Disappointing results with a new commercially available thoracic endograft

Collapse of zone 0 landing TEVAR (Najuta) and the development of higher brain dysfunction

Although thoracic endovascular repair (TEVAR)-specific complications often develop, stent-graft collapse is a rare, but fatal complication that requires attention. A 62-year-old male underwent TEVAR for a saccular distal arch aortic aneurysm. After the placement of the Gore TAG (W. L. Gore & Associates, Inc., Newark, DE, USA) from zones 2 to 4, a Najuta endograft (Kawasumi Laboratories, Inc., Tokyo, Japan) was deployed from zone 0. Neither intraoperative angiography nor postoperative contrast-enhanced computed tomography (CT) showed endoleaks or migration. On day 12 after surgery, the patient suddenly lost consciousness during rehabilitation, and CT revealed the collapse of the Najuta endograft. In emergency surgery, the Najuta endograft was removed and the TAG was sutured to the aorta. Although the patient survived, he developed irreversible higher brain dysfunction. The cause of the collapse was examined by the manufacturer and only a slight bird-beak configuration was noted. There were no other findings to indicate the cause of the collapse. The Najuta endograft is a semi-customized system that is created according to the three-dimensional morphology of each individual aortic arch and, thus, is expected to follow the flexion of this vessel. Nevertheless, the risk of collapse needs to be considered.

Efficacy of thermoplastic polyurethane and gelatin blended nanofibers covered stent graft in the porcine iliac artery

Stent-grafts composed of expanded polytetrafluoroethylene (e-PTFE), polyethylene terephthalate (PET) and polyurethane (PU) are characterized by poor endothelialization, high modulus, and low compliance, leading to thrombosis and intimal hyperplasia. A composite synthetic/natural matrix is considered a promising alternative to conventional synthetic stent-grafts. This study aimed to investigate the efficacy of thermoplastic polyurethane (TPU) and gelatin (GL) blended nanofibers (NFs) covered stent-graft in the porcine iliac artery. Twelve pigs were randomly sacrificed 7 days (n = 6) and 28 days (n = 6) after stent-graft placement. The thrombogenicity score at 28 days was significantly increased compared at 7 days (p < 0.001). The thickness of neointimal hyperplasia, degree of inflammatory cell infiltration, and degree of collagen deposition were significantly higher at 28 days than at 7 days (all p < 0.001). The TPU and GL blended NFs-covered stent-grafts successfully maintained the patency for 28 days in the porcine iliac artery. Although thrombosis with neointimal tissue were observed, no subsequent occlusion of the stent-graft was noted until the end of the study. Composite synthetic/natural matrix-covered stent-grafts may be promising for prolonging stent-graft patency.

MANAGEMENT OF LEFT SUBCLAVIAN ARTERY IN TYPE-B AORTIC DISSECTION TREATED WITH THORACIC ENDOVASCULAR AORTA REPAIR

OBJECTIVE

Thoracic endovascular aortic repair (TEVAR) has been the favored approach for the treatment of type B aortic dissection (TBAD). To obtain an adequate proximal landing zone, coverage of the left subclavian artery (LSA) will often be necessary. The occurrence of possible neurologic complications has continued to be debated. We investigated the management of the LSA in patients with TBAD undergoing endovascular repair.

METHODS

We searched the PubMed and MEDLINE databases to October 2020 for studies of TEVAR for TBAD. Data on the study design, demographics, endograft details, LSA coverage and revascularization, mortality, complications, and follow-up were extracted and analyzed. The effects of LSA coverage and revascularization on neurologic complications and outcomes were investigated.

RESULTS

A total of 26 reports (24 retrospective and 2 prospective) were deemed eligible for our study. A total of 1483 patients (mean age, 56.9 ± 6.2 years) had undergone TEVAR for acute (n = 932; 62.9%), subacute (n = 36; 2.4%), or chronic (n = 515; 34.7%) TBAD, with a success rate of 97.8% and hospital mortality of 4.9%. The LSA origin had been covered for 707 patients (47.7%), and 326 had undergone LSA revascularization (surgical, n = 96; endovascular, n = 170; unspecified or not reported, n = 60). LSA revascularization was concomitant for 68.1% of cases, after TEVAR for 1.8%, and not reported for 30.1%. Of 1146 patients, 10 (0.9%) had experienced left arm claudication, and the overall stroke rate was 3.3% (2.7% for the LSA group and 1% for the uncovered LSA group; P = .0815). Of the patients with stroke and a covered LSA, 1% (2 of 203) had undergone LSA revascularization and 4.8% (5 of 105) had not (P = .0478). Twenty-six patients (1.9%) had developed paraplegia: 0.7% (3 of 433) with a covered LSA, 1.4% (7 of 491) with an uncovered LSA (P = .3508), and not reported for 16 patients. Endoleak was present in 138 patients (13.4%) at a mean follow-up of 32.1 ± 25.6 months.

CONCLUSIONS

Our review has shown that LSA coverage during endovascular repair for complicated TBAD will does not significantly increase the risk of neurologic complications; however, revascularization of the LSA should be always recommended.

Delayed Aortic Stent Collapse in Blunt Traumatic Aortic Injury Repair

Background  Endovascular stent grafting has emerged as an option to treat traumatic aorta injuries with reported significantly low mortality and morbidity. Stent collapse is one of the complications that can occur in this type of treatment. The aim of this article is to analyze the expected cause of stent collapse and to draw attention to the importance of the surveillance follow-up, as this phenomenon may occur late postdeployment.

Methods  A retrospectively collected dataset from the two highest volume trauma centers in Saudi Arabia was analyzed between April 2007 and October 2012. A total of 66 patients received stent grafts for traumatic aortic injury and were included in the study. We apply Ishimaru's anatomical aortic arch zones and Benjamin's aortic injury grading systems. There were 35 patients with aortic injury at zone 2, 26 patients in zone 3, and 5 patients in zone 4. About 96% (63) of the injuries were grades 2 and 3, including large intimal flap or aortic wall pseudoaneurysm with change in wall contour. The technical success rate, as defined by complete exclusion of lesions without leaks, stroke, arm ischemia or stent-related complications, was 90%.

Results  Proximal stent collapse occurred in 4.5% of patients (3 of 66 inserted stents) during follow-up of 4 to 8 years (mean, 6 years). Patients with stent collapse tended to have an acute aortic arch angle with long-intraluminal stent lip, when compared with patients with noncollapsed stents. Intraluminal lip protrusion more than 10-mm increased collapse ( p  < 0.001). Stent-grafts sizes larger than 28 mm also demonstrated a higher collapse rate ( p  < 0.001).

Conclusions  The risk of stent collapse appears related to poor apposition of the stent due to severe aortic arch angulation in young patients and to large stent sizes (>28 mm). Such age groups may have more anatomical and aortic size changes during the growth. Clinical and radiological surveillance is essential in follow-up after stent-graft treatment for traumatic aortic injury.

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.

Results of Thoracic Endovascular Grafting in Different Aortic Segments

Purpose:

To compare the results of thoracic endovascular grafting of different aortic segments performed with commercially available stent-grafts.

Methods:

Between January 1999 and October 2006, 178 patients (150 men; mean age 69.4±10.2 years) underwent endovascular grafting of the thoracic aorta (68 hybrid procedures) with commercially produced stent-grafts from 4 manufacturers. Patients were divided into 3 groups according to the aortic segment involved: 64 aortic arch cases (37 hybrids for supra-aortic trunks revascularization), 100 descending thoracic aorta (DTA) cases (17 hybrid: 12 for access and 5 for associated abdominal aortic aneurysm), and 14 thoracoabdominal aorta (TaA) patients excluded from conventional repair (14 hybrids for renal and splanchnic revascularization).

Results:

The technical success was 93.8% (167/178). Overall 30-day mortality was 5.6% (10/178). There were 10 (5.6%) type I endoleaks. Initial clinical success was 88.2% (157/178). At a mean follow-up of 29.3±21.2 months, the midterm clinical success was 89.9% (160/178). In the arch group, the technical success was 85.9% (55/64). Thirty-day mortality was 6.3% (4/64). There were 8 (12.5%) type I endoleaks. Initial and midterm clinical success rates were 79.7% (51/64) and 85.9% (55/64), respectively. In the 100-patient DTA group, the technical success was 98.0%. Thirty-day mortality was 2.0%. The type I endoleak rate was 2.0%. Clinical success was 96.0% initially and 95.0% at midterm. All 14 of the TaA cases were completed successfully, but 30-day mortality was 28.6% (4/14). There were no type I endoleaks. Clinical success rates initially and at midterm were both 71.4% (10/14).

Conclusion:

Over the last 6 years, synergy between endovascular and surgical procedures allowed treatment of all segments of the thoracic aorta. Overall perioperative and medium-term results were reasonably favorable; however, they were more satisfactory when the descending thoracic aorta alone was involved. Hybrid procedures allowed treatment of all aortic segments, but they decreased the success rates significantly. Endovascular grafting is currently our preferred method of treating pathologies involving the DTA and aortic arch, while our data suggest limiting the use of stent-grafts to high-risk patients or compassionate indications when the thoracoabdominal aorta is involved.

Incidence and outcomes after infolding or collapse of thoracic stent grafts

OBJECTIVE

Device-related complications in the thoracic aorta are partly due to the unavoidable proximal angulation and increased flow-related forces. The present study evaluated the incidence, predictors, and outcome of the complication of infolding with the GORE TAG thoracic endoprosthesis (TAG device) to better understand the factors that might help predict these events.

METHODS

We reviewed all complaints reported to W. L. Gore and Associates (Flagstaff, Ariz) related to device infolding after the use of the GORE TAG device on or before December 2008. Events related to device infolding were evaluated. Reporting physicians and local company representatives were contacted, when necessary, to assemble all available imaging, data, and outcomes related to these case reports. When available, computed tomography images were reviewed to confirm aortic landing zone diameters, which were subsequently compared with the implanted device size.

RESULTS

From 1998 through December 2008, device infolding was reported in 139 patients (mean age, 40 ± 17 years; 73.4% men) from 33,289 device implants (reported incidence, 0.4%). Events were noted in implants for trauma (60%), dissection (19%), aneurysm (10%), and other (9%) and unknown (2%) etiologies. In 77 patients with available imaging, the average minimum aortic diameter was 21.4 ± 4.4 mm. The mean device diameter was 28.5 ± 3.5 mm, with an average oversizing of nearly 33%. Of reported patients, 51% were asymptomatic, with the diagnosis being made on routine chest imaging. Time to diagnosis was 76 ± 222 days (median, 9.5 days). Only 16 patients received no intervention after the diagnosis of device infolding, all of whom were asymptomatic. The other 123 patients underwent 135 interventions. Of these, 30 patients (24%) underwent open surgical conversion and complete or partial endograft removal. The other interventions included a variety of endovascular techniques, such as large balloon-expandable stent(s) in 40%, relining with additional endograft(s) in 31%, and repeat ballooning in seven patients. Ten patients died after device infolding, all after one or more attempts to repair the infolded device: five died of symptoms related to the infolding and five secondary to the intervention undertaken to correct the device infolding.

CONCLUSIONS

TAG device infolding appears to be an infrequent event, primarily occurring in young trauma patients secondary to excessive oversizing and severe proximal aortic angulation. However, there clearly exists a need for devices that treat such patients. As a result, future device designs should consider the compression failure mode when being designed in order to help prevent such events.

Delayed endovascular treatment of descending aorta stent graft collapse in a patient treated for post- traumatic aortic rupture: a case report

BACKGROUND

We report a case of delayed endovascular correction of graft collapse occurred after emergent Thoracic Endovascular Aortic Repair (TEVAR) for traumatic aortic isthmus rupture.

CASE PRESENTATION

In 7th post-operative day after emergent TEVAR for traumatic aortic isthmus rupture (Gore TAG® 28-150), a partial collapse of the endoprosthesis at the descending tract occurred, with no signs of visceral ischemia. Considering patient's clinical conditions, the graft collapse wasn't treated at that time. When general conditions allowed reintervention, the patient refused any new treatment, so he was discharged.Four months later the patient complained of severe gluteal and sural claudication, erectile disfunction and abdominal angina; endovascular correction was performed. At 18 months the graft was still patent.

DISCUSSION AND CONCLUSION

Graft collapse after TEVAR is a rare event, which should be detected and treated as soon as possible. Delayed correction of this complication can be lethal due to the risk of visceral ischemia and limbs loss.

Endograft collapse after thoracic endovascular aortic repair

PURPOSE

To provide insight into the causes, timing, and optimal management of endograft collapse after thoracic endovascular aortic repair (TEVAR).

METHODS

A comprehensive review was conducted of all published cases of endograft collapse after TEVAR identified using Medline, Cochrane Library Central, and EMBASE. In total, 32 articles describing 60 patients (45 men; mean age 40.6 ± 17.2 years, range 17-78) with endograft collapse were included. All data were extracted from the articles and systematically entered into a database for meta-analysis.

RESULTS

In the 60 cases of endograft collapse, TEVAR had most commonly been applied to repair traumatic thoracic aortic injuries (39, 65%), followed by acute and chronic type B aortic dissections (9, 15%). The median time interval between TEVAR and diagnosis of endograft collapse was 15 days (range 1 day to 79 months). On average, the collapsed endografts were oversized by 26.7% ± 12.0% (range 8.3%-60.0%). Excessive oversizing was reported as the primary cause of endograft collapse in 20%, and a small radius of curvature of the aortic arch was responsible for 48% of the cases. The 30-day mortality was 8.3%, and the freedom from procedure-related death at 3 years after diagnosis of stent-graft collapse was 83.1% for asymptomatic patients compared with 72.7% for patients who had symptoms at diagnosis (p=0.029).

CONCLUSION

Endograft collapse typically occurs shortly after TEVAR, most frequently after endovascular repair of traumatic aortic injury. A high level of suspicion for endograft collapse in the first month after TEVAR, as well as further improvement of current endovascular devices, may be required to improve the long-term outcomes of patients after TEVAR.

A multicenter experience of the management of collapsed thoracic endografts

OBJECTIVES

Thoracic endograft collapse after thoracic endovascular aortic repair (TEVAR) is a potentially devastating complication. This study evaluates the management of thoracic stent graft collapse.

METHODS

A multicenter review of thoracic stent graft collapse was performed from 2005 to 2009. Diagnosis and preoperative planning was performed by computed tomography angiography (CTA). Outcome measures included success of endovascular salvage, postoperative complications, and conversion to open repair.

RESULTS

Eleven patients (10 men) with thoracic endograft collapse were identified. Mean age was 41.2 years old (range, 21-66 years). Indications for the index TEVAR were traumatic aortic transections in 8 patients and acute type B dissections in 3 patients. All were initially treated with the TAG endoprosthesis (Gore and Associates, Flagstaff, Ariz). The median duration from initial repair to diagnosis of collapse was 9 days (range, 1 day-38 months). All collapses were initially treated by endovascular means using another TAG device in 7 patients, a Talent (Medtronic, Santa Rosa, Calif) thoracic stent graft in 3 patients, and a Palmaz (Cordis Endovascular, Warren, NJ) stent in 1 patient. In 1 patient, the secondary TAG did not resolve the collapse and required a Palmaz stent placement. Technical success rate was 91%, while re-expansion of the collapsed endograft was achieved in all patients. Early and late complications were observed in 3 patients. Delayed (>30 days) open conversion with device explantation was performed for an aortoesophageal fistula, physiological aortic coarctation, and prevention of a recurrent collapse in 1 patient each. There were no perioperative deaths or recurrent collapses.

CONCLUSION

Endograft collapse can be successfully managed by endovascular techniques in most cases. Redo-TEVAR using high radial force devices should be considered the initial treatment of choice. Late endograft-related complications after treatment of collapsed endografts are not uncommon and can be safely managed by open conversion.

Hybrid endovascular repair in aortic arch pathologies: a retrospective study

The aortic arch presents specific challenges to endovascular repair. Hybrid repair is increasingly evolving as an alternative option for selected patients, and promising initial results have been reported. The aim of this study was to introduce our experiences and evaluate mid-term results of supra aortic transpositions for extended endovascular repair of aortic arch pathologies. From December 2002 to January 2008, 25 patients with thoracic aortic aneurysms and dissections involving the aortic arch were treated with hybrid endovascular treatment in our center. Of the 25 cases, 14 were atherosclerotic thoracic aortic aneurysms and 11 were thoracic aortic dissection. The hybrid repair method included total-arch transpositions (15 cases) or hemi-arch transpositions (10 cases), and endovascular procedures. All hybrid endovascular procedures were completed successfully. Three early residual type-I endoleaks and one type-II endoleak were observed. Stroke occurred in three patients (8%) during the in-hospital stage. The perioperative mortality rate was 4%; one patients died post-operatively from catheter related complications. The average follow-up period was 15 ± 5.8 months (range, 1–41 months). The overall crude survival rate at 15 months was 92% (23/25). During follow-up, new late endoleaks and stent-raft related complications were not observed. One case (4%) developed a unilateral lower limb deficit at 17 days and was readmitted to hospital. In conclusion, the results are encouraging for endovascular aortic arch repair in combination with supra-aortic transposition in high risk cases. Aortic endografting offers good mid-term results. Mid-term results of the hybrid approach in elderly patients with aortic arch pathologies are satisfying.

Midterm results after endovascular treatment of acute, complicated type B aortic dissection

BACKGROUND

The purpose of this study was to assess the efficacy and midterm results of endovascular treatment of acute, complicated type B aortic dissection.

METHODS

Between January 2001 and February 2010, 32 patients (7 women, 25 men) with acute, complicated type B aortic dissection (mean age, 56 years; range, 35 to 83 years), defined as either aortic rupture, malperfusion, intractable pain, or uncontrolled hypertension, underwent endovascular stent graft placement with either the Gore Excluder/TAG device (n = 11), Medtronic Talent/Valiant device (n = 16), Bolton Relay (n = 2), or a combination of these stents (n = 3). Follow-up was 94% complete and averaged 26 ± 23 months.

RESULTS

Technical feasibility and success with deployment proximal to the entry tear was 87%, requiring partial or total coverage of the left subclavian artery (LSA) in 9 patients (28%). Hospital mortality was 12% ± 11% (95% confidence limit) with 2 late deaths (17 and 98 months after implant). Causes of hospital death included rupture in 2, retrograde type A dissection in 1, and multiorgan failure in 1 patient. Three patients (11%) experienced new neurologic complications (2 paraparesis and 1 hemiparesis). Six patients with malperfusion required branch vessel stenting. Furthermore, 2 had an early type Ia endoleak. Actuarial survival at 1 and 5 years was 81% and 76%, respectively. Freedom from treatment failure at 1 and 5 years (including reintervention, aortic rupture, device-related complication, and aortic related death) was 78% and 61%, respectively.

CONCLUSIONS

Endovascular stent-graft placement in acute, complicated type B aortic dissection proves to be a promising alternative therapeutic treatment modality in this relatively difficult patient cohort. Refinements, especially in stent design and application, may further improve the prognosis of patients in this life-threatening situation.

Unsuccessful treatment of a collapsed thoracic stent graft by Palmaz stent

A Gore TAG Excluder stent graft was deployed in a 35-year-old woman for an isthmic saccular aneurysm. At 12-hour follow-up, we diagnosed a proximal collapse. A Palmaz stent was used to reopen the proximal segment. Two months later, she presented with a transient ischemic attack (embolic process) related to a suboptimal apposition of the Palmaz stent in the distal aortic arch. This led to open surgical replacement of the ascending aorta and aortic arch with reimplantation of the supraaortic branches. Reopening of a stent graft collapse with a Palmaz stent might be a short-term solution; however, its presence can lead to embolic complications.

Endovascular device design in the future: transformation from trial and error to computational design

Endovascular devices have been designed by trial and error, with bench and animal testing followed by human clinical trials to determine whether the devices are safe and effective. Despite remarkable advances over the past 15 years, there are persistent concerns regarding the long-term durability of endovascular devices. This may be due to deficiencies in device design, which has lagged behind other industries in adopting computational methods that are now routinely used to design, develop, and test new aircraft and automobiles. Similar computational design and failure mode simulations that evaluate performance under stress conditions have not been widely applied in the development of endovascular devices. Advances in medical imaging and computational modeling now allow simulation of physiological conditions in patient-specific 3-dimensional vascular models, which can provide a framework to design and test the next generation of endovascular devices. This modeling will allow the prospective design of devices that can withstand the force variations in the cardiovascular system that occur during bending, coughing, and varying degrees of exercise, as well as the extremes encountered during sudden impact in contact sports. Utilization of computational design methodology that takes into consideration the physiology of the cardiovascular system will improve future endovascular devices so that they are safer and more effective and durable.

Infolding and collapse of thoracic endoprostheses: manifestations and treatment options

OBJECTIVES

We sought to review the clinical sequelae and imaging manifestations of thoracic aortic endograft collapses and infoldings and to evaluate minimally invasive methods of repairing such collapses.

METHODS

Two hundred twenty-one Gore endografts (Excluder, TAG; W. L. Gore & Associates, Inc, Flagstaff, Ariz) were deployed in 145 patients for treatment of pathologies including aneurysms and pseudoaneurysms, dissections, penetrating ulcers, transections, fistulae, mycotic aneurysms, and neoplastic invasions in 6 different prospective trials at a single institution from 1997 to 2007. Device collapses and infoldings were analyzed retrospectively, including review of anatomic parameters, pathologies treated, device sizing and selection, clinical sequelae, methods of repair, and outcome.

RESULTS

Six device collapses and infoldings were identified. Oversized devices placed into small-diameter aortas and imperfect proximal apposition to the lesser curvature were seen in all proximal collapses, affecting patients with transections and pseudoaneurysms. Infoldings in patients undergoing dissection represented incomplete initial expansion rather than delayed collapse. Delayed collapse occurred as many as 6 years after initial successful deployment, apparently as a result of changes in the aortic configuration from aneurysmal shrinkage. Clinical manifestations ranged from life-threatening ischemia to complete lack of symptoms. Collapses requiring therapy were remedied percutaneously by bare stenting or in one case by branch vessel embolization.

CONCLUSIONS

Use of oversized devices in small aortas carries a risk of device failure by collapse, which can occur immediately or after years of delay. When clinically indicated, percutaneous repair can be effectively performed.

Evaluation of a new disease-specific endovascular device for type B aortic dissection

OBJECTIVE

The study objective was to evaluate the feasibility, safety, and early technical and clinical success rate of a new endovascular device specifically designed for aortic dissection that has recently become available in Europe.

METHODS

From June of 2005 to the present, the Zenith Dissection Endovascular System (William Cook Europe, Bjaerverskov, Denmark) was used in 11 selected patients (all male, with a median age of 58 years [range, 45-76 years]) with type B chronic aortic dissection with a compression or collapse of the true lumen. All procedures were performed under general anesthesia with preoperative cerebrospinal fluid drainage in 4 patients. One-step open surgical supra-aortic vessels re-routing was performed in 6 patients to obtain an adequate proximal landing zone: Left carotid-subclavian artery bypass was performed in 5 patients, and right-to-left common carotid artery bypass and left subclavian to common carotid artery transposition was performed in 1 patient. Clinical follow-up visits and computed tomography scans were obtained at 1, 6, and 12 months, and yearly thereafter.

RESULTS

A secondary technical success was obtained in all patients (100%), and 30-day clinical success was achieved in 10 patients (91%). A type IA entry flow was observed in 1 patient. No mortality was recorded. Occlusion of visceral/renal arteries, retrograde dissections, and device-induced tears in the intimal lamellae were not observed. Periprocedural morbidity included temporary renal failure in 1 patient and postimplantation syndrome with fever and leukocytosis for 23 days in 1 patient. No cases of paraplegia were recorded. At a median follow-up of 12 months (range, 2-30 months), we observed a clinical success rate of 91%. No migration of the device was observed. No late occlusion of the visceral or renal arteries was recorded at follow-up.

CONCLUSION

The perioperative and short-term follow-up results showed that the Zenith Dissection Endovascular System for the treatment of aortic dissection can be safely used without affecting the patency of the branches covered by the bare stent. However, these results need to be validated in a larger group of patients with a mid-term follow-up.

Endovascular treatment of aortic arch aneurysms

BACKGROUND: Endovascular approach to the aortic arch is an appealing solution for selected patients. OBJECTIVE: To compare the technical and clinical success recorded in the different anatomical settings of endografting for aortic arch disease. METHODS: Between June 1999 and October 2006, among 178 patients treated at our institution for thoracic aorta disease with a stent-graft, the aortic arch was involved in 64 cases. According to the classification proposed by Ishimaru, aortic zone 0 was involved in 14 cases, zone 1 in 12 cases and zone 2 in 38 cases. A hybrid surgical procedure of supra-aortic debranching and revascularization was performed in 37 cases. RESULTS: Zone 0. Proximal neck length: 44±6 mm. Initial clinical success was 78.6%: two deaths (stroke), one type Ia endoleak. At a mean follow-up of 16.4±11 months the midterm clinical success was 85.7%. Zone 1. Proximal neck length: 28±5 mm. Initial clinical success was 66.7%: 0 deaths, four type Ia endoleaks. At a mean follow-up of 16.9±17.2 months the midterm clinical success was 75.0%. Zone 2. Proximal neck length: 30±5 mm. Initial clinical success was 84.2%: two deaths (one cardiac arrest, one multiorgan embolization), three type Ia endoleaks, one case of open conversion. Two cases of delayed transitory paraparesis/paraplegia were observed. At a mean follow-up of 28.0±17.2 months the midterm clinical success was 89.5%. CONCLUSIONS: This study and a literature review demonstrated that hybrid procedure for aortic arch pathology is feasible in selected patients at high risk for conventional surgery. Our experience is still limited by the relatively small sample size. We propose to reserve zone 1 for patients unfit for sternotomy or in cases with aortic neck length > 30 mm following left common carotid artery debranching. We recommend to perform complete aortic rerouting of the aortic arch in cases with lesser comorbidities and shorter aortic neck.

Thoracic aneurysm repair: managing severe tortuosity with brachiofemoral traction

Challenging anatomy of the thoracic aorta is often encountered, and aortic tortuosity may be a major impediment to the propulsion of the stent-graft. Traction on both ends of a guidewire, with one end exiting the right upper extremity and the other end exiting the lower extremity, is an excellent option to manage thoracic aorta tortuosity. Careful application of simple guidelines may lessen associated risks and improve safety.

Transposition of arch vessels and endovascular stenting of saccular aneurysm of distal arch--a case report

Endovascular repair of thoracic aneurysms has emerged as an attractive alternative especially in high-risk patients. However, the aortic curvature and potential coverage of the epiaortic vessels limit the use of stent-grafts in aneurysms located in the aortic arch. We report a case with a saccular aneurysm in the distal arch and proximal descending aorta, where we have transposed the epiaortic vessels to gain a longer proximal neck in the aortic arch to safely deploy an endovascular stent.

Results of Endografting of the Aortic Arch in Different Landing Zones

INTRODUCTION

Endovascular approach to the aortic arch is an appealing solution for selected patients. Aim of this study is to compare the technical and clinical success recorded in the different anatomical settings of endografting for aortic arch disease.

METHODS

Between June 1999 and October 2006, among 178 patients treated at our Institution for thoracic aorta disease with a stent-graft, the aortic arch was involved in 64 cases. According to the classification proposed by Ishimaru, aortic "zone 0" was involved in 14 cases, "zone 1" in 12 cases and "zone 2" in 38 cases. A hybrid surgical procedure of supraortic debranching and revascularization was performed in 37 cases to obtain an adequate proximal aortic landing zone.

RESULTS

"Zone 0" (14 cases). Proximal neck length: 44+/-6mm. Initial clinical success 78.6%: 2 deaths (stroke), 1 type Ia endoleak. At a mean follow-up of 16.4+/-11 months the midterm clinical success was 85.7%. "Zone 1" (12 cases). Proximal neck length: 28+/-5mm. Initial clinical success 66.7%: 0 deaths, 4 type Ia endoleaks. At a mean follow-up of 16.9+/-17.2 months the midterm clinical success was 75.0%. "Zone 2" (38 cases) Proximal neck length: 30+/-5mm. Initial clinical success 84.2%: 2 deaths (1 cardiac arrest, 1 multiorgan embolization), 3 type Ia endoleaks, 1 case of open conversion. Two cases of delayed transitory paraparesis/paraplegia were observed. At a mean follow-up of 28.0+/-17.2 months the midterm clinical success was 89.5%.

CONCLUSIONS

Total debranching of the arch for "zone 0" aneurysms allowed to obtain a longer proximal aortic landing zone with lower incidence of endoleak, however a higher risk of cerebrovascular accident was observed. The relatively high incidence of adverse events in "zone 1" could be associated to a shorter proximal neck, therefore this landing zone is reserved for patients unfit for sternotomy. In case of endoleak, discovered after a satisfactorily positioned endograft in the arch, the rate of spontaneous resolution within the first 6 months is high.

Anatomic factors associated with acute endograft collapse after Gore TAG treatment of thoracic aortic dissection or traumatic rupture

OBJECTIVE

The potentially devastating complication of total or near total thoracic endoprosthesis collapse has been described with the TAG device (W. L. Gore & Associates, Flagstaff, Ariz). This rare complication has resulted in a warning to clinicians and speculation about the etiology of this problem. This report evaluates potential causative anatomic factors that may increase the probability of endoprosthesis collapse in patients undergoing endovascular thoracic aneurysm repair (TEVAR).

METHODS

Preoperative and postoperative computed tomography scans were collected worldwide representing six patients who had experienced radiologically confirmed TAG endoprosthesis collapse. These were compared with a matched cohort of five patients with a TAG endoprosthesis in the same anatomic position in which no collapse occurred. Anatomic variables of aortic arch angulation, apposition, intraluminal lip length, proximal aortic diameter, distal aortic diameter, intragraft aortic diameter, percentage of oversizing, and angle of the proximal endograft to the aortic arch were compared between groups. Differences between groups were determined using the Student t test, with P < .05 considered significant.

RESULTS

The two groups (collapse vs no collapse) were evenly matched demographically, and all underwent endoluminal treatment with the TAG device, with no differences in gender, graft position in the aorta, operative indication, or age (P = NS). Distal sealing zone aortic diameter +/- standard deviation of 18.9 +/- 1.7 mm vs 22.7 +/- 2.7 mm and minimum aortic diameter within the endograft of 18.6 +/- 1.7 mm vs 22.4 +/- 3.1 mm predicted collapse (P < .05). Proximal aortic diameter, apposition, intraluminal lip length, aortic arch angle, and angle of proximal endograft to aortic arch did not predict collapse (P = NS).

CONCLUSION

Thoracic endograft collapse is an exceedingly rare event. In this series, endoprosthesis collapse occurred in patients who were treated outside the manufacturer's instructions for use for minimum required aortic diameter. Although distal aortic diameter and minimum intragraft aortic diameter predicted collapse, other variables may also influence this complication but were not significant owing to potential type II statistical errors. In the future, caution should be exercised when contemplating TEVAR in patients with small (<23 mm) aortic diameters.

Endovascular Repair of Traumatic Rupture of the Thoracic Aorta: Single-Center Experience

PURPOSE

Traumatic rupture of the thoracic aorta secondary to blunt chest trauma is a life-threatening emergency and a common cause of death, usually following violent collisions. The objective of this retrospective report was to evaluate the efficacy of endovascular treatment of thoracic aortic disruptions with a single commercially available stent-graft.

METHODS

Nine men (mean age 29.5 years) were admitted to our institution between January 2003 and January 2006 due to blunt aortic trauma following violent motor vehicle collisions. Plain chest radiography, spiral computed tomography, aortography, and transesophageal echocardiography were used for diagnostic purposes in all cases. All patients were diagnosed with contained extramural thoracic aortic hematomas, secondary to aortic disruption. One patient was also diagnosed with a traumatic thoracic aortic dissection, secondary to blunt trauma. All subjects were poor surgical candidates, due to major injuries such as multiple bone fractures, abdominal hematomas, and pulmonary contusions. All repairs were performed using the EndoFit (LeMaitre Vascular) stent-graft.

RESULTS

Complete exclusion of the traumatic aortic disruption and pseudoaneurysm was achieved and verified at intraoperative arteriography and on CT scans, within 10 days of the repair in all patients. In 1 case the deployment of a second cuff was necessary due to a secondary endoleak. In 2 cases the left subclavian artery was occluded to achieve adequate graft fixation. No procedure-related deaths have occurred and no cardiac or peripheral vascular complications were observed within the 12 months (range 8-16 months) follow-up.

CONCLUSIONS

This is the first time the EndoFit graft has been utilized in the treatment of thoracic aortic disruptions secondary to chest trauma. The repair of such pathologies is technically feasible and early follow-up results are promising.

Endovascular Treatment of Descending Thoracic Aortic Aneurysms with the EndoFit Stent-Graft

OBJECTIVE

To evaluate the mid-term feasibility, efficacy, and durability of descending thoracic aortic aneurysm (DTAA) exclusion using the EndoFit device (LeMaitre Vascular).

METHODS

Twenty-three (23) men (mean age 66 years) with a DTAA were admitted to our department for endovascular repair (21 were ASA III+ and 2 refused open repair) from January 2003 to July 2005.

RESULTS

Complete aneurysm exclusion was feasible in all subjects (100% technical success). The median follow-up was 18 months (range 8-40 months). A single stent-graft was used in 6 cases. The deployment of a second stent-graft was required in the remaining 17 patients. All endografts were attached proximally, beyond the left subclavian artery, leaving the aortic arch branches intact. No procedure-related deaths have occurred. A distal type I endoleak was detected in 2 cases on the 1 month follow-up CT scan, and was repaired with reintervention and deployment of an extension graft. A nonfatal acute myocardial infarction occurred in 1 patient in the sixth postoperative month. Graft migration, graft infection, paraplegia, cerebral or distal embolization, renal impairment or any other major complications were not observed.

CONCLUSION

The treatment of DTAAs using the EndoFit stent-graft is technically feasible. Mid-term results in this series are promising.

Great Vessel Management for Endovascular Exclusion of Aortic Arch Aneurysms and Dissections

OBJECTIVES

To evaluate a recent approach for the endovascular repair of thoracic aortic aneurysms and dissections involving the aortic arch in high risk patients (HRP).

METHODS

Amongst 102 thoracic aortic aneurysms and dissections, we treated 25 patients for aortic arch endovascular exclusion after transposition of the great vessels, of which 14 (56%) had thoracic aortic arch aneurysms and 11 type A and B chronic aortic dissections. Total transpositions were done in 15 cases (60%) and hemi-arch transpositions in 10. We then used Talent, Excluder and Zenith endografts in 12, seven and six cases, respectively.

RESULTS

Surgical transpositions were complicated by one minor stroke, which worsened to a major stroke (4%) after endovascular exclusion. After endovascular exclusions, two patients (8%) died from catheterization related complications. One patient had a delayed minor stroke (4%). The successful exclusion rate was 92%. During follow-up (15+/-5.8 months), one patient (4%) developed unilateral limb palsy, successfully treated by CSF drainage. The late exclusion rate remained 92%. No stent-related complications were seen.

CONCLUSIONS

Transposition of supra-aortic vessels allows the endovascular exclusion of the aortic arch in HRP. Aortic endografting after surgical transposition proved to be feasible and offers good mid-term results. Specialized surgical centers with both endovascular and surgical expertise are required to treat these patients.

Dynamic cine-CT angiography for the evaluation of the thoracic aorta; insight in dynamic changes with implications for thoracic endograft treatment

OBJECTIVE

Thoracic aneurysm preoperative imaging is performed using static techniques without consideration of normal aortic dynamics. Improved understanding of the native aortic environment into which thoracic endografts are placed may aid in device selection. It is unclear what comprises normal thoracic aortic pulsatility. We studied these phenomena dynamically using ECG-gated 64-slice CTA.

METHODS

Maximum diameter and area change per cardiac cycle was measured at surgically relevant anatomic thoracic landmarks in ten patients; 1.0 cm proximal and distal to the subclavian artery, 3.0 cm distal to the subclavian artery, and 3.0 cm proximal to the celiac trunk. Data was acquired using a novel ECG-gated dynamic 64-slice CT scanner during a single breath hold with a standard radiation dose and contrast load. Eight gated data sets, covering the cardiac cycle were reconstructed, perpendicular to the central lumen.

RESULTS

There is impressive change in both maximum diameter and area in the thoracic aorta during the cardiac cycle. Mean maximum diameter changes of greater than 10% are observed in the typical sealing zones of commercially available endografts corresponding to diameter increases of up to 5mm. Aortic area increases by over 5% per cardiac cycle.

CONCLUSIONS

ECG-gated dynamic CTA with standard radiation dose is feasible on a 64-slice scanner and provides insight into (patho) physiology of thoracic aortic conformational changes. Clinicians typically oversize thoracic endografts by 10%. With aortic pulsatility resulting in diameter changes of up to 17.8%, the potential exists for endograft undersizing, graft migration, intermittent type I endoleak, and poor patient outcome. Furthermore, aortic pulsatility is not evenly distributed, and non-circular stentgraft designs should be considered in the future since aortic distension in the aneurysm neck is not evenly distributed.

Symptomatic collapse of a thoracic aorta endoprosthesis

We present the case of a 40-year-old man who underwent aortic endoprosthesis implantation for a traumatic lesion of the thoracic aorta (Gore TAG, 26 x 100 mm, after the instructions for use for a thoracic aorta of 22-24 mm). At 6 months, he came to the emergency room for a hypertensive crisis and acute pulmonary edema. The chest radiograph and thoracoabdominal computed tomographic angiography study showed collapse of the endoprosthesis and a type I proximal leak. A second TAG graft was inserted within the previously collapsed device, and re-expansion was achieved, with resolution of the initial symptoms. At 3 and 6 months, the patient remained asymptomatic, and there were no new findings on computed tomographic angiography.

Complicated Acute Type B Dissections—An 8-years Experience of Endovascular Stent-graft Repair in a Single Centre

OBJECTIVE

To analyze the experience of a single centre using stent-grafts for treatment of complicated acute aortic type B-dissections (EVR-ABD).

DESIGN

Retrospective analysis of prospectively collected data from patients undergoing EVR-ABD between January 1997 and December 2004.

METHODS

EVR-ABD was performed in 31 patients (20 males, median age 74 years (IQR: 64-79)). Indications for treatment were aortic rupture (22 patients), intractable pain and hypertension (six patients), acute bowel ischemia (two patients) and transient paraplegia, lower limb and renal ischemia in one patient. Initially home-made devices (five patients) and subsequently commercially available thoracic stent-grafts were used.

RESULTS

Five patients (16%) died within 30 days of EVR-ABD. Postoperative complications occurred in 15 (48%) patients, including one paraplegia converted to paraparesis after cerebrospinal fluid drainage, five strokes, three lower limb ischemia, three myocardial infarction, two pneumonia and one colitis). Re-interventions were required in nine patients (29%). Six more deaths occurred during a median follow-up of 22 (IQR: 16-34) months, two related to the stent-graft and four due to cardiac disease.

CONCLUSIONS

Stent-graft repair of complicated acute type B dissections seems to provide acceptable results and, therefore, it may be considered a valuable alternative to open surgery.

Stent-graft repair for thoracic aortic disease: results of an independent nationwide study in France from 1999 to 2001

BACKGROUND

The purpose of this study was to assess the overall short-term outcome of stent-graft repair for thoracic aortic disease in France between June 1999 and May 2001.

METHODS

This retrospective study was designed by the French National Health Insurance Fund for Salaried Workers. To ensure objectivity, data were retrieved at each center and checked by a team of medical advisors.

RESULTS

Between June 1999 and May 2001, a total of 166 stent-graft repairs for thoracic aortic disease were performed in 166 patients, mainly by surgeons in the operating room (88%). Patients were classified according to the American Society of Anesthesiologists as status I or II in 24% of cases, status III in 56%, and status IV or V in 20%. The diameter of the thoracic aneurysm was less than 50 mm in 17% of cases. Seventeen patients (10%) died during the first 3 months, including 8 within the first 30 days after the procedure. A total of 49 complications were noted in 34 patients (20.5%). Endoleaks occurred in 27 patients (16.3%), including 8 that necessitated further treatment. Other stent-related complications included rupture (n = 3), aortoesophageal or tracheal fistula (n = 3), paraplegia (n = 6), stent migration (n = 2), visceral embolism (n = 5), and cerebral embolism (n = 2). There were 14 delivery-related complications (8%) at the catheterization site. Non-stent-related complications occurred in 14 (8%).

CONCLUSIONS

This nationwide study demonstrates that stent-graft repair for thoracic aortic disease can be performed with acceptable postoperative morbidity. However, it is not a risk-free procedure and should continue to be used in an investigative setting.

Endovascular repair of proximal endograft collapse after treatment for thoracic aortic disease

We report two cases of proximal endograft collapse with an almost complete aortic occlusion after endovascular tube-graft treatment of thoracic aortic disease (thoracic aneurysm after a type B dissection, traumatic blunt aortic rupture) using the TAG Gore system. Oversizing of endografts is known to cause this complication. In our two cases, however, the oversizing was between 12% and 21.7%, which is less than the allowed oversizing of 25% that is recommended by the manufacturer. This endograft-related complication might be due to a poor alignment of the currently available endografts in highly angulated and tight aortic arches. In the first case, a combined endovascular and open emergent repair procedure achieved a reopening of the proximal endograft by proximal extension (TAG Gore). In the second case, proximal extension was not considered owing to a precise positioning of the endograft distal to the left carotid artery. A balloon-expanding Palmaz stent was therefore placed interventionally in the proximal part of the TAG graft to expand the endograft and to avoid another collapse of the device. This proximal endograft collapse has to be acknowledged as a potentially hazardous complication. We therefore recommend that the proximal part of thoracic endografts in the aortic arch should be closely monitored and we offer two possible endovascular solutions for resolving the problem of proximal endograft collapse.

Experiences of Intentional Carotid Stenting in Endovascular Repair of Aortic Arch Aneurysms—Two Case Reports

Endovascular repair of thoracic aneurysms has emerged as an attractive alternative especially in patients at high risk. However, the left common carotid artery limits the use of stent-grafts in aneurysms located in the aortic arch or close to the left subclavian artery. We report two cases with aneurysms in the distal arch and proximal descending aorta, where we have used a carotid stent in juxtaposition to an aortic stent-graft, to gain a longer proximal neck in the aortic arch in an attempt not to rely only on a by-pass graft feeding the left carotid artery.

Collapse of a Stent-Graft Following Treatment of a Traumatic Thoracic Aortic Rupture

PURPOSE

To report a collapsed stent-graft used to treat a traumatic aortic rupture.

CASE REPORT

A Gore TAG stent-graft was placed in a 20-year-old man with multiple injuries. Postimplantation computed tomographic angiography (CTA) demonstrated no contrast extravasation and total exclusion of the traumatic rupture. Routine CTA 3 months after implantation revealed a collapsed stent-graft located in the outer curve of the distal aortic arch. A Talent stent-graft was placed successfully within the collapsed prosthesis. Postimplantation CTA demonstrated no contrast extravasation and good apposition of the endograft to the aortic wall. At 6 months, the repair remains secure; there is no sign of graft collapse or endoleak.

CONCLUSIONS

Collapse of stent-grafts can occur after treatment for traumatic aortic ruptures; endovascular methods can be used to restore a satisfactory luminal contour.

Single Center Experience with a New Commercially Available Thoracic Endovascular Graft

PURPOSE

To evaluate the intra-operative performance and clinical outcome of a new commercially available stent-graft for the treatment of thoracic aortic diseases.

METHODS AND PATIENTS

From January 2003 to October 2004, 45 consecutive patients received endovascular treatment with the Zenith TX1 device for diseases of the thoracic aorta at a single center in northern Italy. Indications included disease of the descending thoracic aorta in 26 cases, of the aortic arch in 17 cases and of the thoraco-abdominal aorta in two cases. We treated 38 atherosclerotic aneurysms, two post-traumatic aortic ruptures, two penetrating ulcers, two chronic dissections and one case was treated for aortic bleeding after voluntary acid ingestion for attempted suicide. General anesthesia was used in 20 cases. Combined or hybrid endovascular and open surgical repair was performed in 11 patients. Mean follow-up was 7 months (range 1-22 months).

RESULTS

Technical success was obtained in 44 patients (98%). One primary type I endoleak occurred (2%). ICU was used in 12 cases with a mean stay of 1 day. The mean hospital stay was 6 days (range 4-13 days). There were no hospital deaths or strokes but one transient paraplegia (2%). A type II endoleak was observed in one case and resolved spontaneously 1 month later. No aneurysm enlargement, endograft migration or structural failures were observed during follow-up. Two late unrelated-deaths were observed.

CONCLUSIONS

This stent-graft does not fulfill all the characteristics of the ideal graft, however, it proved to be safe and allowed satisfactory short term results in this group of patients treated at a single center.

Late Surgical Conversion After Thoracic Endograft Failure due to Fracture of the Longitudinal Support Wire

PURPOSE

To report complications from a thoracic endograft wire fracture and early experience with elective conversion after thoracic endografting.

CASE REPORT

A 43-year-old man underwent urgent endovascular repair of a symptomatic post-traumatic thoracic aneurysm in 1999. The patient had been involved in a car accident 14 years before. He developed clinical and radiological signs of graft infection 46 months after stent-graft implantation. Multidetector computed tomography confirmed a fracture of the longitudinal support wire in the Excluder thoracic stent-graft. Additionally, radiological signs of suspected endograft infection were described. Due to concerns over a potential chronic infection, the stent-graft was successfully excised, and a polyester graft was implanted 50 months after primary endovascular repair.

CONCLUSIONS

Recognition or strong suspicion of endograft infection requires conversion with removal of the device. Long-term follow-up after endografting is necessary to assess material fatigue that undermines the durability of these implants.

Endovascular Treatment of Aortic Arch Aneurysms

INTRODUCTION

The aim of this study was to review our clinical experience with endovascular treatment of aortic arch aneurysms using different commercially available grafts (Gore, Talent, Endomed, Cook).

METHODS

From 1999 to 2004, 97 patients received endovascular treatment for diseases of the thoracic aorta. In 30 cases (26 males, 4 females) the aortic arch was involved. The left subclavian artery was overstented (Ishimaru zone '2') in 18 cases (60%). Only in the first three cases had the subclavian artery been revascularized. The left common and subclavian arteries were covered (zone '1') in 6 (20%) cases-all had the carotid artery reconstructed, either simultaneously (five cases) or as a staged procedure (one case). Finally, the whole aortic arch was over-stented (zone '0') in 6 (20%) cases, with simultaneous (five cases) or staged (one case) grafting of the supra-aortic vessels from the ascending aorta.

RESULTS

Perioperative mortality was 2/30 (7%), due to graft migration (zone '2') and intra-operative stroke (zone '0'), respectively. One minor stroke was observed. No cases of paraplegia were recorded. Three type I endoleaks were observed. Two resolved at 6 months follow-up; one zone '0' graft is still being followed. There was one surgical conversion for endograft failure 2 weeks after implantation. Thus, the technical success rate was 87% (26/30) cases. The mean follow-up time was 23+/-17 months. No new onset endoleaks or aneurysm-related deaths were recorded.

CONCLUSIONS

Currently available grafts may be deployed in the aortic arch in most instances. De-branching of the aortic arch with surgical revascularization for zone '0' and '1' seems to be adequate to obtain a satisfactory proximal landing zone.

Endovascular treatment of thoracic aortic diseases: Combined experience from the EUROSTAR and United Kingdom Thoracic Endograft registries

PURPOSE

The objective of this study was to assess the initial and 1-year outcome of endovascular treatment of thoracic aortic aneurysms and dissections collated in the European Collaborators on Stent Graft Techniques for Thoracic Aortic Aneurysm and Dissection Repair (EUROSTAR) and the United Kingdom Thoracic Endograft registries.

METHODS

Four hundred forty-three patients underwent endovascular repair of thoracic aortic disease between September 1997 and August 2003 (EUROSTAR, 340 patients; UK, 103 patients). Patients represented 4 major disease groups: degenerative aneurysm (n = 249), aortic dissection (n = 131), false anastomotic aneurysm (n = 13), and traumatic aortic injury (n = 50).

RESULTS

Mean age in the entire study group was 63 years. Fifty-two percent of patients were deemed at high risk for open surgery because of major comorbidity. Sixty percent of patients underwent an elective procedure, and 35% required emergency treatment. Conventional indications for treatment of aortic dissection, including aortic expansion, continuous pain, rupture, or symptoms of branch occlusion constituted the basis for endograft placement in 57% of patients, whereas in 43% of patients aortic dissections were asymptomatic. Primary technical success was obtained in 87% of patients with degenerative aneurysm and in 89% with aortic dissection. Paraplegia was a postoperative complication in 4.0% of patients with degenerative aneurysm and 0.8% of patients with aortic dissection (not significant). Thirty-day mortality in the entire study group was 9.3%, with mortality rates after elective procedures of 5.3% for degenerative aneurysms and 6.5% for aortic dissection. Mortality for degenerative aneurysm after emergency repair was higher (28%; P <.0001) then after elective procedures. For aortic dissection the emergency repair rate was 12% (not significant compared with elective repair of aortic dissection, and P = .025 compared with emergency repair of degenerative aneurysm). One-year follow-up was complete in 195 patients. The outcome at 1 year was more favorable for aortic dissection than for degenerative aneurysm with regard to aortic expansion (0% vs 15%; P = .001) and late survival (90% vs 80%; P = .048). In the groups with false anastomotic aneurysm and traumatic aortic injury, 30-day mortality rates were 8% and 6%, respectively.

CONCLUSION

This multicenter experience demonstrates acceptable rates for operative mortality and paraplegia after endovascular repair of thoracic aortic disease. Outcome after 30 days and 1 year was more favorable for aortic dissection than for degenerative aneurysm. However, the durability of this technique is currently unknown, and continued use of registries should provide data from long-term follow-up.