Results of urgent and emergency thoracic procedures treated by endoluminal repair

Aorto-oesophageal and aortobronchial fistulae following thoracic endovascular aortic repair: a national survey

OBJECTIVE

We evaluated the incidence of aorto-oesophageal (AEF) and aortobronchial (ABF) fistulae after thoracic endovascular aortic repair (TEVAR), and investigated their clinical features, determinants, therapeutic options and results.

METHODS

We conducted a voluntary national survey among Italian universities and hospital centres with a thoracic endovascular programme.

RESULTS

Thirty-nine centres were contacted, and 17 participated. Of the patients who underwent TEVAR between 1998 and 2008, 19/1113 (1.7%) developed AEF/ABF. Among indications to TEVAR, aortic pseudo-aneurysm was associated with the development of late AEF/ABF (P = 0.009). Further, emergent and complicated procedures resulted in increased risk of AEF/ABF (P = 0.008 and P < 0.001, respectively). Eight patients were treated conservatively, all of whom died within 30 days. Eleven patients underwent AEF/ABF surgical treatment, with a perioperative mortality of 64% (7/11). At a mean follow-up of 17.7 +/- 12.5 months, overall survival was 16% (3/19).

CONCLUSIONS

The incidence of AEF and ABF following TEVAR is not negligible, and is comparable to that following open repair. This finding warrants an ad hoc long-term follow-up after TEVAR, particularly in patients submitted to emergent and complicated procedures. Both surgical and endovascular treatment of AEF/ABF are associated with high mortality. However, conservative treatment does not appear to be a viable option.

An unusual presentation of thoracic aortic aneurysm rupturing into the esophagus: an autopsy case report

Ruptured aortic aneurysms often present with sudden death, and have varied signs and symptoms depending on the site of rupture and hemorrhage. We report a case of an aortic aneurysm with an aorto-esophageal fistula, which showed slow gastrointestinal bleeding for days before death. A 79-year-old male was brought to a hospital emergency unit, with a history of melena for about 3 days, and recent hematemesis. He collapsed immediately after endoscopy and died. A forensic autopsy which was performed due to possible medical malpractice demonstrated a large saccular aneurysm of the descending thoracic aorta with a fistula into the esophagus. A significant finding was a lid or valve shaped thrombus covering the aortic orifice of the fistula, which may have partly contributed to slow bleeding, and which may have been dislodged by endoscopy. This case suggests that very careful management of aorto-esophageal fistula is needed in patients with clinical signs of possible thoracic aortic aneurysm with slow hemorrhage.

Endovascular grafts for treatment of traumatic injury to the aortic arch and great vessels

BACKGROUND

Treatment of traumatic vascular injury using endovascular techniques has evolved as endovascular capabilities have advanced over the past several decades. Several endovascular techniques have been employed to address the challenges of traumatic arterial injury, including coil embolization and the use of stents, which may be either bare metal or covered with graft material. Compared with traditional surgical repair, endovascular stent grafting for the repair of traumatic arterial injury offers the advantage of decreased morbidity because a remote access site may be used, avoiding surgical dissection and lengthy operating times.

METHODS

A Medline (1995-2007) search was performed to find all studies discussing the use of endovascular means to treat supradiaphragmatic arterial trauma.

RESULTS

In this review of 195 studies published between January 1995 and December 2007, the overall technical success rate of endovascular treatment of supradiaphragmatic arterial injury was 96.7%, and the complication rate was 6.4%.

CONCLUSION

The results of this review suggest a potential morbidity and mortality benefit over traditional open repair; however, long-term data are lacking. Long-term follow-up for stent durability is of particular concern in the trauma population, which tends to comprise younger patients with minimal atherosclerotic disease. The success of endovascular techniques is also limited by the availability of skilled interventionalists, properly outfitted angiography suites, and suitable stent graft devices. Despite these challenges, the potential advantages of endovascular stenting make it a welcome addition to the armamentarium of the vascular interventionalist who treats arterial traumatic injuries.

Type B aortic dissections: treating the many to benefit the few?

PURPOSE

It is now more than a decade since aortic stent-grafts were introduced clinically to provide a less invasive and potentially less harmful therapeutic option to treat type B aortic dissections. However, recent publications on best medical treatment and quality of life in patients with chronic type B dissection support conservative treatment due to the low incidence of aneurysm formation, rupture, and disease-related complications. Against this backdrop, we analyzed our experiences and now discuss whether the availability of endografts allowed us to change indications toward a more aggressive endovascular approach to acute and non-complex type B dissections, seeking to determine which patients we should treat and which ones we should observe.

METHODS

Between 1997 and 2008 in our institution in Heidelberg, we treated 172 patients with acute and chronic type B dissections, most (n = 118, 69%) conservatively. However, 54 patients (40 men; mean age 57 years, range 30-82) underwent endovascular repair; 43% (n = 23) were emergency cases. Patients were followed periodically with computed tomographic angiography.

RESULTS

Correct stent-graft deployment was achieved in 50 (93%) patients; the left subclavian artery was intentionally covered in 30 (55%) cases. Two carotid-subclavian bypass grafts were performed at the time of the endovascular repair due to partial coverage of the left common carotid artery. The perioperative complication rate was 19% (n = 10), but there were no neurological sequelae. The 30-day mortality rate was 11% (n = 6). Over a mean 32.1+/-25 months, 4 other patients died (18.5% overall mortality rate); survival estimates by Kaplan-Meier analysis were 80.4% and 66.1% after 1 and 5 years, respectively. Complete false lumen thrombosis was observed in 32 (60%) and a persisting completely patent false lumen in 3. The aortic expansion rate was 31% (17/54) overall. No difference was found between acute and chronic dissections in terms of survival (p = 0.247).

CONCLUSION

Despite a minimally invasive approach, complication and mortality rates for endovascular therapy of type B aortic dissections are considerable. Endografting is limited to symptomatic patients and those with chronic large aneurysmal expansion. At this stage in stent-graft development, asymptomatic patients benefit more from conservative treatment.

Endoluminal repair of distal aortic arch aneurysms causing aorto-vocal syndrome

PURPOSE

We have evaluated the efficacy of endovascular repair of distal aortic arch aneurysms (DAAA) causing recurrent laryngeal nerve palsy.

MATERIAL AND METHODS

Eight patients (five male and three female) with median age of 72 years (range: 59-80) presented with left recurrent laryngeal nerve palsy associated with DAAA. All patients were considered unfit for open surgery. The median aneurysm size was 5.9 cm (range: 5-7.3). Thirteen stents were deployed: eight Gore, four Endofit and one Talent. Epidural anaesthesia was used in all patients. The left subclavian artery was covered in all and the left common carotid in three who had a preliminary right to left carotid-carotid bypass. Routine follow-up (FU) was with computed tomography (CT) at 3-6 months and yearly thereafter.

RESULTS

Exclusion of the aneurysm sac was achieved in all patients. Thirty-day mortality was 0%, with no paraplegia or stroke. Early complications included: rupture of the external iliac artery (one) and common femoral artery thrombectomy (one). One patient died of unknown cause at 17 months. The mean FU in the remaining seven patients was 21 months (range: 6-51). Aneurysm size decreased in five, was unchanged in one and increased in one. Three patients had improvement in voice quality postoperatively. One patient had a recurrent type 1 endoleak which was restented twice. No late deaths have occurred.

CONCLUSION

Though technically the procedures involved were more complicated, endovascular repair of DAAA causing aorto-vocal syndrome is safe and offers a realistic alternative to open surgery. Hoarseness of the voice can improve postoperatively and is associated with reduction in aortic sac diameter.

Endovascular Repair of Traumatic Thoracic Aortic Injuries: A Critical Appraisal

Blunt trauma to the thoracic aorta is life-threatening, with instant fatality in at least 75% of victims. If left untreated, nearly half of those who survive the initial injury will die within the first 24 hours. Surgical repair has been the standard treatment of blunt aortic injury, but immediate operative intervention is frequently difficult due to concomitant injuries. Although endovascular treatment of traumatic aortic disruption is less invasive than conventional repair via thoracotomy, this strategy remains controversial in young patients due to anatomical considerations and device limitations. This article reviews the likely advantages of endovascular interventions for blunt thoracic aortic injuries. Potential limitations and clinical outcomes of this minimally invasive technique are also discussed.

Surgical strategy in aortoesophageal fistulae: endovascular stentgrafts and in situ repair of the aorta with cryopreserved homografts

OBJECTIVE

The surgical treatment of aortoesophageal fistulae (AEF) has a high morbidity and mortality rate. We report our experience with the sequential use of endovascular thoracic stentgrafts and cryopreserved aortic homografts for in situ repair of the descending thoracic aorta.

METHODS

In a 7-year period, 6 patients with AEF were treated at our center. After primary endovascular repair in all cases, 4 patients subsequently underwent in situ repair of the descending thoracic aorta with cryopreserved homografts. Long-term antibiotic therapy was given in all cases. Recent clinical status and radiologic findings on follow-up studies of each patient were analyzed. The mean follow-up time was 35 months (range, 2-76).

RESULTS

Endovascular stentgraft repair was technically successful in all cases. Two patients were not candidates for open surgical repair because of their medical condition; they both died within 8 weeks after discharge from the hospital, 1 from recurrent septic episodes, and the other from upper gastrointestinal bleeding. One of 4 patients who had undergone open surgical repair died 1 year later from upper gastrointestinal bleeding that occurred presumably due to an infectious degeneration of the homograft after secondary infection with a methacillin-resistant Staphyloccocus aureus. In 1 case persistent paraplegia and in another case persistent renal failure occurred.

CONCLUSION

The use of cryopreserved homografts is a valuable alternative to in situ repair with prosthetic vascular grafts or extra-anatomic reconstructions in the surgical treatment of AEF. Endovascular stentgraft placement plays a role as a bridging procedure in emergency situations.

Salvage options after stent collapse in the thoracic aorta

The endograft was originally developed to repair aneurismal disease of the infra-renal aorta and has since realised many other applications, including the treatment of arterial trauma. Traumatic transection of the thoracic aorta is a condition associated with a high mortality and affected patients often have multiple injuries. Endovascular repair of thoracic transection is an attractive option in those patients for whom open surgical repair would be highly dangerous and other groups have reported early technical success. However, we report 3 cases of young patients with traumatic thoracic aortic transection, initially treated successfully by endoluminal stenting, who developed the complication of stent collapse. We discuss here the options available to treat the complication.

Application of endograft to treat thoracic aortic pathologies: A single center experience

PURPOSE

To evaluate our experience of thoracic endoluminal graft (ELG) repair of various thoracic aortic pathologies using a commercially available device approved by the Food and Drug Administration. Our patient population includes patients eligible for open surgical repair and those with prohibitive surgical risk.

METHODS

From March 1998 to March 2006, endovascular stent repair of the thoracic aorta was performed on 406 patients with 324 patients (median age 72; 200 male) receiving the Gore Excluder endograft. Patient demographics, procedural characteristics, complications, including endoleak, spinal cord ischemia, and mortality, were retrospectively reviewed during follow-up. All patients were followed with chest computer tomography at 6 months and yearly. Statistical analysis was performed utilizing the SPSS Windows 11.0 program. Logistic regression (univariate) analysis used to identify risk factors for paraplegia; analysis of variance (ANOVA) for endoleak distribution; and chi(2) used to analyze variables. Survival analysis was done using SAS version 9.1 (SAS Institute, Cary, NC).

RESULTS

Three hundred twenty-four patients were treated with Gore Excluder graft between March 1998 and March 2006. One hundred fifty-seven patients (48.5%) had atherosclerotic aneurysms, 82 (25.3%) had dissections type B (DTB), 34 (10.5%) had penetrating ulcers (PU), 26 (8.0%) with pseudoaneurysms (PSA), 11 (3.4%) had transections (MVAT), 9 (2.8%) aorto-bronchial fistulas (AoBF), 4 (1.2%) embolization, and 1 (0.3%) aorto-esophageal fistula (AoEF). Preoperative aneurysm sac size in TAA ranged from 5 to 12 centimeters, average size 6.3 cm. Sac shrinkage occurred in 65% (102 of 157) of patients. Average postoperative sac size of 5.4 cm in a mean follow-up of 20.4 months. One hundred cases (31.5%) were nonelective; 49 (15.1%) were ruptures. Overall complication was 22.7%, 14.2% (46) in elective cases and 8.5% (28) in nonelective cases. Paraplegia occurred in five (1.5%) patients and paresis in three (0.9%); two of the latter improved and one resolved completely prior to discharge. Incidence of paraplegia was statistically significant (P value < .05) with retroperitoneal approach, perioperative blood loss greater than 1000 cc, and aortic coverage greater than 40 cm. Early endoleaks included 18 (5.5%) type I, four (1.2%) type II, and two (0.6%) type III. Thirty-day mortality was 5.5% (18 related deaths, including three intraoperative deaths). A log rank test did not find statistical differences in actuarial survival with 30-day related mortality between TAA and other pathologies (P = .29) or between DTB and other pathologies (P = .97). Late mortality was 9.6% with 31 unrelated deaths. Follow-up ranged between 1 month and 70 months, average 17 months.

CONCLUSIONS

Endoluminal grafting is a feasible alternative to open surgical repair for thoracic aortic pathologies. After more than 300 cases, 30-day morbidity and mortality compares favorably with open repair. Paraplegia remains low as a complication and increases in incidence with retroperitoneal approach, increased perioperative blood loss, and increased aortic coverage.

Endovascular PTFE-Covered Stent for Treatment of an External Iliac Artery Pseudoaneurysm in the Presence of Chronic Infection

A 75-year-old woman with an external iliac artery pseudoaneurysm, thought to have resulted from a chronic loosening and infection of a total hip replacement, was successfully treated by placement of a covered endoluminal stent.

Endovascular treatment of traumatic rupture of the thoracic aorta

Background

Traumatic rupture of the thoracic aorta is a life-threatening event. Open surgical repair is the ‘gold standard’, but is associated with high mortality and morbidity rates. Endovascular repair is emerging as a potentially safer alternative.

Methods

A systematic review was performed of all published literature on this subject, including the authors' own experience. Using Sumsearch, PubMed and cross-references, all published reports up to January 2006 were identified, and analysed for injuries, perioperative morbidity, mortality, operating time, hospital stay and follow-up.

Results

A total of 284 patients were identified. Reported mortality rates range from 0 to 6 per cent. The procedure-related mortality rate is about 1·5 per cent. Some 6·7 per cent of all procedures were complicated by endoleak and the overall procedure-related morbidity rate was 14·4 per cent. These results are promising compared with those of open repair, but individual experience is limited and there may be some publication bias.

Conclusion

Endovascular repair of traumatic rupture of the thoracic aorta seems to reduce morbidity and mortality in patients with multiple trauma. Ideally, both devices and experienced personnel should be available in trauma centres.

Complications after endovascular repair of acute symptomatic and chronic expanding Stanford type B aortic dissections

OBJECTIVE

To outline the complications after endovascular repair in patients with acute symptomatic and chronic expanding Stanford type B aortic dissections.

METHODS

Between 1997 and 2004, of 125 patients with acute and chronic aortic type B dissections, 88 were treated conservatively. Thirty-seven patients (29 male, mean age 58 years, range 30-82 years) underwent endovascular repair (30%) using 44 stent grafts of 3 different designs: Excluder (W. L. Gore & Associates, Inc, Flagstaff, Ariz), Talent (Medtronic Vascular, Santa Rosa, Calif), and Endofit (Endomed, Inc, Phoenix, Ariz). Indications for treatment were acute symptomatic type B dissection in 15 patients, chronic expanding aortic dissection greater than 55 mm in 14, rupture in 3, and simultaneous type A repair in 5 patients. Twenty-two operations were performed on an emergency basis. Patient characteristics, procedural variables, outcome, and complications were prospectively recorded. All patients underwent follow-up by computed tomography before discharge, at 6 and 12 months, and annually thereafter (mean follow-up: 24 months).

RESULTS

Correct deployment was achieved in 97% of cases. There were no instances of primary conversion, paraplegia, or stroke. Complete false lumen thrombosis was observed in 11 patients (44%). Perioperative complication rate was 22%. Thirty-day mortality rate in acute and chronic dissections was 19% and 0%, respectively. Freedom from aortic reintervention was 81%, 73%, and 68%, freedom from late rupture was 97%, 90%, and 80%, and overall success rate was 76%, 65%, and 57% at 1, 2, and 5 years, respectively. Results for patients with chronic dissections are significantly (P = .038) better than results in those with acute dissections.

CONCLUSIONS

Despite the minimally invasive approach, the complication and mortality rates for endovascular therapy of aortic dissections are still high. Frank reporting of these sequelae is if great importance to clarify the recent limitations of the method.

Endovascular Repair of Ruptured Saccular Aneurysms of the Descending Thoracic Aorta

Open repair of ruptured aneurysms of the descending thoracic aorta (DTA) is associated with early mortality rates of 20%-60% and severe morbidity rates exceeding 40%. The present report describes three octogenarian patients and one sexagenarian patient at poor surgical risk admitted with acutely ruptured saccular DTA aneurysms (two of four were anastomotic) unrelated to trauma or infection who underwent successful endovascular therapy, which involved the use of aortic endovascular cuffs in three cases. Mean intensive care unit and total hospital stay durations were 1.75 days (range, 1-4 d) and 6 days (range, 3-13 d), respectively. At 30 days, all patients were alive and free of repeat intervention, with aneurysm exclusion achieved in all cases but one, which featured a marginal type II endoleak. These data support endovascular therapy for ruptured saccular DTA aneurysms enabling short-term outcomes that otherwise would have been unrealistic.

Emergency endovascular stent-graft treatment for acute thoracic aortic syndromes

OBJECTIVE

We report the results of our ongoing experience of urgent and emergency stent-graft implantation in acute thoracic aortic syndromes.

METHODS AND RESULTS

In the last 5-years, 19 patients were treated for acute thoracic aortic syndromes. Traumatic rupture was diagnosed in 7 patients, complicated acute type B dissection was present in 5 patients, penetrating ulcer in 4, and symptomatic thoracic aortic aneurysm in 3 patients. There were 17 male patients with a mean age of 54 +/-26 years (range 18-87 ; median 63). Patients were treated in the theatre suite under general anesthesia. Stent-graft placement was technically successful in all patients. The early postoperative mortality was 10.5 %. Neurological events or upper arm ischemia due to overstenting of the left subclavian artery were not observed. Average intensive care unit and hospital stay were 18 and 21 days, respectively. Major complications occurred in 6 patients. Follow-up ranged between 3 and 60 months (mean 25) and included clinical examinations and serial CT-angiography at 1, 4 and 12 months, and every year thereafter. Only one type II endoleak was detected and treated by coil embolization of the left subclavian artery.

CONCLUSIONS

Our experience suggests emergency stent-graft repair in patients with acute thoracic aortic syndromes is a less-invasive attractive alternative, showing encouraging early and mid-term results.

An Experimental Model for the Treatment of Lethal Bleeding Injury to the Juxtahepatic Vena Cava With Stent Graft

BACKGROUND

Juxtahepatic vein injuries present a high mortality rate. Our objectives were to develop an experimental model of endovascular lethal injury of the juxtahepatic inferior vena cava (JHIVC) and to evaluate its hemodynamic alterations; to treat the lesion with volume replacement, and a stent graft (SG); and to follow the animals after treatment.

METHODS

Twenty dogs were anesthetized and monitored [heart rate (HR), mean arterial pressure (MAP), vesical and peritoneal pressures], and submitted to a JHIVC endovascular injury. After volume replacement the dogs were divided into two groups: control (GI) and experimental (GII). GI was observed until death. GII was treated with SG and followed by Doppler ultrasound (DUS) and cavography for 4 (GIIA), and 8 weeks (GIIB), and then sacrificed and IVC and SG were analyzed.

RESULTS

GI presented increased abdominal pressures, arterial hypotension, and death after 80 minutes. GII had a 100% survival rate till sacrifice, without clinical repercussions. At DUS and cavography all SG were patent, with monophasic pulsatile flow. On US, SG diameters after 2, 4, and 8 weeks did not show differences. On cavography IVC diameters presented no difference between groups GIIA and GIIB throughout the experiment. These data analyzed for the GII as a whole, showed statistically significant differences. Average lumen diameter reduction of SG was 27.43+/-20,00%. Pressure values in the IVC cranially, caudally to the SG, and inside the SG, did not show differences. In the IVC with the SG we observed a thicker neointima layer, and the injury in the media layer was covered with fibroconnective tissue.

CONCLUSIONS

We developed an experimental dog model of endovascular lethal injury of the JHIVC with significant increase in abdominal pressures, and a mortality rate of 100%. The treatment of this lesion with SG resulted in a thickened neointima layer, and a 27% reduction in the JHIVC lumen diameter, without clinical repercussion, and with a 100% survival rate.

Acute aortic syndrome: pathology and therapeutic strategies

Acute aortic syndrome (AAS) describes the acute presentation of patients with characteristic "aortic pain" caused by one of several life threatening thoracic aortic pathologies. These include aortic dissection, intramural haematoma, penetrating atherosclerotic ulcer, aneurysmal leak, and traumatic transection. AAS heralds imminent aortic rupture. Highlighting acute aortic pathology as an AAS is therefore important to encourage prompt recognition of this condition and avoid diagnostic delays. The management of AAS remains a therapeutic challenge. The traditional surgical approach to acute "type B" (descending thoracic) aortic pathology is unsatisfactory with high morbidity and mortality. Endovascular aortic stent grafts now represent an alternative minimally invasive approach in these patients who are often poor surgical candidates. Studies show endovascular repair to be technically feasible with fewer complications. This review discusses AAS pathology and in particular assesses the current role for endovascular aortic repair in its treatment.

Initial and Midterm Results for Repair of Aortic Diseases With Handmade Stent Grafts

BACKGROUND

The purpose of this study was to determine the initial and midterm results for repair of thoracic and abdominal aortic diseases using handmade stent-grafts (SGs).

METHODS AND RESULTS

Between 1999 and 2004, 41 consecutive patients (31 patients with thoracic and 10 patients with abdominal aortic disease) underwent endovascular stent-graft repair using handmade SGs. The follow-up averaged 24.8+/-17.6 months. The technical and initial clinical success rates were 82.9% (34/41) and 80.5% (33/41), respectively. Primary type I or III endoleaks occurred in 12.2% (5/41) of the patients. The hospital mortality rate was 4.9% (2/41). Persistent type I or III endoleaks occurred in 9.8% (4/41) and SG migrations occurred in 4.9% (2/41) of the patients. Open surgical conversion was undertaken in 12.2% (5/41) of the patients because of an endoleak and/or migration. The mean change observed in the aneurysm diameter was -6.2+/-10.5 mm, and shrinkage in the diameter occurred in 51.4% (18/35) of the cases. There was 1 patient death because of aneurysm rupture. Neither stent fracture nor graft hole was observed. The overall clinical success rate during follow-up was 78.0% (32/41).

CONCLUSION

The initial and midterm results obtained after repair of the aortic diseases using handmade SGs were considered to be satisfactory. More surgical experience and long-term patient follow-up are both required to further reassess the effect of this treatment.

In situ aortic allograft insertion to repair a primary aortoesophageal fistula due to thoracic aortic aneurysm

Aortoesophageal fistula due to thoracic aortic aneurysm is an uncommon cause of gastrointestinal bleeding and has an extremely poor prognosis. In the English literature, we found only 27 successfully managed cases of primary aortoesophageal fistula due to thoracic aortic aneurysm. We present a case of 74-year-old man who experienced the erosion of a thoracoabdominal aortic aneurysm into the esophagus. We successfully performed resection and replacement of the thoracoabdominal aorta with a cryopreserved allograft and total thoracic esophagectomy. A few months later, the esophagus was reconstructed with orthotopic colonic interposition. The patient recovered well and resumed a normal life (12 months' follow-up).

Endovascular Repair of Nontraumatic Ruptured Thoracic Aortic Pathologies

Endovascular repair of ruptured infrarenal abdominal aortic aneurysms (AAA) is receiving increased attention as the number of experienced users increases. Development of thoracic aortic stent grafts has lagged behind infrarenal advancements because of the reported prevalence of disease. In a few centers, however, the experience in performing thoracic stent graft procedures is quite substantial, such that endovascular therapy has been applied to ruptured thoracic aortic pathologies even though data remain limited and this novel therapy remains controversial. We report our combined experience with endovascular repair of ruptured thoracic aneurysms (RTA) and ruptured thoracic dissections (RTD). One hundred eighty-four thoracic stent graft procedures at the University of North Carolina (UNC) and Union Memorial Hospital (UMH) were reviewed and those patients undergoing RTA or RTD repair from January 1, 2000 to December 31, 2003 identified. Patients having procedures for elective repair or aortic transections were excluded from the analysis. Patient presentation, preoperative condition, procedural variables, mortality, and morbidity were examined. Seventy-four percent of the collective procedures were undertaken in high-risk patients (UNC, 38 of 40; UMH, 99 of 144). Twenty-two patients (8.7%; UNC, n = 6; UMH, n = 16) underwent treatment for either an RTA (n = 11) or an RTD (n = 11). The average age of this cohort was 66.5 +/- 15.6 years and the average aneurysm diameter was 73.1 +/- 31.4 mm. The mean duration of symptoms prior to repair was 103.1 +/- 122 hr, influenced primarily by transport times and device availability. Stent graft exclusion was accomplished in 100% of patients with a procedural mortality of 0%. Commercial Talent devices were used in 19 patients (86.4%) and AneuRx device was used in 1 patient (4.5%). In the remaining two (9.1%) patients hand-made devices constructed of Gianturco stents and Dacron fabric were used because of active hemorrhage and lack of appropriate device sizes. Operative time was 135.5 +/- 48.5 min and was associated with an average blood loss of 242.0 +/- 232.4 cc. Thirty-day mortality was 45.5% (RTA, 27.3%; RTD, 63.6%; p = 0.099). Length of stay in the intensive care unit was 6.1 +/- 7.9 days and the mean hospital stay was 11.7 +/- 10.6 days. Major complications were present in 54.5% of RTA (cardiac, 1; pulmonary, 3; cardiovascular accident, 2; spinal cord ischemia, 2; pulmonary embolism, 1), and 81.2% of RTD (multisystem organ failure, 7; pulmonary, 1; common femoral artery injury, 1) but not statistically different between groups. There were only two late complications (cardiac death, endoleak-Ia, 1) that occurred during the mean follow-up of 12.5 +/- 11.3 (range, 1-32) months. These results indicate that endovascular repair of ruptured thoracic pathologies can be accomplished with an acceptable morbidity and mortality. There were no immediate procedural mortalities and complete exclusion was accomplished in all patients. Most postoperative complications arose from preexisting medical conditions and were not procedure related. The benefit of endovascular repair of ruptured thoracic aortic pathologies is promising.

Mid-term Results after Endovascular Repair of the Atherosclerotic Descending Thoracic Aortic Aneurysm

INTRODUCTION

Thoracic aortic aneurysms (TAA) are the most common condition of the thoracic aorta requiring surgical treatment. Despite significant improvement in anesthetic, surgical techniques and postoperative care, the mortality and morbidity rate in TAA-repair remains high. The aim of this study was to assess the morbidity and mortality rate after endovascular stent-graft treatment of atherosclerotic (non-dissecting) TAAs.

METHODS

Thirty-one patients, ASA-classification III-IV, with symptomatic or expanding atherosclerotic TAAs underwent endovascular stent-graft repair between May 1997 and August 2003. Procedures were performed on an emergency basis in 13 patients and elective in 18 patients. Patients were assessed postoperatively by routine CT-scan within 48 h. Further follow up investigations were performed after 3, 6, 12 months and annually thereafter.

RESULTS

Stent-graft placement was successful in all but one patient in whom the stent-graft procedure had to be postponed due severe hemodynamic instability. Perioperative mortality rate was 19% including three haemorrhages, two cardiac events and one respiratory failure (6/31). Technical success rate was 55% (17/31). Completion CT scans performed in 30 patients within 2 days of stent-graft procedure showed type I leaks in seven patients (23%), type II leaks in four patients (13%) and type III leaks in two patients (6%). Further complications included one stroke, one paralysis, one spinalis anterior syndrome and five relevant access related complications. New onset endoleaks, all type I, were observed in seven patients (23%) occurring after 3, 4, 7, 8, 17, 25 and 26 months. Mean follow-up was 15 months (range 2-69 months).

CONCLUSION

Thoracic aortic atherosclerotic aneurysm stent-grafting is feasible but not without significant morbidity and mortality.

Endovascular Surgery and Pathology of the Thoracic Aorta

Although abdominal aortic aneurysms are the most common aortic pathology in the general population, the thoracic aorta is also a frequent site of aneurysms, chronic dissections, transections, and other potentially life-threatening pathologies. Not all of these lesions are amenable to endovascular repair; however, early evidence suggests that endovascular intervention in selected patients has a high rate of acute and midterm success. Indeed, the endovascular procedure reduces operating time and the need for blood transfusions and usually results in shorter intensive care unit and hospital stays compared with open surgery. In addition, overall rehabilitation is comparatively brief. Although these results are encouraging, no outcome data from randomized trials exists, and further study of the long-term efficacy and safety of endoluminal grafting is warranted.