Hybrid open-endoluminal technique for repair of thoracoabdominal aneurysm involving the celiac axis

Management of Abdominal Aortic Aneurysm: A Decade of Progress

Since the world was first introduced to the concept of endovascular aneurysm repair by Parodi's landmark procedures in 1990, stent-grafts have assumed a prominent role in the management of abdominal aortic aneurysm. Most modern systems are trackable, accurate, and secure. The resulting endovascular procedure is safe, durable, effective, and versatile. Perhaps the most significant increment in the applicability of the endovascular technique was achieved by the development of bifurcated stent-grafts, which dispensed with inadequate distal aortic implantation sites. Additional branches and fenestrations now permit endovascular repair in cases of thoracoabdominal, pararenal, juxtarenal, and bilateral iliac aneurysms. These advances in device performance have been accompanied by a rapid dissemination of necessary skills, leading to the development of a new superspecialty of vascular therapy, with elements of vascular surgery, interventional radiology, and interventional cardiology.

Combined Endovascular and Surgical Approach (Hybrid Treatment) for Management of Type IV Thoracoabdominal Aneurysm

The purpose of this article is to report successful hybrid treatment of a sovraprosthetis type IV thoracoabdominal aneurysm.

This technique was used in a 65-year-old man with chronic rupture of a type IV thoracoabdominal aneurysm not suitable for aortic cross-clamping because of a severe cardiopathy (left ventricular ejection fraction 20%); the patient underwent previous repairs of aortic arch and infrarenal abdominal aortic aneurysms. Perioperative complications were absent. Postoperative day 21 computed tomography and monthly duplex ultrasonography confirmed the complete exclusion of the aneurysm with proper perfusion of visceral vessels. At the seventh postoperative month, the patient died of a massive recurrence of myocardial infarction.

Hybrid treatment for thoracoabdominal aneurysms may represent a valid solution for those patients with poor cardiac and respiratory reserve, reducing cardiac stress and the duration of visceral ischemia, which are still the main causes of morbidity and mortality for this type of intervention.

Thoracic Stent Grafts with a Distal Fenestration for the Celiac Axis

Descending thoracic aneurysms can be treated with a stent graft provided that there is sufficient proximal and distal aortic neck length above the celiac axis. One of the options for the treatment of thoracic aneurysms with a too short distal neck is described in this report. For this purpose, a stent graft was constructed with a scallop for the celiac axis. Three cases are presented, and the technical details are described.

Novel approach to a type I endoleak following a hybrid repair of an arch aortic aneurysm

Hybrid surgical and endovascular approaches such as open visceral vessel debranching and subsequent endovascular exclusion of thoracic abdominal aortic aneurysms (TAAA) represents a significant development in treatment of TAAAs. As compared to traditional endovascular aneurysm repair, hybrid repairs commonly have a higher rate of endoleak and other endograft-related complications. In this report, we present a 71 year-old man with significant comorbidities including chronic obstructive pulmonary disease, hypertension and prostate cancer. The patient after undergoing debranching of the thoracic arch followed by endograft repair of an arch aneurysm developed a proximal type I and type II endoleak fed by the previously ligated left subclavian artery. Despite coiling of the left subclavian artery and proximal extension of the endograft, a type I endoleak persisted. Several months after the left subclavian artery was coiled, a catheter was advanced through the coils and beyond the site of ligation directly into the aneurysmal sac. Once in the aneurysmal sac, multiple coils were deployed resulting in successful treatment of the type I endoleak. This report highlights the unique challenges in treating proximal descending thoracic aneurysms and represents the first report of the treatment of a type I endoleak with reaccess through a previously coiled vessel for deployment of embolics directly into the aneurysmal sac.

Endovascular repair for a descending thoracic aortic aneurysm with a stent-graft covering the celiac artery: report of two cases

An adequate landing zone for fixation and sealing is necessary for endovascular aneurysm repair (EVAR). This report presents two cases of a successful EVAR for thoracic aortic aneurysms (TAA) with a stent-graft covering the celiac artery (CA) to secure a distal landing zone. Case 1 was a 61-year-old man with a chronic traumatic descending TAA 12 mm away from the CA. Case 2 was a 79-year-old man with a descending TAA proximal to the CA. Preoperative angiography and computed tomography (CT) scan revealed a normal visceral blood flow including the peripancreatic arteries. Endovascular aneurysm repair with coverage of the CA was performed in both cases. Angiography after the EVAR demonstrated good blood flow to the CA branches via the peripancreatic arteries and a CT scan showed thrombosed aneurysms. Both patients were discharged without any abdominal symptoms. Endovascular aneurysm repair with a stent-graft covering the CA may therefore be an acceptable endovascular approach in treating selected TAA patients with a limited distal landing zone.

The Risks of Celiac Artery Coverage During Endoluminal Repair of Thoracic and Thoracoabdominal Aortic Aneurysms

The risks of purposeful celiac artery coverage during endovascular thoracic aortic aneurysm repair (TEVAR) to obtain an adequate distal landing zone have received scant scientific attention. Patients undergoing TEVAR at 6 tertiary centers from January 2000 to June 2007 were identified (n = 434); cases requiring celiac artery exclusion (n = 19; 4.4% of the total) were analyzed. The mean follow-up was 8.7 months (range, 0.2-21.2). The mean patients' age was 73.6 years (range, 56-86); 57.9% were men. The mean aneurysm diameter was 6.7 cm (range, 5-8.6). In 2 patients, the celiac artery balloon occlusion test was performed prior to TEVAR. In both, intact collateral foregut circulation was seen. Both underwent TEVAR without celiac artery revascularization; 1 did well, whereas the other developed foregut ischemia. In 16 cases (84.2%), the celiac artery was not revascularized prior to TEVAR. In those patients, 19 complications were reported (3 deaths; 2 paraplegia). No similar events occurred in those who underwent celiac artery revascularization (n = 3). Celiac artery coverage during TEVAR is required in 4.4% of cases. TEVAR correlated with a nonnegligible number of major complications. Complications were more frequent and severe in patients who did not have celiac artery revascularization prior to TEVAR. Specific celiac artery coverage complications are rare and not readily predictable based on preprocedure arteriography.

[Thoracoabdominal aortic aneurysm hybrid repair]

Introduction of endografting has significantly changed the treatment options of aortic aneurysms; they can be successfully applied for aortic arch or thoracoabdominal aorta aneurysm repairs, as well. In order to create safe landing zones for the endografts on these segments, a modification of the original anatomy is needed using transpositions and/or bypasses, which is called "debranching". These hybrid procedures that combine traditional and endovascular techniques may reduce surgical trauma and offer solution for patients being unfit for major surgery. We carried out a hybrid intervention in a lady who had a 60 mm Crawford Type IV aortic aneurysm including the orifice of the celiac trunk. First, an aorto-splenic artery PTFE bypass was performed and the celiac trunk was oversewn proximally to its trifurcation. The spleen remained viable through the gastroepiploic artery. Four days thereafter we covered the aneurysm using a 34 mm Thoracic Excluder. The patient tolerated both procedures well, and was discharged in stable condition. One year after this intervention, a follow-up CT scan confirmed the good position of the endograft, no endoleak and involution of the aneurysm was detected. Good patency of the aorto-splenic artery bypass was seen. This was the first thoracoabdominal hybrid surgery case performed in Hungary.

Hybrid Open-endovascular Repair for Thoracoabdominal Aortic Aneurysms: Current Status and Level of Evidence

PURPOSE

To report the results of a systematic review of the literature and to provide evidence for the hybrid open-endovascular repair (HOER) in patients with thoracoabdominal aortic aneurysms (TAAAs).

METHODS

A comprehensive literature review was performed and all studies identified that reported the results of HOER in patients with TAAA and information about primary technical and clinical success in evaluating the immediate and long-term complications such as neurological, renal and respiratory morbidity. All studies were reviewed by two independent observers for the above mentioned parameters.

RESULTS

After careful selection according to the given criteria, 13 studies were included in our statistical analysis. The number of reported patients totalled 58. Of those, 37 were men (64.4%) and the mean age of the patients was 68.1 years (range 35-80, 95%CI [72.8, 64.9]). All patients were unfit for open repair with severe comorbidities. The mean follow-up period was 14.5+/-8.7 months (range 4-36, 95%CI [18.7, 9.9]) and the mean aneurysm diameter was 7.15cm (range 5 to 12, 95%CI [7.87, 6.69]). 229 (97.8%) of the 234 visceral vessel grafts remained patent during the follow-up period. Reintervention was necessary in one (1.6%) of the five patients with an occluded graft. The overall long-term endoleak rate was 20.6% (12/58 patients) and the reintervention rate was 13.7% (8/58 patients). No patients developed procedure-related neurological deficits. The overall early and long-term mortality rate for completed procedures was 15.5% (9/58).

CONCLUSIONS

HOER shows promising mid-term results for high-risk patients who have TAAA, however, present evidence does not allow robust conclusions.

Stent-grafting of the thoracic aorta: feasibility and early results in acute and chronic lesions

BACKGROUND AND AIMS

Conventional surgery of the thoracic aorta is frequently associated with significant mortality and morbidity. Here we present treatment of surgical pathologies of the thoracic aorta using a less invasive endovascular approach.

METHODS

From January 2000 to May 2004, 51 patients (mean age 62.7 +/- 12.8 years, 36 men) underwent endovascular repair of thoracic aortic lesions in our institution. All patients underwent computed tomography scan at discharge, 6 and 12 months and annually thereafter. Clinical follow-up was carried out by outpatient clinic visit or by telephone contact with the patients or their referring physicians. Mean follow-up was 15.8 months.

RESULTS

The 30-day mortality rate was 3.8%, one death in the group of chronic (1.9%) and one in the group of acute lesion (1.9%). The survival rate in the follow-up period was 92.4% at 6 months. Computed tomography angiography confirmed exclusion of the lesion in 25 out of 27 chronic patients, whereas type I and II endoleaks were detected in two patients treated with a secondary procedure. In addition, two patients with an acute type B aortic dissection presented with early endoleaks. The overall rate of complications was 10%. No other endoleaks or deaths were observed at later follow-up.

CONCLUSIONS

The early and mid-term results of endovascular stent-grafting for the treatment of chronic and acute thoracic aortic diseases showed a good outcome and low rate of complications. Stent-grafting of the thoracic aorta is still an investigational procedure that needs further validation.

Hybrid procedures as a combined endovascular and open approach for pararenal and thoracoabdominal aortic pathologies

OBJECTIVES

to report our experience with hybrid vascular procedures in patients with pararenal and thoracoabdominal aortic pathologies.

METHODS

68 patients were treated for thoracoabdominal aortic pathologies between October 1999 and February 2004; 19 patients (16 men; mean age 68, range 40-79) with high risk for open thoracoabdominal repair were considered to be candidates for combined endovascular and open repair. Aortic pathologies included five thoracoabdominal Crawford I aneurysms, one postdissection expanding aneurysm, three symptomatic plaque ruptures (Crawford IV), five combined thoracic descending and infrarenal aneurysms with a healthy visceral segment, three juxtarenal or para-anastomotic aneurysms, and two patients with simultaneous open aortic arch replacement and a rendezvous maneuver for thoracic endografting. Commercially available endografts were implanted with standardized endovascular techniques after revascularization of visceral and renal arteries.

RESULTS

Technical success was 95%. One patient developed a proximal type I endoleak after chronic expanding type B dissection and currently is waiting conversion. Nine patients underwent elective, five emergency and five urgent (within 24 h) repair. 17 operations were performed simultaneously, and 2 as a staged procedure. Postoperative complications include two retroperitoneal hemorrhages, and one patient required long-term ventilation with preexisting subglottic tracheal stenosis. Thirty-day mortality was 17% (one multiple organ failure, one secondary rupture after open aortic arch repair, one myocardial infarction). Paraplegia or acute renal failure were not observed. Total survival rate was to 83% with a mean follow-up of 30 months.

CONCLUSIONS

Midterm results of combined endovascular and open procedures in the thoracoabdominal aorta are encouraging in selected high risk patients. Staged interventions may reduce morbidity.

Endoluminal repair of mycotic thoracic aneurysms

PURPOSE

To report a series of endoluminally repaired mycotic thoracic aneurysms.

CASE REPORTS

Four patients with presumed mycotic aneurysms of the thoracic aorta were treated with endovascular grafts owing to overly high risk for open repair. All aneurysms were successfully excluded at the initial intervention. In one case, which required endograft fenestrations for the superior mesenteric and renal arteries, the patient died 53 days after the procedure, following graft migration and occlusion of major branch vessels. The other 3 patients remain alive and well at a mean follow-up of 16 months with no signs of ongoing sepsis.

CONCLUSIONS

Endoluminal repair of thoracic mycotic aneurysms is technically feasible and, in association with long-term antibiotics, offers at least temporary protection against imminent rupture.

Thoracoabdominal aortic aneurysm repair: review and update of current strategies

BACKGROUND

Surgical repair of thoracoabdominal aortic aneurysms remains a technically challenging operation that requires a multimodality approach to preventing ischemic complications. The purpose of this report is to update our experience and highlight our current clinical strategies.

METHODS

Between January 1, 1986 and December 31, 2001, 1,773 patients underwent thoracoabdominal aortic aneurysm repair. The majority of these patients (1,153, 65%) required Crawford extent I or II repairs. Segmental intercostal or lumbar arteries were reattached in 1,082 patients (61%); left heart bypass was used in 686 patients (38.7%), and 173 patients (9.8%) had cerebrospinal fluid drainage.

RESULTS

The 30-day survival rate was 94.3% (1,672 patients). Postoperative complications included renal failure requiring hemodialysis in 105 patients (5.9%) and paraplegia or paraparesis in 79 patients (4.5%). Actuarial 5-year survival was 73.5% +/- 1.6%.

CONCLUSIONS

This clinical experience demonstrates that current technical strategies enable patients to undergo thoracoabdominal aortic aneurysm repair with excellent early survival and acceptable morbidity.