Spinal cord ischemia after elective stent-graft repair of the thoracic aorta

Acute kidney injury in patients undergoing endovascular or open repair of juxtarenal or pararenal aortic aneurysms

BACKGROUND

The aim of this cohort study was to report the proportion of patients who develop periprocedural acute kidney injury (AKI) after endovascular repair (ER) and open surgery (OS) in patients with juxta/pararenal abdominal aortic aneurysm and to assess potential risk factors for AKI. The study also aimed to report the short- and long-term outcomes of patients with and without AKI.

METHODS

This was a multicenter cohort study of five European academic high-volume centers (>50 OS or 50 ER infrarenal AAA repairs, plus >15 complex AAA repairs per year). All consecutively treated patients were extracted from a prospective vascular surgical registry and the data were scrutinized retrospectively. The primary end point for this study was the development of AKI. AKI was diagnosed when there is a two-fold increase of serum creatinine or decrease of glomerular filtration rate of >50% within 1 week of AAA repair. Secondary end points included long-term mortality and end-stage renal disease (ESRD).

RESULTS

AKI occurred in 16.6% of patients in the ER group vs 30.3% in the OS group (P < .001). The 30-day mortality rate was higher among patients with AKI in both ER (15.4% vs 3.1%; P = .006) and OS (13.2% vs 5.3%; P = .001) groups. Age, chronic kidney disease, presence of significant thrombus burden in the pararenal region, >1000 mL blood loss in ER group were associated with development of AKI. Age, diabetes mellitus, chronic kidney disease, presence of significant thrombus burden in the pararenal region, and a proximal clamping time of >30 minutes in the OS group were associated with the development of AKI, whereas renal perfusion during clamping was the protective factor against AKI development. After a median follow-up of 91 months, AKI was associated with higher mortality rates in both the ER group (58.9% vs 29.7%; P < .001) and the OS group (61.5% vs 27.3%; P < .001). After the same follow-up period, AKI was associated with a higher incidence of ESRD in both the ER group (12.8% vs 3.6%; P = .009) and the OS group (9.9% vs 2.9%; P < .001).

CONCLUSIONS

The current study identified important pre and postoperative factors associated with AKI after juxta/pararenal abdominal aortic aneurysm repair. Patients with postoperative AKI had significantly higher short- and long term mortality and higher incidence of ESRD than patients without AKI.

Descending thoracic aortic mural ulceration is associated with postoperative spinal cord ischemia after branched endovascular aortic aneurysm repair

OBJECTIVE

Paraplegia is one of the most feared complications after thoracoabdominal aortic aneurysm repair. The purpose of this study is to determine whether aortic thrombus characteristics are associated with spinal cord ischemia (SCI) after branched endovascular aneurysm repair (BEVAR).

METHODS

From April 2011 to April 2020, 62 patients underwent elective BEVAR for thoracoabdominal aortic aneurysm and pararenal aortic aneurysms using a low-profile device and had a complete preoperative computed tomography angiography of the aorta from the sinotubular junction to the aortic bifurcation. Aortic thrombus was evaluated for thrombus thickness ≥5 mm, thrombus >2/3 of aortic circumference, and the presence of an ulcer-like thrombus. One point was assigned at each 5 mm axial image if all 3 criteria were met, resulting in a total "shaggy score" for the entire aorta. Data on demographics, procedural details, and outcomes were collected prospectively. All patients underwent a standard spinal cord protection protocol, including routine cerebrospinal fluid drainage. In July 2016, an insulin infusion protocol (IIP) was initiated to maintain postoperative blood glucose levels <120 mg/dL for 48 hours. The primary clinical end point was postoperative SCI.

RESULTS

10 (16%) patients developed postoperative SCI: 6 with transient paraparesis, 2 with persistent paraparesis, and 2 with persistent paraplegia. Patients with SCI were older, had higher shaggy scores, and were less likely to have been on an IIP. There were no significant differences in demographics, aneurysm type, or operative parameters. In a logistic multivariate regression model for SCI, age (odds ratio [OR]: 1.2 [1.1-1.4], P = .02) and shaggy score (OR: 1.2 [1.1-1.4], P = .02) were independently associated with increased risk of SCI, whereas treatment with the IIP was associated with lower risk of SCI (OR: 0.04 [0.006-0.50], P = .05). Of the individual components of the shaggy score, higher descending thoracic aortic ulcer scores were the most strongly associated with postoperative SCI (P = .009).

CONCLUSIONS

Preoperative characterization of aortic wall thrombus is an important adjunctive tool for individualized clinical decision-making and patient counseling about the risk of SCI after BEVAR.

Usefulness of Motor Evoked Potential Measurement and Analysis of Risk Factors for Spinal Cord Ischaemia from 300 Cases of Thoracic Endovascular Aortic Repair

OBJECTIVE

This study investigated the usefulness of motor evoked potentials (MEPs) for intra-operative monitoring to detect the risk of spinal cord ischaemia (SCI) during thoracic endovascular aortic repair (TEVAR). Risk factors for SCI in TEVAR were also analysed.

METHODS

Among 330 TEVARs performed from February 2009 to October 2018, 300 patients underwent intra-operative MEP monitoring. SCI risk groups were extracted based on MEP amplitude changes using a cutoff value of 50%. When the amplitude decreased to < 50% of the pre-operative value, intra-operative mean arterial pressure (MAP) was increased by about 20 mmHg using noradrenaline, whereas MAP was usually controlled to about 80 mmHg during surgery. Other efforts were also made to increase MEP amplitude by increasing cardiac output, correcting anaemia, and finishing the surgery promptly. Based on MEP amplitude data, SCI risk groups were extracted and risk factors for SCI in TEVAR were analysed.

RESULTS

A total of 283 non-SCI risk patients and 17 SCI risk patients by MEP monitoring were extracted; only 1.0% developed immediate paraplegia and none developed delayed paraplegia. Bivariable analysis showed significant differences in chronic kidney disease, haemodialysis, artery of Adamkiewicz closure, and stent graft (SG) covered length ≥ 8 vertebral bodies. Logistic regression analysis showed hyperlipidaemia (odds ratio [OR] 3.55, 95% confidence interval [CI] 1.08 - 11.67; p = .037), SG covered length ≥ 8 vertebral bodies (OR 1.35, 95% CI 1.02 - 1.78; p = .034), and haemodialysis (OR 27.78, 95% CI 6.02 - 128.22; p < .001) were the most influential risk factors for SCI in TEVAR.

CONCLUSION

MEPs might be a useful monitoring tool to predict SCI in TEVAR. In addition, hyperlipidaemia, SG covered length ≥ 8 vertebral bodies, and haemodialysis represent key risk factors for SCI during TEVAR.

Early and Mid-Term Outcomes of Females Treated with t-Branch off the Shelf Device

BACKGROUND

Female sex has been characterized as a risk factor of increased mortality in patients managed for complex aortic aneurysm using endovascular means. This study aimed to present the perioperative and follow-up outcomes of females managed electively or urgently with the t-Branch device and investigate factors affecting the early outcomes.

METHODS

A 2-center retrospective observational study was conducted including elective and urgent female patients managed with the t-Branch device (Cook Medical, Bjaeverskov, Denmark) for thoracoabdominal and pararenal aneurysms between January 1, 2018 and September 30, 2020. Primary early outcomes included technical success and 30-day mortality and morbidity [spinal cord ischemia (SCI) and acute kidney injury]. Follow-up survival and freedom from reintervention rates were assessed using Kaplan-Meier estimates.

RESULTS

In total, 153 females were included; 81 (52.9%) treated urgently. Urgent patients were older (73.2 ± 8.6 vs. 68.5 ± 6.8 years; P < 0.001) and presented higher previous coronary angioplasty/stenting (16.0% vs. 5.6%, P = 0.005) and lower double antiplatelet therapy (DAPT, 46.3% vs. 53.7%, P = 0.04) rates. Technical success was 97.4%. Early mortality was 16.3% (22% in urgent; 12% in elective; P = 0.2) and SCI and acute kidney injury were diagnosed in 13.7% (11% in urgent; 16% in elective; P = 0.2) and 18.3% (22.2% in urgent; 13.9% in elective; P = 0.18), respectively. Multivariate regression analyses showed that DAPT and b-blockers were related to lower 30-day mortality. DAPT was also preventive for SCI. Survival rates were 68.4% [standard error (SE) 0.07] at 12 months for the urgent and 75.6% (SE 0.09) at 24 months for the elective group (P = 0.14). Freedom from reintervention rates were 81.4% (SE 0.06) at 6 months and 64.7% (SE 0.09) at 18 months for the urgent and 81.7% (SE 0.06) at 6 months and 75.4% (SE 0.081) at 18 months for the elective group (P = 0.94).

CONCLUSIONS

Female patients managed with the t-Branch device for thoracoabdominal and pararenal aneurysms in elective and urgent setting presented similar 30-day mortality and SCI rates.

The fate of spinal arteries after the stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair technique: a case series

Objective

We evaluated the patency of the spinal arteries (intercostal and lumbar) after the STABILISE (stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair) technique.

Methods

A retrospective analysis of all patients with aortic dissection treated with the STABILISE technique between April 2018 and July 2021 was performed. Imaging analysis of the spinal cord vascular supply was accomplished using multiplanar and maximum intensity projection reconstructed images of pre- and postoperative computed tomography angiograms at 1 month, 12 months, and annually thereafter.

Results

Twelve patients were treated for complicated aortic dissection. Primary technical success was 100% and mid-term clinical success, at a mean follow-up of 27 ± 12 months, was 90%. No cases of spinal cord ischemia were identified. One patient died after 1 year (non-aortic related), and one patient was lost to follow-up. A significant decrease was found in the mean number of patent spinal arteries in the stent graft area at 1 month (P < .001), 1 year (P < .001), and 2 years (P = .004). However, no significant reduction was found in the number of spinal arteries in either the bare metal stented or nonstented aorta (P > .05).

Conclusions

Use of the STABILISE technique decreased intercostal artery patency in the thoracic stent graft area, but spinal artery patency was not significantly affected by the bare metal stent nor its aggressive ballooning. These findings constitute a step toward a better understanding of the safety of this technique.

Short Term and Long Term Clinical Outcomes of Endovascular versus Open Repair for Juxtarenal and Pararenal Abdominal Aortic Aneurysms Using Propensity Score Matching: Results from Juxta- and pararenal aortic Aneurysm Multicentre European Study (JAMES)

OBJECTIVE

The aim of this study was to compare the short and long term clinical outcomes of endovascular (EVAR) vs. open surgical repair (OSR) of juxtarenal (JAAAs) and pararenal abdominal aortic aneurysms (PAAAs) in five high volume European academic centres.

METHODS

This was a retrospective multicentre cohort study of five high volume European academic centres (> 50 open or 50 endovascular abdominal aortic aneurysm repairs annually) including 834 consecutive patients who were operated on and prospectively followed. Using propensity score matching (PSM) each patient who underwent OSR was matched with one patient who underwent EVAR in a 1:1 ratio (145 patients per group). The primary endpoint was long term all cause mortality, while the secondary endpoint was freedom from aortic related re-intervention.

RESULTS

After a follow up of 87 months, no difference in overall survival between the two groups was observed (38.6% for EVAR vs. 42.1% for OSR; p = .88). Patients undergoing EVAR underwent aortic related re-interventions more frequently (24.1% vs. 6.9%; p < .001). Acute kidney injury (AKI) occurred more frequently in patients in the OSR group (40.7% vs. 24.8%; p = .006). However, most patients who suffered from AKI recovered without further progression to renal failure. In hospital (3.4% for EVAR vs. 4.1% for OSR; p = 1.0) and 30 day (4.1% for EVAR vs. 5.5% for OSR; p = .80) mortality rates did not differ between groups.

CONCLUSION

Both open and endovascular treatment can be performed in high volume aortic centres with low short term mortality and morbidity rates, and good long term outcomes. These data provide useful information to help patients choose between the two procedures when both are feasible.

Favorable Remodeling After TEVAR in Uncomplicated Acute and Subacute Type B Aortic Dissection in Comparison to Conservative Treatment: A Midterm Analysis

PURPOSE

The purpose of the study was to evaluate the midterm and long-term outcomes of patients who underwent thoracic endovascular aortic repair (TEVAR) procedure to treat an uncomplicated acute and subacute type B aortic dissection (uATBAD) with high risk for subsequent aortic complications compared with the group of patients who received a conservative treatment protocol during the same period.

MATERIALS AND METHODS

Between 2008 and 2019, 35 patients who had TEVAR due to uATBAD and those with conservative procedure (n=18) were included in a retrospective analysis and follow-up study. The primary endpoints were false lumen thrombosis/perfusion, true lumen diameter, and aortic dilatation. The aortic-related mortality, reintervention, and long-term survival were the secondary endpoints.

RESULTS

In the study period, 53 patients (22 females) with a mean age of 61.1±13 years were included. No 30-day and in-hospital mortality was recorded. Permanent neurological deficits occurred in 2 patients (5.7%). In the TEVAR group (n=35) and in a median follow-up period of 34 months, a significant reduction of maximum aortic and false lumen diameter as well as a significant increase of true lumen diameter were detected (p<0.001 each). Complete false lumen thrombosis increased from 6% preoperatively to 60% at follow-up. The median difference in aortic, false lumen, and true lumen diameter was -5 mm (interquartile range [IQR]=-28 to 8 mm), -11 mm (IQR=-53 to 10 mm), and 7 mm (IQR=-13 to 17 mm), respectively. In 3 patients (8.6%), a reintervention was needed. Two patients (1 aortic-related) died during follow-up. The estimated survival according to Kaplan-Meyer analysis was 94.1% after 3 years and 87.5% after 5 years. Similar to the TEVAR group, no 30-day or in-hospital mortality was recorded in the conservative group. During follow-up, 2 patients died and 5 patients underwent conversion-TEVAR (28%). In a median follow-up period of 26 months (range=150), a significant increase of maximum aortic diameter (p=0.006) and a tendency to augmentation of the false lumen (p=0.06) were noted. No significant reduction of the true lumen was seen.

CONCLUSIONS

Thoracic endovascular aortic repair in patients at high risk of subsequent aortic complications in uncomplicated acute and subacute type B aortic dissection is safe and is associated with favorable midterm outcomes regarding aortic remodeling.

CLINICAL IMPACT

In a retrospective, single center analysis of prospectively collected data with follow-up, we compared 35 patients with high-risk features who recieved TEVAR in acute and sub-acute uncomplicated type B aortic dissection to a control-group (n=18). The TEVAR group showed a significant positive remoduling (reduction of max. aortic and false lumen diameter and increase of true lumen diameter (p<0.001 each)) during follow-up with an estimated survival of 94.1% after 3 years and 87.5% after 5 years.

Midterm Results of Thoracic Endovascular Aortic Repair with Reentry Closure for Chronic Type B Aortic Dissection with Aneurysmal Dilatation

Objectives: This study aims to discuss the midterm results of thoracic endovascular aortic repair (TEVAR) with reentry closure for chronic type B aortic dissection (CTBAD). Materials and Methods: This retrospective study analyzed 13 patients with CTBAD who underwent TEVAR with reentry closure between July 2014 and December 2020. We evaluated the false lumen (FL) cross-sectional area using computed tomography images of the descending aorta at the level of the bronchial bifurcation, Valsalva sinus, celiac artery, and infrarenal abdominal aorta pre- and postoperation. The study endpoints were technical and clinical success rates, freedom from additional aortic reintervention or surgery, and survival. Results: Technical success was obtained in 12 patients (92.3%) with no hospital mortality and neurological complications. The postoperative observation period was 49.2±21.5 months. The clinical success rate was 76.9% (10 cases), and a postoperative reduction of the FL cross-sectional area was obtained in 53.8% of patients. The 5-year overall survival rate was 64.8% with no aortic-related deaths while the 5-year freedom from additional aortic surgery rate was 66.7%. Conclusions: TEVAR with reentry closure suggests preventing FL dilatation or rupture in CTBAD, but the revision of our devices and further research with more patients and longer follow-up periods are required.

Simultaneous Endovascular Repair Is Not Associated With Increased Risk for Thoracic and Abdominal Aortic Pathologies: Early and Midterm Outcomes

Coexisting multilevel aortic pathologies were caused by atherosclerosis and hypertension and presented in a small subgroup of patients. Endovascular repair is a safe and effective treatment for a variety of aortic pathologies. However, fewer small series and cases were reported using simultaneous thoracic endovascular repair (TEVAR) and endovascular aneurysm repair (EVAR) for both aortic segments. To determine the outcomes of simultaneous and separately TEVAR and EVAR treating for multilevel aortic pathologies. Between 2010 and 2020, 31 patients and 22 patients were treated by one-staged and two-staged repair, respectively at a single center. All patients had the concomitant thoracic and abdominal aortic disease (aortic dissection, aneurysms, and penetrating aortic ulcers). Compared with the patients with two-staged aortic repair, the one-staged repair patients were older (mean age, 68 vs. 57 years; P < 0.001) and had a larger preoperative maximal aortic diameter (67.03 ± 10.65 vs. 57.45 ± 10.36 mm; p = 0.002). The intraoperative and postoperative outcomes show that the procedure times and length of hospital stay (LOS) were longer in the two-staged group. There is no significant difference in postoperative complications between the two groups. In the follow up, the freedom from re–intervention and the mean survival rate for the one-staged group were 100 vs. 100%, 92.4 vs. 95%, and 88 vs. 88% at one, two, and 5 years, respectively, whereas the mean survival rate for the two-staged group was 86.4 vs. 90.5%, 87 vs. 90.5%, and 76 vs. 84% at one, two, and 5 years, respectively, all with no statistical difference. Combined TEVAR and EVAR can be performed successfully with minimal morbidity and mortality. The one-staged repair was not associated with the increased risk for multilevel aortic pathologies treatment.

Staging Endovascular Thoracic and Thoracoabdominal Aortic Aneurysm Repairs and the Risk of Post-operative Spinal Cord Ischemia

OBJECTIVE

Staged aortic aneurysm repair is one method used to decrease the risk of spinal cord ischemia (SCI) following endovascular aortic intervention. Sequential sacrifice of arteries perfusing the spine may allow for improved spinal perfusion through the development of collateral networks over time. To evaluate the impact of staging endovascular aortic aneurysm repairs on SCI, we conducted a conservative analysis of Vascular Quality Initiative (VQI) data.

METHODS

De-identified VQI data were queried for cases of endovascular thoracic and thoracoabdominal aneurysm repairs from year 2014 to 2019. Cases were selected based on inclusion criteria: aneurysmal disease, no ruptures, no prior aortic surgeries, no retreatments, and only cases with complete data on aortic zones and SCI. Chi-square, Student's t-tests, and Mann-Whitney U tests were used for univariable analyses, as appropriate. Logistic regression analyses were used to identify independent predictors of outcome.

RESULTS

There were 116 staged aortic repairs (SARs) (8.2%) performed out of a total of 1421 endovascular aortic repairs that fit study criteria. The overall rate of SCI within the study cohort was 3.4% (n = 48). The distribution of SARs and SCI events according to aortic zone coverage are displayed in Table 1. Patients who underwent staged endovascular aortic repairs had higher rates of SCI, pre-op spinal drain placement, non-African-American race, COPD, smoking history, positive stress tests, aspirin and statin use, increased estimated blood loss, physician-modified endografts, number of aortic zones covered, lower pre-op hemoglobin levels, larger aneurysm sac size, fusiform aneurysms, and longer total procedure times, Table 2. After adjusting for factors associated with SCI, a priori, and factors with a P < 0.1 univariable analysis, SAR was not associated with SCI (odds ratio [OR] = 1.86, 95% confidence interval [CI] = 0.77-4.50, P = 0.17). Of the six factors associated with SCI on univariable analysis, only procedure time ≥6 hours (OR = 2.49, 95% CI = 1.09-5.70, P = 0.031) and the number of aortic zones covered (OR = 1.15, 95% CI = 1.00-1.32, P = 0.047) were predictive of SCI. Staged repairs had a lower proportion of permanent SCI (38%, 3 of 8 cases) compared with repairs that were not staged (68%, 27 of 40 cases), with a relative risk reduction of 44% for those who developed SCI, P = 0.21.

CONCLUSIONS

In a large national data set, SARs were performed for patients with more extensive aortic disease. SARs were only performed in about 8% of cases and the rate of SCI remained low. After adjusting for baseline comorbidities, extent of aortic disease, and other factors that may potentiate SCI, staged aortic aneurysm repair had a similar risk of SCI compared with non-staged repairs. However, there was a trend toward decreased permanent SCI risk in the SAR group.

Systematic review and meta-analysis of association of prophylactic cerebrospinal fluid drainage in preventing spinal cord ischemia after thoracic endovascular aortic repair

OBJECTIVE

We conducted a systemic review and meta-analysis to compare the association between prophylactic cerebrospinal fluid drainage (CSFD) vs non-CSFD in preventing spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) for aneurysm and dissection.

METHODS

The MEDLINE, Embase, and Cochrane databases were systematically searched to identify all relevant studies reported before April 1, 2020. A systematic review and meta-analysis were performed. We assessed the association between CSFD strategies, including routine CSFD vs selective CSFD or no CSFD, and the SCI rates after TEVAR for patients with aortic dissection (AD), solitary thoracic aortic aneurysm (TAA), or thoracoabdominal aortic aneurysm (TAAA). Subgroup analyses were conducted to assess the association between different aortic pathologies, including AD and thoracic aneurysms, and SCI rates after TEVAR with and without prophylactic CSFD. The data are presented as the pooled event rates (ERs) and 95% confidence intervals (CIs).

RESULTS

A total of 34 studies of 3561 patients (2671 with TAA or TAAA and 890 with type B AD) were included in the present analysis. The data are presented as the pooled ERs and 95% CIs. The overall SCI rate for patients who had undergone TEVAR with prophylactic CSFD for AD (ER, 1.80%; 95% CI, 0.88%-2.72%) was significantly lower than that for the aortic aneurysm group (ER, 5.73%; 95% CI, 4.20%-7.27%; P < .0001). The SCI rate after TEVAR with prophylactic CSFD was not significantly different from that without CSFD for AD (P = .51). No association was found between the rates of SCI after TEVAR with routine prophylactic CSFD vs selective prophylactic CSFD for aortic aneurysms (P = .76) and AD (P = .70). The SCI rate after TEVAR without CSFD for aortic aneurysms, including isolated TAA and TAAA (ER, 3.49%; 95% CI, 0.23%-6.76%) was not significantly different from that for AD (ER, 3.20%; 95% CI, 0.00%-7.20%; P = .91). For the patients with TAAAs, the rate of SCI after TEVAR with routine prophylactic CSFD was significantly lower than that with selective prophylactic CSFD (P = .04).

CONCLUSIONS

Our systematic review and meta-analysis has shown that SCI occurs more often after TEVAR for aortic aneurysms than for AD. Routine prophylactic CSFD, compared with selective CSFD, was associated with a lower rate of postoperative SCI after TEVAR for TAAAs. No significant association was found between the SCI rate and routine prophylactic CSFD for patients undergoing TEVAR for isolated TAA or AD.

Paraplegia After Valvular Surgery After Remote Thoracoabdominal Aortic Aneurysm Repair

Neurological disorders are the most unpredictable and feared complications after open surgery or endovascular aortic repair. Paraplegia because of spinal cord injury is well known after thoracoabdominal aortic surgery but not after valvular surgery. We herein present a case of paraplegia after mitral and tricuspid valve surgery in a patient with a history of surgery involving the thoracoabdominal and abdominal aorta. The paraplegia was likely caused by temporary postoperative hypotension as low as 40 mm Hg for more than 10 minutes with decreased spinal perfusion in the intensive care unit.

Paraplegia after Open Repair of Suprarenal Abdominal Aortic Aneurysm

Spinal cord ischemia after open repair of abdominal aortic aneurysm (AAA) is an unpredictable and devastating complication. We present a case report of a patient who developed paraplegia 6 hours after open repair of suprarenal AAA. A 74-year-old man presented with asymptomatic 5.5-cm suprarenal AAA, for which he underwent open repair under general anesthesia. The paraplegia was identified 6 hours after the operation. Postoperative magnetic resonance imaging showed T2 signal hyperintensity and swelling of the spinal cord, which were consistent findings with subacute spinal cord infarction. Although intravenous steroid was administered and lumbar cerebral spinal fluid drainage was instituted, his neurological outcome did not improve. He was discharged after vigorous rehabilitation but still has paraplegia and requires wheelchair for ambulation.

Comparative Outcome Analysis of N-Butyl Cyanoacrylate Embolization of the False Lumen Versus Thoracic Endovascular Aortic Repair in Aortic Dissection

PURPOSE

To evaluate the feasibility, safety, and effectiveness of N-butyl cyanoacrylate (NBCA) embolization for the treatment of aortic dissection.

MATERIALS AND METHODS

In this single-center retrospective study conducted from February 2003 to June 2019, NBCA embolization of an aortic false lumen was attempted in 12 patients (median age, 59 y; range, 41-68 y) and thoracic endovascular aortic repair (TEVAR) was performed in 53 patients (median age, 59 y; range, 37-70 y) for aortic dissection with one or more indications of persisting pain, malperfusion, rupture or impending rupture, maximal aortic diameter ≥ 55 mm, and/or rapid aortic enlargement. The main exclusion criterion for embolization was the presence of fast blood flow in the aortic false lumen on aortography. The efficacy of NBCA embolization and TEVAR was compared by evaluating technical and clinical outcomes, repeat intervention-free survival (RFS), and overall survival (OS).

RESULTS

Technical success was achieved in 11 of the 12 patients treated with NBCA embolization (91.7%), and clinical success was achieved in 9 of these 11 (81.8%). No significant difference was found between embolization and TEVAR in clinical success rates (embolization, 81.8%; TEVAR, 84.9%; P = .409) or procedure-related complications (embolization, 1 patient [8.3%]; TEVAR, 4 patients [7.5%]; P = .701). In addition, embolization showed comparable 5-y RFS (embolization, 82.5% ± 9.3; TEVAR, 85.5% ± 4.8; P = .641) and 5-y OS (embolization, 100%; TEVAR, 95.4% ± 3.2; P = .744) rates to TEVAR.

CONCLUSIONS

NBCA embolization of the false lumen in aortic dissection seems to be a safe and effective treatment modality for the closure of false lumen in selected patients.

Arch replacement with collared elephant trunks: The Siena approach

Objective

To illustrate our experience and results in patients with diffuse aneurysmal disease treated with arch replacement using the Siena collared graft, a device designed in 2002 to improve the elephant trunk technique. Results of the first step surgical implant and the subsequent treatment strategies, with extensive use of endovascular techniques, are reported.

Methods

All aortic arch–replacement procedures using the Siena graft between February 2002 and January 2020 were retrospectively analyzed for early and late clinical outcomes.

Results

Of 146 patients (54 women, 36.9%) with a median age of 69.1 years (interquartile range 58.4-75.0 years), 55 (37.6%) had acute/chronic dissection with false lumen aneurysmal dilatation, 91 (62.3%) had degenerative aneurysms, 45 (30.8%) were redo operations, and 14 (9.5%) had connective tissue disease. First-stage outcomes: 10.9% 30-day mortality (n = 16); 5.4% stroke (n = 8, 6 disabling, 2 nondisabling; 3 fatal); and 0.6% paraplegia. Outcomes for 113 second-stage procedures (77.3%, n = 97 endovascular [66.4%], n = 16 surgical [10.9%]) were 5.3% and 8.8% 30-day and 180-day mortality; no stroke; 10.6% paraplegia. Median follow-up was 5.7 years (range: 0-18.02 years) median survival was 16.65 years (95% lower confidence limit, 10.06 years) with no significant difference between aneurysm and dissection patients. Freedom from further treatment was 87.0% (95% confidence interval, 79.9%-94.7%) at 5 years and 71.4% (95% confidence interval, 71.4%-84.7%) at 10 years; median time to reintervention was 2.59 years (interquartile range, 0.52-5.20 years) with no difference (P = .22) between dissection and aneurysm groups.

Conclusions

Siena collared graft represents a reliable platform for the treatment of diffuse aneurysmal disease. This device offers the flexibility required in the treatment of extended aortic lesions and guarantees the choice of the most appropriate approach for treatment completion. In this context, the availability of hybrid grafts has not modified the role of this device in arch surgery.

Endovascular Treatment of a Life-threatening Blunt Thoracic Aortic Injury in Polytraumatized Patients - A Single Center Experience

A retrospective analysis of our group of patients, efficacy, safety and the results of endovascular treatment of descending thoracic aorta by using stentgraft implantation in polytraumatized patients. In the period between 6/2006 and 2/2020, in the processing of data, we analysed retrospectively patients with polytrauma diagnosed with thoracic aortic rupture or transection (TAT) and treated with multiple injuries. Clinical characteristics, complications, pathological features, and hospital follow-up data were retrieved from our group. In our group of 28 polytraumatized patients referred to our Trauma Centre with current TAT, all 28 patients with such a thoracic aortic injury were treated by using thoracic stentgraft implantation. In our group of patients, the average Injury Severity Score (ISS) was 22 for women (min 19, max 27) and 26 for men (min 17, max 41), respectively. We reached 100% technical implantation success rate with our patients. In our group, we had 30-day mortality of 10.7% (3 patients) and the in-hospital mortality was 17.8% (5 patients). Surviving patients had calculated ISS score of 25 (min 17, max 41); dead patients had an ISS score of 28 (min 19, max 34) - p≤0.05. Endovascular treatment of TAT, as a minimally invasive and effective procedure with rapid bleeding control, may increase survival chances for severely compromised polytraumatized patients in the context of multiple-organ damage and the need for a major cardio-vascular surgery.

Safety and efficacy of the percutaneous thoracic endovascular repair with regional anesthesia

OBJECTIVES

Thoracic endovascular aortic repair (TEVAR) is typically performed with general anesthesia (GA) and surgical cutdown (G-TEVAR). As the latest generation of TEVAR delivery systems are smaller, we introduced percutaneous TEVAR with regional anesthesia (RA) (R-TEVAR) and an arteriotomy closure device. In this study, we compare the safety and efficacy of R-TEVAR to that of the G-TEVAR.

METHODS

This single-center observational study included consecutive patients who underwent either G-TEVAR between January 2015 and October 2018 (33 patients) or R-TEVAR (41 patients) between January 2018 and April 2020. RA was achieved using an ultrasound-guided nerve block.

RESULTS

The mean outer diameter of the delivery device was significantly smaller in R-TEVAR (18.5 vs. 22.7 Fr; p < 0.01) and the time from arriving into the operating room to beginning of surgery (34.1 vs. 68.5 min; p < 0.01), procedural time (46.4 vs. 103.6 min; p < 0.01), and operating room stay time (108.3 vs. 194.6 min; p < 0.01) were significantly shorter. The mean rate of change in blood pressure was significantly lower in the R-TEVAR group (7.7% vs. 32.2%; p < 0.01). One case of spinal cord ischemia occurred in the G-TEVAR group (0% vs. 3.0%; p = 0.262) and one case of inadequate hemostasis and conversion to surgical cutdown without GA occurred in the R-TEVAR group (2.4% vs. 0%; p = 0.366).

CONCLUSIONS

The R-TEVAR is safe and minimally invasive. Further, RA may provide additional benefits of mean blood pressure stability and early recognition of neurologic complications.

New Preoperative Spinal Cord Ischemia Risk Stratification Model for Patients Undergoing Thoracic Endovascular Aortic Repair

PURPOSE

Our objective was to determine significant predictors of spinal cord ischemia (SCI) following Thoracic Endovascular Aortic Repair (TEVAR) and to further develop a simple and clinically orientated risk score model.

METHODS

A retrospective review of data from the Society of Vascular Surgery/Vascular Quality Initiative national data set was performed for all patients undergoing TEVAR from January, 2014 to June 2018. Preoperative demographics, procedure-related variables, and clinical details related to SCI were examined. A SCI risk score was developed utilizing a multivariable logistic regression model.

RESULTS

For the 7889 patients in the final analysis who underwent TEVAR during the study period, the mean age was 67.6 ± 13.9, range 18 to 90 years, and the majority was male (65%). Postoperative outcomes included stroke (3.0%), myocardial infarction (2.9%), inhospital mortality (5.4%), transient SCI (1.5%), and permanent SCI (2.1%). Nearly half of the overall cases were performed in high volume centers. Predictors of increased risk for SCI included age by decade (odds ratio [OR]: 1.2), celiac coverage (OR: 1.5), current smoker (OR: 1.6), dialysis (OR: 1.9), 3 or more aortic implanted devices (OR: 1.7), emergent or urgent surgery (OR: 1.5), adjunct aorta-related procedure (OR: 2.5), adjunct not related (OR: 2.6), total estimated length of aortic device (19-31 cm, OR: 1.9 and ≥32 cm, OR: 3.0), ASA class 4 or 5 (OR: 1.6), and procedure time ≥154 minutes (OR: 1.8). Two predictors decreased the risk of SCI, cases from high-volume centers (OR: 0.6) and eGFR ≥ 60 (OR: 0.6). To evaluate the risk score model, probabilities of SCI from the original regression, raw score, and raw score categories resulted in area under the curve statistics of 0.792, 0.786, and 0.738, respectively.

CONCLUSIONS

Spinal cord ischemia remains one of the most feared complications of TEVAR. Incidence of SCI in this large series of patients with TEVAR was 3.6% with nearly 60% being permanent. The proposed model provides an assessment tool to guide clinical decisions, patient consent process, risk-assessment, and procedural strategy.

Previous thoracic aortic repair is not associated with adverse outcomes after thoracic endovascular aortic repair

BACKGROUND

As many as 20% of patients who have undergone previous thoracic aortic repair will require reintervention, which could entail thoracic endovascular aortic repair (TEVAR). A paucity of data is available on mortality and the incidence of spinal cord ischemia (SCI) and other postoperative complications associated with TEVAR after previous aortic repairs exclusive to the thoracic aorta. The aim of the present study was to assess the effect of previous thoracic aortic repair on the 30-day mortality and SCI outcomes for patients after TEVAR.

METHODS

The Society for Vascular Surgery Vascular Quality Initiative database was queried for all cases of TEVAR from 2012 to 2018. Patients were excluded if they had undergone previous abdominal aortic repair, the TEVAR had extended beyond aortic zone 5, or SCI data were missing. The 3 cohorts compared were TEVAR with previous ascending aortic or aortic arch repair (group 1), TEVAR with previous descending thoracic aortic repair (group 2), and TEVAR without previous repair (group 3). The primary outcomes of interest were 30-day mortality and SCI. The secondary outcomes included stroke, myocardial infarction, cardiac complications, respiratory complications, postoperative length of stay, and reintervention. The patient variables were compared using χ2 tests, analysis of variance, or Kruskal-Wallis tests, as appropriate. Logistic regression analysis was performed to identify the predictors of 30-day mortality and SCI.

RESULTS

A total of 4010 patients met the inclusion criteria, with 470 in group 1, 132 in group 2, and 3408 in group 3. The 30-day mortality was 4% (19 of 470) in group 1, 6% (8 of 132) in group 2, and 6% (213 of 3408) in group 3 (P = .17). The incidence of SCI was 3% (14 of 470) in group 1, 3% (4 of 132) in group 2, and 3.8% (128 of 3408) in group 3 (P = .65). Stroke, reintervention, myocardial infarction, and cardiac complications were not significantly different among the 3 groups. The incidence of respiratory complications was greatest for group 3 (11%; 360 of 3408) compared with groups 1 (9%; 44 of 470) and 2 (4%; 5 of 132; P = .034). Similarly, the postoperative length of stay was longest for group 3 (9.6 ± 19.4 days vs 8.2 ± 18.3 days for group 1 and 5.9 ± 8.6 days for group 2; P = .038). The independent predictors of 30-day mortality for all TEVAR patients included units of packed red blood cells transfused intraoperatively, urgent or emergent repairs, older age, increasing serum creatinine level, inability to perform self-care, total procedure time, occlusion of the left subclavian artery intraoperatively, distal endograft landing zone 5, and diabetes. The predictors of SCI included the total procedure time, urgent and emergent repairs, and increasing serum creatinine level.

CONCLUSIONS

TEVAR after previous thoracic aortic repair was not associated with an increased risk of SCI or 30-day mortality compared with TEVAR without previous aortic repair.

Detectability of the artery of Adamkiewicz on computed tomography angiography of the aorta by using ultra-high-resolution computed tomography

PURPOSE

To evaluate the detectability of AKA on aortic computed tomography angiography (CTA) using ultra-high-resolution computed tomography (UHRCT).

MATERIALS AND METHODS

Twenty-eight patients were enrolled. They underwent aortic CTA with UHRCT (UHRCTA) and had previously undergone aortic conventional CTA (CCTA). The injection protocol of UHRCTA was the same as that of CCTA. The bolus tracking technique was used. UHRCTA images were reconstructed with adaptive iterative dose reduction (strong) and with forward-projected model-based iterative reconstruction solution. The matrix size and slice thickness on UHRCT were 1024 and 0.25 mm, respectively, and those on conventional CT were 512 and 0.5 or 0.67 mm, respectively. The UHRCTA and CCTA images were visually compared by using four scales. A score of 4 or 3 indicated that the AKA was assessable. In this instance, the contrast-to-noise ratios of each UHRCTA were measured. The exposure dose and signal-to-noise ratios were also investigated.

RESULTS

The AKA visualization scores obtained with UHRCTA with forward-projected model-based iterative reconstruction solution were significantly higher than those with adaptive iterative dose reduction (p = 0.018) and CCTA (p = 0.0024).

CONCLUSION

UHRCT can contribute to the better visualization of the AKA on aortic CTA.

Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) Reporting Standards for Type B Aortic Dissections

This Society for Vascular Surgery/Society of Thoracic Surgeons (SVS/STS) document illustrates and defines the overall nomenclature associated with type B aortic dissection. The contents describe a new classification system for practical use and reporting that includes the aortic arch. Chronicity of aortic dissection is also defined along with nomenclature in patients with prior aortic repair and other aortic pathologic processes, such as intramural hematoma and penetrating atherosclerotic ulcer. Complicated vs uncomplicated dissections are clearly defined with a new high-risk grouping that will undoubtedly grow in reporting and controversy. Follow-up criteria are also discussed with nomenclature for false lumen status in addition to measurement criteria and definitions of aortic remodeling. Overall, the document provides a facile framework of language that will allow more granular discussions and reporting of aortic dissection in the future.

Spinal subarachnoid hemorrhage in type B aortic dissection: a rare presentation

Paraplegia is a common complication encountered during surgical and endovascular repair of aortic diseases. At times, it is also a presenting feature of aortic dissection. Involvement of more than one spinal blood supply system is the most common cause of spinal cord ischemia. Proper planning is needed to prevent and treat spinal cord ischemia. We report this rare case of acute type B aortic dissection that presented with paraplegia due to a spinal subarachnoid hemorrhage.

Medullary ischemia after endovascular procedure of infrarenal aorta in a patient with dual anticoagulant and antiplatelet therapy: a case report

Background

Medullary ischemia secondary to surgical procedures of the infrarenal aorta is an infrequent and mostly devastating complication of this procedure, and its nonspecific clinical presentation makes it difficult to promptly diagnose. Prevention measures for this complication are not yet clear; therefore, the need for anticoagulant and/or antiplatelet therapy is discussed.

Case presentation

This paper reports a case of a 69-year-old Hispanic man presenting with sudden pain and signs of ischemia on his left lower extremity 8 weeks after endovascular repair with endoprosthesis of an infrarenal aorta and left iliac aneurysm. The patient was admitted to the emergency room, where an extensive arterial thrombosis compromising the right iliac and femoral arteries was diagnosed. Dual anticoagulation and antiplatelet therapies were initiated, and therapeutic ranges were achieved. Nonetheless, the patient presented medullary ischemia by microembolization diagnosed by contrast-enhanced magnetic resonance imaging, with unsatisfactory evolution of an intracranial hemorrhagic event without documented excessive anticoagulation. The patient developed permanent pure motor deficit of his lower extremities, absence of sphincter control, and mild cognitive impairment.

Conclusions

This is a complex and extremely rare case. It is important to continue with clinical investigations that give more clarity about the onset of anticoagulation, antiplatelet therapy, and management of dual schemes to decrease the risk of complications in this type of surgical procedure.

Off pump hybrid extra-anatomic techniques for aortic arch repair-own experience

Background

Treatment of the aortic arch pathologies is technically challenging. In this study we assess early and late outcomes of hybrid aortic arch repairs that comprise extra-anatomic surgical procedures completed by thoracic endovascular interventions [thoracic endovascular aortic repair (TEVAR)].

Methods

Since 2007, 21 patients (8 women and 13 men) with a median age of 48 years have undergone hybrid procedures for aortic arch pathologies. All of them were treated without cardio-pulmonary bypass. All survivors were followed up regularly and imaging examination were performed. A technical success, procedural complications as well as the early and late mortality and morbidity rates were evaluated.

Results

All patients survived surgery and TEVAR was technically successful in all of them. However, 2 individuals died (in-hospital mortality rate 9.5%) during in-hospital stay, both due to multi-organ failure (MOF). Additionally, one patient developed symptoms of cerebral stroke, another one of spinal cord ischemia. During the follow-up that ranged from 6 to 118 months and was completed by 100% of the survivors, one patient died 3 years after procedure because of sepsis (aorto-oesophageal fistula prior to intervention) and late vascular graft occlusions were noted in three cases.

Conclusions

Hybrid procedures on the aortic arch that comprise surgical and endovascular interventions has become an attractive and safe therapeutic option with acceptable mortality and morbidity rate. They may be considered as a method of choice in treatment of the elderly and high-risk patients.

Endovascular treatment of complex diseases of the thoracic aorta-10 years single centre experience

BACKGROUND

Introduction of invasive endovascular techniques constituted a real a breakthrough in the treatment of aortic aneurysm dissection and rupture. We assessed the effectiveness and safety of thoracic endovascular aortic repair (TEVAR) in patients with thoracic aortic pathologies.

METHODS

Between 2007 and 2017, 118 patients with thoracic aortic pathology underwent TEVAR. Among them, 20 (16.9%) patients required hybrid procedures. Stent grafts indication were thoracic aortic aneurysm in 46 (39.0%) patients, type B dissection in 68 (57.6%) patients and other indications in 4 (3.3%). Procedural success rate, in-hospital and late mortality and morbidity were evaluated.

RESULTS

The patients were followed-up for a mean of 55 months (range, 6-118 months). The technical success rate was 96%. Five patients died during the first 30 days after procedure (mortality 4.2%), four due to ischemic stroke followed by multi-organ failure and another one hemodynamically significant type I endoleak. Most of them were noted in the first years of our study. Five others died during post-discharged period. Four patients developed neurological complications, including stroke (n=2; 1.7%) and paraparesis (n=2; 1.7%). There were 6 (5.1%) primary (5 type I and 1 type II) and 3 (2.5%) secondary endoleaks (1 type I and 2 type III). Secondary interventions were required in 8 subjects. There was one case of stent collapse and two retrograde aortic dissection.

CONCLUSIONS

Treatment of descending aortic diseases by using stent graft implantation has become the method of choice, decreasing the risk of open surgery, especially in patients with severe clinical state and comorbidities. However, effectiveness and safety may be achieved by experience team.

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.

Paraplegia prevention in aortic aneurysm repair by thoracoabdominal staging with 'minimally invasive staged segmental artery coil embolisation' (MIS²ACE): trial protocol for a randomised controlled multicentre trial

INTRODUCTION

Spinal cord injury (SCI) including permanent paraplegia constitutes a common complication after repair of thoracoabdominal aortic aneurysms. The staged-repair concept promises to provide protection by inducing arteriogenesis so that the collateral network can provide a robust blood supply to the spinal cord after intervention. Minimally invasive staged segmental artery coil embolisation (MIS²ACE) has been proved recently to be a feasible enhanced approach to staged repair.

METHODS AND ANALYSIS

This randomised controlled trial uses a multicentre, multinational, parallel group design, where 500 patients will be randomised in a 1:1 ratio to standard aneurysm repair or to MIS²ACE in 1-3 sessions followed by repair. Before randomisation, physicians document whether open or endovascular repair is planned. The primary endpoint is successful aneurysm repair without substantial SCI 30 days after aneurysm repair. Secondary endpoints include any form of SCI, mortality (up to 1 year), length of stay in the intensive care unit, costs and quality-adjusted life years. A generalised linear mixed model will be used with the logit link function and randomisation arm, mode of repair (open or endovascular repair), the Crawford type and the European System for Cardiac Operative Risk Evaluation (euroSCORE) II as fixed effects and the centre as a random effect. Safety endpoints include kidney failure, respiratory failure and embolic events (also from debris). A qualitative study will explore patient perceptions.

ETHICS AND DISSEMINATION

This trial has been approved by the lead Ethics Committee from the University of Leipzig (435/17-ek) and will be reviewed by each of the Ethics Committees at the trial sites. A dedicated project is coordinating communication and dissemination of the trial.

TRIAL REGISTRATION NUMBER

NCT03434314.

Spinal Cord Ischemia after Endovascular Aortic Repair of a Unilateral Iliac Artery Dissecting Aneurysm: A Case Report

PURPOSE

Spinal cord ischemia (SCI) is a rare complication of endovascular repair of abdominal aortic aneurysm that is attributed to the variable anatomy of the artery of Adamkiewicz, embolization of the collateral circulation, or hypoperfusion of cord structures secondary to hypotension.

CASE REPORT

A hypertensive 83-year-old male with chronic obstructive pulmonary disease presented with a 2.3-cm right iliac artery dissecting aneurysm. Paraplegia occurred on the first day after endovascular repair of iliac artery aneurysm. Postoperative magnetic resonance imaging showed multiple foci of spinal cord ischemia involvement from T10 to L1. Neither arterial pressure augmentation nor steroid therapy was effective. We hypothesized that the compromised blood flow from the artery of Adamkiewicz, combined with the transient hypotension and embolism, resulted in spinal cord infarction. The patient was eventually transferred to a nursing facility, with no improvement in his neurological status.

CONCLUSIONS

SCI after endovascular aortic repair is an extremely rare and unpredictable complication. Physicians should pay more attention to the patients with comorbidities of atherosclerosis, chronic obstructive pulmonary disease, or peripheral artery occlusive disease.

Aortic remodeling in Type B aortic dissection after thoracic endovascular aortic repair with an aortic extender cuff implantation

Objective

This study investigated the safety and efficiency of thoracic endovascular aortic repair (TEVAR) plus an aortic extender cuff placement in treating Stanford Type B aortic dissections (TBADs).

Methods

Clinical data on 157 patients with TBADs who underwent TEVAR in two tertiary medical centers from February 2013 to March 2018 were analyzed retrospectively. An estimated mismatch rate >120% was the indication for placement of an aortic extender cuff. Results in the perioperative and follow-up periods (≥3 months) were analyzed, especially those of aortic remodeling.

Results

In total, 106 patients (67.5%) underwent standard TEVAR, and 51 (32.5%) received TEVAR plus an aortic extender cuff placement. The primary technical success rate was 96.8% (152/157). Perioperative adverse events included endoleak (2%, 3/157), spinal cord ischemia (SCI) (1.3%, 2/157), and transient renal failure (0.6%, 1/157), with no between-group differences. The median follow-up was 15 months (range 3–71 months). Ten cases of late stent complications were observed, including three endoleak, one upper limb ischemia, one stent distortion, and five stent graft-induced distal re-dissection (SIDR). Patients with a cuff had less distal re-dissection and fewer second interventions, but the differences lacked significance. In the last follow-up, the TEVAR+Cuff group were found to have better true lumen recovery and false lumen shrinkage, and increased complete false lumen thrombosis in the thoracic and abdominal segments; however, no statistical difference was evident in comparison with the TEVAR group (P>0.05).

Conclusion

TEVAR plus an aortic extender cuff implantation improves remodeling of the dissected thoracic aorta, thus reducing the potential of SIDR. Furthermore, the covered stent with a length of 250 mm does not increase the rate of SCI or paraplegia. However, these results should be confirmed in a larger series of patients with longer follow-up.

Risk of spinal cord ischemia after thoracic endovascular aortic repair

Background

Spinal cord ischemia (SCI) is a recognized grave complication after thoracic endovascular aortic repair (TEVAR). The present study aimed to evaluate the incidence and investigate risk of SCI after TEVAR based on current prophylactic strategies designed against established risk factors.

Methods

The study retrospectively reviewed a prospectively maintained database to investigate patients who underwent TEVAR successfully between January 2009 and December 2012 in a single cardiovascular center. Detailed assessment of SCI risk was routinely performed for all patients before TEVAR was carried out. Prophylactic measures, including left subclavian artery (LSA) revascularization, blood pressure augmentation and cerebrospinal fluid (CSF) pressure control after TEVAR, were employed in high-risk patients and physical neurological examinations were regularly done to evaluate SCI after TEVAR. Patients were further divided into SCI group and non-SCI group.

Results

A total of 650 patients were enrolled in the study. Eleven patients (1.69%) developed SCI after TEVAR. Baseline level of hemoglobin was significantly lower in the SCI group (113.00 vs. 128.50, P=0.023). More patients in the SCI patients in the SCI group underwent TEVAR under general anesthesia (45.5% vs. 17.7%, P=0.033). A significantly higher incidence of post TEVAR hypotension was found in the SCI group (2.7% vs. 27.3%, P=0.004). Logistic regression analysis revealed that post-TEVAR hypotension (OR, 8.379; 95% CI, 1.833-38.304; P=0.006) was strongly associated with development of SCI and high normal baseline hemoglobin was a protective factor (OR, 0.969; CI, 0.942-0.998; P=0.037). The mortality in hospital and mortality at 1 year were not significant different between the SCI and the non-SCI group (0% vs. 1.6% P=1.000; 9.1% vs. 3.0%, P=0.294, respectively). While length of post-TEVAR stay (13.00 vs. 7.00 days, P=0.000) and length of hospital stay (20.00 vs. 13.00 days, P=0.001) were significantly greater in the SCI group.

Conclusions

Our study revealed that, based on current prophylactic measures to curtail SCI, including LSA revascularization, blood pressure augmentation and CSF pressure control after TEVAR, post-TEVAR hypotension remains a major and independent risk factor for SCI and high normal baseline hemoglobin level is protective. SCI results in longer post-TEVAR stay and hospital stay, but not associated with increased mortality. Robust precautions should be taken against underlying causes for post-TEVAR hypotension and low level of hemoglobin should be avoided.

Urgent Endovascular Treatment for Non-traumatic Descending Thoracic Aortic Rupture

PURPOSE

To evaluate the efficacy of endovascular repair of non-traumatic rupture of the descending thoracic aorta.

MATERIALS AND METHODS

From January 2011 to August 2017, 22 consecutive patients (16 men, mean age 73.7 years, range 63-92 years) with non-traumatic rupture of the descending thoracic aorta were treated endovascularly. Thirty-day mortality as well as procedure-related morbidity including stroke, renal, pulmonary and spinal complications were retrospectively assessed. Median follow-up was 29 months (range 6-65 months).

RESULTS

Nine patients had type B dissections, and 13 had atherosclerotic aortic aneurysms. The technical success was 100%; 86.3% of patients (19/22) were treated percutaneously. Thirteen patients (59%) received a single endograft, 8 (36%) received 2 endografts, and 1 received 3 endografts. The endograft diameters ranged between 28 and 46 mm. Two dissection patients received additional distal bare metal true lumen stents. Eleven patients required additional drainage of thoracic hematoma. Three primary percutaneous sites (15.7%) required surgical revision. No spinal cord ischemic or renal complications were observed. Stroke was observed in 2 patients (9%), both with full coverage of left subclavian artery origin. Four patients (18%) required tracheostomy with prolonged respiratory support (range 10-15 days). The median intensive care unit stay was 5 days (range 1-27 days). The 30-day mortality was 18.1% (4/22).

CONCLUSION

Endoluminal repair of non-traumatic rupture of the descending thoracic aorta can be performed percutaneously. It showed a 30-day mortality of 18.1%, and no spinal cord injury or renal complications were observed in surviving patients at follow-up.

LEVEL OF EVIDENCE

Level 4, case series.

Turtleheading the Tough Aortic Necks! A Novel Endovascular Method to Avoid Bird-beaking, Invagination, and Stent Migration in Thoracic Aortic Grafts

Conventional repair of aortic pathology such as thoracic aortic aneurysms (TAA), aortic dissections, and intramural hematomas (IMH) involves major cardiothoracic surgery. Complication rates can be as high as 30%, therefore percutaneous endograft placement has become the new gold standard. However, not every patient is a suitable candidate for endovascular repair of a thoracic aneurysm, especially, patients with a very short proximal landing zone neck or a difficult type II or type III configuration of the aortic arch. Emerging techniques have been described in the literature, but until now none have been able to confidently conquer this problem. Stacked stents in a “turtlehead” fashion offer a solution to this obstacle. The turtlehead technique utilizes commercially available stents deployed in an on-label fashion to create a rigid yet conformable endograft that can precisely treat difficult proximal landing zone necks.

Spinal cord injury after thoracic endovascular aortic aneurysm repair

PURPOSE

Thoracic endovascular aortic aneurysm repair (TEVAR) has become a mainstay of therapy for aneurysms and other disorders of the thoracic aorta. The purpose of this narrative review article is to summarize the current literature on the risk factors for and pathophysiology of spinal cord injury (SCI) following TEVAR, and to discuss various intraoperative monitoring and treatment strategies.

SOURCE

The articles considered in this review were identified through PubMed using the following search terms: thoracic aortic aneurysm, TEVAR, paralysis+TEVAR, risk factors+TEVAR, spinal cord ischemia+TEVAR, neuromonitoring+thoracic aortic aneurysm, spinal drain, cerebrospinal fluid drainage, treatment of spinal cord ischemia.

PRINCIPAL FINDINGS

Spinal cord injury continues to be a challenging complication after TEVAR. Its incidence after TEVAR is not significantly reduced when compared with open thoracoabdominal aortic aneurysm repair. Nevertheless, compared with open procedures, delayed paralysis/paresis is the predominant presentation of SCI after TEVAR. The pathophysiology of SCI is complex and not fully understood, though the evolving concept of the importance of the spinal cord's collateral blood supply network and its imbalance after TEVAR is emerging as a leading factor in the development of SCI. Cerebrospinal fluid drainage, optimal blood pressure management, and newer surgical techniques are important components of the most up-to-date strategies for spinal cord protection.

CONCLUSION

Further experimental and clinical research is needed to aid in the discovery of novel neuroprotective strategies for the protection and treatment of SCI following TEVAR.

Treatment of serious complications following endovascular aortic repair for type B thoracic aortic dissection

Objective

This study aimed to describe treatment of serious complications after primary thoracic endovascular aortic repair (TEVAR) in type B aortic dissection.

Methods

From June 2008 to March 2016, serious complications occurred in 58 patients without Marfan syndrome who received TEVAR for type B aortic dissection.

Results

Complications included endoleak, distal true lumen collapse, retrograde dissection, stroke, stent–graft (SG) migration and mistaken deployment, lower limb ischaemia, and SG fracture. Treatment included endovascular repair, surgical procedures, or conservative medication. Forty-six patients recovered from complications. Twelve patients were not cured. The median follow-up time was 29.5 months (2–61 months). The overall 30-day mortality rate was 1.7% (1/58) and the total mortality rate following secondary complications was 8.6% (5/58). The causes of death were stroke and aortic rupture.

Conclusion

Some treatments need to be performed after TEVAR because of severe complications. A reduction in these complications can be achieved by optimal evaluation of patients, selection of SGs, and specialized endovascular manipulation.

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.

Perioperative cerebrospinal fluid drainage for the prevention of spinal ischemia after endovascular aortic repair

Endovascular treatment of thoracic and thoracoabdominal aortic diseases is accompanied by a risk of spinal ischemia in 1-19% of patients, depending on the entity and extent of the disease. The use of perioperative drainage of cerebrospinal fluid is one of the invasive measures to reduce the occurrence of this severe complication. This article reviews the incidence of spinal ischemia, its risk factors, the evidence for carrying out cerebrospinal fluid drainage and its modern use by means of an automated, pressure controlled system (LiquoGuard®7).

Simultaneous Endovascular Repair for Thoracic and Abdominal Aortic Pathologies: Early and Midterm Results

BACKGROUND

To analyze information from a single clinical center, evaluating early and midterm results of simultaneous thoracic endovascular aortic repair (TEVAR) and endovascular aneurysm repair (EVAR) for coexisting thoracic and abdominal aortic pathologies.

METHODS

From January 2005 to December 2014, 13 patients (8 men, 5 women; mean age, 75.3 years; range, 69-82 years) with concomitant thoracic and abdominal aortic disease (aneurysms, type B dissection, penetrating aortic ulcers) were treated with simultaneous TEVAR and EVAR. All patients had significant comorbidities. No preoperative cerebrospinal fluid drainage was performed. The follow-up rate was 100% during a period of 36 months (range, 1-60 months).

RESULTS

Technical success was achieved in all 13 patients, including deliberate partial or total coverage of the left subclavian artery in 3 patients, coverage of both internal iliac arteries in 1 patient, and coverage of left subclavian artery and unilateral internal iliac artery in 1 patient. The average procedural time was 160 min (range, 120-200 min). Mean blood loss was 140 mL (range, 100-250 mL). Four types of commercially available stent grafts (SGs) were used. The lengths of the thoracic SGs were 150-200 cm. Overall survival was 92.3% at 1- and 3-year follow-ups. None of the patients developed stroke or paralysis. The average hospital stay was 9 days (range, 7-12 days). No patients developed endoleak or SG migration.

CONCLUSIONS

Combined TEVAR and EVAR can be performed successfully with minimal morbidity and mortality. When anatomically feasible, simultaneous TEVAR and EVAR is a viable alternative to staged or hybrid repair.

Increased plasma VEGF levels following ischemic preconditioning are associated with downregulation of miRNA-762 and miR-3072-5p

Ischemic preconditioning (IPC) has protective effects against ischemia-perfusion injury of organs. In the present study, we investigated the associated mechanisms after performing remote IPC (rIPC) of lower limbs by clamping abdominal aorta in mice. Subsequent experiments showed decreased damage and paralysis of lower limbs following spinal cord injury (SCI). Concomitantly, plasma vascular endothelial growth factor (VEGF) levels were increased 24 h after rIPC compared with those in sham-operated animals. In subsequent microRNA analyses, thirteen microRNAs were downregulated in exosomes 24 h after rIPC. Further studies of femoral CD34-positive bone marrow (BM) cells confirmed downregulation of these seven microRNAs 24 h after rIPC compared with those in sham-operated controls. Subsequent algorithm-based database searches suggested that two of the seven microRNAs bind to the 3′ UTR of VEGF mRNA, and following transfection into CD34-positive BM cells, anti-miR-762, and anti-miR-3072-5p inhibitors led to increased VEGF concentrations. The present data suggest that rIPC transiently increases plasma VEGF levels by downregulating miR-762 and miR-3072-5p in CD34-positive BM cells, leading to protection against organ ischemia.