Five-year results of thoracic endovascular aortic repair with the Zenith TX2

Five-year outcomes of endovascular treatment for aortic dissection from the Global Registry for Endovascular Aortic Treatment

OBJECTIVE

The Global Registry for Endovascular Aortic Treatment (GREAT) is an International prospective multicenter registry collecting real-world data on performance of Gore aortic endografts. The purpose was to analyze the long-term outcomes and patient survival rates, as well as device performance in patients undergoing thoracic endovascular aortic repair for acute and chronic and complicated or uncomplicated type B aortic dissection (TBAD).

METHODS

From August 2010 to October 2016, 5014 patients were enrolled in the GREAT registry. The study population were patients treated with thoracic endovascular aortic repair for TBAD through 5-year follow-up (days 0-2006). The primary outcomes for this analysis were all-cause and aortic-related mortality, stroke, aortic rupture, endoleaks, migration, fracture, compression, and any reintervention through 5 years.

RESULTS

We identified 265 patients. The mean age was 60.9 ± 11.9 years (range, 19-84 years; 211 males [79.6%]). Devices used were the Gore TAG and Conformable Gore TAG Thoracic Endoprosthesis. There were 228 patients (86.0%) who underwent primary endovascular treatment (144 off-label [54.3%]); 22 (8.3%) underwent reintervention after prior endovascular procedure and 15 (5.7%) underwent reintervention after prior open procedure. Kaplan-Meier estimated freedom from all-cause mortality at 5 years was 71.1%. Freedom from aortic-related mortality through 5 years was 95.8%. There was no significant difference in freedom from all-cause mortality during the follow-up period in complicated or uncomplicated disease. At 30 days and through 5 years, respectively, for all the following outcomes, the aortic rupture rate was 1.1% (n = 3) and 1.9% (n = 5). The stroke rate was 1.1% (n = 3) and 4.2% (n = 11). The spinal cord ischemic event rate was 1.5% (n = 4) and 2.6% (n = 7). Reinterventions were required in 6.4% (n = 17) and 21.1% (n = 56) of patients. The need for conversion to open repair was 0.4% (n = 1) and 2.6% (n = 7). Additional graft placement was required in 3 patients (1.1%) and 16 patients (6.0%). The endoleak rate at 30 days was 3.4% (n = 9); type IA (n = 1 [0.4%]), type IB (n = 4 [1.5%]), type II (n = 1 [0.4%]), type III (n = 1 [0.4%]), and unspecified (n = 4 [1.6%]). Through 5 years, the endoleak rate was 12.1% (n = 32); type IA (n = 7 [2.6%]), type IB (n = 10 [3.8%]), type II (n = 9 [3.4%]), type III (n = 2 [0.8%]), and unspecified (n = 12 [4.5%]). There were no cases of stent migration, compression or fracture through 5 years.

CONCLUSIONS

Results at the 5-year follow-up demonstrate that the use of the Gore TAG and Conformable Gore TAG Thoracic Endoprosthesis can be supported in treatment of TBAD (acute, chronic, complicated, and uncomplicated). These data demonstrate strong device durability, beneficial patient outcomes, and support for the treatment of thoracic aortic dissection with an endovascular approach. Complete 10-year follow-up in GREAT as planned will be advantageous.

Endovascular treatment for thoracic aortic disease from the Global Registry for Endovascular Aortic Treatment

OBJECTIVE

Global Registry for Endovascular Aortic Treatment (GREAT) is an international prospective multicenter registry collecting real-world data on performance of W. L. Gore thoracic and abdominal aortic endografts. This analysis evaluated the long-term differences in patient survival and device performance in patients undergoing thoracic endovascular aortic repair (TEVAR) for any thoracic aortic pathology.

METHODS

From August 2010 to October 2016, 5014 patients were enrolled in GREAT. The population of interest was comprised of only patients treated for thoracic aortic pathologies. Through 5 years, primary outcomes were all-cause and aortic-related mortality, stroke, aortic rupture, endoleaks, migration, fracture, compression, paraplegia, and any reintervention through 5 years, grouped by pathology. Secondary outcomes were reintervention rate and freedom from serious device- and aortic-related events.

RESULTS

The 578 patients with thoracic aortic pathologies enrolled in GREAT and identified for this analysis were categorized by common pathologies: thoracic aneurysm (n = 239), thoracic dissection (n = 203), arch (n = 26), and other (n = 110). The mean age of this population was 66.1 ± 12.8 years, and 64.7% were male. Procedure survival was 99.7%. In the overall group, at index procedure to 30 days and 31 days to 5 years, Kaplan-Meier estimates of freedom from all-cause mortality were 99.6% and 66.4%, respectively, and for aortic-related mortality were 97.7% and 94.6%, respectively. Aortic rupture rate was 0.5% (n = 3) at 30 days and 1.4% (n = 8) through 5 years. Stroke and spinal cord ischemic events were 1.9% (n = 11) and 1.6% (n = 9) at 30 days and at 5 years were 3.6% (n = 20), 0.5% (n = 3), respectively. Reinterventions were required in 7.3% (n = 42) at 30 days and 12.4% (n = 69) through 5 years. The number of patients with endoleaks at 30 days was 2.1% (n = 12): n = 3 (1.1%) for each of types IA, 1B, and II; n = 2 (0.3%) for type III; and n = 4 (0.7%) for unspecified. Through 5 years, the percentage of patients was 8.3% (n = 40): n = 15 (3.1%) for type IA; n = 10 (2.1%) for type IB; n = 11 (2.3%) for type II; and n = 9 (1.9%) for unspecified. One patient (0.2%) had stent migration at 30 days (aneurysm group); none were reported through 5 years. There were no incidents of stent compression or fracture from index procedure through 5 years.

CONCLUSIONS

Data herein demonstrates durability and support for treatment of thoracic aortic disease with the GORE TAG conformable thoracic stent graft, including no incidents of stent compression/fracture and high freedom from aortic-related mortality. The planned analysis of follow-up to 10 years in GREAT will be beneficial.

Endovascular Repair in Blunt Thoracic Aortic Injury: A 10-Year Single Center Experience

BACKGROUND

Life-threatening blunt thoracic aortic injury (BTAI) typically occurs alongside multiple other traumatic injuries. Symptoms of BTAI can range from being asymptomatic in the case of intimal tears to becoming catastrophic in the case of uncontained aortic ruptures. The aim of this research was to examine the clinical outcomes for those who underwent thoracic endovascular aortic repair (TEVAR) in hospital settings.  Methods: A cross-sectional retrospective study was conducted using patient data that were extracted from Al-Noor Specialist Hospital, Makkah, Saudi Arabia, for the duration between January 2011 and December 2021. This study included data from all patients aged 18 and up who had been diagnosed with BTAI and had undergone TEVAR. The BTAI diagnoses were confirmed using CT scans. Logistic regression was utilized to identify predictors of patients' health status improvement and length of stay.

RESULTS

A total of 80 patients were involved. Around 50.0% (n=40) of the patients had grade 3 thoracic aortic injuries. The median duration of stay was 14.00 days (Interquartile range 21.00). Only one patient developed post-procedure complications (1.3%). Almost one-third (31.3%; n=25) of the patients required subclavian coverage. One patient developed intraoperative endoleak (1.3%). One patient developed an access site complication (1.3%). The mortality rate within 30 days of the operation was 1.3%. The vast majority of the patients (92.5%; n=74) showed improvement upon discharge from the hospital. The baseline patient characteristics and length of hospitalization had no effect on the improvement of patient status upon discharge or their length of stay (p>0.05).

CONCLUSION

Patients with BTAI have shown an excellent success rate with TEVAR and a low complication rate. Predictors of procedure success and length of stay need to be identified; however, this can't be done without larger-scale investigations. This can aid in the development of preventative measures that improve clinical outcomes for the patients.

Late Endograft Migration After Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-analysis

PURPOSE

The objective of this systematic review was to report the cumulative incidence of endograft migration (EM), as well as the morbidity, reintervention rates, and mortality related to EM. This study aimed to provide evidence-based data on patient-relevant sequelae of EM after thoracic endovascular aortic repair (TEVAR) performed using contemporary aortic endografts.

MATERIALS AND METHODS

A systematic electronic search of literature in MEDLINE (via PubMed), Web of Science, and Cochrane Central Register of Controlled Trials was performed. The pooled synthesis of outcomes was performed using the inverse variance method.

RESULTS

Seven prospective non-randomized and 4 retrospective studies, including a total of 1783 patients presenting 70 EMs, were considered for the quantitative analysis. The pooled rate of EM was 4% (95% CI, 2%-7%; range, 0.2%-11%; I2=82%); pooled morbidity rate was 31% (95% CI, 12%-59%; range, 0%-100%; I2=64%) and pooled reintervention rate was 32% (95% CI, 15%-56%; range, 0%-100%; I2=55%). The pooled mortality rate due to EM was 5% (95% CI, 1%-21%; range, 0%-40%; I2=24%).

CONCLUSION

For the first time, this meta-analysis provides pooled reference estimates of EM after TEVAR. Thus, the results hold the potential to further characterize EM after TEVAR. The clinical relevance of EM is underlined by its association with high rates of endoleak-related morbidity, reintervention, and mortality. Close standardized surveillance after TEVAR for early detection of EM and prophylaxis of its sequelae is essential.

In Vivo Efficacy of an Adhesive Bioresorbable Patch to Treat Aortic Dissections

Endovascular repair of aortic dissection still presents significant limitations. Preserving the mechanical and biological properties set by the aortic microstructure is critical to the success of implantable grafts. In this paper, we present the performance of an adhesive bioresorbable patch designed to cover the entry tear of aortic dissections. We demonstrate the power of using a biomimetic scaffold in a vascular environment.

Systematic Review on In Situ Laser Fenestrated Repair for the Endovascular Management of Aortic Arch Pathologies

Background: In situ laser-fenestrated thoracic aortic endovascular repair (FTEVAR) has emerged as a valuable alternative for aortic arch management. This review assessed the early and follow-up outcomes of in situ laser-FTEVAR in aortic arch pathologies. Methods: The PRISMA statement was followed. The English literature was searched, via Ovid, until 15 October 2022. Observational studies, published after 2000, reporting on early and follow-up outcomes for the in situ laser-FTEVAR were eligible. The Newcastle–Ottawa Scale was used to assess the risk of bias. Primary outcomes were the technical success, stroke, and mortality at 30-days, and the secondary were the mortality and reintervention during follow-up. Results: Six retrospective studies from 591 and 247 patients were included. Fifty-nine (23.9%) patients were managed for aortic arch aneurysms and 146 (59.1%) for dissections; 22.6% of them for type A. Technical success was at 98% (range 90–100%). Eight patients died (3.2%) and 11 cases presented any type of stroke (4.5%) during the 30-day follow-up. The mean follow-up was 15 months (1–40 months). Ten deaths were reported (4.2%); one was aortic-related (10%). Thirteen re-interventions (6.0%) were performed. Conclusions: In situ laser-FTEVAR for aortic arch repair may be performed with high technical success and low 30-day and midterm follow-up mortality, stroke, and re-intervention rates when applied in well selected patients and performed by experienced teams.

Stent-Graft Migration Post-Endovascular Repair of Thoracic Aorta: A Retrospective Cohort Study

Background Migration of the stent-graft post-thoracic endovascular aortic repair (TEVAR) is not uncommon; however, it is sparsely reported. The objective of this study was to assess the incidence, risk factors, and complications of stent-graft migration post-TEVAR.

Materials and Methods Thirty-one patients who underwent TEVAR were retrospectively analyzed. The demographic, anatomical, and procedure-related factors were assessed. The measurements were done along the greater curvature of aorta around two fixed anatomic landmarks, that is, left common carotid artery or neoinnominate artery (hybrid repair) proximally and celiac artery distally. Aortic elongation and migration at proximal, distal, as well as at overlapping zone were measured. More than 10 mm of migration was considered significant.

Results Significant migration was observed in six (19%) patients. No significant migration was observed in the overlapping zone. The proximal landing zone 3 (odds ratio [OR] 12.78, p 0.01) was a significant risk factor, whereas landing zone 2 was a protective factor against the migration (OR 0.08, p 0.02). The odds for migration were more in segments I/3 and II/3 compared with I/2 and II/2, respectively, as per Modified Arch Landing Areas Nomenclature. A single complication was seen in the migration group which was treated by an overlapping stent graft.

Conclusion The stent-graft migration after TEVAR is not uncommon. Type 3 proximal landing zone was a significant risk factor for migration with an increased risk toward I/3 and II/3. Proximal landing zone 2 as well as adequate overlapping distance in multiple stent grafts can prevent migration.

Ethical Approval No IECPG-227/24.06.2020

Outcomes of Endovascular Repair of Aortic Aneurysms with the GORE® Thoracic Branch Endoprosthesis for Left Subclavian Artery Preservation

OBJECTIVE OR BACKGROUND

Thoracic endovascular aortic repair has emerged as the dominant paradigm for treatment of patients with descending thoracic aortic aneurysms. For aneurysms involving the aortic arch in the region of the left subclavian artery (LSA), branch vessel preservation to maintain blood flow to the LSA is recommended. Branched aortic endografts are an alternative to surgical revascularization of the LSA.

METHODS

Across 34 investigative sites, 84 patients with Zone 2 aneurysm were enrolled in a nonrandomized, prospective study of a single branched aortic endograft. The thoracic branch endoprosthesis device allows for graft placement proximal to the LSA and incorporates a single side branch for left subclavian perfusion.

RESULTS

Over half of the patients were male (63%). Their average age was 70 (±11) years. The aneurysm morphology was fusiform in 43 and saccular in 41 patients. The mean aneurysm diameter at screening was 56.2 mm. The mean follow up was 30 months (range 2.6 to 50.7 months). Reported here are the patient outcomes at 1 and 12 months. Pre-defined technical success with implantation of the device in landing Zone 2 was achieved in 92% (n=77) of patients. There were no cases of aortic rupture, lesion-related mortality, or new onset renal failure. There was no peri-operative (30-day) mortality. A single case each of permanent paraplegia and paraparesis occurred. Three patients experienced a procedure-related stroke. Through 12 months, four patients died; none of the deaths were adjudicated as related to the device or procedure. One aortic reintervention was required. A single case of aortic enlargement (core laboratory) was reported at 6 months. Type 1 (n=3) and III (n=5) endoleaks occurred in 9.8% of patients of which one (Type III) required reintervention.

CONCLUSIONS

Results from this device study in patients with Zone 2 aneurysm demonstrate that early safety and efficacy outcomes are maintained up to 12 months after the endovascular procedure with low mortality and reintervention rates and an acceptable frequency of procedural complications, including neurologic complications.

Identifying risk factors for early neurological outcomes following thoracic endovascular aortic repair using the SUMMIT database

OBJECTIVES

The aim of this study was to assess risk factors for early neurological complications following thoracic endovascular aortic repair (TEVAR) for multiple thoracic aortic diseases using an aggregated dataset.

METHODS

The Study to Assess Outcomes After Endovascular Repair for Multiple Throacic Aortic Disease dataset included data from 6 studies evaluating Zenith thoracic endografts. Post hoc analysis identified early (30-day) neurological complications by TEVAR indication and corresponding risk factors.

RESULTS

The study included 594 TEVAR patients (67% male; mean age 66 ± 15 years) with thoracic aortic aneurysm (n = 329), ulcer (n = 56), acute (n = 126) or non-acute (n = 33) type B aortic dissection (TBAD) or blunt injury (n = 50). Overall early stroke rate was 3.5% (n = 21). Overall early paraplegia and paraparesis rates were 1.3% (n = 8) and 2.5% (n = 15), respectively. Multivariable analysis identified acute TBAD [versus others, odds ratio (OR) = 3.47, 95% confidence internal (CI): 1.41-8.52) and longer procedural time (OR = 1.33, CI: 1.02-1.73) as early stroke risk factors. Risk factors for paraplegia or paraparesis included more endografts deployed (OR = 2.43, CI: 1.30-4.55), older age (OR = 1.05, CI: 1.01-1.10) and higher preoperative serum creatinine (OR = 1.31, CI: 1.05-1.64). Endografts landing proximal to the left subclavian artery (LSA) increased stroke rate (versus distal to the LSA; 6.8% vs 2.3%, P = 0.014). Intraoperative LSA revascularization was performed in 20.9% of patients with endografts proximal to the LSA; revascularization did not significantly alter stroke rate (8.1% with revascularization vs 6.4% without, P = 0.72).

CONCLUSIONS

Acute TBAD and prolonged procedure time increased early stroke risk, while more endografts placed, age and preoperative renal impairment increased early paraplegia or paraparesis risk. For acute TBAD, endograft placement proximal to the LSA, but not LSA patency, increased stroke risk.

A 10-Year Single-Center Experience With the GORE TAG Conformable Thoracic Stent Graft in the Treatment of Thoracic Aortic Disease

Objective:

The aim of this study was to report 10-year real-world single-center experience with the GORE TAG conformable thoracic aortic graft (CTAG), focusing on rupture-free survival, aortic-related reintervention, and device-related complications during midterm and long-term follow-up (FU).

Methods:

This retrospective study analyzes results of thoracic endovascular aortic repair (TEVAR) performed between January 2009 and December 2018. Out of 419 TEVAR procedures within this period, 194 patients (male 57.2%, 111/194), with a mean age of 65 ± 13 years, were treated with the CTAG device. Indication for TEVAR was a thoracic aortic aneurysm in 24.7% (48/194), type B aortic dissection in 32.5% (63/194), penetrating aortic ulcer 15.5% (30/194), and miscellaneous 27.3% (53/194). Emergently were operated 43.8% (85/194) patients. Median follow-up (FU) including computed tomography imaging was 43.5 months (Q1-Q3: 8.6–67.0) and was completed in 91.2% (177/194) of patients.

Results:

Overall survival rates were 75.8% (95% confidence interval [CI] = [0.76–0.70]) and 56.6% (95% CI = [0.57–0.50]) at 12 and 60 months, respectively. Cumulative incidence for aortic rupture was 11.9% (95% CI = [0.07–0.17]) at 60 and 90 months, respectively. Cumulative incidence for aortic-related reintervention was 27.5% (95% CI = [0.21–0.34]) at 60 and 90 months. Cumulative incidence for migration was 2.8% (95% CI = [0.004–0.05]) and 3.9% (95% CI = [0.007–0.07]) at 60 and 90 months, respectively. New endograft infections or material fatigue were not observed.

Conclusions:

The herein reported 10-year real-world single-center experience with the CTAG observed favorable long-term outcome. Thus, the device demonstrates appropriate persistent safety, efficacy, and clinical durability up to long-term FU in the treatment of diverse thoracic aortic pathologies.

Endovascular repair of the aorti arch

AIM

The study was aimed at assessing the in-hospital results of aortic arch endoprosthetic repair using different variants of endovascular supraaortic debranching.

PATIENTS AND METHODS

The analysis included 27 patients subjected within the framework of aortic arch endoprosthetic repair to various types of supraaortic endobranching, including the technique of parallel prostheses and implantation of fenestrated stent grafts. We analysed the clinical and morphological status of patients prior to operation, peculiarities of the intervention (type of debranching and Ishimaru's classification zones in which the reconstruction was performed) and in-hospital results of treatment.

RESULTS

The patients' mean age amounted to 66 years. The main nosology (70%) was an aortic aneurysm. Nearly in 30% of cases, the operation was performed emergently for acute aortic syndrome. The main causes of refusal from the traditional prosthetic repair included chronic kidney disease (22.5%), chronic obstructive pulmonary disease (11%), acute cerebral ischaemia within the previous 6 months (15%). The technical success rate of the operation was achieved in 100% of cases. The average duration of the intervention amounted to 226 min, with the mean blood loss equalling 355 ml. The majority of reconstructions were performed in zones 1 and 2 according to Ishimaru (59 and 33%, respectively), in 2 (7%) patients prosthetic repair was performed in zone 0. The total number of the aortic branches involved into reconstruction amounted to 45. Intervention-related complications included 3 (11%) cases of acute cerebral circulation impairment, 2 (7.4%) aortic branch occlusions, and 1 (3.7%) type II endoleak. The in-hospital and 30-day mortality rates amounted to 3.7 and 7.4%, respectively.

CONCLUSION

Aortic arch endoprosthetic repair using supraaortic endobranching is considered to be an effective alternative method of treatment for patients with various pathology of the aortic arch and contraindications to traditional prosthetic repair involving artificial blood circulation.

Endovascular repair of descending thoracic aortic aneurysms-a mid-term report from the Global Registry for Endovascular Aortic Treatment (GREAT)

OBJECTIVES

The aim of this study was to evaluate the short- to mid-term outcomes of descending thoracic aortic aneurysm (DTAA) repair from the Gore Global Registry for Endovascular Aortic Treatment (GREAT).

METHODS

This is a multicentre sponsored prospective observational cohort registry. The study population comprised those treated for DTAA receiving GORE thoracic aortic devices for DTAA repair between August 2010 and October 2016. Major primary outcomes were early and late survival, freedom from aorta-related mortality and freedom from aorta-related reintervention.

RESULTS

There were 180 (58.1%) males and 130 (41.9%) females: the mean age was 70 ± 11 years (range 18-92). The median maximum DTAA diameter was 60 mm (interquartile range 54-68.8). Technical success was achieved in all patients. Operative mortality, as well as immediate conversion to open repair, was never observed. At the 30-day window, mortality occurred in 4 (1.3%) patients, neurological events occurred in 4 (1.3%) patients (transient ischaemic attacks/stroke n = 3, paraplegia n = 1) and the reintervention rate was 4.5% (n = 14). Estimated survival was 95.6% [95% confidence interval (CI) 92.6-97.4] at 6 months, 92.7% (95% CI 89.1-95.2) at 1 year and 57.3% (95% CI 48.5-65.1) at 5 years. Freedom from aorta-related mortality was 98.3% (95% CI 96.1-99.3) at 6 months, 98.3% (95% CI 96.1-99.3) at 1 year and 92.2% (95% CI 83.4-96.4) at 5 years. Freedom from thoracic endovascular aortic repair (TEVAR)-related reintervention at 5 years was 87.2% (95% CI 81.2-91.4).

CONCLUSIONS

TEVAR for DTAAs using GORE thoracic aortic devices is associated with a low rate of device-related reinterventions and is effective at preventing aorta-related mortality for up to 5 years of follow-up.

CLINICAL REGISTRATION NUMBER

NCT number: NCT01658787.

SUBJECT COLLECTION

161, 164.

Hybrid repair versus conventional open repair for thoracic aortic arch aneurysms

BACKGROUND

Thoracic aortic arch aneurysms (TAAs) can be a life-threatening condition due to the potential risk of rupture. Treatment is recommended when the risk of rupture is greater than the risk of surgical complications. Depending on the cause, size and growth rate of the TAA, treatment may vary from close observation to emergency surgery. Aneurysms of the thoracic aorta can be managed by a number of surgical techniques. Open surgical repair (OSR) of aneurysms involves either partial or total replacement of the aorta, which is dependent on the extent of the diseased segment of the aorta. During OSR, the aneurysm is replaced with a synthetic graft. Hybrid repair (HR) involves a combination of open surgery with endovascular aortic stent graft placement. Hybrid repair requires varying degrees of invasiveness, depending on the number of supra-aortic branches that require debranching. The hybrid technique that combines supra-aortic vascular debranching with stent grafting of the aortic arch has been introduced as a therapeutic alternative. However, the short- and long-term outcomes of HR remain unclear, due to technical difficulties and complications as a result of the angulation of the aortic arch as well as handling of the arch during surgery.

OBJECTIVES

To assess the effectiveness and safety of HR versus conventional OSR for the treatment of TAAs.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 22 March 2021. We also searched references of relevant articles retrieved from the electronic search for additional citations.

SELECTION CRITERIA

We considered for inclusion in the review all published and unpublished randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing HR to OSR for TAAs.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all titles and abstracts obtained from the literature search to identify those that met the inclusion criteria. We retrieved the full text of studies deemed as potentially relevant by at least one review author. The same review authors screened the full-text articles independently for inclusion or exclusion.

MAIN RESULTS

No RCTs or CCTs met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

Due to the lack of RCTs or CCTs, we were unable to determine the safety and effectiveness of HR compared to OSR in people with TAAs, and we are unable to provide high-certainty evidence on the optimal surgical intervention for this cohort of patients. High-quality RCTs or CCTs are necessary, addressing the objective of this review.

Long-term outcomes of the conformable TAG thoracic endoprosthesis in a prospective multicenter trial

BACKGROUND

The Gore conformable TAG thoracic endoprosthesis (CTAG) was engineered to enhance conformability in the thoracic aorta and has demonstrated greater deployment accuracy and wall apposition than the original TAG device. The Food and Drug Administration approved the CTAG in 2011 based on the 1-year results of the pivotal trial for the CTAG device. In the present report, we have documented the outcomes for those patients through 5 years.

METHODS

The CTAG aneurysm study was a prospective, multicenter trial that assessed the safety and effectiveness of the CTAG device as treatment of descending thoracic aortic aneurysms. Follow-up imaging assessments consisted of radiographs and computed tomography at annual intervals through 5 years. A core imaging laboratory was used to assess the aneurysm size, device integrity, and endoleaks.

RESULTS

A total of 66 patients were enrolled (51 pivotal arm patients and 15 continued access patients) from October 2009 through September 2011. The baseline characteristics, procedural characteristics, and outcomes through 2 years were reported previously. Through 5 years, five patients (7.6%) had required device-related reintervention (one type Ia endoleak or contained rupture of the descending thoracic aorta, one type Ib endoleak, two indeterminate endoleaks, and one thoracic aortic pseudoaneurysm). Four patients (6.1%) had died of aneurysm-related causes, with one death occurring within 30 days of the index procedure. A total of 24 patients (36.3%) had died during the 5-year study period. Seven patients (10.6%) had experienced stroke or transient ischemic attack through 5 years, with one early stroke (postoperative day 28). Prosthesis or intercomponent migration was observed in six patients (9.1%) through 5 years; however, no patient had developed a type III junctional endoleak. No stent-graft fracture or compression was observed through 5 years. At 5 years, 14 patients (50.0%) showed sac regression, 5 (17.9%) showed sac expansion, and 9 (32.1%) showed sac stability using on a 5-mm threshold for change.

CONCLUSIONS

Thoracic endovascular aortic repair with the CTAG device was associated with low rates of aneurysm-related mortality and reintervention through 5 years. Proximal endoleak was rare, and most patients showed sac regression or stability at 5 years after the initial thoracic endovascular aortic repair.

Tortuosity of the Descending Thoracic Aorta in Patients with Aneurysm and Type B Dissection

OBJECTIVE

Tortuosity in the descending thoracic aorta (DTA) comes with aging and increases the risk of endoleaks after TEVAR. With this report, we would like to define and classify tortuosity in the DTA of patients with thoracic aortic disease.

METHODS

Retrospective case-control study of two hundred seven patients, comparing sixty-nine controls without aortic disease (CG), to sixty-nine patients with descending thoracic aortic aneurysm (AG) and sixty-nine patients with type B aortic dissection (DG). 3Mensio Vascular software was used to analyze CTA scans and collect the following measurements; tortuosity index, curvature ratio and the maximum tortuosity of the DTA. The DTA was divided into four equal zones. The maximum tortuosity was divided into three groups: low (<30°), moderate (30°-60°) and high tortuosity (>60°).

RESULTS

Compared to the CG, tortuosity was more pronounced in the DG, and even more in the AG, evidenced by the tortuosity index (1.11 vs. 1.20 vs. 1.31; p < 0.001), curvature ratio (1.00 vs. 1.01 vs. 1.03; p < 0.001), maximum tortuosity in degrees (28.17 vs. 33.29 vs. 43.83; p < 0.001) and group of tortuosity (p < 0.001). The maximum tortuosity was further distal for the DG and AG, evidenced by the zone of maximum tortuosity (4A vs. 4B vs. 4B; p < 0.001).

CONCLUSION

This study shows that tortuosity in the DTA is more prominent in diseased aortas, especially in aneurysmal disease. This phenomenon needs to be taken into account during planning of TEVAR to prevent stent graft-related complications and to obtain positive long-term outcome.

Single-center midterm results with the low-profile Zenith Alpha thoracic endovascular stent graft

OBJECTIVE

The analysis of endovascular treatment of thoracic aortic diseases using new low-profile stent grafts in large series is crucial to understanding the durability of these devices. The present study reports the midterm outcomes of a single-center experience using the Zenith Alpha thoracic endovascular stent graft.

METHODS

The outcomes of 270 procedures performed on 262 patients (197 men; mean age, 70.5 ± 9.5 years) using the Zenith Alpha thoracic endovascular stent graft from November 2013 to December 2019 for different thoracic aortic diseases were analyzed. The primary endpoints were 30-day clinical success and midterm (5-year) clinical success. The secondary endpoints were the adverse event rate at 30 days and midterm and access- and device-related complications. The follow-up of surviving patients was performed using computed tomography angiography and office visits at 1, 6, and 12 months and annually thereafter. Kaplan-Meier analysis was performed for overall survival, and freedom from thoracic aortic endovascular repair-related mortality and related reinterventions.

RESULTS

The overall 30-day mortality was 5.2% (2.5% for elective and 30.8% for nonelective cases). Type I endoleaks were identified in six patients. The 30-day primary technical and clinical success rates were 97.8% and 92.6%, respectively. Femoral cutdown was used in 41.1% of cases and percutaneous access in 58.5%. The rate of femoral artery complications after the percutaneous approach was 5.1%, with the need for surgical conversion in 1.9%. The stroke rate was 4.1% (major stroke, 2.2%), and the spinal cord ischemia rate was 3.7% (permanent paraplegia, 0.7%). Of the 248 survivors, 239 complied with the follow-up protocol with adequate computed tomography angiograms available images. Overall follow-up survival was 94.0% at 1 year, 91.6% at 2 years, 88.9% at 3 years, and 88.5% at 5 years. The unplanned secondary endovascular procedure rate was 5.3%. No stent fractures or new-onset type I endoleaks due to stent graft migration were observed in the study cohort.

CONCLUSIONS

The midterm outcomes of this new generation of low-profile devices were satisfactory. The reported low incidence of secondary procedures and the absence of migrations are promising for the long-term durability of these devices.

Long-term Results of Thoracic Endovascular Aortic Repair Using a Low-Profile Stent-Graft

PURPOSE

To evaluate the long-term results associated with the Zenith Alpha thoracic stent-graft, which was designed to address challenging access vessel anatomy.

MATERIALS AND METHODS

A retrospective analysis was conducted of 44 consecutive patients (mean age 72.5±8.3 years; 25 men) treated in a single center between August 2010 and October 2014 with a minimum follow-up of 5 years in survivors. The Zenith Alpha thoracic stent-graft was used to treat thoracic aortic aneurysms (n=37), thoracoabdominal aortic aneurysm (n=5), or penetrating aortic ulcer (n=2). Ten patients (23%) were American Society of Anesthesiologists class IV, and 9 (20%) had nonelective procedures. Access vessel anatomy was demanding (mean minimum diameter 5.4 mm, tortuosity index 1.3). The primary endpoint at 5 years was ongoing clinical success (freedom from aneurysm-/procedure-related death, secondary intervention, type I or III endoleak, infection, thrombosis, aneurysm expansion, rupture, or conversion). Secondary endpoints were freedom from all-cause mortality, device migration, stent fractures, fabric erosions, endoleaks, neurological events, and access vessel complications.

RESULTS

The ongoing clinical success was 84% (37 of 44 patients) owing to 4 aneurysm-related deaths (9%), 3 type I or III endoleaks (1 in a deceased patient), and 1 aneurysm expansion without detectable endoleak. There were 3 access vessel complications (7%), and no postoperative neurological events. Migration was observed in 2 cases (5%). There were no stent fractures or fabric tears.

CONCLUSION

Despite the alterations in stent-graft design and material to reduce profile, the Zenith Alpha thoracic stent-graft showed favorable long-term results even in multimorbid patients with demanding iliac anatomy.

Thoracic Endovascular Aortic Repair in the Setting of Compromised Distal Landing Zones

BACKGROUND

The short-term and intermediate-term outcomes of two distinct approaches to thoracic endovascular aortic repair (TEVAR) for descending aortic aneurysms in patients with compromised distal landing zones are reported.

METHODS

Fifty-one patients (38 female, average age 72 ± 9 years) underwent 55 TEVARs (2008 to 2018) for aneurysmal disease. Inclusion criteria consisted of TEVAR in a compromised distal landing zone, defined as follows: diameter 3.5 cm or greater; cross-sectional thrombus 50% or greater; or 25% or greater circumferential mural calcification in the 2 cm supraceliac aorta; or tortuosity index of 1.1 or more over the 10 cm supraceliac aorta. Treatment cohorts were (1) TEVAR alone (n = 29), and (2) TEVAR with adjunct consisting of visceral snorkel graft with distal stent extension (n = 20) or EndoAnchors (Medtronic, Minneapolis, MN [n = 6]).

RESULTS

Perioperative complication rate was 20%. Thirty-day mortality was 5% including one access-site related intraoperative death and one postoperative death from embolic mesenteric ischemia. Median clinical follow-up was 2.2 years. Intermediate-term outcomes include type 1B endoleaks, 35%; 0.5 cm or more per year maximal aortic diameter growth, 9%; reintervention, 15%; and all-cause mortality, 25%. The distal landing zone diameter increased by 0.3 cm per year in the TEVAR alone cohort; however, it decreased by 0.1 cm per year in the adjunct cohort ( P = .04).

CONCLUSIONS

Thoracic endovascular aortic repair is a viable alternative for the treatment of thoracoabdominal aortic aneurysms in patients with compromised distal landing zones, although these patients may benefit significantly from the development of branched thoracoabdominal devices. In the interim, the use of TEVAR adjuncts may limit progressive degeneration of the distal landing zone in this patient population.

Current Status of Endoluminal Treatment of Descending Thoracic Aortic Aneurysms

Thoracic endovascular aortic repair (TEVAR) was proved to be effective in thoracic descending aortic aneurysm (TDAA) repair in 1994 and approved by the FDA in 2005. Since then, TEVAR has become the first-line, recommended treatment for intact or ruptured DTAA or as a bridge to definitive open surgical repair in connective tissue disease. TEVAR has decreased perioperative morbidity and mortality compared to open surgery due to the lack of thoracotomy, aortic cross-clamping and left heart bypass. Improvement in materials, manufacturing and device delivery systems have allowed for the expansion of indications. Thoughtful and accurate pre-procedure planning is the hallmark of successful TEVAR. Familiarization and adherence to the instructions for use for an aortic device will give the best possible chance of success.

Two-year evaluation of fenestrated and parallel branch endografts for the treatment of juxtarenal, suprarenal, and thoracoabdominal aneurysms at a single institution

OBJECTIVE

Despite numerous recent pivotal and small-scale trials, real-world endovascular management of juxtarenal aneurysms (JRA), suprarenal aneurysms (SRA), and thoracoabdominal aortic aneurysms (TAAA) remains challenging without consensus best practices. This study evaluated the mortality, graft patency, renal function, complication, and reintervention rates for fenestrated and parallel endografts in complex aortic aneurysms repairs.

METHODS

This retrospective review of consecutive included patients with JRA, SRA, or TAAA who underwent complex endovascular repair from August 2014 to March 2017 at one high-volume institution. Treatment modality was a single surgeon decision based on patients anatomy and the urgency of the repair. Patient demographics, hospital course, and follow-up visits inclusive of imaging were analyzed. Ruptured aneurysms were excluded. Survival rates and outcomes were determined using the Kaplan-Meier method with log-rank tests.

RESULTS

Seventy complex endovascular aortic repairs were performed; 38 patients with TAAA were treated with snorkel/sandwich parallel endografts (21 celiac, 28 superior mesenteric arteries, 58 renal arteries) and 32 patients with JRA/SRA were treated by fenestrated endovascular aneurysm repair (FEVAR) with 94 total fenestrations (2 celiac, 30 SMA, 62 renal). The mean patient age was 74.8 ± 10.0 years. Sixty percent were male, and the mean aortic aneurysm diameter was 6.0 ± 1.4 cm. Perioperative mortality was 3.1% (1/32) for FEVAR compared with 2.6% (1/38) for parallel endografts (P = .9). All-cause reintervention rates were 15.6% in FEVAR (5/32) vs 23.6% with parallel endografts (9/38; P = .4). Branch reintervention rates per each branch endograft were 4.3% for FEVAR (4/94; 2 renal stent occlusions, 1 colonic ischemia without technical issue found on reintervention, 1 perinephric hematoma) vs 3.7% for parallel endografts (4/107; 2 renal and 1 celiac stent thromboses, and 1 renal stent kink; P = .41). The endograft branch thrombosis rate was 2.1% in FEVAR (2/94) vs 2.7% in parallel endografts (3/109; P = .77). Reinterventions owing to endoleaks were performed in five patients (2 type I, 2 type III, and 1 gutter endoleak; 13.1%) with parallel grafts vs no endoleak reinterventions in FEVAR. The overall survival and freedom from aneurysm-related mortality at 24 months was 78% and 96.9% in FEVAR vs 73% and 93.4% for parallel endografts (P = .8 and P = .6). The median follow-up was 12 months (range, 1-32 months).

CONCLUSIONS

Parallel and fenestrated endografts have acceptable and comparable mortality and patency rates in endovascular treatment of JRA, SRA, and TAAA. This study reaffirms that parallel endografts are a safe and viable alternative to fenestrated devices for complex aortic aneurysmal disease despite often treating more urgent patients and more complicated anatomy unable to be treated with FEVAR.

Spinal Subarachnoid Hematoma After Cerebrospinal Fluid Drainage in Thoracoabdominal Aortic Aneurysm Repair: Case Report and Literature Review

BACKGROUND

Cerebrospinal fluid (CSF) drainage reduces the risk of paraplegia in thoracoabdominal aortic aneurysm (TAAA) repair. Intracranial hemorrhage after TAAA repair has been reported as a rare complication of CSF drainage; however, spinal subarachnoid hematoma has never been reported. Here, we present a case of lumbosacral subarachnoid hematoma after CSF drainage in TAAA repair.

CASE DESCRIPTION

The patient was a 76-year-old man who was hospitalized for TAAA repair. Just before the operation, a CSF drainage catheter was inserted into the L4/5 vertebral interspace. Continuous CSF drainage was performed during the operation. The CSF drain was clamped just after the operation, and the drainage catheters were removed at 24 hours after the operation. On postoperative day 1, the patient experienced pain and paralysis in both lower limbs that worsened over time. Magnetic resonance imaging of the brain and spinal cord was indicative of a spinal subarachnoid hematoma. Removal of hematoma with thoracolumbar and lumbosacral laminectomy was performed, and immediately after the surgery, the pain and paralysis in both lower limbs improved. Six months after the removal of the hematoma, the paralysis in both lower limbs completely resolved and the patient achieved the preinjury activity level.

CONCLUSIONS

We present a rare case of lumbosacral subarachnoid hematoma after CSF drainage in TAAA repair. We should consider spinal subarachnoid hematoma when paralysis in the lower limbs occurs after CSF drainage.

Clinical Outcomes of the Seal® Thoracic Stent Graft for Traumatic Aortic Injury in a Korean Multicenter Retrospective Study

BACKGROUND

Thoracic endovascular aneurysm repair (TEVAR) has been used as a primary treatment for blunt traumatic aortic injury (TAI). However, the outcomes of midterm surveillance of Seal® stent-graft durability for TAI have not been extensively studied. Thus, we aimed to report the midterm outcomes of TEVAR using the Seal® stent graft for blunt TAI.

METHODS

Patients with blunt TAI treated with TEVAR using the Seal® thoracic stent graft between 2007 and 2013 in Korea were included. Midterm outcomes included technical/clinical success, in-hospital death, aorta/procedure/device-related adverse events, secondary procedures, and 30-day and all-cause mortality.

RESULTS

A total of 99 patients (54% men; mean age, 48 years) were included. Grade III or higher injuries were present in 95% of patients, including 15 free ruptures of the thoracic aorta, and 64% of injuries were located in zone III. The median procedure and hospitalization duration were 90 min and 11 days, respectively. The technical success rate was 98%. The number of in-hospital mortalities (n = 8) and stroke (n = 2) were observed at 30 days. Late stroke and paraplegia (>30 days) were not observed during the mean 49 ± 26 months of follow-up (median, 48 months; range, 0-117 months). There were no aorta-related mortalities or conversions to open repair. Secondary procedures were performed in 8 patients, all of which were carotid-subclavian bypasses for delayed left subclavian occlusion. The all-cause mortality rate was 5% at 30 days and 8% at 1 year. The survival rate was 95% at 30 days, 92% at 1 year, 92% at 3 years, and 89% at 5 years. One type Ia endoleak occurred at 18 months after the procedure.

CONCLUSIONS

TEVAR with the Seal® stent graft for TAI showed favorable midterm outcomes. The incidence of major adverse events after the procedure was low.

Descending thoracic endovascular aortic repair does not require cardiothoracic surgery support

Objective

Descending thoracic endovascular aneurysm repair (D-TEVAR) is often performed by vascular surgeons. At many institutions, cardiothoracic surgery support is required for an elective TEVAR to take place. Oftentimes, this means a dedicated cardiopulmonary bypass team must be available. This study aims to investigate that TEVAR is a safe procedure that does not require such a resource-intensive “back-up plan.”

Methods

This is a retrospective analysis of data collected from March 2014 to January 2018 of 18 patients who underwent TEVAR at a tertiary care facility with a level I trauma center. There were 11 males and 7 females with an average age of 68.8 years old (range 19–97; SD ± 19.52). The average body mass index (BMI) was 24.7 kg/m2 (range 16.8–35; SD ±4.67). Nine were never smokers, four were former smokers, and five were currently smoking at the time of the procedure. The most common presenting symptom prior to intervention was chest pain ( n = 10), followed by cough/dyspnea ( n = 5), back pain ( n = 3), and trauma ( n = 2).

Results

The average maximum diameter of the thoracic aortic aneurysms (TAA) treated with TEVAR was 5.49 cm ( n = 7; range 4.3–6.7; SD ± 0.855). Six patients had Stanford Type B aortic dissections. Two patients with TAAs had concomitant, rapidly expanding aortic ulcers. Two patients had traumatic pseudoaneurysms, one of which ruptured prior to TEVAR. One patient had an expanding 1.9 × 1.8 cm saccular pseudoaneurysm of the aortic arch. The mean follow-up time was 69.2 weeks ( n = 17; range 3–166; SD ± 62.67), and one patient did not follow up following their initial TEVAR procedure. Of the 18 patients who received TEVAR, there were no major complications. Two patients experienced a type II endoleak. No patients required conversion to an open procedure, nor did any patients necessitate intervention by cardiothoracic surgery or cardiopulmonary bypass support.

Conclusion

These data suggest that cardiothoracic surgery support is not required for descending thoracic endovascular aneurysm repair (D-TEVAR). Further research is warranted on the risk factors associated with open conversion during these procedures.

Single-center experience with an inner branched arch endograft

OBJECTIVE

Whereas open repair is the "gold standard" for most aortic arch diseases, a subgroup of patients might benefit from an endovascular approach. The introduction of branched stent grafts with dedicated design to address the challenges of the ascending aorta and the aortic arch has opened an entirely new area of treatment for these patients. We investigated the early outcomes of branched thoracic endovascular aortic repair (b-TEVAR) in various types of disease of the aortic arch.

METHODS

A retrospective analysis was conducted of prospectively collected data from a single center of all consecutive patients treated with b-TEVAR. The indication for elective endovascular repair was consented in an interdisciplinary case conference. All patients were treated with a custom-made inner branched arch endograft with two internal branches (Cook Medical, Bloomington, Ind) and left-sided carotid-subclavian bypass. Study end points were technical success, 30-day mortality, and complications as well as late complications and reinterventions.

RESULTS

Between 2012 and 2017, there were 54 patients (38 male; median age, 71 years) treated with diseases of the aortic arch. Indications for therapy involved degenerative aortic arch or proximal descending aortic aneurysms requiring arch repair (n = 24), dissection with or without false lumen aneurysms (n = 26), and penetrating aortic ulcers (n = 4). Forty-three cases (80%) were performed electively and 11 urgently for contained ruptures (n = 3) or symptomatic aneurysms (n = 8) with endografts already available for the patient or with grafts of other patients with similar anatomy. Technical success was achieved in 53 cases (98%). The 30-day mortality and major stroke incidence were 5.5% (3/54) and 5.5% (3/54), respectively; in-hospital mortality was 7.4% (n = 4), and minor strokes (including asymptomatic new cerebral lesions) occurred in 5.5% (n = 3). There were two cases of transient spinal cord ischemia with complete recovery and one of paraplegia. No retrograde type A dissections or cardiac injuries were observed. Three early stent graft-related reinterventions were necessary to correct proximal endograft kinking with type IA endoleak in one patient, a bridging stent graft stenosis in another patient, and false lumen persistent perfusion from dissected supra-aortic vessels in the last patient. Mean in-hospital stay was 14 ± 8 days. During a mean follow-up of 12 ± 9 months, three nonaorta-related deaths and one aorta-related death distal to the arch repair were observed.

CONCLUSIONS

Treatment of aortic arch diseases with b-TEVAR is feasible and safe with acceptable mortality and stroke rates.

Operated descending thoracic and thoracoabdominal atherosclerotic aortic aneurysm prognosis

BACKGROUND

The long-term survival of patients treated from descending thoracic aneurysm (DTA) is well known, more than those treated from a thoracoabdominal aortic aneurysm (TAAA). Moreover, studies are rarely focused on the aneurysmal etiology and include both degenerative and post dissecting aneurysms. The aim of this study is to compare the long-term survival of patients operated from DTA or TAAA due to degenerative atherosclerosis.

METHODS

Thirty-nine atherosclerotic aneurysm patients were operated between January 2007 and July 2015 at Rouen University Hospital. Eighteen DTA patients were operated by TEVAR and 21 TAAA patients (8 type I and 13 type III) by open approach. The main endpoint was remote survival patients.

RESULTS

Overall, the initial population was similar in the two groups. However, one third of DTA were treated in context of emergency for painful aneurysm versus 9.5% of patients with TAAA (P=0.066). Survival median of 18 DTA was 18 months (1-68). Survival median of 21 TAAA followed was 66 months (1-91). Survival in both groups was statistically different with the log-rank test (P=0.044).

CONCLUSIONS

Long-term prognosis of atherosclerotic DTA may be worse than that of TAAA's. This retrospective study reflects experience in the management of DTA and TAAA in a single-center. Prospective data in patients treated with endovascular procedures for DTA or TAAA, with fenesterated or branched endoprosthesis, are warranted to confirm these results.

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

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

Endovascular Treatment of Various Aortic Pathologies: Review of the Latest Data and Technologies

The technologies and innovations applicable to endovascular treatment for complex aortic pathologies have progressed rapidly over the last two decades. Although the initial outcomes of an endovascular aortic repair have been excellent, as long-term data became available, complications including endoleaks, endograft migration, and endograft infection have become apparent and are of concern. Previously, the indication for endovascular therapy was restricted to descending thoracic aortic aneurysms and abdominal aortic aneurysms. However, its indication has expanded along with the improvement of techniques and devices, and currently, it has become possible to treat pararenal aortic aneurysms and Crawford type 4 thoracoabdominal aortic aneurysm (TAAA) using the off-the-shelf devices. Additionally, custom-made devices allow for the treatment of arch or more extensive TAAAs. Endovascular treatment is applied not only to aneurysms but also to acute/chronic dissections. However, long-term outcomes are still unclear. This article provides an overview of available devices and the results of endovascular treatment for various aortic pathologies.

Result of Thoracic Endovascular Aortic Repair for Patients with Esophageal Cancer

BACKGROUND

Bleeding from the thoracic aorta is potentially fatal in patients with advanced esophageal cancer. Thoracic endovascular aortic repair (TEVAR) was recently applied for aortic invasion by esophageal cancer. However, only a few case reports have been published. This study was performed to clarify the effectiveness and safety of TEVAR for patients with advanced esophageal cancer.

METHODS

We retrospectively reviewed 18 patients who underwent TEVAR for esophageal cancer. We also performed a literature search and reviewed 21 similar cases.

RESULTS

From 2007 to 2016, 10 patients were treated on an emergent basis for aortic hemorrhage (salvage group) and 8 patients underwent urgent prophylactic surgery (prophylactic group). Hemostasis was achieved in all cases. One (10%) patient in the salvage group died of aspiration pneumonia on postoperative day 1, while all patients in the prophylactic group survived for >1 month. The median survival period in the salvage and prophylactic group was 3.25 and 11.10 months, respectively. The longest survivor was still alive 9 years after TEVAR and chemoradiotherapy. No fatal adverse events or negative impacts on subsequent treatment for esophageal cancer occurred.

CONCLUSIONS

TEVAR is feasible, safe, and effective in preventing fatal aortic hemorrhage secondary to esophageal cancer invasion, although it is palliative in most cases. Because the outcomes of emergent TEVAR after bleeding tended to be worse in the salvage than in prophylactic group, prophylactic TEVAR may be considered a viable treatment option for patients with aortic invasion by advanced esophageal cancer.

Late type III endoleak after thoracic endovascular aneurysm repair and previous infrarenal stent graft implantation - a case report and review of the literature

Thoracic endovascular aortic repair (TEVAR) effectively improved the results of thoracic aortic aneurysm treatment. TEVAR is a less invasive procedure that can be performed under local anesthesia with shorter hospital stay. The perioperative morbidity and mortality rates are lower for endovascular than open repair, but the rate of secondary interventions is higher for TEVAR. We report a case of an elderly man with synchronous abdominal and thoracic aortic aneurysms. A type III dangerous endoleak was recognized 3 years after TEVAR. It was successfully repaired during an endovascular procedure. There were no new endoleaks after 12 months of follow-up. TEVAR may be the only option of treatment for risky and elderly patients. However, postoperative monitoring is necessary to exclude different types of endoleaks. Most of them undergo effective endovascular repair.

Assessment of aortic wall thrombus predicts outcomes of endovascular repair of complex aortic aneurysms using fenestrated and branched endografts

OBJECTIVE

The goal of this study was to investigate the correlation between atherothrombotic aortic wall thrombus (AWT) and clinical outcomes in patients treated by fenestrated-branched endovascular aortic repair (F-BEVAR) and present a new classification system for assessment of AWT burden.

METHODS

The clinical data of 301 patients treated for pararenal and thoracoabdominal aortic aneurysms (TAAAs) by F-BEVAR was reviewed. The study excluded 89 patients with extent I to III TAAA because of extensive laminated thrombus within the aneurysm sac. Computed tomography angiograms were analyzed in all patients to determine the location, extent, and severity of atherothrombotic AWT. The aorta was divided into three segments: ascending and arch (A), thoracic (B) and renal-mesenteric (C). Volumetric measurements (cm³) of AWT were performed using TeraRecon software (TeraRecon Inc, Foster City, Calif). These volumes were used to create an AWT index by dividing the AWT volume from the total aortic volume. A classification system was proposed using objective assessment of the number of affected segments, thrombus type, thickness, area, and circumference. Clinical outcomes included 30-day mortality, neurologic and gastrointestinal complications, renal events (Risk, Injury, Failure, Loss of kidney function, End-stage renal disease [RIFLE]), and solid organ infarction.

RESULTS

The study included 212 patients, 169 men (80%) and 43 women (20%), with a mean age of 76 ± 7 years. A total of 700 renal-mesenteric arteries were incorporated (3.1 ± 1 vessels/patient). AWT was classified as mild in 98 patients (46%) and was considered moderate or severe in 114 (54%). There was one death (0.5%) at 30 days. Solid organ infarction was present in 50 patients (24%), and acute kidney injury occurred in 45 patients (21%) by RIFLE criteria. An association with higher AWT indices was found for time to resume enteral diet (P = .0004) and decline in renal function (P = .0003). Patients with acute kidney injury 2 by RIFLE criterion had significantly higher (P = .002) AWT index scores in segment B. Spinal cord injury occurred in three patients (1.4%) and stroke in four (1.9%), but were not associated with the AWT index. Severity of AWT using the new proposed classification system correlated with the AWT index in all three segments (P < .001). Any of the end points occurred in 35% of the patients with mild and in 53% of those with moderate or severe AWT (P = .016).

CONCLUSIONS

AWT predicts solid organ infarction, renal function deterioration, and longer time to resume enteral diet after F-BEVAR of pararenal and type IV TAAAs. Evaluation of AWT should be part of preoperative planning and decision making for selection of the ideal method of treatment in these patients.

Symptomatic Intragraft Thrombus following Endovascular Repair of Blunt Thoracic Aortic Injury

Thoracic endovascular aortic repair (TEVAR) can be complicated by graft collapse, endoleaks, and stent migration. The incidence of these complications and other outcomes is poorly understood in young trauma victims who receive endovascular aortic repair of blunt thoracic aortic injury (BTAI). A 29-year-old pedestrian was struck by a vehicle resulting in polytrauma including BTAI with transection distal to the left subclavian artery origin. The patient underwent successful TEVAR. Nine months later, the patient developed transient paresthesia below the waist that progressed to bilateral lower extremity paralysis and malperfusion syndrome below the diaphragm including nonpalpable pulses in the lower extremities, acute renal failure, and ischemic colitis. Imaging demonstrated near occlusive thrombosis of the distal end of the thoracic endograft. An emergent axillobifemoral bypass resolved the organ malperfusion and acute limb ischemia. Patients who have undergone TEVAR for BTAI may develop asymptomatic or symptomatic intragraft thrombosis. In patients presenting with malperfusion syndrome below the diaphragm, extra-anatomic bypass can expeditiously resolve symptoms until definitive treatment can be performed. Oversizing of thoracic stents in trauma patient may lead to intragraft thrombosis.

Clinical Outcomes for Endovascular Repair of Thoracic Aortic Disease Using the Seal Thoracic Stent Graft: A Korean Multicenter Retrospective Study

PURPOSE

To investigate the midterm outcomes of thoracic endovascular aneurysm repair (TEVAR) with the use of the Seal stent graft for four categories of thoracic aortic disease.

MATERIALS AND METHODS

This retrospective multicenter study evaluated the records of 216 Korean patients who underwent TEVAR with the Seal stent graft during 2007-2010. The study outcomes were (i) perioperative death, (ii) endoleak, (iii) repeat intervention, (iv) aortic-related death, and (v) all sudden unexplained late deaths.

RESULTS

The overall technical success rate was 94% (203 cases), and the disease-specific rates were 97% (88 cases) for aneurysms, 96% (71 cases) for dissections, 82% (32 cases) for traumatic aortic disease, and 100% (12 cases) for intramural hematoma and/or penetrating aortic ulcer. There were 6 acute surgical conversions (2 for aneurysms and 4 for dissections). There were 18 endoleaks, 4 retrograde ascending aortic dissections, and 6 stent graft-induced new entries. The 1-, 3-, and 5-year overall survival rates were 93% ± 3, 90% ± 4, and 90% ± 4, respectively.

CONCLUSIONS

TEVAR with the Seal thoracic stent graft provided a high technical success rate and low mortality and complication rates during midterm follow-up. However, additional long-term studies are needed to evaluate the durability and late complications associated with this device.

Durable outcomes of thoracic endovascular aortic repair with Zenith TX1 and TX2 devices

OBJECTIVE

Long-term data regarding the safety and durability of thoracic endovascular aortic repair (TEVAR) are limited. The study objective was to evaluate the long-term outcomes of TEVAR in high-risk patients with descending thoracic aortic pathology.

METHODS

High-risk patients were treated with thoracic endografts (2001-2011) under a prospective, physician-sponsored, investigational device exemption trial. Three-dimensional reconstructions and measurements were performed on computed tomography scans acquired before discharge, at 1, 6, and 12 months, and then yearly thereafter.

RESULTS

The study included 200 patients, of whom 171 were treated for thoracic aneurysm, 28 for chronic dissection, and 1 for aortobronchial fistula. Patients were monitored for an average of 4.8 ± 3.3 years, and 93 (46.5%) were monitored for >5 years. Operative mortality was 6.5%. Survival at 30 days and at 1, 5, and 9 years was 94.0%, 85.8%, 55.6%, and 31.4%, and freedom from aneurysm-related death was 94.0%, 92.4%, 91.7%, 91.7%, respectively. Sixty-one endoleaks occurred in 54 patients (28%). Sixty-seven reinterventions were performed in 50 patients. Overall freedom from reintervention at 30 days, 1, 5, and 9 years was 87.9%, 82.9%, 75.5%, and 64.0%, respectively. Forty-seven reinterventions (70%) were thoracic aneurysm-related, 35 (74%) of which were endovascular procedures. Thirty of these were to correct endoleaks at a median of 1.4 years (interquartile range, 0.2-5.0 years).

CONCLUSIONS

TEVAR is durable and associated with high long-term aneurysm-related survival. Long-term imaging follow-up remains critical to identify endoleaks or rare device durability issues, most of which can be monitored or managed with endovascular therapies.

Air Embolism During TEVAR

Purpose: To investigate the amount of gas released from Zenith thoracic stent-grafts using standard saline flushing vs the carbon dioxide flushing technique. Methods: In an experimental bench setting, 20 thoracic stent-grafts were separated into 2 groups of 10 endografts. One group of grafts was flushed with 60 mL saline and the other group was flushed with carbon dioxide for 5 minutes followed by 60 mL saline. All grafts were deployed into a water-filled container with a curved plastic pipe; the deployment was recorded and released gas was measured using a calibrated setup. Results: Gas was released from all grafts in both study groups during endograft deployment. The average amount of released gas per graft was significantly lower in the study group with carbon dioxide flushing (0.79 vs 0.51 mL, p=0.005). Conclusion: Thoracic endografts release significant amounts of air during deployment if flushed according to the instructions for use. Application of carbon dioxide for the flushing of thoracic stent-grafts prior to standard saline flush significantly reduces the amount of gas released during deployment. The additional use of carbon dioxide should be considered as a standard flush technique for aortic stent-grafts, especially in those implanted in proximal aortic segments, to reduce the risk of air embolism and stroke.