hybrid techniques, imaging, and genetic screening may improve the outcomes of TBAD patients even further. We present a comprehensive review of the recommended management strategy based on current evidence in the literature.

Endovascular Repair for Thoracic Aortic False Aneurysms: Single-Center Experience in 102 Patients

BACKGROUND

Thoracic aortic false aneurysm is unusual and experience with endovascular repair is limited. We evaluate the efficacy of endovascular repair in patients with thoracic aortic false aneurysms.

METHODS

The early and midterm outcomes of endovascular repair in 102 patients with thoracic aortic false aneurysms were analyzed.

RESULTS

There were 80 men and 22 women (age 54.9 ± 13.7 years). Emergent or urgent endovascular repair was done in 19 cases (18.6%) and elective in 83 (81.4%). Procedure was successful in 99.0%. Early death occurred in 4 patients (3.9%). No early death occurred in elective patients. Early complications occurred in 7 patients (6.9%). Follow-up was complete in 100% for 24.0 ± 18.5 months (range, 1.5 to 67.3). Fourteen late deaths occurred (13.7%). Late events occurred in 9 patients (8.8%). Survival at 6 month, 1 year and 3 years was 90.7%, 86.7% and 84.5%, respectively.

CONCLUSIONS

Satisfactory early and midterm outcomes have been achieved with endovascular repair in this series. Although emergent or urgent patients had higher rates of early mortality and morbidity, the majority of them achieved stable late survival as long as they survived at least 6 months. These results argue favorably for use of endovascular repair in the management of patients with thoracic aortic false aneurysms.

Usefulness of contrast-enhanced transoesophageal echocardiography to guide thoracic endovascular aortic repair procedure

AIMS

Thoracic endovascular aortic repair (TEVAR) is commonly considered as a valid alternative to surgery. Endoleaks occurrence is one of the principal limitations of TEVAR. Transoesophageal echocardiography (TEE) is often adopted in adjunct to fluoroscopy and angiography (ANGIO) during stent-graft implantation. In the present study, we compare intraprocedural ANGIO, TEE, and contrast-enhanced TEE (cTEE), and we also evaluate their accuracy in early endoleaks detection and characterization.

METHODS AND RESULTS

Fifty-four patients with thoracic aortic disease suitable for TEVAR were prospectively enrolled in the study. After stent placement, the result of the procedure was assessed by ANGIO, TEE, and cTEE. The use of contrast (Sonovue, Bracco) significantly improved TEE quality (P = 0.0001). cTEE was superior in entry tears, false and true lumen and aneurysm thrombosis identification, and microtears and ulcer-like projections detection before stent deployment. After stent deployment, cTEE was more accurate than TEE and ANGIO in the detection of slow flow in the false lumen and in the aneurismal sac (P = 0.0001), and in the remaining flow identification (P = 0.0001). Notably, cTEE is more accurate in the endoleaks detection (P = 0.0001) and in the incomplete stent expansion diagnosis and need for a further balloon inflation (P 0.002), or a further stent implantation (P 0.006), compared with TEE and ANGIO.

CONCLUSION

TEVAR procedures are improved by the complimentary use of contrast fluoroscopy, multiplane TEE with Doppler flow interrogation, and cTEE. This triple imaging approach provides additional information in all phases of the procedure improving safety of stent-grafting and the procedural outcomes.

A review of follow-up outcomes after elective endovascular repair of degenerative thoracic aortic aneurysms

Long-term outcomes of elective thoracic endovascular aortic repair (TEVAR) for degenerative thoracic aortic aneurysms (TAA) are not well defined. A review of the literature on the follow-up outcomes of elective TEVAR for degenerative TAA resulted in 22 relevant articles. Two- and five-year freedom from aneurysm-related death varied between 93.0% and 100.0%, and 82.4% to 92.7%, respectively. Two-year and five-year all-cause survival ranged between 68.0% and 97.2% and 47.0% to 78.0%, respectively. Follow-up ranged between 17.3 and 66.0 months. Most common endograft-related complication was endoleak, with reported rate between 1.4% and 14.8% during six months up to five years of follow-up. Endovascular reinterventions were reported in 0.0–32.3%, secondary open surgery was needed in 0.0% to 4.7% during follow-up. Aneurysm-related survival rates after elective TEVAR for degenerative TAA are acceptable. However, reported incidences of endograft-related complications vary considerably in the literature, but the majority can be managed with conservative treatment or additional endovascular procedures.

Long-term results of endovascular repair for distal arch and descending thoracic aortic aneurysms treated by custom-made endografts: usefulness of fenestrated endografts

OBJECTIVE

We evaluated early and long-term results of atherosclerotic aneurysm repair with custom-made endografts.

MATERIALS AND METHODS

Eighty-one consecutive patients underwent thoracic endovascular aortic repair with custom-made endografts. Fenestrated grafts were used in 37 patients (45.7%) to maintain blood flow of the neck and a landing zone for as long as possible for distal arch or proximal descending aneurysms. The rates of perioperative mortality, stroke, paraplegia, and primary endoleaks were assessed to evaluate in-hospital safety. The rates of endoleak development, survival, and freedom from aortic-related death were assessed to evaluate long-term efficiency.

RESULTS

Twenty-four patients (29.6%) underwent urgent operations, and 38 (46.9%) underwent distal arch or proximal descending aortic aneurysm repair. There was one case (1.2%) of in-hospital mortality and no cases of stroke. Permanent spinal injury occurred in one patient (1.2%). Early and late endoleaks occurred in one and 16 patients, respectively. The actuarial survival rates were 88.9%, 64.9%, and 51.7% at 1, 5, and 10 years, respectively. The actuarial rates of freedom from endoleaks were 90.1%, 81.3%, and 68.6% at 1, 5, and 10 years, respectively.

CONCLUSION

Early results of custom-made endografts were excellent, and fenestrated endografts were safe for distal arch and proximal descending aortic aneurysms.

The role of mandatory lifelong annual surveillance after thoracic endovascular repair

Thoracic endovascular aortic repair (TEVAR) has become an attractive and well-accepted option for the management of the various thoracic aortic pathologies that vascular surgeons are confronted with. As in the abdominal aorta, current management trends include the treatment of younger patients with longer life expectancies, raising the issue of postoperative surveillance. There are several relevant differences between these anatomic areas when it comes to surveillance, including the relative inaccessibility of the thoracic aorta to ultrasound interrogation and the increased variability of thoracic aortic pathologies and post-TEVAR complications. In addition, concerns regarding radiation-induced carcinogenesis and contrast-induced nephropathy reduce the enthusiasm of many surgeons for regular computed tomography surveillance. Most agree that surveillance is important after TEVAR, but the method, duration, and frequency of that surveillance is much less clear and is the topic of this debate.

The hybrid repair of a penetrating ulcer in a patient with a bovine arch; debranching followed by endovascular stent placement

Aortic arch disease has conventionally been a subject for open surgical repair, which may require circulatory arrest, accompanied by a long perfusion and extended cross-clamp time. A 2-stage approach utilizing an elephant trunk procedure followed by a descending aortic replacement, or utilizing a frozen elephant trunk with endovascular extension is not well tolerated by multimorbid patients. On the other hand, the endovascular repair of an aortic arch disease is limited by aortic branching. Hybrid repair consists of revascularization of arch vessels followed by endovascular stenting.

Results with the Talent thoracic stent graft in the VALOR trial

OBJECTIVE

We report the 5-year outcomes of thoracic endovascular aneurysm repair (TEVAR) using the Medtronic Vascular Talent Thoracic Stent Graft System (Medtronic Vascular, Santa Rosa, Calif) in patients considered low or moderate risk for open surgical repair.

METHODS

The Evaluation of the Medtronic Vascular Talent Thoracic Stent Graft System for the Treatment of Thoracic Aortic Aneurysms (VALOR) trial was a prospective, nonrandomized, multicenter, pivotal study conducted at 38 U.S. sites. Between December 2003 and June 2005, VALOR enrolled 195 patients who were low or moderate risk (0, 1, and 2) per the modified Society for Vascular Surgery and American Association for Vascular Surgery criteria. The patients had fusiform thoracic aortic aneurysms (TAAs) and/or focal saccular TAAs/penetrating atherosclerotic ulcers. Standard follow-up interval examinations were conducted at 1 month, 6 months, 1 year, and annually thereafter.

RESULTS

Over the 5-year follow-up, 76 deaths occurred (43.9%). Freedom from all-cause mortality was 83.9% at 1 year and 58.5% at 5 years. Most deaths were due to cardiac, pulmonary or cancer-related causes. Freedom from aneurysm-related mortality (ARM) was 96.9% at 1 year and 96.1% at 5 years. There was only 1 case of ARM after the first year of follow-up. Over the 5-year follow-up period, four patients were converted to open surgery and four patients experienced aneurysm rupture. The 5-year freedom from aneurysm rupture was 97.1% and the 5-year freedom from conversion to surgery was 97.1%. The incidence of stent graft migration (>10 mm) was ≤ 1.8% in each year of follow-up. The rate of type I endoleak was 4.6% at 1 month, 6.3% from 1 month to 1 year, and 3.8% during year 5. The rate of type III endoleak was 1.3% at 1 month, 1.9% from 1 month to 1 year, and 1.9% during year 5. Through 5 years, 28 patients (14.4%) underwent 31 additional endovascular procedures on the original target lesion. The 5-year freedom from secondary endovascular procedures was 81.5%.

CONCLUSIONS

Through 5-year follow-up in patients who were candidates for open surgical repair, TEVAR using the Talent Thoracic Stent Graft System has demonstrated sustained protection from ARM, aneurysm rupture, and conversion to surgery, and durable stent graft performance. Close patient follow-up remains essential after TEVAR.

Descending thoracic aortic surgery: update on mortality, morbidity, risk assessment and management

PURPOSE OF REVIEW

The purpose of this review is to summarize the literature on thoracic aortic surgery, as well as key management guidelines in the perioperative period. This is particularly timely, as endovascular techniques continue to evolve and become more available.

RECENT FINDINGS

Endovascular treatment of thoracic aortic disease is expanding in applications and case complexity.

SUMMARY

With the expanded use of endovascular techniques to treat aortic disease, midterm and long-term outcome studies and comparisons to open surgical approach are now being published with increasing frequency. This review analyzes the available literature on preventing adverse outcomes after descending thoracic aortic surgery, with specific attention to mortality, morbidity, risk assessment and management in the perioperative setting.

Thoracic or thoracoabdominal approaches to endovascular device removal and open aortic repair

BACKGROUND

Endovascular aortic repair is becoming increasingly common and diverse in its application despite ongoing uncertainty about long-term durability. Recent reports detail late conversion to open surgical repair to treat disease progression and repair failure. We describe our experience with using thoracic or thoracoabdominal approaches to endovascular device removal and open aortic repair after previous endovascular procedures.

METHODS

Thirty-five patients underwent open aortic repair through thoracotomy (n=7) or thoracoabdominal incision (n=28) 0.5 to 48 months after undergoing endovascular thoracic (n=27) or abdominal (n=8) aortic procedures. Indications for open repair included expanding aneurysm (n=23), device infection (n=8), fistula (n=5), pseudoaneurysm (n=2), aneurysm rupture (n=2), and restenosis (n=1). Endovascular devices were completely removed in 26 patients and partially removed in 9. Descending thoracic aortic repair was performed in 10 patients, thoracoabdominal aortic repair in 24, and juxtarenal abdominal aortic repair in 1.

RESULTS

There were 2 in-hospital deaths (6%), both in patients who presented with endovascular device infection. There were 8 late deaths. Overall 1-year survival was 83%±7%. Among the patients who presented with infected devices, 3 experienced major late complications, including persistent infection, pseudoaneurysm, and recurrent fistula; 2 of these patients succumbed to late deaths.

CONCLUSIONS

Open surgical repair after previous endovascular aortic procedures is successful in the majority of patients, particularly in those without device infections. Achieving definitive aortic repair in patients with infected endovascular devices is particularly challenging.

Potential long-term complications of endovascular stent grafting for blunt thoracic aortic injury

Blunt thoracic aortic injury (BTAI) is a rare, but lethal, consequence of rapid deceleration events. Most victims of BTAI die at the scene of the accident. Of those who arrive to the hospital alive, expedient aortic intervention significantly improves survival. Thoracic endovascular aortic repair (TEVAR) has been accepted as the standard of care for BTAI at many centers, primarily due to the convincing evidence of lower mortality and morbidity in comparison to open surgery. However, less attention has been given to potential long-term complications of TEVAR for BTAI. This paper focuses on these complications, which include progressive aortic expansion with aging, inadequate stent graft characteristics, device durability concerns, long-term radiation exposure concerns from follow-up computed tomography scans, and the potential for (Victims of Modern Imaging Technology) VOMIT.

A novel detachable filter to prevent thromboembolism during endovascular surgery

OBJECTIVE

Thromboembolism remains a serious complication during endovascular surgery. Commercially available filter devices, which are unified with the stenting systems, provide short-time performance owing to the adhesion of thrombus to the filters themselves. We have, therefore, developed a new detachable filter that can be used in all major aortic branches and shows greater longevity. The present study assessed the efficacy of the new detachable filter and examined the feasibility of deploying and retrieving the filters.

METHODS

We first performed in vitro studies. Our experimental flow model used silicon tubing to simulate the aortic branches. Polystyrene-divinylbenzene microspheres (100 and 200 μm in diameter), which simulated embolic particles, were injected into the tubing after the detachable filter was deployed. The capture efficacy (number of microspheres trapped in the detachable filter/total injected microspheres) was calculated. In the in vivo studies, the detachable filters were implanted into the carotid, visceral, and renal arteries of 5 mongrel dogs. Angiography was performed every 30 minutes. At 5 hours after implantation, each detachable filter was retrieved by a gooseneck snare catheter.

RESULTS

In the in vitro studies, our detachable filters showed high capture efficacy, capturing 99.2% of the 100-μm microspheres and 99.4% of the 200-μm microspheres. In the in vivo studies, all detachable filters were successfully deployed into the major branches. Each angiographic study revealed smooth flow without any embolic obstruction of the filter. At 5 hours after deployment, all devices were completely retrieved by the snare catheter without aortic injury.

CONCLUSIONS

The new detachable filter showed high efficacy in capturing the particles. All detachable filters were successfully deployed for 5 hours, and the filters were retrieved from the aortic branches without any complications. This novel detachable filter can help prevent serious distal thromboembolism during endovascular surgery.