Complications after Endovascular Treatment of Thoracic Aortic Aneurysms

Outcome After Conservative and Endovascular Treatment of Stanford Type B Aortic Intramural Hematomas - A Single-Center Retrospective Study

OBJECTIVES

Aortic intramural hematoma (IMH) is a rare disease. Thus far, only limited data is available and the indications for conservative and endovascular treatment are not well defined. The aim of this study was to investigate clinical presentation, course, CT imaging features and outcome of patients with type B aortic IMHs.

METHODS

We included all patients with type B IMHs between 2012 and 2021 in this retrospective monocentric study. Clinical data, localization, thickness of IMHs and the presence of ulcer-like projections (ULPs) was evaluated before and after treatment.

RESULTS

Thirty five patients (20 females; 70.3 y ± 11 y) were identified. Almost all IMHs (n = 34) were spontaneous and symptomatic with back pain (n = 34). At the time of diagnosis, TEVAR was deemed indicated in 9 patients, 26 patients were treated primarily conservatively. During the follow-up, in another 16 patients TEVAR was deemed indicated. Endovascularly and conservatively treated patients both showed decrease in thickness after treatment. Patients without ULPs showed more often complete resolution of the IMH than patients with ULPs (endovascularly treated 90.9% (10/11) vs 71.4% (5/7); conservatively treated 71.4% (10/14) vs 33.3% (1/3); P = .207). Complications after TEVAR occurred in 32% and more frequently in patients treated primarily conservatively (37.5% vs 22.2%). No in-hospital mortality was observed during follow-up.

CONCLUSIONS

Prognosis of IMH seems favourable in both surgically as well as conservatively treated patients. However, it is essential to identify patients at high risk for complications under conservative treatment, who therefore should be treated by TEVAR. In our study, ULPs seem to be an adverse factor for remodeling.

Clinical features and outcomes after endovascular therapy for penetrating aortic ulcer and intramural hematoma

OBJECTIVES

To identify the differences between clinical features and outcomes after endovascular therapy for penetrating aortic ulcer (PAU) and intramural hematoma (IMH).

METHODS

From January 2009 to March 2020, patients who underwent endovascular therapy for PAU and IMH were enrolled. Information on patient demographics, presentation, PAU and IMH morphology, laboratory examination, and clinical follow-up information was collected and analyzed. Univariate analysis was performed to identify the differences between IMH and PAU, and Kaplan-Meier was used to calculate the cumulative survival rate and freedom from reintervention.

RESULTS

A total of 114 patients were enrolled; 80 (70.2%) of them were diagnosed with PAU. Compared with PAU, patients with IMH were younger (p = 0.006), more likely to be admitted emergently (p = 0.001), had longer hospital stay (p = 0.028), and had higher levels of C-reactive protein (p = 0.030). Meanwhile, patients with IMH were more likely to be associated with hypertension (p = 0.020) and pleural effusion (p < 0.001) and less likely to have a history of acute coronary syndrome (p = 0.019) and prior cardiovascular intervention (p = 0.017). The five-year freedom from reintervention and cumulative survival rate were 94.2% (95% confidential interval, 88.9%-99.9%) and 87.8% (95% confidential interval, 79.5%-96.9%) in PAU patients and 89.6% (95% confidential interval, 75.8%-99.9%) and 85.1% (95% confidential interval, 68.0%-99.9%) in IMH patients, respectively. There was no significant difference in freedom from reintervention (p = 0.795) or cumulative survival rate (p = 0.817).

CONCLUSIONS

IMH appeared to occur in younger patients with hypertension and usually had an acute onset, while PAU was more likely to be found incidentally in older patients with atherosclerosis. Endovascular therapy was effective in both IMH and PAU patients with encouraging outcomes.

Intramural hematoma and penetrating ulcer in the descending aorta: differences and similarities

Acute aortic syndromes include a variety of overlapping clinical and anatomic diseases. Intramural hematoma (IMH), penetrating atherosclerotic ulcer (PAU), and aortic dissection can occur as isolated processes or can be found in association. All these entities are potentially life threatening, so prompt diagnosis and treatment is of paramount importance. IMH and PAU affect patients with atherosclerotic risk factors and are located in the descending aorta in 60-70% of cases. IMH diagnosis can be correctly made in most cases. Aortic ulcer is a morphologic entity which comprises several entities-the differential diagnosis includes PAU, focal intimal disruptions (FID) in the context of IMH evolution and ulcerated atherosclerotic plaque. The pathophysiologic mechanism, evolution and prognosis differ somewhat between these entities. However, most PAU are diagnosed incidentally outside the acute phase. Persistent pain despite medical treatment, hemodynamic instability, maximum aortic diameter (MAD) >55 mm, significant periaortic hemorrhage and FID in acute phase of IMH are predictors of acute-phase mortality. In these cases, TEVAR or open surgery should be considered. In non-complicated IMH or PAU, without significant aortic enlargement, strict control of cardiovascular risk factors and frequent follow-up imaging appears to be a safe management strategy.

Clinical Application of an Original Flexible MK Stent-Graft for Nonruptured Thoracic Aortic Aneurysms: Early Experience

Objective

To obtain early MK stent-grafting results for nonruptured thoracic aortic aneurysms and thoracoabdominal aortic aneurysms.

Methods

The authors analyzed 47 patients who underwent treatment using MK stent-grafting. All patients (40 men and 7 women; mean age, 70.8 years) underwent elective procedures. Straight, curved, or tapered MK stents were constructed from a nitinol wire and covered with seamless, cylindrical woven polyester fabric grafts. The mean stent-graft diameter was 24 to 48 mm. In cases where the aneurysm had a short proximal neck (under 15 mm), supraaortic arch artery bypass surgery was planned to lengthen the neck.

Results

Simple stent-grafting without bypass was performed in 26 patients, whereas stent-grafting with supraaortic arch artery bypass was performed in 21 patients. An 18 or 20 F sheath was used as the delivery system in 46 patients (96%). In all 47 patients, the stent-grafts were successfully deployed. Two patients died while in hospital, and another 2 patients suffered a stroke. No other perioperative complications were observed. Postoperative computed tomography after 3 months showed complete thrombus formation in 42 patients (93.3%; 42/45 patients).

Conclusions

Forty-seven patients with thoracic aortic aneurysm were treated with our original flexible MK stent-graft system. Using a small sheath system, straight or curved M-K stent-grafts could be deployed to adequately fit to the aorta as planned. Furthermore, simultaneous bypass surgery widened the application of stent-grafting. However, careful long-term observation is necessary, and further studies are needed to assess such stent-grafting with bypass surgery.

Cerebral embolization, silent cerebral infarction and neurocognitive decline after thoracic endovascular aortic repair

Background

Silent cerebral infarction is brain injury detected incidentally on imaging; it can be associated with cognitive decline and future stroke. This study investigated cerebral embolization, silent cerebral infarction and neurocognitive decline following thoracic endovascular aortic repair (TEVAR).

Methods

Patients undergoing elective or emergency TEVAR at Imperial College Healthcare NHS Trust and Guy's and St Thomas' NHS Foundation Trust between January 2012 and April 2015 were recruited. Aortic atheroma graded from 1 (normal) to 5 (mobile atheroma) was evaluated by preoperative CT. Patients underwent intraoperative transcranial Doppler imaging (TCD), preoperative and postoperative cerebral MRI, and neurocognitive assessment.

Results

Fifty-two patients underwent TEVAR. Higher rates of TCD-detected embolization were observed with greater aortic atheroma (median 207 for grade 4–5 versus 100 for grade 1–3; P = 0·042), more proximal landing zones (median 450 for zone 0–1 versus 72 for zone 3–4; P = 0·001), and during stent-graft deployment and contrast injection (P = 0·001). In univariable analysis, left subclavian artery bypass (β coefficient 0·423, s.e. 132·62, P = 0·005), proximal landing zone 0–1 (β coefficient 0·504, s.e. 170·57, P = 0·001) and arch hybrid procedure (β coefficient 0·514, s.e. 182·96, P &lt; 0·001) were predictors of cerebral emboli. Cerebral infarction was detected in 25 of 31 patients (81 per cent) who underwent MRI: 21 (68 per cent) silent and four (13 per cent) clinical strokes. Neurocognitive decline was seen in six of seven domains assessed in 15 patients with silent cerebral infarction, with age a significant predictor of decline.

Conclusion

This study demonstrates a high rate of cerebral embolization and neurocognitive decline affecting patients following TEVAR. Brain injury after TEVAR is more common than previously recognized, with cerebral infarction in more than 80 per cent of patients.

Techniques for Preserving Vertebral Artery Perfusion During Thoracic Aortic Stent Grafting Requiring Aortic Arch Landing

Thoracic endografting offers many advantages over open repair. However, delivery of the device can be difficult and may necessitate adjunctive procedures. We describe our techniques for preserving perfusion to the left subclavian artery despite endograft coverage to obtain a proximal seal zone. We reviewed our experience with the Talent thoracic stent graft (Medtronic, Santa Rosa, CA). From 1999 to 2003, 49 patients received this device (29 men, 20 women). Seventeen patients required adjunctive procedures to facilitate proximal graft placement. We performed left subclavian-to-left common carotid artery transposition (6), left common carotid-to-left subclavian artery bypass with ligation proximal to the vertebral artery (7), and left common carotid-to-left subclavian artery bypass with proximal coil embolization (4). Patients who had anatomy unfavorable to transposition or bypass with proximal ligation (large aneurysms or proximal vertebral artery origin) were treated with coil embolization of the proximal left subclavian artery in order to prevent subsequent type II endoleaks. Technical success rate of the carotid subclavian bypass was 100%. Patient follow-up ranged from 3 to 48 months with a mean of 12 months. Six patients had follow-up <6 months owing to recent graft placement. Primary patency was 100%. No neurologic events occurred during the procedure or upon follow-up. One patient had a transient chyle leak that spontaneously resolved in 24 hours. Another patient had a phrenic nerve paresis that resolved after 3 weeks. We believe that it is important to maintain patency of the vertebral artery specifically when a patent right vertebral system and an intact basilar artery is not demonstrated. Furthermore, we describe a novel technique of coil embolization of the proximal left subclavian artery in conjunction with left common carotid-to-left subclavian artery bypass. This circumvents the need for potentially hazardous mediastinal dissection and ligation of the proximal left subclavian artery in cases of large proximal aneurysms or unfavorable vertebral artery anatomy.

Stent Grafts for Thoracic Aortic Pathology: Single-Center Experience in Western Australia

The purpose of this article is to report a single-center experience in treating thoracic aortic pathology with stent grafts. This is a retrospective review of cases done within a period of 30 months.

Between January 2002 and May 2004, 12 patients were treated in our institution with thoracic stent grafts ( n = 12) for various clinical conditions. There were seven men and five women. Three patients required emergency treatment ( n = 3), two for aortic transection and one for iatrogenic injury during lung biopsy. Others were treated electively ( n = 9).

All patients were high risk for open surgery. There was one perioperative death, with a patient with multiple trauma succumbing to head injury 4 weeks after stent graft insertion. There was no incidence of paraplegia. Three patients underwent bypass surgery in the neck to achieve an adequate proximal seal zone prior to stent grafting. One patient with an aneurysm of the descending thoracic aorta required an extension limb below the original graft for an increase in sac size, possibly owing to endotension. Renal failure occurred in one patient and resolved without dialysis. One patient died 18 months after her procedure, possibly owing to aneurysm expansion.

Stent grafts are a viable alternative to open surgery for thoracic aortic pathology in high-risk individuals. Visceral and spinal cord ischemia is less prevalent with stent grafts compared with open surgery. The short-term results are promising. Long-term follow-up is awaited. Stent grafts might have greater impact in the thoracic aorta than the abdominal aorta for which they were initially developed.

Endovascular Repair versus Open Repair for Isolated Descending Thoracic Aortic Aneurysm

PURPOSE

To compare the outcomes of thoracic endovascular aortic repair (TEVAR) with those of open repair for descending thoracic aortic aneurysms (DTAA).

MATERIALS AND METHODS

We compared the outcomes of 114 patients with DTAA and proximal landing zones 3 or 4 after TEVAR to those of 53 patients after conventional open repairs. Thirty-day and late mortality were the primary endpoints, and early morbidities, aneurysm-related death, and re-intervention were the secondary endpoints.

RESULTS

The TEVAR group was older and had more incidences of dissecting aneurysm. The mean follow-up was 36±26 months (follow-up rate, 97.8%). The 30-day mortality in the TEVAR and open repair groups were 3.5% and 9.4% (p=0.11). Perioperative stroke and paraplegia incidences were similar between the groups [5.3% vs. 7.5% (p=0.56) and 7.5% vs. 3.5% (p=0.26), respectively]. Respiratory failure occurred more in the open repair group (1.8% vs. 26.4%, p<0.01). The incidence of acute kidney injury requiring dialysis was higher in the open repair group (1.8% vs. 9.4%, p<0.01). The cumulative survival rate was higher in the TEVAR group at 2 to 5 years (79.6% vs. 58.3%, p=0.03). The free from re-intervention was lower in the TEVAR group (65.3% vs. 100%, p=0.02), and the free from aneurysm-related death in the TEVAR and open repair groups were 88.5% and 86.1% (p=0.45).

CONCLUSION

TEVAR is safe and effective for treating DTAAs with improved perioperative and long-term outcomes compared with open repair.

A review of follow-up outcomes after elective endovascular repair of degenerative thoracic aortic aneurysms

Long-term outcomes of elective thoracic endovascular aortic repair (TEVAR) for degenerative thoracic aortic aneurysms (TAA) are not well defined. A review of the literature on the follow-up outcomes of elective TEVAR for degenerative TAA resulted in 22 relevant articles. Two- and five-year freedom from aneurysm-related death varied between 93.0% and 100.0%, and 82.4% to 92.7%, respectively. Two-year and five-year all-cause survival ranged between 68.0% and 97.2% and 47.0% to 78.0%, respectively. Follow-up ranged between 17.3 and 66.0 months. Most common endograft-related complication was endoleak, with reported rate between 1.4% and 14.8% during six months up to five years of follow-up. Endovascular reinterventions were reported in 0.0–32.3%, secondary open surgery was needed in 0.0% to 4.7% during follow-up. Aneurysm-related survival rates after elective TEVAR for degenerative TAA are acceptable. However, reported incidences of endograft-related complications vary considerably in the literature, but the majority can be managed with conservative treatment or additional endovascular procedures.

Thoracic Aortic Trauma: Outcomes and Hospital Resource Utilization after Endovascular and Open Repair

Thoracic endovascular aortic repair (TEVAR) has evolved as a treatment option for the management of thoracic aortic trauma as an alternative to open thoracic aortic repair (OTAR). Population-level outcomes are not known and were evaluated. Secondary data analysis of the 2005–2006 Nationwide Inpatient Sample data was performed, and 1,561 patients with thoracic aortic injury (mean age 44.8 ± 18.8 years; men 77.2%) were identified. Of these, 510 underwent emergent surgical intervention: 240 OTAR (47%) and 270 TEVAR (53%). Males were more likely to undergo any surgery (77.2% vs 22.8%; p = .03). Hospital mortality after OTAR was greater compared to TEVAR (14.61% vs 7.43%; p = .009). OTAR patients were more likely to have pulmonary complications (37.8% vs 21.65; p < .0001) but were less likely to have stroke (2.1% vs 5.8%; p = .03) compared to TEVAR patients. After adjustment, OTAR patients remained more likely to die compared to TEVAR patients (OR 11.5; 95% CI 4.0–33.2). Hospital length of stay and hospital cost were significantly greater for OTAR than for TEVAR. An increase in patients with thoracic aortic injury undergoing repair was found (23.0% vs 40.3%; p < .0002). In trauma, TEVAR was associated with decreased hospital mortality, hospital use, and pulmonary complications but increased rates of stroke. Further implementation of TEVAR for management of thoracic aortic trauma may improve future outcomes and reduce hospital resource use.

Endovascular repair of nonruptured thoracic aortic aneurysms: systematic review

Thoracic aortic aneurysms represent a major health problem. Untreated thoracic aortic aneurysms may rupture, which has a dismal outcome. The standard treatment for thoracic aneurysms is open surgical repair, but it is associated with high mortality and morbidity. Endovascular repair provides a less invasive and safer alternative. A systematic review was performed of all published literature on the above subject. Our primary objective was to measure 30-day mortality for nonruptured thoracic aortic aneurysms. Studies describing other pathologies, such as aortic dissection, mycotic aneurysms, penetrating ulcers, traumatic transactions, and pseudoaneurysms, and studies from which independent data for thoracic aortic aneurysm could not be separately extracted were excluded. Case series describing less than 10 patients and all case series describing ruptures or concealed ruptures were excluded as well. Twenty-six case series and one comparative study were identified. This formed a cohort of 1,038 patients. Technical success was possible in more than 97% of patients. The 30-day mortality was calculated to be 5.1% even though the group under study was mostly those who were refused surgery by a surgeon or had a higher surgical risk. The incidence of paraplegia and stroke was 3.1% and 4.7%, respectively. Early endoleak was seen in 16.7% of patients, whereas 11.7% of patients developed late endoleak, but most did not require any additional procedure. The rate of reintervention was 14.9%. The 12-month mortality rate was 14.2%. Endovascular repair shows encouraging short-term results. It is associated with significantly less mortality and morbidity, but long-term results need to be further investigated.

[Traumatic thoracic aorta rupture: preclinical assessment, diagnosis and treatment options]

Traumatic aortic rupture is a life-threatening injury which is frequently associated with blunt thoracic trauma or found coincidentally in heavily traumatized patients. Depending on the degree of disruption of the damaged aortic wall, vascular injury is associated with a high primary mortality rate and a significant risk of secondary aortic rupture. Early clinical signs which may indicate a ruptured thoracic aorta are left sided thoracic pain, reduced ventilation, tachycardia and dyspnoe as well as hypotension in the lower extremities. The primary aim for emergency treatment is to maintain vital organ function and to hemodynamically stabilize the patient. Surgical treatment was previously performed by either direct aortic suture or segmental alloplastic graft interposition using the clamp and sew technique with or without extra-anatomic shunts or extracorporeal circulation. However, endovascular stent graft implantation has now become another treatment option for traumatic aortic rupture. According to the reported data and our own experience there is increasing evidence that endovascular aortic repair might become the treatment of choice for patients with traumatic aortic rupture, with the option of an early, less invasive intervention thus avoiding thoracotomy. Regular follow-up is necessary to detect possible stent graft migration or leakage which could require additional endovascular or open surgical re-interventions.

The Role of CT Angiography in the Diagnosis of Blunt Traumatic Thoracic Aortic Disruption and Unsuspected Carotid Artery Injury

We have replaced aortography and open thoracic surgery to diagnose and treat blunt traumatic thoracic aortic disruption (TTAD) in favor of CT angiography (CTA) and endovascular repair. The purpose of this study is to review our experience with the management and outcomes of TTAD and associated carotid artery injuries. In January 2003, we initiated a protocol that used CTA to evaluate all patients with suspected TTAD from blunt trauma. When TTAD was diagnosed, patients were managed by endovascular repair using abdominal aortic extension cuffs. Twenty-nine patients with TTAD were managed by endovascular repair. In all patients, abdominal endograft extension cuffs successfully excluded the traumatic disruptions. Six (21%) of these patients had concomitant, unsuspected carotid artery injury diagnosed by CTA. One patient had bilateral carotid artery dissections, sustained irreversible brain injury, and died. Four patients with common carotid dissections were successfully treated by anticoagulation and made uneventful recoveries. One patient with a common carotid–innominate artery dissection and pseudoaneurysm underwent endovascular repair. This study indicates that CTA and endovascular repair provide accurate diagnostic and therapeutic results in the management of blunt TTAD. Furthermore, CTA should include arch and cervical views to detect an unsuspected, concomitant carotid artery injury.

The French National Authority for Health reports on thoracic stent grafts

OBJECTIVE

This study was conducted to determine the efficacy and safety of stent grafts in the treatment of thoracic aortic aneurysms and dissections.

METHOD

Our health technology assessment method combined a critical review of the literature with experts' opinions. Several databases, useful Web sites, and the gray literature were searched from January 1995 to December 2004. Some manually retrieved major articles published in 2005 were also included. The draft report was submitted to and discussed by a working group of 12 members nominated by relevant medical societies. The amended report was submitted to a multidisciplinary group of 12 peer reviewers for comment.

RESULTS

Endovascular stent grafting (ESG) repair for lesions of the thoracic aorta, including aneurysms, dissections, and aortic isthmus ruptures, is probably beneficial in terms of operative mortality and severe morbidity, with an incidence of paraplegia of 2.1% (range 0%-7%) for ESG vs 5% (range, 3%-15%) for surgery, provided that there is a rigorous medium-term assessment and that anatomic factors are favorable. A proximal neck length of at least 2 cm is needed to insert the stent graft. Indications for ESG in thoracic aortic aneurysm and dissection are similar to those for surgery. Endovascular stent grafting is particularly appropriate in patients with multiple traumas to the thoracic aorta in whom concomitant lesions are a contraindication to open surgery. Endovascular stent graft repair can only be done in public or private centers with expertise in both endovascular and surgical procedures and with adequate technical facilities. Patients should be informed of the advantages and drawbacks of both methods. A multidisciplinary discussion should address risks of converting to open surgery and possible need for a cardiopulmonary bypass. Patients should be monitored annually by computed tomography scan or magnetic resonance imaging and plain radiographs because long-term results are uncertain (possible stent graft deterioration, onset of aortic disease). They should be told of the need for surveillance and possible further treatment.

CONCLUSIONS

A prospective registry of all thoracic aorta procedures (endovascular treatment, open surgery, thoracic ESG plus extra-anatomic bypass) needs to be set up. All practitioners and stent graft manufacturers should contribute to this registry. It should include information on patient monitoring in order to (1) select patients who could be treated by ESG repair, (2) assess the feasibility of a randomized controlled study comparing ESG and surgery, (3) assess the medium-term outcome of different devices, and (4) obtain a better understanding of the health economics aspects.

Risk factors for perioperative stroke during thoracic endovascular aortic repairs (TEVAR)

PURPOSE

To determine the clinical and anatomical risk factors for cerebrovascular accidents (CVA) in patients undergoing thoracic endovascular aortic repair (TEVAR).

METHODS

Between September 2000 and December 2006, 196 patients (135 men; mean age 68.6+/-13.5 years, range 17-92) underwent TEVAR for a variety of aortic pathologies. The majority (156, 79.6%) were treated with the TAG stent-graft. Demographics, pathologies, intraoperative procedure-related measures, device usage, and postoperative outcomes were assessed. CVA was defined as a new focal or global neurological (motor or sensory) deficit lasting >48 hours associated with acute intracranial abnormalities on computed tomography or magnetic resonance brain imaging. Spinal cord ischemia was excluded. In a subset of patients with planned left subclavian artery (LSA) coverage and an incomplete circle of Willis or a dominant left vertebral artery, prophylactic carotid-subclavian bypasses were performed.

RESULTS

Nine (4.6%) patients suffered a CVA. Factors not predictive of a CVA on univariate analysis included aortic pathology, urgency of repair, ASA classification, type of anesthesia, blood loss, procedure time, and device used. Proximal extent of repair (with or without extra-anatomical revascularization) was significantly associated with a higher incidence of strokes (zones 0-2 versus 3-4, p=0.025). Five (55.6%) patients with a CVA had documented intraoperative hypotension (systolic blood pressure<80 mmHg). Additionally, while 2 patients had hemispheric infarcts, 5 had acute posterior circulation infarcts involving the cerebellum and brainstem; a single patient had both anterior and posterior circulation infarcts. Seven of the CVA patients had proximal coverage of the thoracic aorta in zones 0-2; of these, 6 had posterior circulation infarcts. Selective LSA revascularization based on preoperative cerebrovascular imaging resulted in lower rates of CVA (6.4% to 2.3%, p=0.30) and posterior circulation infarcts (5.5% to 1.2%, p=0.13).

CONCLUSION

Proximal extent of repair may serve as a surrogate marker for greater severity of degenerative disease of the aortic arch. Avoidance of intraoperative hypotension and preservation of antegrade vertebral perfusion may be important in prevention of posterior circulation strokes.

Stent-grafting of the thoracic aorta by the cardiothoracic surgeon

BACKGROUND

We evaluated endovascular stent-grafting as a new technique in aortic surgery.

METHODS

One hundred ninety-six stent-grafts were implanted in the thoracic aorta in 172 patients. All procedures but one were performed in the operating room by a team of cardiothoracic surgeons; 112 operations (57%) were emergency procedures. Twenty-four procedures (12%) were reoperations for endoleaks. The left subclavian artery origin was covered in 46 cases and the left common carotid artery in 2 cases. Access was by femoral cut-down in 174 procedures, percutaneous femoral approach in 1, and by conduit to the iliac arteries or infrarenal aorta in 17. Surgical reconstruction of damaged access vessels became necessary in 10 cases.

RESULTS

Thirty-day mortality was 9.7% (19 patients). Paraplegia occurred in 1.0% (2 patients). Primary technical success was 85.2%, secondary 91.8%. Six conversions to open repair were necessary, 3 during the procedures and 3 secondarily before discharge. Actuarial survival was 79% at 1 year, 67% at 3 years, and 55% at 5 years.

CONCLUSIONS

The results are excellent, taking into account the high incidence of emergency procedures and that open surgery is not promising in many patients. The cardiothoracic surgeon can perform the procedure after adequate training in endovascular techniques. Surgical skills are mandatory because of the potential need for extended surgical approach to the access vessels or immediate conversion to open surgery. Therefore, the operating room is the preferred site for this procedure.

[The vascular surgeon's role in intensive care]

The role of vascular surgeons in the intensive care unit includes two major tasks: (1) consultant activity in complications of different operative specialties, for instance postoperative venous thrombosis after Wertheim's operation, mesenteric superior artery embolus, or arterial injury after total prosthetic replacement of the hip, (2) postoperative care following vascular surgery in order to identify and treat specific complications such as limb ischemia after reconstructive surgery, compartment monitoring after reperfusion injury of the aorta or extremities, carotis monitoring after postoperative apoplexy, and subsumed identification and treatment of ischemic and postischemic states in organs and tissues. Keeping vascular reconstructive options open is particularly important for polytrauma patients with blunt or open vascular injuries beginning from the thoracic aorta ending with subtotal amputation of the lower leg. Vascular surgeons in an intensive care setting play the central role in setting diagnostic course and therapy measures, while organ substitute therapy is within the administrative jurisdiction of the intensivist. Considering the complexity of morbidity in vascular patients, consultation by the intensivist, cardiologist, and neurologist is warranted.

Midterm results of endovascular treatment of atherosclerotic aneurysms of the descending thoracic aorta

OBJECTIVE

We sought to determine the midterm results of endovascular repair of atherosclerotic aneurysms of the thoracic descending aorta by using second-generation, commercially available stent grafts.

METHODS

Between 1996 and 2005, 45 patients (mean age, 68 +/- 11 years) with aneurysms of the descending thoracic aorta underwent endovascular repair. Aortic dissections, penetrating ulcers, and traumatisms were excluded. The mean follow-up was 24.7 +/- 21.6 months (maximum, 6.7 years).

RESULTS

No patients died, and no conversion to surgical intervention was required during the procedures. Three (6.7%) patients died during the first month, and 6 (14.7%) died later on. The main complications were strokes (13.3%), vascular access complications (8.9%), aortic complications (6.6%), paraplegia (4.4%), and sudden deaths (4.4%). Nineteen (42%) primary endoleaks were encountered: 3 required reinterventions, 15 spontaneously thrombosed, and 1 patient died. Except for 2 sudden unexplained deaths, no aortic complications were observed after 1 month. Actuarial survival estimates at 1, 3, and 5 years were 87.6% +/- 5.3%, 76.9% +/- 7.4%, and 70.6% +/- 9.2%, respectively. Actuarial freedom from death related to the treated aortic disease was 94.3% +/- 4.0%, 94.3% +/- 4.0%, and 86.4% +/- 8.4% at 1, 3, and 5 years, respectively. Aspirin status of greater than 3 (P = .005), high aortic diameter (P = .007), and long covered lengths (P = .02) were determinant for mortality. Actuarial freedom from complication was 62.6% +/- 7.7%, 58.9% +/- 8.1%, and 58.9% +/- 8.1% at 1, 3, and 5 years, respectively. The location of the aneurysm (P = .05) and a high aortic diameter (P = .04) were both determinants for endoleaks.

CONCLUSIONS

Stent grafting of atherosclerotic aneurysm of the thoracic descending aorta is safe and effective. Further studies are mandatory to determine the most relevant indications and the long-term efficacy of such treatment.

Complications after endovascular stent-grafting of thoracic aortic diseases

Background

To update our experience with thoracic aortic stent-graft treatment over a 5-year period, with special consideration for the occurrence and management of complications.

Methods

From December 2000 to June 2006, 52 patients with thoracic aortic pathologies underwent endovascular repair; there were 43 males (83%) and 9 females, mean age 63 ± 19 years (range 17–87). Fourteen patients (27%) were treated for degenerative thoracic aortic aneurysm, 12 patients (24%) for penetrating aortic ulcer, 8 patients (15%) for blunt traumatic injury, 7 patients (13%) for acute type B dissection, 6 patients (11%) for a type B dissecting aneurysm; 5 patients (10%) with thoraco-abdominal aortic aneurysms were excluded from the analyses. Fifteen patients (32%) underwent emergency treatment. Overall, mean EuroSCORE was 9 ± 3 (median 15, range 3–19). All procedures were performed in the theatre under general anesthesia. All complications occurring during hospitalisation were recorded. Follow-up protocol featured CT-A, and chest X-rays 1, 4 and 12 months after intervention, and annually thereafter.

Results

Primary technical success was achieved in all patients; procedures never aborted because of access difficulty. Conversion to standard open repair was never required. Mean duration of the procedure was 119 ± 75 minutes (median 90, range 45–285). Mean blood loss was 254 mL (range 50–1200 mL). The mean length of the aorta covered by the SGs was 192 ± 21 mm (range 100–360). The LSA was over-stented in 17 cases (17/47, 36%). Overall 30-day operative mortality was 6.4% (3/47). Major complications included pneumonia (n = 9), cerebrovascular accidents (n = 4), arrhythmia (n = 4), acute renal failure (n = 3), and colic ischemia (n = 1). Overall, endoleak rate was 14%.

Conclusion

Although this report is a retrospective and not comparative analysis of thoracic aortic repair, the combined minor and major morbidity rate was lower than previous reported to results of either electively and emergency performed conventional repair.

Endovascular management of traumatic ruptures of the thoracic aorta: A retrospective multicenter analysis of 28 cases in The Netherlands

BACKGROUND

Minimally invasive endovascular treatment of a traumatic rupture of the thoracic aorta is a new strategy in the care of multitrauma patients. We report the experience in The Netherlands with endovascular management of patients with acute traumatic ruptures of the thoracic aorta.

METHODS

We reviewed 28 patients with a traumatic thoracic aortic rupture treated with a thoracic aortic endograft between June 2000 and April 2004. All patients underwent treatment at one of the four participating level 1 trauma centers. Data collected included age, sex, injury severity score, type of endovascular graft, endovascular operation time, length of stay, length of stay in the intensive care unit, and mortality. Follow-up data consisted of computed tomographic angiography and plain chest radiographs at regular intervals.

RESULTS

All patients (mean age, 40.9 years; SD, 18.5 years) experienced severe traumatic injury, and the mean injury severity score was 37.1 (SD, 7.8). All endovascular procedures were technically successful, and the median operating time for the endovascular procedure was 58 minutes (interquartile range, 47-88 minutes). The overall hospital mortality was 14.3% (n = 4), and all deaths were unrelated to the aortic rupture or stent placement. There was no intervention-related mortality during a median follow-up of 26.5 months (interquartile range, 10-34.6 months). Postoperative data showed no severe endovascular graft- or procedure-related morbidity, except for one patient with an asymptomatic collapse of the endovascular graft during regular follow-up. This was corrected by placing a second graft.

CONCLUSIONS

This study shows that the results of immediate endovascular repair of a traumatic aortic rupture are at least equal to those of conventional open surgical repair. Especially in these multitrauma patients with traumatic ruptures of the thoracic aorta, endovascular therapy seems to be preferable to conventional open surgical repair.

Endovascular Repair of Thoracic Aortic Lesions Using Infrarenal Devices: Lessons Learned and Continued Applications

The application of endovascular devices for the treatment of a variety of thoracic aortic lesions has flourished worldwide over the past decade. Until physicians become facile with recently approved thoracic devices and these devices are immediately available even in emergency situations, the use of endovascular abdominal components offers physicians more options in managing thoracic lesions. We evaluated the safety, efficacy, and outcomes of commercially available, infrarenal endovascular graft components for managing lesions of the thoracic aorta. Nineteen patients were treated outside of a clinical trial using commercially available endovascular devices. The indications for treatment included acute traumatic lesions (n = 7), symptomatic ulcers (n = 4), focal aneurysms or pseudoaneurysms (n = 7), and symptomatic type B dissection (n = 1). The endovascular components included Excluder Aortic Cuffs (n = 9), AneuRx Aortic Cuffs (n = 5), Zenith Aortic Cuffs (n = 2), Zenith Aortic Tube Grafts (n = 2), and graft combinations (n = 1). Seventeen patients (89%) underwent successful endovascular treatment of their thoracic lesion. One patient required elective surgical conversion, and a second patient had a dissection that was not completely sealed endovascularly. There was no periprocedural mortality, and the major complication rate was 16% (3/19). Two patients had asymptomatic troponin leaks, and one patient developed an iliac rupture at the device introduction site, hypotension, and paraplegia. At a mean follow-up of 12.3 months, all successfully treated patients continue to have complete exclusion of the treated lesion. Infrarenal endovascular graft components can be very useful in the treatment of selected patients with amenable thoracic lesions until thoracic devices are available in all necessary sizes, readily accessible to treating physicians, and cost-effective.

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.

Endovascular Treatment of Aortic Arch Aneurysms

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Surgical management of thoracic aortic lesions. Aneurysm, dissection and traumatic rupture]

Surgical management of distinct thoracic aneurysmal lesions stands at the crossroads. Until recently, the only treatment options for thoracic aortic lesions were surgical repair or medical management. There is increasing evidence that endovascular therapy will be useful in treating thoracic aortic disease, possibly becoming the preferred approach. Endovascular surgery will affect the incidence of open thoracic aortic surgery not only by producing a lower mortality risk but also a significantly lower incidence of paraplegia. In designing adequate treatment options of complex and difficult-to-treat thoracic aortic lesions, novel three-dimensional imaging reconstructions are mandatory.

Complications of endovascular repair of high-risk and emergent descending thoracic aortic aneurysms and dissections

PURPOSE

The advent of endovascular prostheses to treat descending thoracic aortic lesions offers an alternative approach in patients who are poor candidates for surgery. The development of this approach includes complications that are common to the endovascular treatment of abdominal aortic aneurysms and some that are unique to thoracic endografting.

METHODS

We conducted a retrospective review of 60 emergent and high-risk patients with thoracic aortic aneurysms (TAAs) and dissections treated with endovascular prostheses over 4 years under existing investigational protocols or on an emergent compassionate use basis.

RESULTS

Fifty-nine of the 60 patients received treatment, with one access failure. Thirty-five patients received treatment of TAAs. Four of these procedures were performed emergently because of active hemorrhage. Twenty-four patients with aortic dissections (16 acute, 8 chronic) also received treatment. Eight of the patients with acute dissection had active hemorrhage at the time of treatment. Three devices were used: AneuRx (Medtronic; n = 31), Talent (Medtronic; n = 27), and Excluder (Gore; n = 1). Nineteen secondary endovascular procedures were performed in 14 patients. Most were secondary to endoleak (14 of 19), most commonly caused by modular separation of overlapping devices (n = 8). Other endoleaks included 4 proximal or distal type I leaks and 2 undefined endoleaks. The remaining secondary procedures were performed to treat recurrent dissection (n = 1), pseudoaneurysm enlargement (n = 3), and endovascular abdominal aortic aneurysm repair (n = 1). One patient underwent surgical repair of a retrograde ascending aortic dissection after endograft placement. Procedure-related mortality was 17% in the TAA group and 13% in the dissection group, including 2 acute retrograde dissections that resulted in death from cardiac tamponade. Overall mortality was 28% at 2-year follow-up.

CONCLUSION

Although significant morbidity and mortality remain, endovascular repair of descending TAAs and dissections in patients at high-risk patients can be accomplished with acceptable outcomes compared with traditional open repair. The major cause for repeat intervention in these patients was endoleak, most commonly caused by device separation. Improved understanding of these complications may result in a decrease in secondary procedures, morbidity, and mortality in these patients. The need for secondary interventions in a significant number of patients underscores the necessity for continued surveillance.