Surgery for ruptured thoracic and thoraco-abdominal aortic aneurysms

Urgent endovascular repair of thoracoabdominal aneurysms using an off-the-shelf multibranched endograft

OBJECTIVES

Our goal was to report outcomes of the endovascular repair of urgent thoracoabdominal aortic aneurysms (TAAAs) using the Cook Zenith t-Branch off-the-shelf multibranched endograft.

METHODS

Between 2010 and 2020, we collected patients with TAAAs who received an urgent endovascular repair using the Cook Zenith t-Branch (had a rupture, symptoms or diameter >80 mm). Thirty-day mortality, spinal cord ischaemia (SCI) and clinical success were assessed as early outcomes. Freedom from reintervention, target visceral vessel patency and survival were considered during follow-up.

RESULTS

Sixty-five cases were managed using the Cook Zenith t-Branch for 27 (42%) TAAA ruptures, 8 (12%) symptomatic TAAAs and 30 (46%) asymptomatic TAAAs with a diameter >80 mm. Crawford's extent I-II-III and IV were noted in 54 (83%) and 11 (17%), respectively. Eleven (17%) patients had SCI with 3 (5%) cases of permanent paraplegia. Postoperative dialysis (P = 0.04) and ruptured TAAAs (P = 0.05) were associated with SCI. Sixteen (25%) patients had reinterventions within the first 30 days postoperatively. The 30-day mortality was 14% (9). Ruptured TAAAs (P = 0.05) and technical failures (P = 0.01) were correlated with in-hospital mortality. Clinical success was 78% (51 patients). The mean follow-up was 18 ± 14 months. Survival at 24 months was 47% with no late TAAA-related deaths. Patients with ruptured TAAAs had lower survival than those who did not have ruptured TAAAs (52% vs 60% at 1 year; P = 0.05). Target visceral vessel patency and freedom from reintervention at 24 months were 89% and 60%, respectively.

CONCLUSIONS

An off-the-shelf multibranched endograft is safe and effective for treating urgent TAAAs. Postoperative SCI and 30-day mortality are satisfactory for this challenging clinical scenario. The early reintervention rate is not negligible. Midterm survival is low, especially in patients with a ruptured TAAA; therefore, accurate patient selection is mandatory.

Emergency Stent-Graft Placement for Impending Rupture of the Descending Thoracic Aorta

Purpose:

To present initial experience with emergent stent-graft placement for impending rupture of the descending thoracic aorta.

Case Reports:

Intramural hematoma (IMH) of the descending thoracic aorta was diagnosed by transesophageal echocardiography and computed tomography in 3 patients with acute onset of severe thoracic pain. Because of signs of impending rupture, e.g., pleural effusion, sustained pain, or transadventitial bleeding, the patients underwent emergency stent-graft placement, which was successful in all cases. No procedure-related complications were observed. Follow-up to 18 months has revealed no evidence of endoleak, and all patients remain free of symptoms.

Conclusions:

Emergency stent-graft placement may be a promising alternative to conventional surgery in patients with impending aortic rupture due to IMH.

"Open" repair of ruptured thoracoabdominal aortic aneurysm (experience of 51 cases)

Introduction

Surgical treatment of toracoabdominal aortic aneurysms (TAAA) represents a difficult problem for the vascular surgeon and may become a formidable challenge in an emergency procedure. In patient with hemodynamic instability, protective measures as cerebral spinal fluid drainage and bio-pump against spinal cord, visceral and renal ischemia, may be ineffective or impracticable.

Material and methods

We report our experience of 51 emergency-operated patients with TAAA out of 660 treated between 1994 and 2014; 48 patients (94%) were hemodynamically unstable, 3 (6%) were hemodynamically stable. The TAAA patients were evaluated, according to Crawford classification, as: 18 type I, 13 type II, 15 type III, 5 type IV.

Results

Overall mortality was 23 cases out of 51 (43.1%); 8 deaths occurred during the surgical procedure and 14 in the postoperative period. Early deaths, subdivided by Crawford TAAA classification, were: type I 9/18 (50%), type II 9/13 (69.2%), type III 7/15 (46.6%), type IV 3/5 (60%).

Paraplegia-paraparesis developed in 6 cases out of 43 (16.2%), excluding 8 deaths during the operative procedure. Acute renal failure was observed in 8 out of 43 patients (18.6%). Dialysis was found to be a risk factor for hospital mortality (p = 0.03). Pulmonary insufficiency was diagnosed in 15 patients out of 43 (34.8%), and 5 patients (15.5%) needed tracheostomy, out of whom 3 died (p = 0.04%). Postoperative bleeding was present in 8 cases out of 43 (18.6%). Inferior laryngeal nerve palsy was present in 6 cases out of 43 (13.5%). The follow-up period comprised 1-3-5-10 years postoperative follow-up. The actuarial survival rate of patients discharged from hospital was respectively 75%, 63%, 48%, 35%.

Conclusions

In the literature there are very few studies published on emergency treatment for TAAA. Having usually low numbers of patients in the groups wider experiences are still needed to give more light on the pathophysiology and surgical treatment of this type of TAAA, which are still being treated according to the individual surgeon's experience.

Spinal cord injury following thoracic and thoracoabdominal aortic repairs

Objective

To discuss the currently available approaches to prevent spinal cord injury during thoracic and thoracoabdominal aortic repairs.

Methods

We carried out a PubMed search up to 2013 using the Medical Subject Headings: “aortic aneurysm/surgery” and “spinal cord ischemia”; “aortic aneurysm, thoracic/surgery” and “spinal cord ischemia”; “aneurysm/surgery” and “spinal cord ischemia/cerebrospinal fluid”; “aortic aneurysm/surgery” and “paraplegia”. All 190 original articles satisfying our inclusion criteria were analyzed for incidence, predictors, and other pertinent variables related to spinal cord injury, and we compared the results in recent publications with those in earlier reports.

Results

The mean age of the 38,491 patients was 65.3 ± 4.9 years. The overall incidence of paraplegia and/or paraparesis was 7.1% ± 6.1% (range 0%–32%). The incidence of spinal cord injury before 2000, from 2001 to 2007, and 2008–2013 was 9.0% ± 6.7%, 7.0% ± 6.1%, and 5.9% ± 5.2%, respectively ( p = 0.019). Various predictors of spinal cord injury were identified, extent of disease being the most common. Modification of surgical techniques, use of adjuncts, and better understanding of spinal cord perfusion physiology were attributed to the decrease in postoperative spinal cord injury in recent years.

Conclusions

Spinal cord injury after thoracic and thoracoabdominal aortic repair poses a real challenge to cardiovascular surgeons. However, with evolving surgical strategies, identification of predictors, and use of various adjuncts over the years, the incidence of spinal cord injury after thoracic/thoracoabdominal aortic repair has declined. Embracing a multimodality approach offers a good insight into combating this grave complication.

The use of heparin in patients with ruptured abdominal aortic aneurysms

The use of systemic heparin in patients with ruptured abdominal aortic aneurysms (rAAAs) remains a contentious issue with no clear guidelines. This review reports the current understanding, at a molecular and clinical level, of the possible benefits and risks of heparin in emergency aneurysm repair (both open and endovascular). MEDLINE, EMBASE, AMED, SCOPUS, CINAHL and Cochrane Library were searched for all articles containing the keywords 'rupture', 'abdominal', 'aneurysm' and 'heparin'. Current experience, indications and outcomes were analyzed. Articles were searched for both endovascular and open repair of AAAs. A total of eight studies were included for analysis in the systematic review. Of these, only one paper focused specifically on heparin use in open repair of ruptures and suggested a benefit. Of the remaining seven, two were self-reporting retrospective studies assessing individual surgeons' practice, one was a case report and the remaining four included mention of heparin use but with no outcome data. The evidence available suggests that a pro-coagulable state exists in rAAAs. This may be responsible for the morbidity and mortality postprocedure, which arises predominantly from multiple organ failure and cardiac compromise rather than outright hemorrhage. This diathesis may respond well to heparin administration, suggesting that heparin administration in ruptured aneurysms is appropriate.

Should Patients With Contained Rupture of a Descending Aortic Aneurysm Only Receive Unilateral Artificial Ventilation? Case Report of a Death During an Operation

The danger of thoracic aneurysm rupture increases with the size of the aneurysm. We report on a 59-year-old man who developed a secondary aneurysm of the descending thoracic aorta within the residual type A dissection that was approximately 9-cm long and in which a contained rupture occurred. The patient died as a result of a massive hemorrhage during the anesthesiological preparation for emergency operation a short time after double-lumen intubation and commencement of controlled artificial ventilation. Autopsy revealed an atelectatic lower pulmonary lobe that had partially fused with the aneurysm. The fusion may have been so substantial that it may have acutely eliminated the covering of the contained rupture during artificial ventilation.

Contemporary results of open repair of ruptured descending thoracic and thoracoabdominal aortic aneurysms

OBJECTIVE

The purpose of this study was to evaluate the results of open repair for ruptured descending thoracic and thoracoabdominal aortic aneurysm (RDTAA).

METHODS

A retrospective review identified 41 consecutive cases of open surgical repair in 40 patients presenting with nontraumatic, atherosclerotic RDTAA from 1996 to 2006. Patients with traumatic injuries or complicated dissections were excluded. Patient characteristics and preoperative, intraoperative, and postoperative variables were collected from the medical record. Univariate and logistic regression were used to identify factors contributing to mortality and morbidity in these patients.

RESULTS

The operative mortality rate was 26.8% (11/41). All but two deaths occurred within 24 hours of operation; seven were intraoperative. Overall actuarial survival rates at 1 and 2 years were 53.7% and 47.1%, respectively. For those who survived to hospital discharge, the respective numbers were 73.3% and 64.4%. Intraoperative hypotension and blood transfusion requirements were independent predictors of perioperative death. Octogenarians had a mortality rate equivalent to that of the younger population (25% vs 27.6%; not significant). There was a strong trend toward an improved outcome in the latter part (2003-2006) compared with the first part (1995-2002; 13.6% vs 42.1%, respectively; P = .075).

CONCLUSIONS

Direct open repair for RDTAA can be achieved with acceptable mortality and morbidity rates even in elderly patients. Improved outcome can be expected with increased volume and experience. This series should help establish a reference against which the results of endovascular endeavors and hybrid procedures could be compared.

Endovascular stent-graft placement for vascular failure of the thoracic aorta

It still remains undetermined whether endovascular stent-graft placement (ESGP) is the optimal initial treatment for elective cases of thoracic aortic disease because of unknown long-term results. However, it is also recognized that ESGP contributes to better outcome as an initial treatment for aortic emergency, such as rupture, aortic injury, and complicated acute type B aortic dissection. Despite the fact that most patients are elderly, early mortality rates of ESGP are reportedly around 10% in cases of ruptured degenerative thoracic aortic aneurysm. Postoperative morbidity is also superior in ESGP compared with conventional open repair. Postoperative paraplegia has rarely occurred with ESGP. In cases of blunt aortic injury (BAI), other complications may also be present because of other serious injuries. ESGP has changed the surgical strategy for BAI and partially resolved some of the clinical dilemmas. Early mortality rate is almost zero when a stent graft can be placed before re-rupture. While BAI is a very good indication for ESGP, young patients need careful management and attention because of the unknown long-term outcome. In cases of complicated acute type B aortic dissection, the two main determinants of death, shock from rupture and visceral ischemia, could be managed by ESGP with or without conventional endovascular interventions. Recent reports disclosed less than 10% early mortality with ESGP for complicated acute aortic dissection. Even if the possibility of endotension remains, ESPG seems to be beneficial for these critical patients as the preferable initial treatment. The importance of close follow-up should be stressed to avoid some devastating late complications following ESGP.

Endovascular treatment of thoracic aortic disease: Mid-term follow-up

OBJECTIVE

The aim of this study was to evaluate the mid-term follow-up in a cohort of patients with acute or chronic descending aortic disease treated by stent-graft repair.

BACKGROUND

Since 1999, endovascular stent-graft placement has been reported as an alternative treatment to surgical approach for a variety of thoracic aortic diseases; however, results beyond initial short-term follow-up are not widely available for the broad range of applications.

METHODS

From March 2001, 43 consecutive patients with traumatic aortic transection (group A = 16) and complicated type B aortic dissection or aneurysm (group B = 27) underwent stent-graft implantation. All patients underwent computed tomography (CT) scan as preoperative assessment and in 26 a transesophageal echo (TEE) exam was performed.

RESULTS

Technically successful stent-graft deployment was achieved in all patients. No patient required surgical conversion and no cases of paraplegia occurred. The overall in-hospital mortality was 9.3%. A residual endoleak (type II) was detected in one group B patient who was managed conservatively. The mean follow-up was 29 +/- 8 months (range 10-48 months). No patient died during late follow-up after hospital discharge. At 12 months, one patient (2.5%) who had stent graft repair of an aortic dissection developed an asymptomatic type I endoleak. Three asymptomatic patients with chronic dissection had a persistent retrograde perfusion of the thoracic false lumen via a distal tear(s) in the dissection septum.

CONCLUSION

Our results of stent-graft treatment of complicated and uncomplicated diseases of the descending aorta confirms that this alternative to open repair is a safe, less invasive, and relatively low risk approach. Medium-term follow-up results suggest that it is effective and durable therapy with low associated mortality and morbidity rates.

Endovascular stent-graft placement for acute and contained rupture of the descending thoracic aorta

OBJECTIVES

To identify determinants of postinterventional death after endovascular stent-graft placement for acute rupture of the descending thoracic aorta, an emerging therapeutic modality for this highly life-threatening condition.

METHODS

Between July 1999 and November 2004, 17 patients (14 males; mean age, 65+/-16 (25-83) years) underwent stent-graft repair of the descending thoracic aorta for acute rupture from a thoracic aneurysm (TAA, n=6), acute aortic dissection (AAD, n=6), penetrating aortic ulcer (PAU, n=3), or blunt chest trauma (n=2). Immediate, 30-day, 1-year, and 3-year mortality was assessed. Twenty-one clinical and procedural variables were evaluated in a post-hoc analysis regarding their influence on mortality. Of these, four preprocedural factors with the greatest impact were used to construct a rupture score with a scale from 0 (no adverse prognostic factors present) to 4 (all four adverse factors present).

RESULTS

Stent-graft placement was technically feasible in all patients. Complete exclusion of the ruptured aortic pathology could be achieved in only 11 (65%) patients, despite implantation of 1.6+/-0.9 stent-grafts per patient, with a median length of 130 mm. There was one procedure-related early complication (bleeding at the access site). One patient died immediately following the procedure because of progressive mediastinal hematoma, although the rupture site was effectively sealed. Overall survival rates were (76.5+/-10.3)% at 30 days and (52.9+/-12.1)% at 1 year and remained at (52.9+/-12.1)% at 3 years. The four most important preprocedural denominators of death were (1) TAA or AAD as the underlying etiology of aortic rupture (P=0.024), (2) maximum aortic diameter>5 cm (P=0.024), (3) presence of mediastinal hematoma (P=0.056), and (4) an estimated lesion length requiring >1 stent-graft to be covered (P=0.009). Furthermore, residual leakage at the conclusion of the procedure (P=0.009), postprocedural need for dialysis (P=0.004), and prolonged ventilation (P=0.043) were significantly associated with postprocedural death. Using a threshold of >or=3, the rupture score constructed on the basis of the four preprocedural denominators of death was found to be well suited to discriminate postprocedural death (1-year survival: (20.0+/-12.7)% in patients with a rupture score>or=3 vs. 100% in patients with a rupture score<3, P=0.001).

CONCLUSION

Endovascular stent-graft placement in patients with acute aortic rupture was technically feasible, albeit still associated with high mortality. A simple risk score constructed in retrospect, on the basis of preprocedural prognostic factors, appeared to provide a useful separation of candidates who are likely to benefit from a straightforward endovascular procedure and should be tested prospectively in future studies.

Early outcomes after elective and emergent endovascular repair of the thoracic aorta

BACKGROUND

Endovascular treatment of thoracic aortic pathology has emerged as a viable alternative to open surgical repair in both the elective and emergent settings. The aim of this study was to evaluate preoperative work-up, intra-operative strategy, and outcomes of endovascular stent-grafting of the thoracic aorta in patients undergoing elective repair and those undergoing emergent repair.

METHODS

All patient information was obtained by a retrospective review of an established clinical database for all endovascular thoracic stent-graft cases. From October 1999 to August 2005, 70 patients were treated with endovascular stent-grafts for lesions of the thoracic aorta. Thirty-five patients had an elective endovascular procedure, and 35 patients had an emergent procedure.

RESULTS

Thirty-five patients in the endovascular (EL) group were treated for aneurysm (n = 34) and type B dissection (n = 1). Thirty-five patients in the emergent (EM) group were treated for aneurysm (n = 10), intramural hematoma (n = 10), type B dissection (n = 7), traumatic rupture (n = 7), and aortoesophageal fistula (n = 1). Preoperative angiography was performed in 94.3% (33/35) of EL patients but in only 45.7% (16/35) EM patients (P < .005). The EM procedures had significantly shorter operative times, used lower contrast volumes, used fewer stent-graft components (mode 2, range 1 to 5 vs mode 1, range 1 to 3; P = .02), and spinal cerebrospinal fluid drains were used significantly less often (82.9% vs 57.1%, P = .04). Both groups had similar 30-day morbidity, mortality (0/35 EL vs 1/35 [2.9%] EM, P = .99), postoperative endoleak (9/35 [25.7%] EL vs 7/35 [20.0%] EM, P = .78), endovascular failure (3/35 [8.6%] EL vs 5/35 [14.3%] EM, P = .71), and patient survival.

CONCLUSION

There are significant differences in the underlying pathology, preoperative evaluation, and operative course between elective and emergency treatment endovascular procedures for lesions of the thoracic aorta. Endovascular repair of thoracic aortic lesions can be accomplished with low perioperative mortality and morbidity rates, as well as acceptable endoleak and endovascular failure rates for both elective and emergency procedures.

Antifibrinolytic Use and Bleeding During Surgery on the Descending Thoracic Aorta: A Multivariate Analysis

OBJECTIVES

The purpose of this study was to determine the potential benefit of antifibrinolytic (AF) therapy in improving hemostasis in descending aortic surgery in which extracorporeal distal perfusion is used.

DESIGN

Retrospective database study.

SETTING

University hospital.

PARTICIPANTS

Seventy-two patients who underwent descending thoracic or thoracoabdominal aortic replacement during the period from January 1993 through December 1996 when the use of AF therapy was emerging.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Seventy-two records met criteria for inclusion. The use of AF therapy had no significant effect on any bleeding or transfusion outcome in any model. Excessive chest tube drainage postoperatively was independently associated with repeat surgery and intraoperative hypothermia. The risk of receiving a red blood cell (RBC) transfusion was independently predicted by low preoperative hemoglobin and age > or =65 years. Cross-clamp was an independent predictor of receiving a transfusion of non-RBC products (p = 0.03).

CONCLUSIONS

The authors could not show a beneficial effect of AF therapy on bleeding and transfusion, although current practice shows that this therapy continues to be used. Because heterogeneity of patient population exists and bias cannot be completely excluded, a prospective investigation evaluating efficacy and safety in this population is warranted.

Telementoring During Endovascular Treatment of Abdominal Aortic Aneurysms:A Prospective Study

PURPOSE

To explore the use of telementoring for distant teaching and training in endovascular aortic aneurysm repair (EVAR).

METHODS

According to a prospectively designed study protocol, 48 patients underwent EVAR: the first 12 patients (group A) were treated at a secondary care center by an experienced interventionist, who was training the local team; a further 12 patients (group B) were operated by the local team at their secondary center with telementoring by the experienced operator from an adjacent suite; and the last 24 patients (group C) were operated by the local team with remote telementoring support from the experienced interventionist at a tertiary care center. Telementoring was performed using 3 video sources; images were transmitted using 4 ISDN lines. EVAR was performed using intravascular ultrasound and simultaneous fluoroscopy to obtain road mapping of the abdominal aorta and its branches, as well as for identifying the origins of the renal arteries, assessing the aortic neck, and monitoring the attachment of the stent-graft proximally and distally.

RESULTS

Average duration of telementoring was 2.1 hours during the first 12 patients (group B) and 1.2 hours for the remaining 24 patients (group C). There was no difference in procedural duration (127+/-59 minutes in group A, 120+/-4 minutes in group B, and 119+/-39 minutes in group C; p=0.94) or the mean time spent in the ICU (26+/-15 hours in group A, 22+/-2 hours in group B, and 22+/-11 hours for group C; p=0.95). The length of hospital stay (11+/-4 days in group A, 9+/-4 days in group B, and 7+/-1 days in group C; p=0.002) was significantly different only for group C versus A (p=0.002). Only 1 (8.3%) patient (in group A: EVAR performed by the experienced operator) required conversion to open surgery because of iliac artery rupture. This was the only conversion (and the only death) in the entire study group (1/12 in group A versus 0/36 in groups B + C, p=0.31).

CONCLUSIONS

Telementoring for EVAR is feasible and shows promising results. It may serve as a model for development of similar projects for teaching other invasive procedures in cardiovascular medicine.

Descending Thoracic Aortic Rupture: Role of Endovascular Stent-Grafting

BACKGROUND

The mortality of patients with descending thoracic aortic rupture who are treated by conventional surgery is high. Our current strategy for the management of descending thoracic aortic rupture is to treat seriously ill patients with endovascular stent-grafting using handmade grafts, and to treat other patients with traditional open repair. The aim of this study was to assess the early results of our strategy.

METHODS

Twenty-nine consecutive patients with descending thoracic aortic rupture were referred to Sapporo Medical University Hospital from June 2001 to January 2004. Eighteen of these 29 patients were selected for endovascular stent-grafting because of polytrauma (n = 7), comorbidities (n = 6), advanced age (n = 2), past history of left thoracotomy (n = 2), and patient's preference (n = 1). The remaining 11 patients underwent traditional graft replacement of the diseased aorta. Their outcomes and follow-up data were collected and analyzed retrospectively.

RESULTS

The in-hospital mortality rate was 14% (4/29). The mortality rate for surgical patients and stent-grafting patients was 9% (1/11) and 17% (3/18), respectively. The survival rate of patients at 2 years was 63% +/- 10%. In the follow-up period, 2 of the 18 patients who underwent endovascular stent-grafting required open repair, and 1 patient underwent a redo endovascular stent-grafting procedure because of stent failure. One of these 3 patients died of an intraoperative retrograde type A aortic dissection.

CONCLUSIONS

The early results of endovascular stent-grafting for the treatment of high-risk patients with descending thoracic aortic rupture are promising. Early results of open repair can also be improved by the selection of stabilized patients. However, the requirement of reintervention indicates that detailed follow-up examinations in patients who have undergone endovascular stent-grafting with handmade stent-grafts should be performed.

Penetrating atherosclerotic ulcer of the aorta: treatment by endovascular stent-graft placement

PURPOSE OF THE REVIEW

To summarize the current clinical experience with endovascular stent-graft repair in patients presenting with penetrating atherosclerotic ulcer of the descending thoracic aorta.

RECENT FINDINGS

Penetrating atherosclerotic ulcer is increasingly acknowledged as a pathologic variant of classic false lumen aortic dissection with a high incidence of bleeding complications and rupture in up to 40% of patients. So far, no generally accepted therapeutic regimen has been established, as the natural history of penetrating atherosclerotic ulcer is not yet fully understood. Recently, however, penetrating atherosclerotic ulcer is increasingly considered to be treated more aggressively (preferentially surgically). Given the high morbidity and mortality of aortic surgery, endovascular stent-graft repair may be an attractive, less invasive alternative in selected patients with penetrating atherosclerotic ulcer. Sealing of a penetrating ulcer by the stent-graft reduces wall stress and thus provides stabilization of the diseased aortic segment.

SUMMARY

To date, there is limited experience with endovascular repair in penetrating atherosclerotic ulcer, suggesting that endovascular stent-graft repair is safe and effective. Long-term results are, however, required to fully establish the efficacy of endovascular repair in penetrating atherosclerotic ulcer.

Ruptured descending and thoracoabdominal aortic aneurysms

BACKGROUND

Advances in end-organ protection have dramatically reduced the incidence of the life-threatening complications associated with the elective repair of thoracoabdominal and descending thoracic aortic aneurysms. However, in the setting of a ruptured thoracic aneurysm, one may not have the luxury of complex end-organ support. We analyzed our experience with ruptured thoracic aneurysms to define morbidity and mortality in the present era.

METHODS

One hundred seventy-two patients with thoracoabdominal or descending thoracic aneurysms were operated on between July 1997 and October 2001. Forty presented with either a contained or free rupture. Three techniques were used for aortic reconstruction: clamp and sew, left heart bypass, and hypothermic circulatory arrest. Adjuncts for neurologic and renal support were used when circumstances and anatomy permitted.

RESULTS

Seven of 40 patients died in the hospital (17.5%). Four patients died intraoperatively, all of acute myocardial infarction. Five of the seven deaths were in patients who presented in shock. Two patients (5%) experienced paraplegia, 3 (7.5%) had renal failure requiring hemodialysis, 8 (20%) required a tracheostomy, and 6 (15%) had recurrent nerve palsies. There was one stroke (2.6%). Mean diameter of ruptured aneurysms was 8.5 cm.

CONCLUSIONS

Ruptured thoracic aneurysms can be repaired with a gratifying rate of salvage. Rapid diagnosis and triage for repair is necessary to avoid progressive deterioration into shock. The incidence of myocardial infarction, and the mortality associated with this event, underscores the need for aggressive cardiac evaluation in the elective thoracic aneurysm patient. The size at rupture also emphasizes the need for earlier referral for elective aneurysm repair.

Emergency surgery for thoracoabdominal aortic aneurysms with acute presentation

PURPOSE

The mortality rate for elective repair of thoracoabdominal aortic aneurysms is as low as 4% in some surgical centers. However, patients with emergent presentation with acute pain, rupture, or complicated acute dissection traditionally have a poor outcome. We evaluated the results of surgery in a large contemporary series of patients with acute presentation at a tertiary referral center with a special interest and experience in aortic surgery.

METHODS

Between 1986 and 1998, 1220 patients underwent repair of thoracoabdominal aortic aneurysms. One hundred twelve patients had acute presentation, and 1108 patients underwent elective repair. Data were collected in a prospectively generated database.

RESULTS

Seventy-six patients had rupture, and 36 patients had acute dissection without rupture. The operative mortality rate was 6% for elective cases and 17% for acute cases (P =.0004). The long-term survival was longer for the elective group compared with the acute group (mean, 8.3 +/- 0.4 years versus 5.5 +/- 0.7 years; P <.005). Age did not influence survival rate in the acute group. Postoperative pulmonary complications, paraplegia/paraparesis, and renal impairment occurred in 45%, 14%, and 25%, respectively, of acute cases and were significantly more common than in elective cases (P < or =.01). Left heart bypass was used in 34 acute patients (30%), and intercostal arteries were reattached in 66 acute patients (59%). Surgery without the use of either adjunct was associated with significantly higher mortality and renal impairment rates.

CONCLUSION

Repair of thoracoabdominal aortic aneurysms with acute presentation is associated with worse outcome compared with elective cases. Nevertheless, repair may be performed with reasonable mortality and morbidity rates at specialized centers. In the acute setting, the use of surgical adjuncts is associated with improved outcome and should be used when possible. Age does not impact on survival rate in patients with acute presentation, and surgery should not be restricted to only younger patients.

Surgical repair of ruptured thoracic and thoracoabdominal aortic aneurysms

BACKGROUND

Rupture is the single most common cause of death in patients with thoracic aortic and thoracoabdominal aneurysm (TAA/TAAA) and is almost uniformly fatal.

METHODS

This was a retrospective review of patients admitted to a single practice with rupture of a TAA/TAAA between 1993 and 2000.

RESULTS

Twenty-two consecutive patients with a leaking TAA/TAAA were identified. The aetiology of rupture was either secondary to a degenerative TAAA or a type B dissection. Seventeen patients underwent surgery; one had a Crawford extent I, seven an extent II, one an extent III and two an extent IV TAAA. Six patients had an acute type B dissection with rupture in the upper descending thoracic aorta. The 30-day survival rate was 88 per cent (15 of 17 patients). Actuarial survival at 1 year in patients who had surgery was 65 per cent. Survival at 1 year for all presenting patients who consented to surgery was 40 per cent. Median survival was greater than 36 months.

CONCLUSION

As a result of improving medical care, more patients with a contained rupture of a TAA/TAAA may present for treatment. Surgery is complex and requires specialist teams for optimal care.

Endovascular treatment of acute bleeding complications in traumatic aortic rupture and aortobronchial fistula

OBJECTIVE

Herein we report our experience in placement of endovascular stentgrafts in the descending aorta in patients with acute bleeding complications due to traumatic rupture or aortobronchial fistula.

METHODS

Six patients (one woman, five men, mean age 47+/-19 years) were treated from September 1995 to February 2000 by implantation of endovascular stentgrafts in the descending aorta. Indications included traumatic ruptures of the aortic isthmus (n=3) and aortobronchial fistulas (n=3). All procedures were performed under general anaesthesia. The implants were introduced under fluoroscopic guidance via the aorta (n=1), the iliac (n=4) or femoral (n=2) artery, respectively.

RESULTS

All aortobronchial fistulas and ruptures were sealed up successfully. There was no perioperative morbidity and no procedure-related morbidity except one patient who received aortofemoral reconstruction because of iliac occlusive disease. All patients are alive and well after a mean follow-up of 31 months (range 6-60). Two patients had recurrent hemoptysis, in one case, the patient received a second implant (distal extension), the other patient was managed conservatively.

CONCLUSION

Endovascular treatment by a stentgraft is a safe and reliable procedure in the management of acute bleeding complications in patients with aortic rupture or aortobronchial fistulas.

Elective endovascular treatment of descending thoracic aortic aneurysms and chronic dissections with stent-grafts

PURPOSE

To report our experience of endovascular stent-graft placement in patients with descending thoracic aortic dissections and aneurysms and to evaluate the feasibility, safety, and clinical outcomes of the treatment.

MATERIALS AND METHODS

Stent-grafts were placed in the descending thoracic aortas of 23 patients with saccular aneurysms (n = 11) and Stanford type B chronic aortic dissections of the descending thoracic and abdominal aorta (n = 12). All stent-grafts were individually constructed of self-expandable stainless steel stents covered with polytetrafluoroethylene. Vascular access was achieved through the femoral artery in all patients. Clinical status of each patient was monitored and postoperative CT was performed within 1 month of the procedure and at 3-12-month intervals after the procedures.

RESULTS

Successful exclusion of the primary entry tears of dissections and the inlets of saccular aneurysms was achieved in all but two patients with aortic dissection. The overall technical success rate was 91.3% (dissection: 10 of 12 = 83%; aneurysm: 11 of 11 = 100%). All patients in whom technical success was achieved showed complete thrombosis and significant decrease in diameter of the thoracic false lumen (preoperative: 5.3 cm +/- 0.9; postoperative: 4.3 cm +/- 0.9; P = .004) or aneurysm sac (preoperative: 5.3 cm +/- 1.7; postoperative: 2.8 cm +/- 2.5; P = .001). In addition, five patients demonstrated complete resolution of the dissected thoracic false lumen (n = 2) and aneurysm sac (n = 3). However, in all patients with aortic dissection, the abdominal aorta was not significantly changed in size (P = .302) and shape and their false lumen flows remained persistent. Immediate postoperative complications were detected in 12 patients (52%); 10 had fever, leukocytosis, and elevation of C-reactive protein, another had wound infection, and another had transient abdominal pain. Three patients died 2, 3, and 12 months after the procedure: one from septic shock, another from underlying mediastinitis, and the other from an unexplained cause. The remaining 20 patients were well after the procedure (1-9 days; mean, 3 days), without any stent-graft-related complications or discomfort (follow up period: 10-65 mo; mean: 25.1 mo +/- 15.6). The cumulative survival rate after the stent graft was 100% at 30 days and 91% at 12 months.

CONCLUSIONS

For treatment of aortic dissection and saccular aneurysm of the descending thoracic aorta, endovascular stent-graft repair may be a technically feasible and effective treatment modality.

Surgical treatment for a ruptured thoracic aortic aneurysm

OBJECTIVE

The treatment for a ruptured thoracic aortic aneurysm remains controversial. This study was undertaken to assess the outcome from surgery.

METHODS

Between 1993 and 1998, we have performed 19 operations for a ruptured thoracic aortic aneurysm. Patients with an impending rupture or a chronic false aneurysm were excluded. There were 11 men and 8 women, with a mean age of 70.5 +/- 6.7 years. The aneurysm was caused by dissection in 8 patients. Of these, 7 were acute (Stanford type A, 6; type B, 1), and the other one was chronic (type B). Aortic rupture occurred into the pericardial cavity (n = 7), into the left lung (n = 6), the mediastinum (n = 3), the pleural cavity (n = 2), or into the esophagus (n = 1). Severely unstable hemodynamics were noted in 12 patients with a rupture into the pericardium, mediastinum, or pleural cavity (Group A). Inotropic support was required in each of these patients. Metabolic acidosis developed all but 1 patient. The 7 patients with a rupture into the lung or esophagus coughed or vomited blood (Group B). The operative approach was anterior (n = 17) or lateral (n = 2). Grafts were placed in the ascending aorta (n = 4), ascending and transverse arch aorta (n = 7), transverse arch aorta (n = 3), or in the descending thoracic aorta (n = 5). Selective cerebral perfusion was used in 13 patients.

RESULTS

There were 5 hospital deaths (26.3%). The postoperative complications included central nervous system dysfunction (n = 3), low cardiac output syndrome or cardiac arrhythmias (n = 3), respiratory failure (n = 4), acute renal failure (n = 1), and local or systemic infections (n = 4). The perioperative event-free rate was 36.8% overall, 25% in Group A, and 57.1% in Group B.

CONCLUSIONS

Patients with unstable hemodynamics require prompt operative intervention. Rupture into the esophagus is associated with a high mortality rate. Rupture in a thoracic aortic aneurysm can be successfully treated with emergency surgery.

Penetrating atherosclerotic ulcer of the descending thoracic aorta: treatment by endovascular stent-graft

PURPOSE

To present four cases of penetrating ulcer of the descending thoracic aorta treated by transfemoral insertion of an endoluminal stent-graft.

METHODS

Four patients with penetrating aortic ulcers were reviewed. Three cases were complicated by rupture, false aneurysm, or retrograde dissection. All patients were treated by endovascular stent-graft and were followed by helical computed tomography (CT).

RESULTS

Endovascular stent-graft deployment was successful in all patients. However, in one case we observed a perigraft leak that spontaneously disappeared within the first month, and two interventions were needed for another patient. Following treatment, one episode of transient spinal ischemia was observed. The 30-day survival rate was 100%, but one patient died from pneumonia with cardiac failure 34 days after the procedure. In one patient, helical CT performed at 3 months showed a false aneurysm independent of the first ulcer. This patient refused any further treatment and suddenly died at home (unknown cause) after a 6-month follow-up period.

CONCLUSION

Transluminal placement of endovascular stent-grafts for treatment of penetrating ulcers of the descending thoracic aorta appears to be a possible alternative to classical surgery. After treatment, follow-up by CT is essential to detect possible complications of the disease.

Surgical management of hemorrhage from rupture of the aortic arch

BACKGROUND

Control of hemorrhage in patients with active bleeding from rupture of the aortic arch is difficult, because of the location of the bleeding and the impossibility of cross-clamping the aorta without interfering with cerebral perfusion. A precise and swift plan of management helped us salvage some patients and prompted us to review our experience.

METHODS

Six patients with active bleeding of the aortic arch in the mediastinum and pericardial cavity (5 patients) or left pleural cavity (1 patient), treated between 1992 and 1996, were reviewed. Bleeding was reduced by keeping the mediastinum under local tension (3 patients) or by applying compression on the bleeding site (2 patients), or both (1 patient) while circulatory support, retransfusion of aspirated blood, and hypothermia were established. The diseased aortic arch was replaced during deep hypothermic circulatory arrest, which ranged from 25 to 40 minutes. In 3 patients, the brain was further protected by retrograde (2 patients) or antegrade (1 patient) cerebral perfusion.

RESULTS

Hemorrhage from the aortic arch was controlled in all patients. Two patients died postoperatively, one of respiratory failure and the other of abdominal sepsis. Recovery of neurologic function was assessed and complete in all patients. The 4 survivors are well 8 to 49 months after operation.

CONCLUSIONS

An approach relying on local tamponade to reduce bleeding, rapid establishment of circulatory support and hypothermia, retransfusion of aspirated blood, and swift repair of the aortic arch under circulatory arrest allows salvage of patients with active bleeding from an aortic arch rupture.

Aortobronchial and aortoesophageal fistulae as risk factors in surgery of descending thoracic aortic aneurysms

OBJECTIVE

Assess outcome of patients with descending thoracic aortic aneurysms complicated by aortobronchial and aortoesophageal fistulae in comparison to patients undergoing repair of aortic aneurysms without fistulae.

METHODS

In a consecutive series of 145 patients (age 60 +/- 12 years) with repair of descending thoracic and thoracoabdominal aortic aneurysms, 11 patients (8%; age 63 +/- 9; NS) primarily presented for hematemesis and/or hemoptysis. In 8/11 patients (73%) an aortobronchial fistula was identified, and 3/11 patients (27%) suffered from an aortoesophageal fistula. Five of 11 patients (45%) had undergone previous aortic surgery in the same region.

RESULTS

Extent of aortic segments (range 1-8) replaced was 3.1 +/- 1.4 for all versus 2.6 +/- 0.9 for fistulae (NS). Aortic cross clamp time was 38 +/- 22 min for all versus 45 +/- 15 min for fistulae (NS). Mortality at 30 days was 18/145 (12%) for all versus 16/134 (12%) without fistulae versus 2/11 (18%) with fistulae (NS). Paraparesis and or paraplegia was observed in 11/145 (8%) for all versus 10/134 (7%) without fistulae versus 1/11 (9%) for cases with fistulae (NS). Nine additional patients died after hospital discharge, seven without fistulae and two with fistulae (days 80, and 120) bringing the 1-year mortality up to 23/134 (17%) without fistulae versus 4/11 (36%) with fistulae (NS). Further analysis shows that the 1-year mortality accounts for 1/8 patients (13%) with aorto-bronchial fistulae versus to 3/3 patients (100%) with aorto-esophageal fistulae (esophageal versus bronchial fistula: P = 0.018; esophageal versus no fistula: P = 0.006).

CONCLUSIONS

Outcome of patients suffering from descending thoracic aortic aneurysms complicated by aorto-bronchial fistulae can be similar to that without fistulae, whereas for cases complicated by aorto-esophageal fistulae the prognosis seems to remain poor even after successful hospital discharge.