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

Complications after Endovascular Treatment of Thoracic Aortic Aneurysms

Purpose:

To retrospectively determine the value of stent-graft repair of descending thoracic aortic aneurysms by analyzing the results and complications.

Methods:

From May 1997 to July 2002, 45 patients (33 men; mean age 69 years, range 31–88) received endovascular treatment for thoracic aortic aneurysms. In 11 patients, emergency treatment was necessary for a contained rupture. The medical records of these patients were reviewed to gather data on the procedures, immediate results, complications, mortality, and survival in follow-up.

Results:

In all cases, the stent-grafts were successfully implanted. In 15 (33%) cases, the subclavian artery was covered by the stent-graft without complications. There was no paraparesis/paraplegia; 2 (4.4%) patients suffered a stroke intraoperatively. The in-hospital mortality was 2.2% (n = 1); 3 (6.7%) patients died within 30 days. Primary endoleaks occurred in 8 (17.8%) cases. Procedural success (technical success without endoleak or death) was 80% (93.3% after primary endoleak repair). During follow-up, 2 (4.4%) secondary endoleaks developed. All endoleaks were treated successfully or sealed spontaneously (n = 2). At a mean 24-month follow-up (range 1–62), 84% of patients were alive.

Conclusions:

The endovascular treatment of thoracic aortic aneurysms appears to be safe and effective, with lower morbidity and mortality than in conventional open operations. For these reasons, endovascular treatment should be administered whenever possible.

Update in the management of type B aortic dissection

Stanford type B aortic dissection (TBAD) is a life-threatening aortic disease. The initial management goal is to prevent aortic rupture, propagation of the dissection, and symptoms by reducing the heart rate and blood pressure. Uncomplicated TBAD patients require prompt medical management to prevent aortic dilatation or rupture during subsequent follow-up. Complicated TBAD patients require immediate invasive management to prevent death or injury caused by rupture or malperfusion. Recent developments in diagnosis and management have reduced mortality related to TBAD considerably. In particular, the introduction of thoracic stent-grafts has shifted the management from surgical to endovascular repair, contributing to a fourfold increase in early survival in complicated TBAD. Furthermore, endovascular repair is now considered in some uncomplicated TBAD patients in addition to optimal medical therapy. For more challenging aortic dissection patients with involvement of the aortic arch, hybrid approaches, combining open and endovascular repair, have had promising results. Regardless of the chosen management strategy, strict antihypertensive control should be administered to all TBAD patients in addition to close imaging surveillance. Future developments in stent-graft design, medical therapy, surgical and hybrid techniques, imaging, and genetic screening may improve the outcomes of TBAD patients even further. We present a comprehensive review of the recommended management strategy based on current evidence in the literature.

Treatment with Aortic Stent Graft Placement for Stanford B-Type Aortic Dissection in a Patient with an Aberrant Right Subclavian Artery

A 71-year-old man visited our hospital with the chief complaint of back pain and was diagnosed with acute aortic dissection (Debakey type III, Stanford type B). He was found to have a variant branching pattern in which the right subclavian artery was the fourth branch of the aorta. We performed conservative management for uncomplicated Stanford type B aortic dissection, and the patient was discharged. An ulcer-like projection (ULP) was discovered during outpatient follow-up. Complicated type B aortic dissection was suspected, and we performed thoracic endovascular aortic repair (TEVAR). The aim of operative treatment was ULP closure; thus we placed two stent grafts in the descending aorta from the distal portion of the right subclavian artery. The patient was released without complications on postoperative day 5. Deliberate sizing and examination of placement location were necessary when placing the stent graft, but operative techniques allowed the procedure to be safely completed.

A systematic review of spinal cord injury and cerebrospinal fluid drainage after thoracic aortic endografting

BACKGROUND

The use of thoracic endovascular aneurysm repair (TEVAR) is increasing. Similar to open repair, TEVAR carries a risk of spinal cord ischemia (SCI). We undertook a systematic review to determine whether preoperative cerebrospinal fluid (CSF) drainage reduces SCI.

METHODS

PubMed, the Cochrane Library, and conference abstracts were searched using the keywords thoracic endovascular aortic repair, cerebrospinal fluid, spinal cord ischaemia, TEVAR, and aneurysm. Studies reporting SCI rates and CSF drain rates for TEVAR patients were eligible for inclusion. SCI rates across studies were pooled using random-effects modeling. Study quality was evaluated using the Downs and Black score.

RESULTS

Study quality was generally poor to moderate (median Downs and Black score, 9). The systematic review identified 46 eligible studies comprising 4936 patients; overall, SCI affected 3.89% (95% confidence interval, 2.95.05%-4.95%). Series reporting routine prophylactic drain placement or no prophylactic drain placement reported pooled SCI rates of 3.2% and 3.47%, respectively. The pooled SCI rate from 24 series stating that prophylactic drainage was used selectively was 5.6%.

CONCLUSIONS

Spinal chord injury is uncommon after TEVAR. The role of prophylactic CSF drainage is difficult to establish from the available literature. High-quality studies are required to determine the role of prophylactic CSF drainage in TEVAR.

Midterm outcomes of open surgical repair compared with thoracic endovascular repair for isolated descending thoracic aortic disease

Objective

This study aimed to assess the surgical morbidity and mortality of thoracic endovascular repair (TEVAR) as compared with open surgical repair (OSR) for isolated descending thoracic aortic disease.

Materials and Methods

From January 1, 2006 through May 31, 2010, a total of 68 patients with isolated descending thoracic aortic disease were retrospectively reviewed for the presence of perioperative complication, 30-day mortality, and clinical success. The patients were divided into two groups (group 1, OSR, n = 40 vs. group 2, TEVAR, n = 28) and these groups were compared for major variables and late outcomes.

Results

The mean age was 58 years (group I = 54 vs. group II = 63 years, p = 0.011). Significant perioperative complications occurred in 12 patients: 8 (20%) in group I and 4 (13%) in group II (p = 0.3). There were five 30 day mortalities of which 4 occurred in group I and 1 in group II (p = 0.23). Clinical success (effective aortic remodeling and complete false lumen obliteration or thrombosis) was achieved in 20 patients (71%). Mean Kaplan-Meier survival rate at 1 year was similar for both groups (group 1 = 87% vs. group 2 = 80%, p = 0.65).

Conclusion

Thoracic endovascular repair for isolated thoracic aortic disease shows comparable results to OSR. However, the potential for endoleak or rupture remains a challenge that needs to be addressed in the future. Therefore, close follow-up study is needed for the evaluation of satisfactory long-term outcomes.

[Endovascular treatment of traumatic ruptures of the thoracic aorta]

Traumatic rupture of the descending aorta is an acute life-threatening event. The most common cause is deceleration trauma resulting in a sudden stretching of the aortic isthmus as for example in car and motorcycle accidents and falls from a great height. Exemplified by a case report of a multiply injured 57-year-old male the diagnostic pathways, therapy and postoperative complications are presented.

Standard of practice for the endovascular treatment of thoracic aortic aneurysms and type B dissections

Thoracic endovascular aortic repair (TEVAR) represents a minimally invasive technique alternative to conventional open surgical reconstruction for the treatment of thoracic aortic pathologies. Rapid advances in endovascular technology and procedural breakthroughs have contributed to a dramatic transformation of the entire field of thoracic aortic surgery. TEVAR procedures can be challenging and, at times, extraordinarily difficult. They require seasoned endovascular experience and refined skills. Of all endovascular procedures, meticulous assessment of anatomy and preoperative procedure planning are absolutely paramount to produce optimal outcomes. These guidelines are intended for use in quality-improvement programs that assess the standard of care expected from all physicians who perform TEVAR procedures.

Standard of practice for the endovascular treatment of thoracic aortic aneurysms and type B dissections

Thoracic endovascular aortic repair (TEVAR) represents a minimally invasive technique alternative to conventional open surgical reconstruction for the treatment of thoracic aortic pathologies. Rapid advances in endovascular technology and procedural breakthroughs have contributed to a dramatic transformation of the entire field of thoracic aortic surgery. TEVAR procedures can be challenging and, at times, extraordinarily difficult. They require seasoned endovascular experience and refined skills. Of all endovascular procedures, meticulous assessment of anatomy and preoperative procedure planning are absolutely paramount to produce optimal outcomes. These guidelines are intended for use in quality-improvement programs that assess the standard of care expected from all physicians who perform TEVAR procedures.

Endovascular treatment of atherosclerotic and other thoracic aortic aneurysms

The incidence of thoracic aortic aneurysms (TAAs) is increasing with the present rate of occurrence at 10.9 cases per 100,000 people per year. The estimated 5-year risk of rupture of a TAA with a diameter between 4 and 5.9 cm is 16%, but it rises to 31% for aneurysms ≥ 6 cm. Despite increasing awareness of the importance of early diagnosis and treatment options, there are no clear guidelines available at the time of writing. Nor is there any clear evidence for specific pharmacological treatment able to resolve or delay the disease progression. Endovascular treatment (EVT), proposed as an alternative to surgery, has been considered a therapeutic innovation, especially because it is minimally invasive, which allows treatment even in high surgical risk patients. Vascular imaging is crucial for patient selection, endoprosthesis choice, and planning of the treatment because not all aneurysms are suitable. Early and midterm results are encouraging, but long-term results are necessary to definitively assess reliability of stent-graft materials and improvement in patient survival. In the choice between surgical or endovascular repair of TAAs, many factors must be considered, including the clinical situation, comorbidities, anatomy, choice of equipment, and last, but not less important, experience of the clinical team.

Neurological Complications Following Endoluminal Repair of Thoracic Aortic Disease

Open surgery for thoracic aortic disease is associated with significant morbidity and the reported rates for paraplegia and stroke are 3%-19% and 6%-11%, respectively. Spinal cord ischemia and stroke have also been reported following endoluminal repair. This study reviews the incidence of paraplegia and stroke in a series of 186 patients treated with thoracic stent grafts. From July 1997 to September 2006, 186 patients (125 men) underwent endoluminal repair of thoracic aortic pathology. Mean age was 71 years (range, 17-90 years). One hundred twenty-eight patients were treated electively and 58 patients had urgent procedures. Anesthesia was epidural in 131, general in 50, and local in 5 patients. Seven patients developed paraplegia (3.8%; two urgent and five elective). All occurred in-hospital apart from one associated with severe hypotension after a myocardial infarction at 3 weeks. Four of these recovered with cerebrospinal fluid (CSF) drainage. One patient with paraplegia died and two had permanent neurological deficit. The rate of permanent paraplegia and death was 1.6%. There were seven strokes (3.8%; four urgent and three elective). Three patients made a complete recovery, one had permanent expressive dysphasia, and three died. The rate of permanent stroke and death was 2.1%. Endoluminal treatment of thoracic aortic disease is an attractive alternative to open surgery; however, there is still a risk of paraplegia and stroke. Permanent neurological deficits and death occurred in 3.7% of the patients in this series. We conclude that prompt recognition of paraplegia and immediate insertion of a CSF drain can be an effective way of recovering spinal cord function and improving the prognosis.

The Frozen Elephant Trunk Technique for Treatment of Thoracic Aortic Aneurysms

BACKGROUND

The frozen elephant trunk technique allows for single-stage repair of combined aortic arch and descending aortic aneurysms using a hybrid prosthesis with a stented and a nonstented end. This report summarizes the operative and follow-up data (mean follow-up: 20 months) with this new treatment.

METHODS

Between September 2001 and March 2006, 39 patients (15 women; mean age, 62 years) were operated on after approval by the local Institutional Review Board. Indications for operation were aneurysms in 18 patients and aortic dissections in 21. The stented end of the hybrid prosthesis was placed through the opened aortic arch under fluoroscopic control using hypothermic circulatory arrest and selective antegrade cerebral perfusion.

RESULTS

All patients survived the procedure. Five patients (12.8%) died early postoperatively, with two deaths directly related to the procedure. Symptoms of neurologic dysfunction developed in 5 patients and resolved completely in 2. In 1 patient, the descending aorta was perforated owing to misplacement of the stented end of the hybrid prosthesis. In 23 of 25 patients with postoperative computed tomography imaging (>6 months postoperatively), complete thrombus formation around the frozen elephant trunk was observed.

CONCLUSIONS

This procedure is performed through a median sternotomy and combines the concepts of the elephant trunk principle and endovascular stenting of descending aortic aneurysms. Favorable intraoperative and postoperative results in the follow-up with thrombus formation around the stented descending aortic segment has encouraged us to evaluate all patients with thoracic aneurysms extending proximal and distal of the left subclavian artery for this treatment.

Treatment of a Persistent False Lumen with Aneurysm Formation Following Surgical Repair of Type A Dissection

We describe the case of a 68-year-old man who developed aneurysmal dilatation of the proximal descending thoracic aorta 8 years after repair of a type A dissection. The aneurysm was due to an anastomotic leak at the distal end of the previous repair in the ascending aorta with antegrade perfusion of the false lumen. Surgical repair of the anastomotic leak partially obliterated the false lumen and computed tomography scan demonstrated thrombosis in a large proportion of the false lumen aneurysm. Follow-up with surveillance scans showed persistent filling of this aneurysm due to retrograde flow of blood within the false lumen. Coil embolization of the false lumen within the thoracic aorta was performed which successfully thrombosed the aneurysm with a reduction in diameter. Late aneurysm formation may complicate type A dissection repairs during follow-up due to a persistent false lumen, especially if there is an anastomotic leak. This case report describes a strategy to deal with this difficult clinical problem.

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.

The frozen elephant trunk technique

The so-called 'frozen elephant trunk' technique is adapted from the classical elephant trunk technique first described by H.G. Borst in 1983 and allows the repair of concomitant aortic arch and proximal descending aortic aneurysms in a single stage. A 'hybrid' vascular graft consisting of a conventional tube graft with an endovascular stented graft at the distal end is utilised to achieve a blood-tight seal in the descending aorta that cannot easily be accessed directly from an anterior approach. Thus, the concept of a traditional elephant trunk, otherwise completed with a secondary endovascular or surgical procedure, is achieved in one single step. First intra- and postoperative results of this technique in terms of successful exclusion of the proximal descending aortic aneurysm are good and following the learning curve, the prolongation of circulatory arrest and cerebral perfusion, as compared to the traditional elephant trunk procedure, is within minutes and thus acceptable. Currently all patients with thoracic aneurysms extending from the arch beyond the left subclavian artery are evaluated for this treatment at our institution. Furthermore, acute aortic dissections (type A and B) are an area of intensive clinical evaluation at present.

Results of endovascular repair of the thoracic aorta with the Talent Thoracic stent graft: The Talent Thoracic Retrospective Registry

BACKGROUND

Endovascular treatment of thoracic aortic diseases demonstrated low perioperative morbidity and mortality when compared with conventional open repair. Long-term effectiveness of this minimally invasive technique remains to be proven. The Talent Thoracic Retrospective Registry was designed to evaluate the impact of this therapy on patients treated in 7 major European referral centers over an 8-year period.

METHODS

Data from 457 consecutive patients (113 emergency and 344 elective cases) who underwent endovascular thoracic aortic repair with the Medtronic Talent Thoracic stent graft (Medtronic/AVE, Santa Rosa, Calif) were collected. Follow-up analysis (24 +/- 19.4 months, range 1-85.1 months) was based on clinical and imaging findings, including all adverse events. To ensure consistency of data interpretation and event reporting, one physician reviewed all adverse events and deaths for the whole cohort of patients. In the case of discrepancies, the treating physicians were queried.

FINDINGS

Among 422 patients who survived the interventional procedure (in-hospital mortality 5%, 23 patients), mortality during follow-up was 8.5% (36 patients), and in 11 of them the death was related to the aortic disease. Persistent endoleak was reported at imaging follow-up in 64 cases: 44 were primary (9.6%) and 21 occurred during follow-up (4.9%). Seven patients with persistent endoleak had aortic rupture during follow-up, at a variable time from 40 days to 35 months, and all subsequently died. A minor incidence of migration of the stent graft (7 cases), graft fabric alteration (2 cases), and modular disconnection (3 cases) was observed at imaging. Kaplan-Meier overall survival estimate at 1 year was 90.97%, at 3 years was 85.36%, and at 5 years was 77.49%. At the same intervals, freedom from a second procedure (either open conversion or endovascular) was 92.45%, 81.3%, and 70.0%, respectively.

CONCLUSION

Endovascular treatment for thoracic aortic disease with the Talent stent graft is associated with low early morbidity and mortality rates also for patients who are at high risk and treated on an emergency basis. Follow-up data indicate a substantial durability of the procedure with a high freedom from related death and secondary interventions.

Problems Encountered during and after Stent-Graft Treatment of Aortic Dissection

PURPOSE

The authors report their experiences with the problems encountered during and after stent-graft placement in patients with aortic dissections.

MATERIALS AND METHODS

Between July 1994 and December 2003, stent-graft placement was performed in 60 patients with aortic dissections, 9 patients with Stanford type A dissection and 51 patients with type B. Ten patients had acute dissection and 50 patients had chronic dissection. Each patient was followed for 12 to 107 months (mean, 33 mo). All cases were retrospectively reviewed for any problem that occurred during and after the procedure.

RESULTS

During the procedure, there were two cases (3%) of stent-graft migration, one case (2%) of stent-graft torsion, two cases (3%) of stent-graft folding due to oversizing, three cases (5%) of persistent thoracic false lumen flow by the appearance of a hidden intimal tear, one case (2%) of new intimal tear that resulted in retrograde type A dissection, and 12 cases (20%) of type I endoleaks on aortograms taken immediately after the procedure. During the follow-up period, one case (2%) of transient cerebral ischemia, six cases (10%) of persistent type I endoleaks, two cases (3%) of type II endoleaks through the intercostal artery, four cases (7%) with progressive dilatation of abdominal false lumen, six cases (10%) of new intimal tears which resulted in saccular aneurysms (n=4) or new dissections (n=2) on either or both ends of the stent-graft, and two cases (3%) of mechanical failure were observed. Overall, five patients (8%) required surgical conversion, and there were no cases of procedure-related mortality.

CONCLUSION

Various problems can occur during and after stent-graft placement in aortic dissection. The thorough evaluation of preoperative imaging and close follow-up are mandatory to optimize the management of such problems.

Underlying aortic pathology and clinical health status determine success of endovascular stent-grafting for descending thoracic aortic disease

Despite advances in medical and surgical treatment, acute as well as chronic diseases of the thoracic aorta are still associated with a high mortality. For the descending thoracic aorta, endovascular stent-graft placement competes with surgical therapy for clinical outcome. From July 1999 till December 2004, a total of 84 patients (64 +/- 14 years) with aortic disease of the descending thoracic aorta were treated. Nine patients had acute (AAD) and 35 chronic aortic dissection (AD), 16 had thoracic aortic aneurysms (TAA), 21 had penetrating aortic ulcer (PAU), and 3 patients had traumatic dissection (trans). Initial clinical status was assessed using the American Society of Anesthesiologists (ASA) classification. Fifty-three patients were in class 2, 16 in class 3, 8 in class 4, and 7 in class 5. Stent-graft placement was performed in the cardiac catheterization laboratory with the patient under general anesthesia. Technical success was obtained in 81/84 patients (96%). Within 30 days, seven patients (8%) died, four of them due to aortic rupture. In 14 patients, additional stent-grafts had to be implanted due to type I endovascular leakage (n = 5) or additional entry site adding up to a total of 107 implanted stent-grafts. During a follow-up period of 21 +/- 18 months, 17 additional patients died (22%). In 10 patients, death was disease- or procedure-related (13%). This long-term mortality depended on the underlying disease and was highest in the group with TAA (45%) followed by AAD (38%) and AD (18%). Patients in ASA class 4 and 5 had a significantly worse outcome. No aortic-related death occurred among patients with PAU or traumatic transsections. Overall, there was only one transient neurological deficit. Endovascular stent-graft placement has acceptable results in the treatment of patients with disease of the descending thoracic aorta. The outcome strongly depends on the underlying aortic pathology and the clinical health status of the patients. Randomized trials are necessary in order to establish the exact value of this new therapeutic option.

Endovascular stent-graft placement in aortic dissection: a meta-analysis

AIMS

This article summarizes all available published data with respect to clinical success, complications, and outcomes of endovascular stent-graft placement among patients with descending aortic dissection (AD).

METHODS AND RESULTS

We performed a meta-analysis of all published series on retrograde endovascular stent-graft placement encompassing >or=3 patients with AD. Thirty-nine studies, involving a total of 609 patients, were included. Procedural success was reported in 98.2+/-0.5% of patients. Major complications were reported in 11.1+/-1.4%, with the most dreaded neurologic complications in 2.9+/-0.7% patients. Periprocedural stroke was encountered more frequently than paraplegia (1.9+/-0.6% vs. 0.8+/-0.4%). Overall complications were significantly higher in patients undergoing stent-graft placement for acute AD than in patients with chronic AD (21.7+/-2.8% vs. 9.1+/-2.3%, P=0.005). The overall 30-day mortality was 5.3+/-0.9%, and was three-fold higher in patients with acute AD when compared with chronic AD (9.8+/-2.2% vs. 3.2+/-1.4%, P=0.015). In addition, 2.8+/-0.7% of patients died over a mean follow-up period of 19.5+/-7.1 months. Kaplan-Meier analysis yielded overall survival rates of 90.6+/-1.6% at 6 months, 89.9+/-1.7% at 1 year, and 88.8+/-1.9% at 2 years, respectively.

CONCLUSION

Endovascular stent-graft placement in type B-AD is technically feasible with success rates of >95% in selected cohort. Although minimally invasive, major complications occurred in 14-18% of patients depending upon the acuity of presentation, with very low incidence of paraplegia. Both, acute and mid-term mortality of this novel treatment strategy appear to favourably compare with surgical treatment but further studies are necessary to compare stent-graft placement with medical treatment in uncomplicated AD.

Endovascular repair of the descending thoracic aorta: evidence for the change in clinical practice

The purpose was to review outcome data following endovascular repair of the descending thoracic aorta from reports published between 1994 and 2004. To accomplish this task, 1,518 patients underwent endovascular repair for thoracic aortic disease; 810 thoracic aortic aneurysms, 500 type B thoracic aortic dissections, and 106 traumatic ruptures. The 30-day mortality rate was 5.5% and 6% for late postoperative deaths. The primary technical success rate was 97%, with only 15 patients requiring open conversion. Neurologic deficits occurred in 29 patients. In total, 118 endoleaks were reported; 29 were restented, and the remainder required surgical intervention. Graft infection occurred in 6 cases, and migrations were detected in 10. The conclusion reached is that endovascular repair of descending thoracic aortic disease is feasible and can be achieved with low rates of perioperative morbidity and mortality. As few long-term data exist on the durability of thoracic stent grafts, lifelong surveillance remains necessary.

Endovascular Repair of the Thoracic Aorta: Lessons Learned

BACKGROUND

Available information on outcome and best strategies for thoracic endovascular repair is somewhat limited and unclear. We sought to gain a better understanding of these issues through a retrospective review of our 8-year clinical experience in the treatment of thoracic aortic aneurysms and dissections.

METHODS

A retrospective chart review of 186 patients undergoing stent-graft repair of thoracic aortic lesions at our institution during the 92-month period ending on December 31, 2004 was performed. Patients were divided into two groups based on the indication for treatment; group A had thoracic aortic aneurysms (TAA) and group B had type B aortic dissections (TBAD). Both groups were analyzed for outcome variables including technical success, mortality, major morbidity, endoleak rate and type, secondary endovascular interventions, and long-term survival. Mean follow-up was 40 months (range, 1 to 92 months).

RESULTS

Compared to group B, group A patients were older and had a higher incidence of peripheral vascular disease and chronic obstructive pulmonary disease. Sixty percent of all patients were American Society of Anesthesiologists class III and the remainder were class IV (38.3%) and V (1.7%). The procedure was completed in 180 patients (96.7%), with all 6 failures being access-related. The average procedure time was 149 minutes (range, 72 to 405). The 30-day mortality was 4.7% (9 patients), and serious morbidity was 19.9% (37 patients). Eight patients (4.3%) developed spinal cord ischemia, 4 immediately after the procedure and 4 delayed (1 to 3 days). Total hospital length of stay averaged 6.7 days. Secondary endovascular interventions were successful in 17 patients with angiographically confirmed endoleaks (type I and III). At an average follow-up of 40 months, freedom from all-cause mortality was 62.5% in group A and 58.1% in group B.

CONCLUSIONS

Stent-graft repair for TAA and TBAD can be achieved with high technical success and comparatively low rates of morbidity and mortality. Midterm survival appears to be favorable. Further refinements in device technology and procedural techniques are needed.

Elective stent-graft treatment of aortic dissections

PURPOSE

To retrospectively review 8 years' experience with stent-graft treatment of aortic dissections at a single institution.

METHODS

Forty-six patients (31 men; mean age 59 years, range 38-88) underwent stent-graft treatment for 9 Stanford type A and 37 type B aortic dissections (9 acute phase, 13 subacute, 24 chronic). Custom-designed self-expanding stainless steel Z stents covered with polytetrafluoroethylene were used (n=20) until low-profile modular stent-grafts became available for percutaneous delivery (n=26).

RESULTS

Endovascular stent-graft deployment was technically successful in 44 (96%) patients; the 2 failed cases owing to intraprocedural migration and graft torsion were converted to surgery. There were 5 type I endoleaks for a clinical success (entry tear exclusion) of 85% (39/46). Complications included 3 cases of transient renal failure, 2 puncture site pseudoaneurysms, 1 guidewire-induced new intimal tear (converted), and 2 cases of stent-induced saccular aneurysms (1 converted). Follow-up at a mean 34 months (range 12-96) showed complete resolution of the thoracic false lumen in 14 (74%) of 19 acute/subacute patients treated successfully; 3 (16%) showed a reduced thoracic false lumen diameter. In the 23 chronic-phase patients treated successfully, 8 (35%) had complete resolution of the thoracic false lumen, and 11 (48%) showed size reduction. Enlargement of the abdominal aortic false lumen due to persistent flow into re-entry tear(s) occurred in 3 (13%).

CONCLUSIONS

Stent-graft treatment is a feasible and effective treatment modality in aortic dissection. However, close follow-up is mandatory to monitor new intimal tear, saccular aneurysms, or enlargement of the abdominal aortic false lumen.

Traumatische Aortenverletzungen bei polytraumatisierten Patienten

Herein we report our results of treatment of traumatic aortic ruptures in severely injured patients with either open surgery or endovascular stent graft repair. Data were analyzed retrospectively from the trauma registry of the DGU (Deutsche Gesellschaft fur Unfallchirurgie) over a time period from 1993 through 2002. All patients with traumatic rupture of the aorta were included and analyzed for injury severity (ISS), blood pressure (mmHg), hemoglobin (mg/%), and AIS (Abbreviated Injury Score) of the thoracic, abdominal, and upper extremity regions. Patients treated between 1998 and 2002 were further examined (operation within 24 h, duration of intervention, blood transfusion, and lethality with regard to either open surgical or endoluminal stent graft repair). Of 14,110 patients, 100 (0.7%) suffered from acute aortic rupture. Mean age was 38 years (+/-19) with an inhospital lethality of 39% (n=39). Mean ISS was 41 (+/-14); 36 patients were treated by open surgery and 5 patients by a stent-assisted endoluminal procedure. Lethality was 17% for open surgery and 0% for stent graft repair. Endovascular approach to traumatic rupture of the aorta is feasible and safe. It has been shown to reduce inhospital lethality and may offer an alternative to open surgery for severely injured patients.

Comparison of a percutaneous separate stent endograft and a conventional thoracic stent-graft for endovascular repair of type B aortic dissection

PURPOSE

To compare the immediate and midterm outcomes of aortic dissection repair with a separate stent endograft (SSE) versus a conventionally constructed thoracic stent-graft.

METHODS

The records of 35 patients treated for type B aortic dissection from September 1997 to April 2003 were reviewed. Seventeen patients (12 men; mean age 58.8+/-11.6 years) underwent endovascular repair with a separate stent endograft (SSE), a custom-made device with a reduced profile suitable for percutaneous introduction through a 12-F sheath. Eighteen patients (10 men; mean age 56.1+/-12.8 years) underwent treatment with a conventional custom-made stent-graft.

RESULTS

Angiographic success was achieved in 13/17 (76.5%) of the SSE-treated patients and 12/18 (66.7%) for the conventional device group (p=0.521). Clinical success (complete obliteration/thrombosis of the false lumen) was achieved in 12/17 (70.6%) and 11/18 (61.1%), respectively (p=0.555). There were 2 cases of stent-graft movement during deployment and 2 access site complications in the conventional stent-graft group, whereas the SSE patients had no complications. Except for 2 conventional stent-graft patients who were lost to follow-up, all patients are alive at a mean 19.5+/-11.6 months for the SSE group and 34.2+/-21.5 months for the conventional stent-graft patients.

CONCLUSIONS

The separate stent endograft can be deployed percutaneously without the need for blood pressure reduction, achieving accurate deployment without migration. In this small clinical experience, patients treated with the SSE had no access site complications and demonstrated midterm results comparable to the conventional stent-graft cohort, suggesting the possible usefulness of this device for the treatment of thoracic aortic dissection.

Transesophageal echocardiography–guided algorithm for stent-graft implantation in aortic dissection

OBJECTIVE

Endovascular stent-graft placement is replacing traditional surgery in type B aortic dissection. Usually stent-graft implantation is performed under fluoroscopic and angiographic guidance, but this relatively new procedure is still burdened with some complications. We investigated the value of a developed algorithm based on transesophageal echocardiography (TEE) for guiding stent-graft implantation in type B aortic dissection.

METHODS

Forty-two patients with type B aortic dissection (chronic in 28 patients with aneurysmal dilatation of the false lumen, and acute complicated in 14 patients) underwent endovascular stent-graft reconstruction of the descending thoracic aorta. TEE was always performed after angiography. TEE-induced variations of the procedure, based on the algorithm, were compared with initial angiography-based decisions.

RESULTS

TEE was decisive for guidewire repositioning (not possible with fluoroscopy) from the false to the true lumen in 3 patients and for correct guidewire entrance in an elephant trunk prosthesis in another patient. After stent-graft implantation color Doppler TEE enabled detection of proximal peri-stent leaks in 13 patients, whereas only 6 (46%) of the 13 leaks were detectable at angiography (P = .008). Most leaks were subsequently eliminated with balloon dilation or further stent grafting. Pulsed Doppler TEE was also useful for differentiating true leaks (13 patients) from Dacron porosity (7 patients). A pulsed-Doppler velocity cutoff value of 50 cm/s enabled differentiation of Dacron porosity (characterized by slow blood flow) from true peri-stent leak (fast flow). After stent-graft implantation TEE demonstrated new intimal tears in the thoracic aorta in 7 patients, whereas only 2 of the 7 new tears were detectable at angiography (P = .024); in 6 of 7 patients the new distal tears were subsequently resolved with placement of additional stents, whereas in a patient with Marfan syndrome new proximal tears determined a type I endoleak, which could not be resolved. Overall, TEE furnished decisive information additional to angiography in determining successful procedural changes in 16 of 42 patients (38%). There were no in-hospital deaths, and pre-discharge spiral computed tomograms showed a good outcome of stent-graft implantation in 37 of 42 patients (88%), with 5 residual type I endoleaks, all previously detected with TEE but impossible to eliminate with either balloon molding or further stent implantation. All but 2 patients (95%) are currently alive at mean follow-up of 30 +/- 18 months.

CONCLUSIONS

TEE algorithm is an easy and useful tool in the operating room to guide correct stent-graft positioning in type B aortic dissection.

Current status of thoracic aortic endograft repair

The advent and success of endovascular repair of abdominal aneurysms had led to the development of catheter-based techniques to treat thoracic aortic pathology. Such diseases, including thoracic aortic aneurysms, acute and chronic type B dissections,penetrating aortic ulcers, and traumatic aortic transection, challenge surgeons to perform complex operative repairs in high-risk patients. The minimally invasive nature of thoracic endografting may provide an attractive alternative therapy especially in patients deemed unfit for thoracotomy. A worldwide review of thoracic endografting demonstrates encouraging short- and midterm outcomes with significant reductions in morbidity and early mortality.Long-term surveillance will be crucial to discover complications unique to thoracic endovascular interventions and to determine which patients are appropriate candidates for stent-graft therapy.

Expanding False Lumen in the Abdominal Aorta 5 Years After Endovascular Repair of a Type B Aortic Dissection:Successful Exclusion of 3 Distal Re-Entry Sites

PURPOSE

To report endovascular treatment of an expanding aneurysmal false lumen several years after successful stent-graft deployment in the descending thoracic aorta for type B aortic dissection.

CASE REPORT

A 54-year-old woman who had a stent-graft placed at the entry site of a type B aortic dissection 5 years prior presented with abdominal discomfort and palpable abdominal mass. Successful remodeling of the thoracic aorta was demonstrated by computed tomography; however, a false lumen aneurysm in the abdominal aorta had expanded from 4.8 to 6.5 cm and caused symptoms. She was successfully treated with 3 additional stent-grafts at 3 re-entry sites. Six months after the procedure, the false lumen aneurysm was completely excluded.

CONCLUSIONS

Endovascular repair of the re-entry sites can prevent further expansion of false lumen aneurysm, which occurs in some patients with type B dissection treated with stent-grafts.

Predictors of Cardiac Morbidity And Mortality in Patients Undergoing Endovascular Repair of the Thoracic Aorta

The aim of this study was to determine predictors of cardiac morbidity and mortality in patients undergoing endovascular repair of the thoracic aorta. This was a retrospective cohort study that took place in a University-affiliated county hospital. Preoperative and intraoperative variables were collected from a consecutive series of patients who underwent repair of the thoracic aorta at our institution between 1998 and 2003. Perioperative complications and mortality were identified for each patient. Fifty-nine patients underwent endovascular repair of the thoracic aorta. The endografts were successfully deployed in 58 (98%) patients. Nine (15%) died perioperatively, 4 (7%) from cardiac causes. There were 12 (20%) perioperative cardiac events. A history of myocardial infarction (MI) was the only preoperative risk factor that was predictive of a cardiac event (p = 0.001). The cardiac event rate was 29% for patients who did not receive perioperative beta-blockade vs. 8% in patients who did (p = 0.04). Intraoperative predictors of MI were estimated blood loss (2480 cc vs. 680 cc, p = 0.01), intravenous (i.v.) fluids (2955 cc vs. 2010 cc, p =0.02), and length of operation (269 min vs. 178 min, p = 0.02). From these results we concluded that mortality associated with endovascular repair of thoracic aorta remains significant. Patients with a history of MI had a higher perioperative cardiac event rate. Intraoperative predictors of perioperative cardiac events included blood loss, i.v. fluid requirement, and length of operation. Perioperative beta-blockade is important in endovascular thoracic surgery as a protection against postoperative cardiac events.

Endovascular Treatment of the Descending Thoracic Aorta

OBJECTIVES

to report our initial experience with endovascular stent graft repair of a variety of thoracic aortic pathology.

DESIGN

retrospective single center study.

MATERIAL AND METHODS

between February 2000 and January 2002, endovascular stent graft repair was performed in 26 patients: traumatic aortic isthmus rupture (n=3), Type B dissection (n=11) and descending thoracic aortic aneurysm (n=12). The deployed stent graft systems were AneuRx-Medtronic (n=1), Talent-Medtronic (n=13) and Excluder-Gore (n=12).

RESULTS

successful deployment of the stent grafts in the intended position was achieved in all patients. No hospital mortality neither paraplegia were observed. Late, non procedure related, death occurred in four patients (15%). Access artery complications with rupture of the iliac artery occurred in two patients and were managed by iliac-femoral bypass. The left subclavian artery was overstented in seven patients (27%). Only the first patient received a carotido-subclavian bypass. The mean maximal aortic diameter decreased significantly in patients treated for descending thoracic aneurysm. Only one patient had an endoleak type II after 6 months without enlargement of the aneurysm. Complete thrombosis of the thoracic false lumen occurred in all but one patient treated for Type B dissection 6 months postoperatively. Two patients underwent a consecutive stent graft placement, due to a large re-entry tear distal to the first stent graft.

CONCLUSIONS

endovascular stent graft repair for Type B dissection, descending thoracic aneurysm and aortic isthmus rupture is a promising less-invasive alternative to surgical repair. Further studies are mandatory to determine its long-term efficacy.

Endovascular treatment of thoracic aortic aneurysms

Endovascular repair of thoracic aortic aneurysms is a promising modality that may someday replace open surgical repair. While stent grafts have been used with moderate success in small to moderate-sized retrospective series, there have been no completed multicenter clinical trials directed at gaining approval from the U.S. Food and Drug Administration. The available data suggest that morbidity and mortality of the procedure may be lowered with endovascular techniques. Paraplegia occurs, but despite the inability to maintain perfusion of intercostal vessels, the rate is at least as low as that associated with open repair. Similar to the minimally invasive repair of infrarenal aneurysms, the trade-off between the open and endovascular approach rests in the necessity to follow patients closely with after endovascular repair. The long-term durability of available devices is unproved, and serial imaging studies must be followed in order to detect device failure prior to the development of devastating clinical sequelae.

Large Vessel Injury following Operation for a Herniated Lumbar Disc

Major vascular injury can occur during an operation for a herniated lumbar disc due to the intimate anatomical relation between the lumbar vertebrae and major vessels. Although occurrence is infrequent, it is associated with high morbidity and mortality. Diagnosis is suspected when early signs of retroperitoneal hemorrhage appear, but may often be delayed for weeks or years. Formation of a pseudoaneurysm or an arteriovenous (A-V) fistula may be of gradual onset and produce initially only a few symptoms. We report here six cases of large vessel injury, which consisted of active bleeding from an injured common iliac artery, or a pseudoaneurysm of the common iliac artery with or without an A-V fistula that occurred following an operation for a herniated lumbar disc and was successfully treated by radiologic intervention and/or surgery. Angiography with the intention of intervention is considered the first step of treatment for a large vessel injury following an operation for a herniated lumbar disc at the level between fourth and fifth lumbar or between fifth lumbar and first sacral intervertebral space.

Endovascular exclusion of thoracic aortic aneurysms: mid-term results of elective treatment and in contained rupture

PURPOSE

The purpose is to present results of endovascular exclusion (stent-graft treatment) of aneurysms of the descending thoracic aorta both in elective cases and in emergencies.

METHODS

Indications for stent-graft treatment were dependent on multislice angio-CT evaluation revealing a proximal neck of at least 10 mm between the left common carotid artery and the onset of aneurysm. All stent grafts were inserted in the operating room; 43 transfemoral, 2 transiliac. The stent grafts used were Corvita, Stenford, Vanguard, AneuRx, Talent, and Excluder. Deployment was achieved under fluoroscopic control, endoleaks were checked for with D S A on the operating table and postoperatively by angio-CT. Long-term follow-up consisted of evaluation with angio-CT after 6 and 12 months, and from there on once a year and with plain chest X-rays. Follow-up was achieved in all patients.

RESULTS

Mean follow-up is 21 months (1-66); 30-day mortality is 3/45, no permanent neurologic deficit. Thirty patients were treated electively, 15 with contained rupture. Left subclavian artery overstenting proved to be necessary in 12 patients for proper proximal sealing of the aneurysm, type I endoleaks were observed in 10 patients, one early conversion, 7 proximal extension cuffs, one sealed spontaneously, one still at risk. Among patients where LSA had been overstented only one wanted a transposition, all others did well without left-hand ischemia or subclavian steal syndrome.

CONCLUSION

Endovascular treatment is less invasive and has reasonable mortality and morbidity but is limited to well-defined morphologies. Mid-term results are promising but it has to be observed whether these will translate into long-term durability.

Midterm outcomes of thoracic aortic stent-grafts: complications and imaging techniques

PURPOSE

To evaluate the midterm outcomes of thoracic aortic stent-grafting and the performance of computed tomographic angiography (CTA), radiography, and magnetic resonance angiography (MRA) in endograft surveillance.

METHODS

Forty-seven patients with traumatic thoracic aortic ruptures (n=16), aneurysms (n=14), false aneurysms (n=3), penetrating ulcers (n=3), and dissections (n=11) treated with stent-grafts were monitored in follow-up using chest radiography and CTA in all patients and MRA in 23 patients. Two perpendicular maximal aortic diameters, the sum of these diameters, and the elliptical cross-sectional area were determined and compared to baseline for the entire group and in subgroup analyses according to lesion type. CTA, MRA, and radiography were compared for their ability to detect endoleak, monitor stent-graft configuration, and measure aortic diameters.

RESULTS

The mortality rate was 8.5%. Severe complications were observed in 14.8% (6% neurological complications); 12 (25.5%) patients had primary endoleaks. Over a mean 11-month follow-up (range 0.25-46 months), the aortic diameters decreased for all patients without endoleak (p<0.001). In the diameter/area subgroup analyses, only the traumatic rupture cohort demonstrated significant decreases in all 4 measurements. CTA and MRA measurements correlated well, but chest radiography was superior to both for visualizing stent-graft shape. In terms of endoleak detection, MRA missed only 1 (12.5%) endoleak (type II) seen on CTA; there were no false positive results with MRA.

CONCLUSIONS

Morbidity and mortality observed after thoracic stent-grafting are acceptable. Radiography is better for monitoring stent-graft conformation, while CTA provides the best overall morphological information. The performance of MRA in endoleak detection is encouraging.

False aneurysms at both ends of a descending thoracic aortic stent-graft: complication after endovascular repair of a penetrating atherosclerotic ulcer

PURPOSE

To report the formation of false aneurysms at both ends of a stent-graft implanted in the descending thoracic aorta to repair a penetrating atherosclerotic ulcer.

CASE REPORT

A 66-year-old woman with a penetrating atherosclerotic ulcer was treated with a 34 x 70-mm homemade Gianturco-type stent covered with polytetrafluoroethylene graft. Four months later, she developed false aneurysms at both ends of the stent-graft. The patient refused further endovascular repairs, so the stent-graft was surgically removed and the aorta repaired.

CONCLUSIONS

This case demonstrates an unusual complication that should be anticipated when a stent-graft is deployed in the acute phase of thoracic aortic ulcer or its variants.

Elective endovascular stent-graft repair of atherosclerotic thoracic aortic aneurysms: clinical results and midterm follow-up

OBJECTIVE

The purpose of this study was to evaluate the clinical and midterm results after endovascular treatment of atherosclerotic thoracic aortic aneurysms.

MATERIALS AND METHODS

Twenty-eight consecutive patients who were 53-82 years old (mean age, 71.6 years) were treated with a commercially available endoprosthesis. Subclavian transposition or bypass surgery was performed before the procedure in eight patients. Size dynamics of the aneurysms were analyzed on the basis of diameter and thrombus volume measurements obtained on three-dimensional CT reconstructions before hospital discharge (n = 22) and at the 1-year (n = 22), 2-year (n = 12), and 3-year (n = 5) follow-ups.

RESULTS

The technical success rate was 100%. There was no 30-day mortality. None of the patients had symptoms due to spinal cord ischemia. The survival rate at 1, 2, and 3 years was 96.1%, 90.9%, and 80.2%, respectively. During the perioperative period, patients presented with leukocytosis (37%), fever (36%), elevated C-reactive protein value (92%), pleural effusion (50%), and periaortic atelectasis (41%). Three early type I endoleaks sealed spontaneously. Three early type II endoleaks persisted over time, and one late type II endoleak was detected. In patients with type II endoleaks, thrombus volume of the aneurysms was constant (n = 2) or increased (n = 2). In patients without endoleaks, mean thrombus volume decreased (-53.2 +/- 56.8 mL, -40%) significantly (p = 0.001) during the first year. There was no significant interval decrease between the 1- and 2-year follow-ups (mean, -2.4 mL, p = 0.92) and between the 2- and 3-year follow-ups (mean, -0.4 mL, p = 0.68).

CONCLUSION

Endovascular treatment of atherosclerotic thoracic aortic aneurysms may result in a substantial reduction of the aneurysm sac in patients without endoleaks.

Endovascular treatment of complicated type-B aortic dissection with stent-grafts:: midterm results

PURPOSE

To report the midterm results of the endovascular treatment of complicated type-B aortic dissection with use of stent-grafts.

MATERIALS AND METHODS

Ten patients with acute (n = 4) or chronic (n = 6) complicated type-B dissection were treated with custom-made stent-grafts. Indications for treatment included uncontrollable hypertension with dissection extension (n = 3), renal ischemia (n = 1), and false lumen aneurysm (n = 6). Stainless-steel Z-stents covered with polyester grafts were placed in the initial six patients. Nitinol stents covered with ultrathin polytetrafluoroethylene were used in the remaining four patients. The patients were followed-up with helical computed tomography for a maximum of 30 months (mean, 20 mo).

RESULTS

There was one technical failure related to the access site. Early complications included deep venous thrombosis (n = 1) and embolic stroke (n = 1). Complete thrombosis of the thoracic false lumen was achieved in six patients and partial thrombosis was achieved in three. Aneurysms developed at the ends of the stainless-steel stents in two patients, requiring additional stent-graft placement. Despite successful remodeling of the thoracic aorta, three of four patients with distal reentry into the abdominal aorta experienced progressive abdominal aortic aneurysm (AAA). AAA rupture developed in two patients; one rupture was fatal and the other was treated with emergency surgery.

CONCLUSIONS

Endovascular treatment of complicated type-B aortic dissection is technically feasible and effective. Closely monitoring the treated aorta is essential to detect early aneurysm formation at the ends of rigid stents. Despite adequate sealing of the tears in the thoracic aorta, dissection with distal reentry phenomenon into the abdominal aorta may evolve into AAA with late rupture.

Endovascular therapy combined with immunosuppressive treatment for pseudoaneurysms in patients with Behçet's disease

PURPOSE

To evaluate the feasibility, efficacy, and outcome of endovascular therapy combined with immunosuppression for the treatment of arterial pseudoaneurysms due to Behçet's disease.

METHODS

Eleven pseudoaneurysms (3 in the abdominal aorta, 3 in the subclavian artery, and individual lesions in the brachiocephalic artery, renal artery, common iliac artery, common carotid artery, and the descending thoracic aorta) in 9 patients with Behçet's disease were treated with 10 stent-grafts and 1 self-expanding stent. All patients with elevated erythrocyte sedimentation rate (ESR) were treated with immunosuppressive agents (azathioprine, prednisolone) before and after the procedure.

RESULTS

Endovascular treatment was successful in all cases, without major adverse events. The ESR was reduced from 42.7+/-18.0 mm/h initially to 18.6+/-12.6 mm/h after immunosuppressive therapy prior to endovascular repair. During follow-up (mean 24.1+/-14.0 months, range 6-43), 8 of 11 lesions showed complete resolution. One stent-graft to treat a postsurgical recurrent carotid artery pseudoaneurysm was occluded, and an abdominal aortic pseudoaneurysm recurred; both patients stopped their medications. ESR during follow-up was 7.9+/-4.5 mm/h.

CONCLUSIONS

Endovascular treatment for pseudoaneurysms due to Behçet's disease is feasible and effective when disease activity is strictly controlled with immunosuppressive therapy.