Open repair remains the gold standard

Tabular review of contemporary open surgical repair experiences for treatment of thoracoabdominal aortic aneurysms

Open surgical repair of thoracoabdominal aortic aneurysms (TAAAs) is one of the most challenging operations due to extensive surgical dissection and exposure, risk of complications and need for reconstruction of the aorta and its branches. In the last two decades, endovascular techniques have evolved and now are considered a viable alternative to open surgical repair in patients with suitable anatomy. Regardless of which technique is selected, open or endovascular, reduction of postoperative morbidity and mortality requires large clinical volume, optimal patient selection and a multidisciplinary team that can take care of the surgical, anesthetic, critical care and postoperative issues that occur after these operations. The aim of this article is to summarize the clinical data on open surgical repair of thoracoabdominal aortic aneurysms in a schematic tabular format.

Exploiting the anti-fibrotic effects of statins on thoracic aortic aneurysm progression: results from a meta-analysis and experimental data

Aims

Thoracic aortic aneurysm (TAA) that progress to acute aortic dissection is often fatal and there is no pharmacological treatment that can reduce TAA progression. We aim to evaluate statins' effects on TAA growth rate and outcomes using a meta-analysis approach.

Methods and results

A detailed search related to the effects of statins on TAA was conducted according to PRISMA guidelines. The analyses of statins' effects on TAA growth rate were performed on 4 studies (n = 1850), while the impact on outcomes was evaluated on 3 studies (n = 2,867). Patients under statin treatment showed a reduced TAA growth rate (difference in means = -0.36 cm/year; 95%CI: -0.64, -0.08; p = 0.013) when compared to controls, patients not taking statins. Regarding the outcomes (death, dissection, or rupture of the aorta, and the need for operative repair), statins exhibited a protective effect reducing the number of events (log odds ratio = -0.56; 95%CI: -1.06, -0.05; p = 0.030). In vitro, the anti-fibrotic effect of atorvastatin was tested on vascular smooth muscle cells (VMSC) isolated from patients with TAA. Our results highlighted that, in transforming growth factor beta 1 (TGF-β1) pro-fibrotic condition, VSMC expressed a significant lower amount of collagen type I alpha 1 chain (COL1A1) when treated with atorvastatin (untreated = +2.66 ± 0.23 fold-change vs. treated = +1.63 ± 0.09 fold-change; p = 0.014).

Conclusion

Statins show a protective effect on TAA growth rate and adverse outcomes in patients with TAA, possibly via their anti-fibrotic properties on VSMC. Given the current lack of effective drug treatments for TAA, we believe our findings highlight the need for more in-depth research to explore the potential benefits of statins in this context.

Two-Stage Surgery Using FROZENIX Partial ET for Frozen Elephant Trunk Technique and Open Descending Aortic Replacement in a Patient With Recurrent Type B Aortic Dissection and Microscopic Polyangiitis: A Case Report

The frozen elephant trunk (FET) technique, initially developed as a one-stage procedure to treat extensive thoracic aortic aneurysms, has since been adapted to address acute and chronic aortic dissections by closing entry tears and expanding the true lumen. It has become widely adopted due to its effectiveness in managing aortic diseases. We present the case of a 39-year-old female with microscopic polyangiitis (MPA) who developed recurrent type B aortic dissection accompanied by rapid expansion. The patient, a compromised host with multiple comorbidities such as glomerulonephritis, chronic renal failure, alveolar hemorrhage, and acute pancreatitis, required urgent surgical intervention. Given the complexity of her condition and the high risks associated with direct surgery, a staged approach was selected. The first stage involved using a novel FET prosthesis, the FROZENIX Partial ET (FPET), inserted via median sternotomy, followed by a left thoracotomy for non-deep hypothermic circulatory arrest (non-DHCA) descending aortic replacement. The surgery led to favorable outcomes without any major complications or sequelae. FPET offers distinct advantages in this complex scenario. Its design features a 2 cm stent-free distal section, which reduces the risk of distal stent graft-induced new entries (dSINEs) and simplifies anastomosis during the second stage of surgery. For patients with severe comorbidities and anatomical challenges that make the thoracic endovascular aortic repair (TEVAR) unsuitable, a staged open surgical approach is a viable alternative, mitigating the risks linked to DHCA. This case underscores the utility of a staged surgical approach using FPET in managing complicated chronic type B aortic dissection in patients with significant comorbidities. The FPET prosthesis facilitates effective lesion control while minimizing the risk of dSINEs and streamlining subsequent surgical procedures, presenting a promising strategy for similar complex cases.

Surgical Decision-Making and Outcomes in Open Versus Endovascular Repair for Various Vascular Diseases

Today's vascular surgeon must navigate their practice through a field of ever-advancing technology while maintaining knowledge of open techniques that remain equally important in the care of their patients. In this article, the authors provide insight into the perioperative decision-making that goes into choosing a surgical plan for each patient based on their disease process, anatomy, nonmodifiable risk factors, and other comorbidities.

Ultra-Hybrid Repair: Open Thoracoabdominal Completion After Descending Stent Grafting

To characterize patient risk profiles and outcomes associated with staged ultra-hybrid repair of extensive aortic disease, in which open thoracoabdominal completion was performed after thoracic stent grafting. From 1/2006 to 1/2021, 92 patients underwent open thoracoabdominal repair of chronic dissection (n=58, 63%), degenerative aneurysm (n=28, 30%), endoleak (n=4, 4.3%), or symptomatic acute type B dissection (n=2, 2.2%) after descending thoracic stent grafting (69, 75%), frozen elephant trunk (5, 5%), or both (18, 20%). The surgical graft was sewn to the distal endovascular device in situ, reducing the extent of the open procedure and eliminating the need for hypothermic circulatory arrest. Mean age was 58±13 years, 89 (97%) were hypertensive, 38 (43%) had chronic obstructive pulmonary disease, 63 (72%) were smokers, 20 (24%) had a prior stroke, and 33 (36%) had a suspected or confirmed heritable aortic condition. Hospital mortality was 7.6% (n=7). Complications included dialysis (16, 20%), tracheostomy (8, 8.7%), stroke (5, 5.7%), and permanent paralysis (6, 6.9%). Survival at 1, 3, and 5 years was 80%, 71%, and 66%, respectively. Mortality was associated with higher blood urea nitrogen and longer distance between the distal endograft edge and proximal patent visceral vessel (P=0.004 and .01, respectively). Patients with extensive aortic disease undergoing open aortic repair after thoracic stent grafting are often young with chronic dissection, multiple comorbidities, or a heritable aortic condition. Success of staged ultra-hybrid operations demonstrates open and endovascular repair strategies are complementary, even when performed in a high-risk patient population.