Staged hybrid repair of type II thoracoabdominal aneurysms

Fenestrated and Branched Stent-Grafts for the Treatment of Thoracoabdominal Aortic Aneurysms: A Systematic Review and Meta-Analysis

Purpose

To investigate the safety and efficacy of total endovascular repair for thoracoabdominal aortic aneurysms (TAAAs) with fenestrated and branched stent-grafts.

Methods

The MEDLINE, EMBASE, and Cochrane databases were searched between January 2001 and December 2021 to identify literature relevant to the use of fenestrated and branched endografts for the treatment of TAAAs. Studies with <4 cases and those on juxtarenal or pararenal aortic aneurysms were excluded. Meta-analyses were conducted to evaluate spinal cord ischemia (SCI), irreversible SCI, renal insufficiency, dialysis, endoleak, reintervention, target vessel patency, 30-day mortality and overall mortality. Fourteen studies comprising 1,114 patients (mean age 72.42 years, 847 men) were selected. The mean TAAA diameter was 67 mm. The Crawford TAAA classification was type I-III in 759 cases, type IV in 344 cases, and type V in 10 cases. Outcomes of the meta-analysis are reported as proportions and 95% confidence intervals (CIs).

Results

The pooled rates for 30-day mortality and overall mortality were 6% and 18%, respectively. The pooled rate for technical success was 94% (95% CI, 93–96%), for SCI was 8% (95% CI, 7–10%), for irreversible SCI was 6% (95% CI, 4–7%), for reversible SCI was 5% (95% CI, 4–6%), for reversible SCI was 2% (95% CI, 2–3%), for renal insufficiency was 7% (95% CI, 5–10%), for dialysis was 3% (95% CI, 2–4%), for target vessel patency was 98% (95% CI, 97–99%), and for reintervention was 15% (95% CI, 9–24%).

Conclusion

Fenestrated and branched endografts for the treatment of TAAAs are safe and effective with acceptable early results. Lifelong regular follow-up and additional prospective studies are necessary to substantiate whether this technique is valid.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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