Single-center experience with simultaneous thoracic endovascular aortic repair and abdominal endovascular aneurysm repair

Successful short interval staged surgery in synchronous type A aortic dissection and giant abdominal aortic aneurysm patient

The surgical therapy of synchronous type A aortic dissection and abdominal aortic aneurysm is complex and rarely reported, especially, when the abdominal aortic aneurysm is unsuitable for intervention. Recently, we have successfully performed sequential two staged surgeries on a 46-year-old woman. The first stage surgeries consisted of the Bentall procedure, total aortic arch replacement, and frozen elephant trunk implantation. The second stage surgeries included replacement from the descending aorta to the sub-renal abdominal aorta, reconstruction of the blood flow to the spinal, the celiac trunk artery, the left and right renal artery, the superior and inferior mesenteric artery, and the iliac artery of both sides. The interval between two surgeries was very short (42 days). The patient was recovered, and all functions of her body were reserved. According to our experience, it is feasible to prevent aortic rupture by short interval staged surgery in selected patients with synchronous type A aortic dissection and un-interventionable abdominal aortic aneurysm.

Spinal cord ischemia following simultaneous EVAR and TEVAR for concomitant thoracic and abdominal aortic aneurysms

OBJECTIVES

In patients with abdominal aortic aneurysms, 10-20% have concomitant thoracic aortic pathologies. These are typically managed with staged endovascular aneurysm repair (EVAR) and thoracic endovascular aortic repair (TEVAR) due to a perceived higher risk of spinal cord ischemia from a simultaneous intervention. We aimed to determine the outcomes of patients undergoing simultaneous EVAR and TEVAR for concomitant aneurysms.

METHODS

A retrospective cohort study was performed using the Vascular Quality Initiative registry from December 2003 to January 2021. Patients undergoing same-day EVAR and TEVAR were included and analyzed in accordance with the Society for Vascular Surgery reporting standards. Primary outcomes were technical success and spinal cord ischemia.

RESULTS

Simultaneous EVAR and TEVAR was performed in 25 patients. Median age was 75.0 (IQR 63.0-79.0) years and 20 (80.0%) patients were male. Two (4.0%) patients were symptomatic and four (16.0%) presented with rupture. Median maximum infrarenal and thoracic aortic diameter was 57.0 (IQR 52.0-65.0). Infrarenal aortic neck length was 15.0mm (IQR 10.0-25.0), and diameter was 27.0mm (IQR 24.5-30.0). Median procedure time was 185.0 minutes (IQR, 117.8-251.3), fluoroscopy time 32.7 minutes (IQR, 21.8-63.1), and contrast volume 165 ml (IQR 115.0-207.0). There were three (12.0%) Type Ia endoleaks and three (12.0%) Type II endoleaks in EVAR's, with one (4.0%) Type Ia and one (4.0%) Type II endoleak in TEVARs. In-hospital mortality occurred in three (12.0%) patients (one elective, two ruptures). Spinal cord ischemia occurred in one (4.0%) patient. This patient had a symptomatic aneurysm. Thoracic coverage extended from Zone 4 to Zone 5 and an emergent spinal drain was placed postoperatively. Symptoms were present on discharge. There was one (4.0%) conversion to open repair which occurred in a ruptured aneurysm. Technical success was achieved in 19 (76.0%) patients, however when excluding ruptured aneurysms, was achieved in 17 (81.0%) patients. Follow-up data was available for 19 (76.0%) patients at a median of 426.0 (IQR 329.0-592.5) days postoperatively. A total of 3 (12.0%) patients died during the late mortality period, at a mean of 509.0 (±503.7) days. Median change in abdominal and thoracic aortic sac diameter was -1.35mm (IQR -11.5-2.5) and 8.0 (IQR -10.5-12.0) respectively.

CONCLUSIONS

Simultaneous EVAR and TEVAR for concomitant abdominal and thoracic aortic aneurysms can be performed with low rates of spinal cord ischemia. Short- and mid-term outcomes are acceptable.

Stent graft in abdominal aortic aneurysm collapsed suddenly after thoracic endovascular aortic repair

Stent graft collapse due to aortic dissection is an extremely rare event. Although endovascular aneurysm repair (EVAR) and thoracic endovascular aortic repair (TEVAR) are increasingly being performed, various complications can occur. We report a case of collapse of a stent graft, which was used to repair an abdominal aortic aneurysm (AAA) after TEVAR for thoracic aortic aneurysm (TAA). A 72-year-old man with a 77 mm AAA and 60 mm TAA underwent EVAR and a TEVAR 2 months later, respectively. CT performed after the TEVAR showed thoracic aorta dissection with associated AAA stent graft collapse. The graft collapsed was due to superior mesenteric artery obstruction. An emergency TEVAR was performed, and the procedure improved the collapsed graft; however, the endoleak of the AAA stent graft persisted. The AAA expanded over several days, warranting an open repair. Our case provides an insight into the cautionary indications for endovascular therapy.

Cerebrospinal fluid drainage and thoracic endovascular aneurysm repair

Spinal cord complications including paraplegia and partial neurologic deficits remain a frequent problem during repair of descending thoracic or thoracoabdominal aortic aneurysms. Effective prevention of this dreaded complication is of paramount importance. Among the many adjuncts that have been proposed to prevent spinal cord complications, spinal fluid drainage is one that has been used by numerous teams. The aim of this review is to answer the following question: does spinal fluid drainage afford spinal cord protection during both open and endovascular repair of thoracic or thoracoabdominal aortic aneurysms?

Early and midterm outcomes of thoracic endovascular aortic repair (TEVAR) for acute and chronic complicated type B aortic dissection

Thoracic endovascular aortic repair (TEVAR) in the current era has been chosen as a dominant and minimally invasive treatment for complicated aorta dissection. This study aimed to assess safety and feasibility of TEVAR in acute and chronic type B aortic dissection.Between January 2011 and December 2013, 85 patients with complicated type B aortic dissection undergoing TEVAR were divided into acute aortic dissection (AAD) (n = 60) group and chronic aortic dissection (CAD) group (n = 25). Computed tomography was used to evaluate postoperative changes in maximal aortic diameter and true and false lumen diameters at 3 levels during a mean follow-up period of 26.4 ± 15.6 months.The technical success rate was 100%. In-hospital and 30-day rates of death were 3.3% in acute group and 0 in chronic group. Postdischarge rates of type I leak, type II leak, and retrograde type A dissection were 6.7%, 5.2%, and 3.4% (acute) and 0%, 4.0%, and 4.0% (chronic), respectively. The maximal aorta diameter remained stable in all the 3 levels in both acute and chronic group. The cumulative freedom from all-cause mortality at 3 years was similar in acute and chronic groups (89.5% vs 95.5%, P = .308). The cumulative freedom from aortic-related mortality was also not significantly different in the acute and chronic groups (92.8% vs 95.2%, P = .531). In the thoracic aorta, TEVAR treatment resulted in a significant increase in true lumen (TL) diameter and decrease in false lumen (FL). However, in the abdominal aorta, TEVAR did not lead to significant change in TL and FL diameters. The rates of complete thrombosis thoracic false lumens were better than that in the abdominal false lumen.TEVAR was a safe and effect therapy for complicated acute and chronic type B dissection with low early and mid-term mortality and morbidity.