Short and midterm results after left subclavian artery coverage during endovascular repair of the thoracic aorta

Predicting the need for subclavian artery revascularization in thoracic endovascular aortic repair: A systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aims to investigate the effectiveness of left subclavian artery revascularization compared with non-revascularization in thoracic endovascular aortic repair, and to summarize the current evidence on its indications.

METHODS

A computerized search was conducted across multiple databases, including MEDLINE, SCOPUS, Cochrane Library, and Web of Science, for studies published up to November 2023. Study selection, data abstraction, and quality assessment (using the Newcastle-Ottawa Scale) were independently conducted by two reviewers, with a third author resolving discrepancies. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models and publication bias was assessed using funnel plots.

RESULTS

In the 76 included studies, left subclavian artery revascularization was associated with reduced risks of stroke (OR, 0.67; 95% CI, 0.45-0.98; n = 15,331), spinal cord ischemia (OR, 0.75; 95% CI, 0.56-0.99; n = 11,995), and arm ischemia (OR, 0.09; 95% CI, 0.01-0.59; n = 8438). No significant reduction in paraplegia (OR, 0.56; 95% CI, 0.21-1.47; n = 1802) or mortality (OR, 0.77; 95% CI, 0.53-1.12; n = 11,831) was observed. Moreover, the risk of endoleak was comparable in both groups (OR, 1.25; 95% CI, 0.55-2.84; P = .60; n = 793), whereas the risk of reintervention was significantly higher in the revascularization group (OR, 1.98; 95% CI, 1.03-3.83; P = .04; n = 272). Both groups had similar risks of major (OR, 0.45; 95% CI, 0.19-1.09; P = .08; n = 1113), minor (OR, 0.21; 95% CI, 0.01-3.45; P = .27; n = 183), renal (OR, 0.61; 95% CI, 0.12-3.06; P = .55; n = 310), and pulmonary (OR, 0.59; 95% CI, 0.16-2.15; P = .42; n = 8083) complications. The most frequent indications for left subclavian artery revascularization were primary prevention of spinal cord ischemia, augmentation of the landing zone, and primary stroke prevention.

CONCLUSIONS

Left subclavian artery revascularization in thoracic endovascular aortic repair was associated with reduced neurological complications but was not found to impact mortality. The study highlights important indications for revascularization as well as significant predictors of complications, providing a basis for clinical decision-making and future research.

[Cost-revenue aspects of endovascular treatment of distal aortic arch pathologies with respect to the introduction of a new thoracic side-branch prosthesis]

BACKGROUND

The standard vascular surgical procedure (SV) for the treatment of distal aortic arch pathologies involves a hybrid approach using a left carotid-subclavian bypass and thoracic endovascular aortic repair. Considering the introduction of a thoracic side branch prosthesis (TBE), the aim of this study was to analyze the cost-revenue aspects of both procedures.

MATERIAL AND METHODS

A retrospective analysis was conducted on cases treated by SV from 2017 to 2022. To draw conclusions regarding the use of TBE, the main diagnoses and procedures of SV were recoded based on current classifications (ICD/OPS 2023) for revenue calculations and regrouped according to aG-DRG 2023. An OPS modification and regrouping were performed for modeling TBE revenues.

RESULTS

A total of 13 cases were identified (mean age 62.5 ± 13.8 years; 10 males). After regrouping, the following DRGs were obtained: F42Z in N = 5, F51A in N = 4, F08B in N = 2, and F07A and F36B each in N = 1. The total revenue after regrouping was € 666,514.13, including an additional payment (ZE) of € 132,729.14. With the modeled application of TBE, a total revenue of € 659,212.19 was achieved. Compared to SV, this represents a revenue decrease of € 16,886.71 (changed DRG), but with an increase in ZE revenue by € 65,559.78 (different ZE). The use of TBE resulted in a saving of 74 occupancy days, including 13.5 days in intensive care.

CONCLUSION

A cost coverage seems probable with a change in the procedure, despite the yet to be determined pricing of TBE. This is highly dependent on the coding quality and the future development of ZE, given the annually changing DRG relative weights. Precise and transparent performance and cost documentation are essential for determining the pricing.

The Call for the "Interventional/Hybrid" Aortic Surgeon: Open, Endovascular, and Hybrid Therapies of the Aortic Arch

Aortic arch pathology is relatively rare but potentially highly fatal and associated with considerable comorbidity. Operative mortality and complication rates have improved over time but remain high. In response, aortic arch surgery is one of the most rapidly evolving areas of cardiac surgery in terms of surgical volume and improved outcomes. Moreover, there has been a surge in novel devices and techniques, many of which have been developed by or codeveloped with vascular surgeons and interventional radiologists. Nevertheless, the extent of arch surgery, the choice of nadir temperature, cannulation, and perfusion strategies, and the use of open, endovascular, or hybrid options vary according to country, centre, and surgeon. In this review article, we provide a technical overview of the surgical, total endovascular, and hybrid repair options for aortic arch pathology through historical developments and contemporary results. We highlight key information for surgeons, cardiologists, and trainees to understand the management of patients with aortic arch pathology. We conclude by discussing training paradigms, the role of aortic teams, and gaps in knowledge, arguing for the need for wire skills for the future "interventional aortic surgeon" and increased research into techniques and novel devices to continue improving outcomes for aortic arch surgery.

Atypical presentation of subclavian steal syndrome with left sided sensorineural deafness

We present a rare manifestation of a common pathology: left sided sensorineural hearing loss secondary to subclavian steal syndrome after thoracic endovascular aortic repair for complicated acute aortic dissection. We describe the vascular physiology that can result in unilateral hearing loss and provide a brief review of subclavian steal syndrome. This case report highlights the importance of avid clinical recognition of an atypical presentation of a common vascular disease.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

TEVAR for aortic arch lesions combining physician-modified endograft and in-situ fenestration

BACKGROUND

The aim of this retrospective study was to investigate the outcomes of combining physician-modified endograft (PMEG) and in-situ fenestration (ISF) for aortic arch repair.

METHODS

A retrospective analysis was performed in 12 patients with aortic arch pathologies who underwent thoracic endovascular aortic repair with PMEG and ISF between June 2019 and February 2020.

RESULTS

Revascularizations of supra-aortic arteries were successfully performed in 91.7% patients (11/12). One patient with aberrant right subclavian artery was unsuccessful because of tortuosity and sharp angle. One patient received endovascular exclusion by Viabahn due to artery injury of the femoral access. During the follow-up (mean 22.7 months), one patient underwent Bentall surgery because of retrograde type A aortic dissection, and one patient received coils embolization due to occurrence of a type I endoleak. In addition, one patient died of myocardial infarction 13 months after surgery. Results obtained after computed tomography angiography confirmed patency of all the supra-aortic arteries.

CONCLUSIONS

Combining PMEG and ISF could be a feasible option for aortic arch lesions in selected patients. Long-term durability concerns require further evaluation.

Chimney Stenting Versus Surgical Debranching for the Treatment of Aortic Arch Pathologies-A Propensity-Matched Analysis

BACKGROUND

Endovascular repair of aortic arch lesions requires revascularization of epiaortic vessels in case of coverage. The objective of this study was to compare the outcomes of surgical bypass versus endovascular reconstruction with a chimney graft.

METHODS

A retrospective analysis of a multicenter register between January 2005 and December 2019 was performed. A total of 127 patients were included and divided into 2 groups: thoracic endovascular aortic repair + surgical debranching (n = 72) and thoracic endovascular aortic repair + chimney stenting (n = 55). The main end points were major neurologic sequelae and type IA endoleak. Propensity score matching was performed to analyse baseline variables related to these outcomes.

RESULTS

The mean follow-up was 35.6 months for the debranching group and 34.1 for the chimney group (P = 0.65). The incidence of stroke was higher in the chimney group although not statistically significant (7.3% vs. 4.1%; P = 0.46); for both groups, a wide angle between the ostium of the target vessel and the aorta and landing in Ishimaru Zone 0 was found to be the main predictors for major neurologic sequelae (P = 0.002 and P = 0.003, respectively). During follow-up, 9 (12.5%) type IA endoleaks occurred in the debranching group and 12 (21.8%) in the chimney group (P = 0.14). Aortic diameter larger than 66 mm and arch angle >46° had a strong association with proximal endoleak incidence (P = 0.001 and P = 0.011, respectively) CONCLUSIONS: Surgical debranching showed better results than chimney stenting in terms of major neurologic events incidence and type IA endoleak, although the difference between the groups was not statistically significant. Further research with larger cohorts is needed to establish the indications for these procedures.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Thoracic Endovascular Aortic Repair (TEVAR) First in Patients with Lower Limb Ischemia in Complicated Type B Aortic Dissection: Clinical Outcome and Morphology

Acute Type B aortic dissection (TBAD) can cause organ malperfusion, e.g., lower limb ischemia (LLI). Thoracic endovascular aortic repair (TEVAR) represents the standard treatment for complicated TBAD; however, with respect to LLI, data is scant. The aim of this study was to investigate clinical and morphological outcomes in patients with complicated TBAD and LLI managed with a "TEVAR-first" policy. Between March 1997 and December 2021, 731 TEVAR-procedures were performed, including 106 TBAD-cases. Cases with TBAD + LLI were included in this retrospective analysis. Study endpoints were morphological/clinical success of TEVAR, regarding aortic and extremity-related outcome, including extremity-related adjunct procedures (erAP) during a median FU of 28.68 months. A total of 20/106 TBAD-cases (18.8%, 32-82 years, 7 women) presented with acute LLI (12/20 Rutherford class IIb/III). In 15/20 cases, true lumen-collapse (TLC) was present below the aortic bifurcation. In 16/20 cases, TEVAR alone resolved LLI. In the remaining four cases, erAP was necessary. A morphological analysis showed a relation between lower starting point and lesser extent of TLC and TEVAR success. No extremity-related reinterventions and only one major amputation was needed. The data strongly suggest that aTEVAR-first-strategy for treating TBAD with LLI is reasonable. Morphological parameters might be of importance to anticipate the failure of TEVAR alone.

Left Subclavian Artery Coverage is Not Associated with Neurological Deficits in Trauma Patients Undergoing Thoracic Endovascular Repair

BACKGROUND

Endovascular repair of the thoracic aorta (TEVAR) outcomes have been studied with interest in complications related to left subclavian artery (LSA) coverage in patients with atherosclerotic pathologies; however, specific data on the management of the LSA in a trauma population is lacking. The objective of this study is to evaluate outcomes following TEVAR for traumatic aortic injury based on LSA coverage.

METHODS

The Vascular Quality Initiative thoracic endovascular aortic repair module (2010-2017) was analyzed. Patients were included if they had a traumatic aortic injury requiring TEVAR. Patients were placed in two groups based on coverage of the left subclavian artery. Patients were propensity score matched and the primary outcomes were cerebrovascular symptoms and spinal cord ischemia. Additional clinical and resource utilization outcomes were analyzed.

RESULTS

451 patients were included in the analysis. There were 268 patients in the LSA not covered group and 183 patients in the LSA covered group. The mean aortic injury grade was 2.88±0.056 vs 2.88±0.049 in the covered versus not-covered group (p=0.957). Glasgow coma scale and injury severity score were not different between the groups. There was no difference between groups for cerebrovascular symptoms or spinal cord ischemia, 1.4% vs 2.8% p=0.684 and 0% vs 2.1% p=0.247, after propensity score matching. Significant differences in access site complications and resource utilization were identified between groups.

CONCLUSION

This is the largest series to evaluate complications based on LSA coverage following TEVAR in trauma patients. Our data demonstrate that coverage of the LSA during TEVAR following blunt trauma is associated with no difference in CNS outcomes. As such, LSA revascularization strategies, while possible, are not directly supported by these data, and should be individualized based on each patient's specific clinical scenario.

Covering/Overstenting of the left subclavian artery (LSA) in thoracic endovascular repair (TEVAR) to treat various thoracic/thoracoabdominal aortic lesions: Is revascularization of the left arm a must? (A retrospective cohort study with 12 years of experience to describe the real-world situation of daily clinical practice and the literature review)

Background: Pathologies of the descending thoracic aorta inwardly extended towards the aortic arch actually shorten the proximal landing zone for aortic prosthesis. This, in turn, worsens the feasibility of the aorta for endovascular therapeutic options of those pathologies. Objective: This work considers the blockage of the left subclavian artery (LSA) through endovascular treatment of the pathologies of the descending aorta as a main work question, which is based on the hypothesis that there is no necessity for primary standard revascularization of the LSA in TEVAR with LSA covering. The researchers have 12 years of experience in treatment of different thoracic aortic lesions. Their experience will also be reviewed in this paper. Design: Retrospective unicenter cohort study in consecutive patients order to describe the real-world situation of daily clinical practice Material: All the patients who had undergone endovascular, hybrid, or open operative therapy of variant pathologies of descending aorta were included in this study. Methods: Various parameters were investigated, including therapeutic procedures such as i) pure endovascular vs. hybrid; ii) year of therapy; iii) symptomatic vs. asymptomatic status of the patients; iv) variant epidemiological factors (age, sex, risk factors, mortality, and follow up); v) overstenting/blocking of the LSA; vi) complications of applied therapies; vii) further operations/interventions to treat such complications; viii) radiologic aortic measurements (such as lumen extensions, false lumen measurements, distance to the supra-aortic and visceral vessels); and ix) multiple other pathological features. Different statistical parameters were also examined. Survival was analysed by the Kaplan–Meier assessment in the group of whole patients vs. the group of over-stented patients. Here the analysis of variance is performed for the independent parameters for the revascularized patients—not the revascularized patients—who had undergone LSA coverage. For statistical approval, U-test was used. The p-value < 0.05 was considered significantly different. The literature review was achieved by a search in PubMed, Google scholar, Research Gate, ScienceDirect, and Cochrane library by using the following terms endovascular, TEVAR, revascularization, stroke, and left-subclavian-artery ischemia. The literature is classified accordingly in relation to the main topic. In fact, the literature undergoes further analysis if it goes with or against our hypothesis. Results: Overall, 112 patients were enrolled in the study. There was no significant difference comparing the not-revascularized vs. the revascularized group of patients, considering the consequences on cerebrovascular blood circulation (in particular, n=1 case [4.8 %] vs. no case [0 %]; p=1) or the spinal cord ischemia (n=2 [9.5 %] vs. n=1 [7.1 %]; p=1). As the main result, there was no case of manifest left arm ischemia and deaths (mortality, 0). Survival was in both groups as follows: 22 [95% CI, 14.154–29.904] months vs. 43 [95% CI, 33.655–51.921] months with no significant statistical difference (p>0.05) . The only statistically significant risk factor found was renal insufficiency (p, 0.028), but this too is considered a trend by the urgency of revascularization. Postoperatively, pneumonia showed a trend of higher frequency (p=0.058) in the revascularized cases (n=0 in the not-revascularized vs. n=3 [21.4 %] in the revascularized cases). There was no significant difference in the occurance of postoperative neurovascular complications (such as cerebrovascular accidents, spinal cord ischemia, or left arm ischemia) by comparing the groups of not-revascularized and revascularized patients. Conclusion: The revascularization of the overstented LSA due to TEVAR should be limited to certain indications, including i) the inadequate intracerebral circle of Willis; ii) the predominantly perfused left vertebral artery with inadequate blood perfusion via the right vertebral artery (e.g., by stenosis), iii) anatomic variance such as the left vertebral artery originating directly from the aortic arch (and must be blocked by TEVAR); iv) the need of an adequate left internal thoracic artery for coronary-artery-bypass grafting (CABG); v) the need of patent LSA for the dialysis shunt of the left arm. However, there is no appropriate evidence as yet based on sufficient study results achieved in trials with an advanced design (such as [double-]blind, multicenter randomized study) that appears to be urgently required.

Early experience with the Bolton Relay Pro/Plus for physician-modified fenestrated TEVAR

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) can be challenging in cases involving the aortic arch and the visceral segment. We report our initial experience with fenestrated TEVAR (f-TEVAR) for thoracic aortic disease involving aortic branches using physician-modified stent grafts (PMSGs).

MATERIALS AND METHODS

Between February 2019 and November 2020 nine patients were treated with a PMSG. Indication to treatment were a symptomatic acute type B aortic dissection (TBAD) in three cases, a penetrating aortic ulcer in three cases (two in zone 3 and one in zone 6), one case of an endoleak type I A after TEVAR, a chronic TBAD after TEVAR in one case and one case of a contained rupture of a thoracoabdominal aneurysm in zone 3. Pre-, intra- and postoperative clinical data were recorded.

RESULTS

The median patient age was 65 (IQR 60.5-71) years, and 8 (89%) patients were men. Nine stent grafts (six Bolton Relay Plus and three Bolton Relay Pro, Terumo Aortic, Vascutek Ltd., Inchinnan, United Kingdom) were deployed. Small fenestrations (8 mm) were created on table, median duration for on table stent graft modifications was 20 minutes (13-22). The technical success rate was 100%. Median operative time was 188 (116-252) minutes. No major adverse events of any sort occurred during the first 30-day postoperatively. There were no type I or type III endoleaks at the end of the procedure, and no cases of spinal cord ischemia. Two access related complications occurred (22%). After a median of 12 (range 5-12) months all patients survived and all target vessels remained patent with one case of fenestration-related type I endoleak, which required open conversion.

CONCLUSIONS

The results of our initial experience with f-TEVAR using PMSGs with the Bolton Relay stentgraft for the treatment of aortic diseases are acceptable. These results should be confirmed on larger patient cohorts.

Stroke, spinal cord ischemia and upper limb ischemia in patients undergoing TEVAR with coverage of the left subclavian artery: a case series study

Background

We performed routine spinal fluid drainage for patients who underwent TEVAR for thoracic aortic pathology together with left subclavian artery coverage, which was needed for achievement of a safe proximal sealing zone. We assessed the occurrence of spinal cord ischemia as well the rate of occurrence of other complications such as stroke, and upper limb ischemia.

Results

This was a case series study done between July 2014 and April 2020, in them all the left subclavian artery was covered to ensure a proximal safe seal zone. Routine spinal fluid drainage was done, keeping the spinal fluid pressure < 10–15 mmHg with catheter in place for 48 h. Data was obtained from twenty-three patients who underwent TEVAR for thoracic aortic dissection (73.91%), thoracic aortic aneurysm (21.74%), or ulcer (4.35%). Planning was based upon multi-slice computed tomographic angiography and covering the left subclavian was mandatory to achieve a proximal sealing zone. Technical success was achieved in 100% of cases. 4.35% of patients had three endograft, 56.52% had two endografts, 39.13% had one endograft. All patients lost their radial pulsations immediately after implantation, 8.70% developed post implantation syndrome(fever) that was managed conservatively, 4.35% developed stroke related to the anterior circulation, 4.35% developed signs of spinal cord ischemia. During the follow up, one patient died within 6 h after the procedure due to extensive myocardial infarction (patient was scheduled for CABG after our procedure). 17.40% developed upper limb symptoms that were tolerable and were managed conservatively.

Conclusion

By adopting routine spinal cord drainage and pressure monitoring, we can consider not to revascularize the left subclavian artery prior to TEVAR if it will be covered.

Role of historical and procedural staging during elective fenestrated and branched endovascular treatment of extensive thoracoabdominal aortic aneurysms

OBJECTIVE

Procedural staging is often performed to reduce the incidence of spinal cord ischemia (SCI) during endovascular treatment of extensive thoracoabdominal aortic aneurysms (TAAAs). However, its role in the case of previous thoracic or infrarenal aortic repair (historical staging) has been controversial. In the present study, we evaluated the SCI rates when procedural staging was routinely used and studied its potential benefits when previous aortic repairs had already been performed.

METHODS

The data from patients treated electively with fenestrated/branched endovascular aortic repair for extent I, II, III, and V TAAAs were retrieved from a multicenter registry (four high-volume national teaching hospitals) and analyzed. The primary endpoint was the rate of SCI and its association with preoperative and postoperative variables, including historical staging, procedural staging, and an impaired collateral network (subclavian or hypogastric stenosis >75% per occlusion). Variables were defined in accordance with the Society for Vascular Surgery reporting standards. A logistic regression model with stepwise selection was used to identify the predictors of SCI.

RESULTS

A total of 240 patients (76% male; median age, 73 years) were analyzed. Of the 240 patients, 43 (18%) had presented with an impaired collateral network, 136 (57%) had had historical staging, and 157 (65%) had received procedural staging. Preoperative spinal fluid cerebrospinal drainage was performed in 130 patients (54%). Permanent grade 3 SCI was observed in 13 patients (5%) and was negatively affected by both an impaired collateral network (odds ratio [OR], 17.3; 95% confidence interval [CI], 1.7-176; P = .016) and the presence of bilateral iliac occlusive disease (OR, 10.1; 95% CI, 1.1-98.3; P = .046). Both historical (OR, 0.02; 95% CI, 0.001-0.46; P = .014) and procedural (OR, 0.01; 95% CI, 0.02-0.7; P = .019) staging mitigated the permanent SCI rates. The need for postoperative transfusions (OR, 1.4; 95% CI, 1.1-1.8; P = .014) and the occurrence of postoperative renal complications (OR, 6.5; 95% CI, 1.2-35.0; P < .001) were associated with the development of SCI. Among the patients with historical staging, no further benefit from procedural staging was observed (SCI with procedural staging, 1%; vs no staging, 2%; P = NS).

CONCLUSIONS

For patients with extensive TAAAs treated with fenestrated/branched endovascular aortic repair, both historical and planned procedural staging were associated with reduced permanent SCI rates. However, no additional benefit was observed when procedural staging was performed in patients with historical staging and an intact collateral network. The protective role of preoperative cerebrospinal fluid drainage placement requires further investigation.

Balloon expandable aortic stent-graft for the treatment of aortic aneurysm and rupture in a dog

OBJECTIVE

To describe the successful placement of an aortic stent graft in a dog suffering from aortic aneurysm and rupture.

CASE SUMMARY

A 4-year-old neutered female mixed breed dog weighing 25 kg was presented with a chief complaint of acute onset of weakness and respiratory distress. On presentation, the dog was lateral and unresponsive, hypothermic, tachycardic, and tachypneic. Pleural effusion was identified in the right hemi-thorax on thoracic-focused sonographic scan for trauma. Thoracic radiographs showed a fluid/soft tissue opacity in the cranial mediastinum and pleural effusion on the right side. Thoracocentesis yielded noncoagulating blood. Hematology revealed normal PCV and total plasma protein that decreased within 24 hours to 20% and 50 g/L (20%/5.0 g/dL), respectively. The dog was treated with IV fluids, tranexamic acid, and fresh frozen plasma. An aortic aneurysm with irregular mineralization of the right ventrolateral aortic wall was identified on computed tomography examination, which also demonstrated a peri-aortic hematoma. A decision was made to attempt treatment with a stent graft. Under general anesthesia, a marker catheter was inserted into the esophagus. A 10-Fr sheath was inserted into the right femoral artery, and an angiography catheter was advanced over a wire. After angiography, a stent graft (12-mm × 50-mm) was placed over the guide wire and deployed under fluoroscopic guidance. The dog recovered uneventfully, with no evidence of recurrent bleeding, and was discharged 2 days after the procedure with antimicrobials, anthelmintic, and antithrombotic treatment. At 90-day follow-up, the dog was doing well, and stent position was radiographically confirmed.

NEW OR UNIQUE INFORMATION PROVIDED

This report describes successful management of aortic aneurysm and dissection, an uncommon and challenging pathology in the veterinary practice with few available treatment options. Stent graft placement is a minimally invasive procedure in which a covered stent is placed over the lesion to prevent rupture.

Outcome analysis of the Gore Conformable Thoracic Stent Graft with active control system for the treatment of arch and descending thoracic aortic disease

OBJECTIVES

The aim of this study was to evaluate technical/clinical outcomes of the Gore TAG Conformable Thoracic Stent Graft with Active Control System (CTAG with ACS) in thoracic aortic disease since its introduction in Europe in 2017.

METHODS

Patients undergoing thoracic endovascular aortic repair (TEVAR) with the device between 2017 and 2020 were identified from a prospectively maintained single-centre database and retrospectively analysed. Predominant indications were aortic dissection (n = 46), thoracic/thoraco-abdominal aneurysm (n = 20/n = 7), penetrating ulcer (n = 14) and intramural haematoma (n = 12). Emergency procedures were performed in 47% (54/115). The primary outcome was technical success. Secondary outcomes were clinical success, serious adverse events and procedure-related reintervention. ACS was assessed regarding angulation, accuracy and apposition. The median follow-up was 8.46 months (interquartile range: 3.18-16.89 months).

RESULTS

A total of 115 consecutive patients (82 males, median age 63; interquartile range: 53-74 years) have been included. Technical success was achieved in 95.7% (110/115). Clinical success rate was 80.9% (93/115); mostly due to procedure-related death (n = 14). Overall mortality was 19.1% (22/115), with significant differences between elective/emergency procedures (log-rank: P < 0.001). Procedure-related serious adverse event rate was 44.3% (51/115). Procedure-related reintervention was performed in 20.9% (24/115). The cumulative incidence for reintervention differed significantly between elective/emergency cases (Gray's test: P = 0.0033). Angulation was used in 40.9% of patients (47/115), mostly in type II arches (52.7%). Deployment accuracy was 87.8% (101/115). Sufficient apposition was present in 93.0% (107/115).

CONCLUSIONS

This single-centre study shows encouraging performance of the CTAG with ACS in an array of aortic pathologies. Although longer-term data must be awaited, ACS leads to overall favourable device placement. Despite ongoing advances in device technology, TEVAR remains challenging and is associated with significant burden inherent to the underlying disease.

The fate of the left subclavian artery in TEVAR for aortic arch pathology

BACKGROUND AND AIM OF STUDY

The origin of the vertebral artery (VA) from the left subclavian (LSA) is variable and must be considered when proximal ligation or embolization is performed post thoracic endovascular aortic repair (TEVAR) and extra-anatomical bypass (EAB). A retrospective study was conducted to understand the patency of the LSA and VAs after TEVAR and the relationship of the EAB to the LSA.

METHODS

Fifty-six patients underwent TEVAR where the LSA origin was occluded. A comparison was performed between the length of the proximal LSA from the arch of the aorta to the origin of the VA. Patient outcomes included posterior or anterior circulation cerebrovascular accident, spinal cord ischemia (SCI), and symptoms and signs of left arm ischemia (LAI). Thirty one underwent EAB with 8 undergoing occlusion of the LSA proximal to the origin of the left VA. A further 25 underwent TEVAR with no EAB performed. The mean (standard deviation) of origin of the VA from the origin at the arch was 37.0 (12.9) mm compared to 34.0 (13.7) mm in those where no bypass was performed (p 0.45). Four patients underwent intraluminal plug occlusion and four had external ligation of the proximal LSA in those undergoing EAB.

CONCLUSIONS

Careful evaluation of the LSA is needed when planning TEVAR as occlusion techniques may be dependent on a minimum length of the VA from the aortic arch. The mean length of the VA from the aorta has high heterogeneity which may dictate the optimum occlusion method for LSA.

Using Machine Learning to Predict Five-Year Reintervention Risk in Type B Aortic Dissection Patients After Thoracic Endovascular Aortic Repair

Purpose: Type B aortic dissection (TBAD) is a high-risk disease, commonly treated with thoracic endovascular aortic repair (TEVAR). However, for the long-term follow-up, it is associated with a high 5-year reintervention rate for patients after TEVAR. There is no accurate definition of prognostic risk factors for TBAD in medical guidelines, and there is no scientific judgment standard for patients’ quality of life or survival outcome in the next five years in clinical practice. A large amount of medical data features makes prognostic analysis difficult. However, machine learning (ML) permits lots of objective data features to be considered for clinical risk stratification and patient management. We aimed to predict the 5-year prognosis in TBAD after TEVAR by Ml, based on baseline, stent characteristics and computed tomography angiography (CTA) imaging data, and provided a certain degree of scientific basis for prognostic risk score and stratification in medical guidelines. Materials and Methods: Dataset we recorded was obtained from 172 TBAD patients undergoing TEVAR. Totally 40 features were recorded, including 14 baseline, 5 stent characteristics and 21 CTA imaging data. Information gain (IG) was used to select features highly associated with adverse outcome. Then, the Gradient Boost classifier was trained using grid search and stratified 5-fold cross-validation, and Its predictive performance was evaluated by the area under the curve (AUC) in the receiver operating characteristic (ROC). Results: Totally 60 patients underwent reintervention during follow-up. Combing 24 features selected by IG, ML model predicted prognosis well in TBAD after TEVAR, with an AUC of 0.816 and a 95% confidence interval of 0.797 to 0.837. Reintervention rate of prediction was slightly higher than the actual (48.2% vs. 34.8%). Conclusion: Machine learning, which combined with baseline, stent characteristics and CTA imaging data for personalized risk computations, effectively predicted reintervention risk in TBAD patients after TEVAR in 5-year follow-up. The model could be used to efficiently assist the clinical management of TBAD patients and prompt high-risk factors.

When is extra-anatomical bypass for the left subclavian artery required to prevent ischaemia after thoracic endovascular stent grafting?

INTRODUCTION

Thoracic endovascular aortic repair (TEVAR) has become an accepted treatment for thoracic aortic disease. However, the principal complications relate to coverage of the thoracic aortic wall and deliberate occlusion of aortic branches over a potentially long segment. Complications include risk of stroke, spinal cord ischaemia (SCI) and arterial insufficiency to the left arm (left arm ischaemia (LAI)). This study specifically scrutinised the development of SCI and LAI after TEVAR for interventions for thoracic aortic disease from 1999 to 2020. In particular, those who underwent extra-anatomical bypass (both immediate and late) were compared to the length of thoracic aortic coverage by the stent graft.

MATERIALS AND METHODS

Ninety-eight patients underwent TEVAR. The presenting symptoms, pathology, procedural and follow-up data were collected prospectively with particular evidence of stroke, SCI and LAI both immediate onset and after 48 h of graft placement.

RESULTS

Fifty underwent TEVAR for an aneurysm (thoracoabdominal aortic aneurysm), 22 for dissection, 19 for acute transection and 7 for intramural haematoma/pseudoaneurysm of the thoracic aorta. Twenty-nine (30%) required a debranching procedure to increase the proximal landing zone (1 aorto-carotid subclavian bypass, 10 carotid/carotid subclavian bypass and 18 carotid/subclavian bypass). Ten patients (10%) died within 30 days of TEVAR. Twenty-four grafts covered the left subclavian artery origin without a carotid/subclavian bypass. Five required a delayed carotid/subclavian bypass for LAI (4) and SCI (1). Six developed immediate signs of SCI after TEVAR and these 11 (group i) had a mean (SD) length of coverage of the thoracic aorta of 30.2 (10.6) cm compared to 21.5 (11.2) cm (group g) in those who had no LAI or SCI post TEVAR, p < 0.05.

CONCLUSIONS

In this series, delayed carotid/subclavian bypass may be required for chronic arm ischaemia and less so for SCI. The length of coverage of thoracic aorta during TEVAR is a factor in the development of delayed SCI and LAI occurrence. Carotid subclavian bypass is required for certain patients undergoing TEVAR (particularly if greater than 20 cm of thoracic aorta is covered).

Early Outcomes of Left Subclavian Artery Revascularization Using Castor Single-Branched Stent-Graft in the Treatment of Type B Aortic Dissection or Intramural Hematoma

Background: More evidence was required to guide the management of left subclavian artery (LSA) during thoracic endovascular aortic repair (TEVAR). The present study aimed to compare the outcomes of LSA coverage with LSA revascularization. Another purpose of this study was to share our experience of LSA revascularization with castor single-branched stent-graft.

Methods: From January 2016 to December 2019, 134 patients with type B aortic dissection (TBAD) or intramural hematoma (IMH) were enrolled and divided into two groups, the LSA-covered group (n = 61) and the LSA-revascularized group (with castor single-branched stent-graft, n = 73). The results, such as in-hospital and 30-day mortality, stroke, paraplegia, left arm ischemia, operation time, endoleak, were compared between the two groups.

Results: The incidence of 30-day stroke in the LSA-covered group (8.2%) was significantly higher compared with the LSA-revascularized group (0%, P = 0.018). 30-day ischemia of left arm occurred in more patients in the LSA-covered group (11.5%, P = 0.003). No statistical difference was found in the incidences of paraplegia, endoleak, in-hospital mortality, and 30-day mortality.

Conclusions: LSA should be revascularized during TEVAR to reduce the incidences of stroke and left arm ischemia. Castor single-branched stent-graft was feasible and safe for treating TBAD or IMH.

Outcomes of single physician-modified fenestrated stent grafts for endovascular repair of thoracic aortic lesions involving the distal aortic arch

OBJECTIVES

Our goal was to evaluate the outcomes of fenestrated thoracic endovascular aortic repair of thoracic aortic lesions involving the distal aortic arch using single physician-modified stent grafts.

METHODS

This single-centre, retrospective study included 58 consecutive patients (mean age, 57 ± 14 years; 11 women) who underwent fenestrated thoracic endovascular aortic repair for thoracic aortic pathologies involving the distal aortic arch using single physician-modified stent grafts between November 2015 and December 2018. Indications included complicated acute type B dissection or intramural haematoma with an unfavourable proximal landing zone (n = 49), type Ia endoleak subsequent to thoracic endovascular aortic repair due to acute type B dissection (n = 1) and distal arch degenerative aneurysms <15 mm from the left subclavian artery (n = 8).

RESULTS

The technical success rate was 94.8%. The 30-day mortality was 1.7%, and the perioperative ischaemic stroke rate was 1.7%. The incidence of perioperative complications was 10.3%. At a mean follow-up of 26.3 months (range, 7-44), all target vessels were patent. All-cause mortality was 5.2%. Estimated 1-, 2- and 3-year survival was 98.3 ± 1.7%, 96.4 ± 2.5% and 93.2 ± 3.9%, respectively.

CONCLUSION

The single fenestrated stent graft technique is feasible and effective for endovascular repair of thoracic aortic pathologies involving the distal aortic arch.

Outcomes of thoracic endovascular aortic repair in thoracic aortic aneurysm and penetrating aortic ulcer using the Conformable Gore TAG within and outside the instructions for use

OBJECTIVE

To describe the outcome of thoracic endovascular aortic repair (TEVAR) in thoracic aortic aneurysm and penetrating aortic ulcer with respect to instructions for use status.

METHODS

Between October 2009 and September 2017, a total of 532 patients underwent TEVAR; of which 195 have been treated using the Conformable GORE® TAG® thoracic endoprosthesis (CTAG). Fifty-six patients of this cohort underwent TEVAR for thoracic aortic aneurysm/penetrating aortic ulcer using the CTAG. Depending on the preoperative computed tomography angiography findings, patients were classified as inside or outside the device's instructions for use. All inside instruction for use patients underwent postoperative reclassification regarding the instructions for use status. Study endpoints included TEVAR-related reintervention, exclusion of the pathology (endoleak type I/III), TEVAR-related mortality, and graft-related serious adverse events. The median duration of follow-up was 29.7 months (range: 0-109.4 months).

RESULTS

Of the 56 patients, 17 were primarily classified as outside instruction for use, and in additional 13 patients, TEVAR was performed outside instruction for use, leading to 30 outside instruction for use patients (53.6%). Twenty-six patients (46.4%) were treated inside instruction for use. Reintervention-free survival was lower in outside instruction for use patients (P = 0.016) with a hazard ratio of 9.74 (confidence interval 1.2-80.2; P = 0.034) for TEVAR-related reintervention. With respect to endoleak type I/III, relevant difference was detected between inside/outside instruction for use status (P = 0.012). The serious adverse event rate was 30.4%, mainly in outside instruction for use patients (P = 0.004). Logistic regression analysis indicated an association between graft-related serious adverse event/instructions for use status (odds ratio 6.11; confidence interval 1.6-30.06; P = 0.012). In-hospital death was seen more frequently in outside instruction for use patients (P = 0.12) as was procedure-related death (log-rank test: P = 0.21).

CONCLUSION

TEVAR for thoracic aortic aneurysm/penetrating aortic ulcer is frequently performed outside instruction for use despite preoperative inside instruction for use eligibility, leading to important consequences for technical/clinical outcome. Instructions for use adherence in TEVAR should be of interest for further large-scale studies.

Midterm Follow-up of Fenestrated and Scalloped Physician-Modified Endovascular Grafts for Zone 2 TEVAR

Purpose: To investigate the midterm outcomes of scalloped or fenestrated physician-modified endovascular grafts (PMEGs) for zone 2 thoracic endovascular aortic repairs (TEVAR). Materials and Methods: Between November 2013 and May 2019, 54 consecutive patients (mean age 63 years; 41 men) were treated with thoracic PMEGs modified with 7 scallops or 47 fenestrations for the left subclavian artery (LSA). Indications for aortic repair were acute complicated type B aortic dissection (17, 31%), degenerative aneurysm (13, 24%), acute traumatic rupture of the aortic isthmus (9, 16%), post chronic dissection aneurysmal evolution (8, 15%), penetrating aortic ulcer (3, 6%), intramural hematoma (2, 4%), and floating thrombus (2, 4%). Results: Technical success was 94%; 3 (6%) LSAs were unintentionally covered. An intraoperative type Ia endoleak was treated during the index procedure. One (2%) patient suffered spinal cord ischemia, with irreversible bilateral paraplegia. Three (6%) patients experience postoperative minor strokes with full neurological recovery. Four (7%) patients died in the perioperative period; 2 (2%) were due to aneurysm rupture. Mean follow-up was 26±16 months; 15 (28%) patients had at least 3 years of follow-up. Two (4%) type II endoleaks were identified and successfully treated (4% reintervention rate); no other endoleaks were identified. All the LSAs remained clinically and radiologically patent. There were no conversions to open repair, ruptures, retrograde dissection, stent fracture, migrations, or other aortic complications. Conclusion: Scalloped or single-fenestrated PMEGs for the LSA appear to be durable and safe in the midterm. Combined with low periprocedural morbidity and mortality, these results suggest that this approach can be considered as an off-label alternative to extend proximal seal to zone 2 for TEVAR. Further studies with a larger number of patients and long-term outcomes are needed to fully validate this approach.

Meta-analysis of the outcomes of revascularization after intentional coverage of the left subclavian artery for thoracic endovascular aortic repair

OBJECTIVE

Coverage of the left subclavian artery (LSA) is often required to achieve complete proximal sealing during thoracic endovascular aortic repair. However, whether LSA revascularization should be performed remains controversial.

METHODS

MEDLINE, Embase, and Cochrane databases were systematically searched to identify all the relevant studies. A random-effects model was applied to pool the effect measures. Dichotomous data were presented using an odds ratio (OR).

RESULTS

There were 32 studies included for qualitative analysis and 31 studies for quantitative analysis. We found that patients who underwent LSA revascularization had a significantly decreased risk of spinal cord ischemia (OR, 0.62; 95% confidence interval [CI], 0.41-0.92; P = .02; I² = 0%), cerebrovascular accident (OR, 0.63; 95% CI, 0.42-0.95; P = .03; I² = 22%), and left upper extremity ischemia (OR, 0.18; 95% CI, 0.09-0.36; P < .00001; I² = 0%). However, no significant differences were found in the risk of paraplegia (OR, 0.91; 95% CI, 0.55-1.51; P = .71; I² = 0%) and 30-day mortality (OR, 0.89; 95% CI, 0.59-1.36; P = .60; I² = 21%) between the groups of patients with and without LSA revascularization.

CONCLUSIONS

Revascularization of the LSA is associated with decreased risks of cerebrovascular accident, spinal cord ischemia, and left upper limb ischemia in thoracic endovascular aortic repair with LSA coverage at the cost of higher local complications, such as possible vocal cord paresis.

Early- and long-term results of thoracic endovascular aortic repair for blunt traumatic thoracic aortic injury: a single-centre experience

OBJECTIVES

Endovascular repair has been proposed as an alternative to classical surgical repair for the management of blunt traumatic thoracic aortic injury. However, the long-term outcomes of endovascular repair and the risks of left subclavian coverage remain unclear.

METHODS

From April 2001 to August 2018, 33 patients with blunt traumatic thoracic aortic injury underwent endovascular repair in our institution. A follow-up computed tomography and a clinical examination were performed before discharge and at 1 month, and yearly or every 2 years thereafter.

RESULTS

The mean age was 45 ± 19 years. The technical success rate was 100%. Complete coverage of the left subclavian artery (LSCA) was performed in 20 patients (60.6%). Among 20 patients with coverage of the LSCA, revascularization was performed in 1 patient. No in-hospital deaths occurred. The clinical follow-up rate was 97%, with a mean period of 7 years and a maximum of 18 years. The survival rates were 100% at 1 year, 95% at 5 years and 88.7% at 10 years after the event. Among the 5 patients (20%) who developed neurological complications, 1 who had undergone implantation of a 200-mm long stent graft and LSCA coverage without revascularization developed paraplegia during the long-term follow-up.

CONCLUSIONS

This study demonstrates that the endovascular treatment of blunt traumatic thoracic aortic injury is a safe and effective therapeutic method over a long-term follow-up period. LSCA coverage and long stent graft placement might be indications for revascularization to prevent spinal cord injury.

Effect of Left Subclavian Artery Revascularisation in Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-analysis

OBJECTIVE/BACKGROUND

Thoracic endovascular aortic repair (TEVAR) is an emerging therapy for thoracic aortic pathologies. However, the role of left subclavian artery (LSA) revascularisation in patients with LSA coverage in TEVAR has not been established. A systematic review and meta-analysis was done to investigate the effect of LSA revascularisation in TEVAR when the LSA was covered.

METHODS

PubMed, Embase, and the Cochrane Library were searched to find relevant randomised controlled trials (RCTs) and cohort studies. The Cochrane Risk of Bias Tool and Newcastle-Ottawa Scale was used to evaluate the methodological quality of RCTs and cohort studies respectively. Relative risks (RRs) with 95% confidence intervals (CIs) were calculated to express differences for dichotomous outcomes. Random effects models were used to combine outcomes for studies with I² > 50%; otherwise, fixed effects models were used. Subgroup analyses and sensitivity analyses were performed to further validate the results.

RESULTS

Sixteen cohort studies with a total of 2591 patients were included in this systematic review and meta-analysis. The average score of the included studies was 7.56. Of the included patients, the peri-operative stroke rate was 6.8% (n = 176/2591). The peri-operative stroke rates of the with and without LSA revascularisation groups were 5.4% and 7.8%, respectively. Compared with no LSA revascularisation, patients with LSA revascularisation had a significantly lower peri-operative stroke rate (RR 0.61; 95% CI 0.45-0.82; I² = 20%) and peri-operative spinal cord ischaemia (SCI) rate (RR 0.59; 95% CI 0.39-0.90; I² = 0). No significant difference was found between the with and without LSA revascularisation groups with respect to peri-operative mortality (RR 0.86; 95% CI 0.60-1.21; I² = 35%) and peri-operative paraplegia (RR 0.81; 95% CI 0.45-1.44; I² = 17%).

CONCLUSION

The results of this review reveal that LSA revascularisation was associated with significantly lower peri-operative stroke and SCI rates. LSA revascularisation should be recommended for patients with LSA coverage in TEVAR. High quality RCTs are needed to further validate the conclusion.

Extra-Thoracic Supra-aortic Bypass Surgery Is Safe in Thoracic Endovascular Aortic Repair and Arterial Occlusive Disease Treatment

OBJECTIVE

The safety and feasibility of supra-aortic debranching as part of endovascular aortic surgery or as a treatment option for arterial occlusive disease (AOD) remains controversial. The aim of this study was to assess the clinical outcome of this surgery.

METHODS

This single centre, retrospective study included 107 patients (mean age 69.2 years, 38.4% women) who underwent supra-aortic bypass surgery (carotid-subclavian bypass, carotid-carotid bypass, and carotid-carotid-subclavian bypass) because of thoracic or thoraco-abdominal endovascular aortic repair (57%; 61/107) or as AOD treatment (42.9%; 46/107) between January 2006 and January 2015. Mortality, morbidity with a focus on neurological complications, and patency rate were assessed. Twenty-six of 107 (14.2%) of the debranching patients were treated under emergency conditions because of acute type B dissection or symptomatic aneurysm. Follow up, conducted by imaging interpretation and telephone interviews, continued till March 2017 (mean 42.1, 0-125, months).

RESULTS

The in hospital mortality rate was 10.2% (11/107), all of these cases from the debranching group and related to emergency procedures (p < .0001). One procedure related death of a patient in the debranching group, who had a lethal stroke 72 months post-operatively following bypass occlusion was observed. Early neurological complications were recognised in 10 patients, including two transient cases of Horner syndrome and vocal cord paralysis as well as six cases of phrenic nerve apraxia. Three cases of stenosis and one case of occlusion were successfully treated. In three AOD patients, the graft had to be exchanged because of peri-graft reaction. Primary and secondary patency rates of 96 patients after 36 months were 95% (SE 2.6%) and 98% (SE 1.8%), respectively.

CONCLUSIONS

Extra-thoracic supra-aortic bypass surgery involves low complication rates and high mid-term bypass patency rates. It is a safe and feasible treatment option in the form of debranching in combination with endovascular aortic aneurysm repair and in AOD.

Post-traumatic acute thoracic aortic injury (TAI)-a single center experience

Background

We assess the effectiveness and our experience in emergency thoracic endovascular aortic repair (TEVAR) in patients with post-traumatic acute thoracic aortic injury (TAI) and associated multiorgan trauma. TAI is a life-threatening condition. It usually results from a sudden deceleration caused by vehicle accident, a fall or some other misfortune. Techniques of endovascular aortic repair have become promising methods to treat emergent TAI.

Methods

Since 2007, 114 patients with thoracic aorta pathologies have been treated by TEVAR. Our study involved 15 (incl. 14 men) of them (13%) who underwent stent graft implantation for post-traumatic either aortic rupture or pseudoaneurysm. The procedural access was limited to small skin incision in one groin and percutaneous puncture of the contralateral femoral artery. We evaluated technical success, early and long-term mortality, complication rate of procedure and throughout clinical and instrumental follow-up.

Results

Technical success rate was 100%. All patients survived the endovascular interventions. No additional procedures or conversions to open surgery were necessary. After the operation, none of the patients had symptoms of stroke or spinal cord ischemia (SCI). No serious stent-graft-related adverse events such as endoleak, infection or migration were noted during follow-up period that ranged from 6 to 108 months.

Conclusions

In our department, techniques of TEVAR with stentgraft implantation have become methods of choice in treatment of traumatic TAIs since they have enabled to minimize operational risk, particularly in unstable multitrauma patients in severe clinical status. TEVAR for TAI performed in emergency settings provide favorable long-term results.

Association of left subclavian artery coverage without revascularization and spinal cord ischemia in patients undergoing thoracic endovascular aortic repair: A Vascular Quality Initiative® analysis

Objectives

Investigate the impact of left subclavian artery coverage without revascularization on spinal cord ischemia development in patients undergoing thoracic endovascular aortic repair.

Methods

The Vascular Quality Initiative thoracic endovascular aortic repair module (April 2011–July 2014) was analyzed. Patients undergoing left subclavian artery coverage were divided into two groups according to revascularization status. The association between left subclavian artery revascularization with the primary outcome of spinal cord ischemia and the secondary outcome of stroke was assessed with multivariable analysis adjusting for between-group baseline differences.

Results

The left subclavian artery was covered in 508 (24.6%) of the 2063 thoracic endovascular aortic repairs performed. Among patients with left subclavian artery coverage, 58.9% underwent revascularization. Spinal cord ischemia incidence was 12.1% in the group without revascularization compared to 8.5% in the group undergoing left subclavian artery revascularization (odds ratio (95%CI): 1.48(0.82–2.68), P = 0.189). Multivariable analysis adjustment identified an independent association between left subclavian artery coverage without revascularization and the incidence of spinal cord ischemia (adjusted odds ratio (95%CI): 2.29(1.03–5.14), P = 0.043). Although the incidence of stroke was also higher for the group with a covered and nonrevascularized left subclavian artery (12.1% versus 8.5%), this difference was not statistically significant after multivariable analysis (adjusted odds ratio (95%CI): 1.55(0.74–3.26), P = 0.244).

Conclusion

For patients undergoing left subclavian artery coverage during thoracic endovascular aortic repair, the addition of a revascularization procedure was associated with a significantly lower incidence of spinal cord ischemia.

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.

Effects of preemptive cerebrospinal fluid drainage on spinal cord protection during thoracic endovascular aortic repair

BACKGROUND

Spinal cord injury (SCI) is reported to occur in 3-12% of thoracic endovascular aortic repair (TEVAR) cases, but is a potentially preventable complication of TEVAR for thoracoabdominal pathologies. Although many strategies have been devised to reduce the incidence of SCI, the effectiveness of prophylactic cerebrospinal fluid drainage (CSFD) and left subclavian artery (LSA) revascularization remains controversial.

METHODS

From 2012 to 2014, 162 patients underwent TEVAR at a single institution. We prospectively collected and retrospectively reviewed the data of 81 patients who underwent preoperative CSFD among the 162 patients. LSA revascularization was routinely used when LSA need to be covered. Preoperative characteristics, intraoperative variables, and outcomes were analyzed.

RESULTS

The mean (SD) age of the patients was 60.6 (12.5) years, and 57 patients (70%) were male. Twenty-five patients (31%) presented with degenerative aneurysm; 48 (59%), type B dissection; 5, (6%) penetrating aortic ulcer; and 3 (4%), intramural hematoma. Thirty-six patients (44%) underwent LSA revascularization before TEVAR. Two (2.5%) of the patients who underwent preoperative CSFD had SCI, of whom one recovered ambulatory status at discharge after hypertensive therapy and another had a permanent disability. Prior abdominal aortic aneurysm (AAA) repair tended to relate to SCI (P=0.065), and preoperative aortic rupture was a significant independent risk factor of SCI (P=0.002).

CONCLUSIONS

Preemptive CSFD as an adjunctive procedure to TEVAR proved to be more effective than selective use of CSFD in other prior reports of SCI cases. Preoperative CSFD is recommended as a prophylactic procedure in patients at high risk of SCI during TEVAR.