Open thoracic or thoracoabdominal aortic aneurysm repair after previous abdominal aortic aneurysm surgery

Ascending Aortic Pseudoaneurysm Following Aortic Valve Replacement: A Case Report and Literature Review

Introduction: Ascending aortic pseudoaneurysm (AAP) rupture is a surgical emergency that needs immediate medical and surgical attention and treatment. This rupture can be caused by a variety of risk factors. Prior cardiovascular surgery is a common cause, and prior aortic valve operation is a rare cause. Case Presentation: In this case report, we describe a 47-year-old male with AAP who had a history of aortic valve replacement because of aortic stenosis.

A Case of Multilevel Aortic Disease Treated Using Cardiatis Multilayer Flow Modulator

A recent systematic review and meta-analysis shows that synchronous and metachronous thoracic and abdominal aortic aneurysms are present in 19.2% of cases. The management remains controversial: elective simultaneous TEVAR and EVAR could increase morbidity due to increased aortic coverage during a single procedure, longer operative times, increased blood loss, and greater contrast exposure. Conversely, simultaneous thoracic endovascular aortic repair (TEVAR) and endovascular aneurysms repair (EVAR) prevent the need for two interventions, reduces future access site complications, and obviates interval aortic complications.

We present a case of a multilevel aortic disease treated in three stages: EVAR, TEVAR, and exclusion of an increasing aortic visceral penetrating aortic ulcer through a multilayer flow modulator endograft with an optimal result.

Visceral segment aortic thrombus is associated with proximal aortic degeneration after infrarenal abdominal aortic aneurysm repair

OBJECTIVE

To identify predictors of aortic aneurysm formation at or above an infrarenal abdominal aortic aneurysm repair.

METHODS

A total of 881 infrarenal abdominal aortic aneurysm repairs were identified at a single institution from 2004 to 2008; 187 of the repairs were identified that had pre-operative and post-operative computed tomography imaging at least one year or greater to evaluate for aortic degeneration following repair. Aortic diameters at the celiac, superior mesenteric, and renal arteries were measured on all available computed tomographic scans. Aortic thrombus and calcification volumes in the visceral and infrarenal abdominal aortic segments were calculated. Multivariable modeling was used with log transformed variables to determine potential predictors of future aortic aneurysm development after infrarenal abdominal aortic aneurysm repair.

RESULTS

Of the 187 patients in the cohort, 100 had an open abdominal aortic aneurysm repair while 87 were treated with endovascular repair. Proximal aortic aneurysms developed in 26% (n = 49) of the cohort during an average of 72 ± 34.2 months of follow-up. After multivariable modeling, visceral segment aortic thrombus on pre-operative computed tomography imaging increased the risk of aortic aneurysm development above the infrarenal abdominal aortic aneurysm repair within both the open abdominal aortic aneurysm (hazard ratio 2.04, p = 0.033) and endovascular repair (hazard ratio 3.31, p = 0.004) cohorts. Endovascular repair was independently associated with a higher risk of future aortic aneurysm development after infrarenal abdominal aortic aneurysm repair when compared to open abdominal aortic aneurysm (hazard ratio 2.19, p = 0.025).

CONCLUSIONS

Visceral aortic thrombus present prior to abdominal aortic aneurysm repair and endovascular repair are both associated with an increased risk of future proximal aortic degeneration after infrarenal abdominal aortic aneurysm repair. These factors may predict patients at higher risk of developing proximal aortic aneurysms that may require complex aortic repairs.

Prevalence of Thoracic Aortic Aneurysms in Patients with Degenerative Abdominal Aortic Aneurysms: Results from the Prospective ACTA Study

OBJECTIVE

There are no recommendations for screening for thoracic aortic aneurysms (TAAs), even in patients with infrarenal abdominal aortic aneurysms (AAAs). The aims of this study were to determine the prevalence of TAAs in patients with AAAs and to analyse the risk factors for this association.

METHODS

This was a multicentre prospective study. The Aortic Concomitant Thoracic and Abdominal Aneurysm (ACTA) study included 331 patients with infrarenal AAAs > 40 mm between September 2012 and May 2016. These patients were prospectively enrolled in three French academic hospitals.

RESULTS

Patients were classified as having a normal, aneurysmal, or ectatic (non-normal, non-aneurysmal) thoracic aorta according to their maximum aortic diameter indexed by sex, age, and body surface area. Thoracic aortic ectasia (TAE) was defined as above or equal to the 90th percentile of normal aortic diameters according to gender and body surface area. Descending TAA was defined as ≥ 150% of the mean normal value, and ascending TAA as > 47 mm in men and 42 mm in women; 7.6% (n = 25) had either an ascending (seven cases; 2.2%) or descending aortic TAA (18 cases; 5.4%), and 54.6% (n = 181) had a TAE. Among the 25 patients with TAAs, five required surgery; two patients had TAAs related to penetrating aortic ulcers < 60 mm in diameter, and three had a TAA > 60 mm. In the multinomial regression analysis, atrial fibrillation (AF) (odds ratio [OR] 11.36, 95% confidence interval [CI] 2.18 - 59.13; p = .004) and mild aortic valvulopathy (OR 2.89, 1.04-8.05; p = .042) were independent factors associated with TAAs. Age (OR 1.06, CI 1.02 - 1.09; p = .003) and AF (OR 4.36, 1.21 - 15.61; p = .024) were independently associated with ectasia.

CONCLUSION

This study confirmed that TAAs coexisting with AAAs are not rare, and one fifth of these TAAs are treated surgically. Systematic screening by imaging the whole aorta in patients with AAAs is clinically relevant and should lead to an effective prevention policy.

Short-term outcomes of the t-Branch off-the-shelf multibranched stent graft for reintervention after previous infrarenal aortic repair

OBJECTIVE

The purpose of this study was to evaluate the outcome of t-Branch (Cook Medical, Bloomington, Ind) stent graft for the treatment of thoracoabdominal and pararenal aortic aneurysms in patients who had previous infrarenal aortic repair.

METHODS

A retrospective two-center study was undertaken. All consecutive patients who underwent endovascular repair using t-Branch stent graft after previous infrarenal aortic repair between January 2010 and August 2018 were included. Demographics, past medical history, cardiovascular risk factors, and intraoperative and perioperative details were recorded. Technical success and early (30-day) mortality, morbidity, target vessel patency, and presence of endoleak were analyzed. During the first year of follow-up, survival, freedom from reintervention, and patency rates were recorded.

RESULTS

There were 32 patients (mean age, 74 ± 7 years; 81% male) included in the study; 24 (75%) patients had prior open surgical repair, and 8 (25%) patients had undergone standard endovascular aneurysm repair. The index operation was performed 9 ± 5 years earlier, including 10 ± 5 years for open surgical repair and 8 ± 6 years for endovascular aortic repair. The indication was progression of the disease in 26 patients (81%) and type IA endoleak in 6 patients (19%). The total number of target vessels incorporated was 117 arteries (3.8 ± 0.6 target vessels per patient). Eleven patients had only three vessels incorporated; celiac trunk was occluded in three patients, and eight patients had one functioning kidney. Technical success rate was 97% (31/32). There was a single technical failure in one patient who had a type IA endoleak after endovascular repair with suprarenal fixation. The stenotic right renal artery was not catheterized at the initial procedure, and retrograde access was achieved through a right subcostal incision 3 days later with successful completion of the repair. Early mortality rate was 13%, and spinal cord ischemia rate was 22% (7/32); four patients had permanent and three had transient neurologic deficits. Early target vessel patency was 100%, and the rate of any endoleak was 9% (3/32); two patients had type II endoleaks and one patient had type III endoleak. The mean follow-up was 5.4 ± 5.9 months. The cumulative survival rate was 82% and 73% at 6 and 12 months, respectively. The freedom from aorta-related mortality was 92% at 6 and 12 months. The cumulative freedom from reintervention during follow-up was 90% at 6 and 12 months. The overall target vessel patency rate was 100% and 97.5% at 6 and 12 months, respectively.

CONCLUSIONS

The use of t-Branch off-the-shelf stent graft for the treatment of aortic disease in patients who had previous infrarenal aortic repair appears to be feasible, with acceptable early outcomes in terms of morbidity and mortality.

Reflection of pioneers: redo thoracoabdominal aortic aneurysm repair controversies in thoracic aortic aneurysm surgery

Reoperative thoracoabdominal aortic aneurysm repair is frequently necessary and brings with it a unique set of challenges. Typically, most reoperative repairs are necessitated by aortic disease progressing into previously healthy aortic tissue from a replaced section of the aorta (an extension of the previous repair) or, to a lesser degree, because of a late complication of prior distal aortic repair (an open or endovascular repair failure). Characterizing the reason for the reoperation as well as the location of prior repair is the first step towards anticipating major outcomes following such repair. Since the introduction of endovascular repair for aortic aneurysms, indications for open repair have become more specific and limited; many centers have justified using endovascular approaches in patients with prior open aortic repair by deeming these patients "high risk" because of their previous incision. Our analysis found that reoperative repairs were not typically subject to worse early outcomes than patients without prior distal aortic repair, except for the more complicated types of reoperation, which involve infection.

Open aortic repair up to previous abdominal aortic surgery

BACKGROUND

To determine whether direct open repair of thoracoabdominal aortic aneurysms after previous abdominal aortic surgery is a safe option.

METHODS

Ten patients were operated between January 2006 and January 2012. Mean age was 70 years (62-78 years). Four aneurysms (Crawford type III) were treated by firstly performed bypasses from the upper thoracic aorta to the celiac trunk, the superior mesenteric artery, and the left renal artery. Secondly performed aortic repair included revascularization of intercostal arteries identified as critical for spinal cord and the right renal artery. Similarly, the 6 aneurysms (Crawford type IV) were treated by firstly performed bypass from the upper thoracic aorta to the left renal artery before aortic repair.

RESULTS

The overall mortality and paraplegia rates were nil. The maximal creatinin sera variation was 48 ± 16% with return to the baseline level before discharge. Five patients presented with pulmonary complications. The duration of stay was 9.3 days (2-29) in the intensive care unit and 24 days (10-40) in the surgical unit. The mean follow-up was 35 months. No patient died during the follow-up.

CONCLUSIONS

In our experience, open redo aortic surgery appears to be safe. The main relevant point is the sequential reconstruction of the aorta including bypasses of the visceral branches that lowered the visceral ischemic damage because of high level aortic cross-clamping.

Effects of sepiapterin infusion on renal oxygenation and early acute renal injury after suprarenal aortic clamping in rats

Acute kidney injury (AKI) can occur after aortic clamping due to microvascular dysfunction leading to renal hypoxia. In this rat study, we have tested the hypothesis that the administration of the precursor of the nitric oxide synthase essential cofactor tetrahydrobiopterin (BH4) could restore renal oxygenation after ischemia reperfusion (I/R) and prevent AKI. We randomly distributed rats into 4 groups: sham group; ischemia-reperfusion group; I/R + sepiapterin, the precursor of BH4; and I/R + sepiapterin + methotrexate, an inhibitor of the pathway generating BH4 from sepiapterin. Cortical and outer medullary microvascular oxygen pressure, renal oxygen delivery, renal oxygen consumption were measured using dual-wavelength oxygen-dependent quenching phosphorescence techniques during ischemia and throughout 3 hours of reperfusion. Kidney injury was assessed using myeloperoxidase staining for leukocyte infiltration and urine neutrophil gelatinase-associated lipocalin levels. Ischemia reperfusion induced a drop in microvascular PO2 (P < 0.01 vs. Sham, both), which was prevented by the infusion of sepiapterin. Sepiapterin partially prevented the rise in renal oxygen extraction (P < 0.001 vs. I/R). Finally, treatment with sepiapterin prevented renal infiltration by inflammatory cells and decreased urine neutrophil gelatinase-associated lipocalin levels indicating a decrease of renal injury. These effects were blunted when adding methotrexate, except for myeloperoxidase. In conclusion, the administration of sepiapterin can prevent renal hypoxia and AKI after suprarenal aortic clamping in rats.