Valiant Thoracic Stent-Graft Deployed With the New Captivia Delivery System:Procedural and 30-Day Results of the Valiant Captivia Registry

A Case of Aortic Strain due to Spring Back Force by Stent Graft 3 Years after Thoracic Endovascular Aortic Repair

A 79-year-old man underwent 1-debranched thoracic endovascular aortic repair (TEVAR) for a saccular aneurysm of the distal arch of the aorta. Computed tomography performed 3 years after surgery revealed a significant displacement of the distal side of the stent graft and severe deformity due to displacement of the aorta. There were no obvious findings after aortic dissection. Endovascular treatment was selected, and surgery was performed semiemergency. Additional TEVAR was performed to restore the aortic shape and displacement to its normal position.

Sex-based outcomes after thoracic endovascular aortic repair: a systematic review and meta-analysis

OBJECTIVE

As it remains unclear whether there are sex-based differences in clinical outcomes after thoracic endovascular aortic repair (TEVAR), this meta-analysis aimed to evaluate differences in early outcomes and overall survival between female and male patients who underwent TEVAR.

METHODS

The PubMed, Embase, Web of Science, and Cochrane Central databases were searched for eligible studies published through June 10, 2023, that reported sex-based differences in clinical outcomes after TEVAR. The primary outcome was operative mortality; second outcomes included stroke, spinal cord ischemia, acute kidney injury, hospital length of stay, and overall survival. Patient characteristics, operative data, and early outcomes were aggregated using the random-effects model, presenting pooled risk ratio (RR) or standardized mean difference along with their corresponding 95% confidence intervals (CIs). Overall survival was assessed by reconstructing individual patient data to generate sex-specific pooled Kaplan-Meier curves. This study was registered in PROSPERO (CRD42023426069).

RESULTS

Of the 1785 studies retrieved, 14 studies met all eligibility criteria, encompassing a total of 17,374 patients, comprising 5026 female and 12,348 male patients. Female patients were older, had a smaller maximum aortic diameter, had lower rates of smoking and coronary artery disease, and had higher rates of anemia. Intraoperatively, female patients were more likely to use iliac conduits and require blood transfusions. There were no sex-based differences in operative mortality (RR: 1.12, 95% CI: 0.90-1.40; P = .309), stroke (RR: 1.14, 95% CI: 0.95-1.38; P = .165), spinal cord ischemia (RR: 1.33, 95% CI: 0.83-2.14; P = .234), acute kidney injury (RR: 0.78, 95% CI: 0.52-1.17; P = .228), and hospital length of stay (standardized mean difference: 0.09, 95% CI: -0.03 to 0.20; P = .141). Pooled Kaplan-Meier estimates showed a worse overall survival in female patients compared with male patients (87.2% vs 89.8% at 2 years, log-rank P = .001).

CONCLUSIONS

Among patients treated by TEVAR, female sex was not associated with increased risk of operative mortality or major morbidity. However, female patients exhibited a lower overall survival after TEVAR compared with male patients.

Aortic arch surgery for type B aortic dissection: How far should we go? The value of a hybrid approach

Traditionally, the management of type B aortic dissection has been the domain of the vascular surgeons. Timing and type of intervention still generate debate. We sought to review our early experience with the treatment of this condition based on a hybrid approach following an aortic multi-disciplinary team meeting involving close cooperation between cardiac surgeons, vascular surgeons, interventional radiologists, vascular anesthetists, and cardiac anesthetists. Four patients (age 41-56 years; 3 males; 1 female) with type B aortic dissection underwent aortic arch surgery through a hybrid approach: one elective procedure consisting of ascending aorta and hemi-arch replacement with debranching followed by thoracic endovascular aortic repair (TEVAR); one redo procedure requiring aortic arch replacement with hybrid frozen elephant trunk; two acute presentations (aortic arch replacement and debranching followed by TEVAR; AVR with ascending aorta, arch, and proximal descending thoracic aorta replacement with conventional elephant trunk and debranching). Deep hypothermic circulatory arrest was required in three patients. Despite respiratory complications and slightly prolonged postoperative course, all patients survived without onset of stroke, paraplegia, malperfusion, endoleak, or need for re-exploration. Follow-up remains satisfactory. Different factors may affect outcome following complex aortic procedures. Nevertheless, close cooperation between cardiac surgeons, vascular surgeons, and interventional radiologists may reduce potential for complications and address aspects that may not be completely within the domain of individual specialists.

Comparison of Two Generations of Thoracic Aortic Stent Grafts and Their Impact on Aortic Stiffness in an Ex Vivo Porcine Model

Objective

Little is known about the cardiovascular changes after TEVAR and regarding the impact on aortic stiffness for different stent graft generations specifically, following changes in device design. The present study evaluated the stent graft induced aortic stiffening of two generations of the Valiant thoracic aortic stent graft.

Methods

This was an ex vivo porcine investigation using an experimental mock circulatory loop. Thoracic aortas of young healthy pigs were harvested and connected to the mock circulatory loop. At a 60 bpm heart rate and stable mean arterial pressure, baseline aortic characteristics were obtained. Pulse wave velocity (PWV) was calculated before and after stent graft deployment. Paired and independent sample t tests or their non-parametric alternatives were performed to test for differences where appropriate.

Results

Twenty porcine thoracic aortas were divided into two equal subgroups, in which a Valiant Captivia or a Valiant Navion stent graft was deployed. Both stent grafts were similar in diameter and length. Baseline aortic characteristics did not differ between the subgroups. Mean arterial pressure values did not change after either stent graft, while pulse pressures increased statistically significantly after Captivia (mean 44 ± 10 mmHg to 51 ± 13 mmHg, p = .002) but not after Navion. Mean baseline PWV increased after both Captivia (4.4 ± 0.6 m/s to 4.8 ± 0.7 m/s, p = .007) and Navion (4.6 ± 0.7 m/s to 4.9 ± 0.7 m/s, p = .002). There was no statistically significant difference in the mean percentage increase in PWV for either subgroup (8 ± 4% vs. 6 ± 4%, p = .25).

Conclusion

These experimental findings showed no statistically significant difference in the percentage increase of aortic PWV after either stent graft generation and confirm that TEVAR increases aortic PWV. As a surrogate for aortic stiffness, this calls for further improvements in future thoracic aortic stent graft designs regarding device compliance.

Red Blood Cell Distribution Width: A Prognostic Marker in Patients With Type B Aortic Dissection Undergoing Endovascular Aortic Repair

Background

Red blood cell distribution width (RDW) is associated with cardiovascular mortality. However, the relationship between preoperative RDW and outcomes after thoracic endovascular aortic repair (TEVAR) in type B aortic dissection (TBAD) remains to be determined.

Methods

We review the records of 678 patients with TBAD and treated with TEVAR in three centers. Patients were divided into two groups according to the admission RDW cut-off by receiver operating characteristic curve analysis [≤13.5% (n = 278) and >13.5% (n = 400)]. The association between RDW and long-term mortality was evaluated using Cox survival analysis. Additionally, we used general additive models (GAM) with restricted cubic splines (RCS) to explore non-linear relationships between RDW and outcomes.

Results

Subjects with a high RDW had significantly higher in-hospital mortality rates (1.4 vs. 4.3%, P = 0.038). A total of 70 subjects died after a median follow-up period of 3.3 years. Kaplan–Meier analysis showed that subjects with an RDW >13.5% had worse survival rates than those with lower RDW values (P < 0.001). Multivariate Cox proportional hazard modeling revealed that an RDW >13.5% was an independent predictor of long-term mortality (adjusted HR = 2.27, P = 0.006). Also, we found that there was a non-linear relationship between RDW and mortality from RCS, and RDW of 13.5% might be an inflection point to distinguish the long-term mortality risk of TBAD patients.

Conclusion

As an inexpensive and routinely measured parameter, RDW holds promise as a novel prognostic marker in patients with TBAD receiving TEVAR. We found that an RDW >13.5% on admission was independently associated with increased long-term mortality.

Impact of Female Sex on Outcomes of Patients Undergoing Thoracic Endovascular Aortic Aneurysm Repair: A Ten-Year Retrospective Nationwide Study in France

The impact of sex on the outcomes of patients with cardiovascular disease is still incompletely understood. The aim of this nationwide multicenter observational study was to investigate the impact of sex on post-operative outcomes in patients undergoing thoracic endovascular aortic repair (TEVAR) for intact thoracic aortic aneurysm (iTAA). The French National Health Insurance Information System was searched to identify these patients over a ten-year retrospective period. Post-operative outcomes, 30-day and overall mortality were recorded. Among the 7383 patients included (5521 men and 1862 women), females were significantly older than males (66.8 vs. 64.8 years, p < 0.001). They were less frequently diagnosed with cardiovascular comorbidities. Post-operatively, women had less frequently respiratory (10.9 vs. 13.7%, p = 0.002) as well as cardiac complications (34.3 vs. 37.3%, p = 0.023), but they had more frequently arterial complications (52.8 vs. 49.8%, p = 0.024). There was no significant difference on overall mortality for a mean follow-up of 2.2 years (26.9 vs. 27.6%, p = 0.58). In the multivariable regression model, female sex was not associated with 30-day or overall mortality. Although women had a favorable comorbidity profile, the short-term and long-term survival was similar. The significantly higher rate of arterial complications suggests that women may be at higher risk of access-vessel-related complications.

RETRACTED: Anesthesic and surgical guideline for the treatment of the thoraco-abdominal aorta. Consensus Document of the Spanish Societies of Anesthesia and Cardiovascular Surgery

Este artículo ha sido retirado por indicación del Editor Jefe de la revista, después de constatar que parte de su contenido había sido plagiado, sin mencionar la fuente original: European Heart Journal (2014) 35, 2873 926.: https://academic.oup.com/eurheartj/article/35/41/2873/407693#89325738 El autor de correspondencia ha sido informado de la decisión y está de acuerdo con la retirada del artículo. El Comité Editorial lamenta las molestias que esta decisión pueda ocasionar. Puede consultar la política de Elsevier sobre la retirada de artículos en https://www.elsevier.com/about/our-business/policies/article-withdrawal

One-Year Results From the SURPASS Observational Registry of the CTAG Stent-Graft With the Active Control System

Purpose: To report the outcomes from the observational SURPASS registry, which was created to assess the performance of the Conformable TAG (CTAG) stent-graft with the Active Control System (ACS) in patients undergoing thoracic endovascular aortic repair (TEVAR) in a real-world setting. Materials and Methods: The SURPASS registry (ClinicalTrials.gov; identifier NCT03286400) was an observational, prospective, single-arm, post-market, international study that enrolled patients undergoing TEVAR using the CTAG with ACS for both acute and chronic thoracic aortic disease between October 2017 and July 2018. The CTAG with ACS features 2-stage deployment of the stent-graft and an optional angulation mechanism that modifies only the proximal end of the stent-graft. During the observation period, 127 patients (mean age 67.1±12.1 years, range 27–86; 92 men) were enrolled and treated for an array of aortic pathologies, including chronic and acute lesions and 4 ruptured descending thoracic aneurysms. The primary outcome of this study was technical success; secondary outcomes were clinical success and major adverse events at 30 days and 12 months. The numbers of 2-stage device deployments and applications of the angulation mechanism were recorded, along with the reasons for use. Results: Technical success of the TEVAR was 97.6% owing to unintentional partial coverage of supra-aortic branches in 3 cases (the vessels were patent on imaging). The stent-graft was repositioned at its intermediate diameter in 79 patients (62.2%), and the angulation feature was applied in 64 cases (50.4%), mainly to improve proximal wall apposition and orthogonality in the aorta. The desired effect was achieved in 60 cases (93.8%). There was no device compression, bird-beak configuration, fracture, or graft occlusion. The 30-day and 12-month clinical success rates were 97.6% and 92.9%, respectively. There were 3 aorta-related deaths at 30 days and a further 3 at 12 months. Fatalities were due to a retrograde type A dissection (0.8%), paraplegia, bowel ischemia, sepsis in the setting of a mycotic aneurysm, aneurysm rupture post aortoesophageal fistula, and multiorgan dysfunction syndrome. Three endoleaks (2 type Ia and 1 type III) required reintervention. Conclusion: In the SURPASS registry, the use of the CTAG device with ACS showed promising outcomes despite the challenging pathologies. The new delivery system enables a controlled staged delivery with in situ adjustments during positioning, facilitating the treatment of complex aortic disease.

Utility of age, creatinine, and ejection fraction score in patients with type B aortic dissection undergoing thoracic endovascular aortic repair

BACKGROUND

Older age, renal and cardiac dysfunction are predictors of poor outcome in aortic dissection. The aim of this study was to evaluate the association of the age, creatinine and ejection fraction (ACEF) score with adverse events in patients with type B aortic dissection (TBAD) undergoing thoracic endovascular aortic repair (TEVAR).

METHODS

The study enrolled 605 patients from January 2010 to July 2015, who were classified into three groups according to the tertiles of ACEF score: Tertile 1 (≤0.77, n = 204), Tertile 2 (0.77-0.96, n = 205) and Tertile 3 (>0.96, n = 196). The association between ACEF, AGEF (age, glomerular filtration rate and ejection fraction) and the updated version of the ACEF (ACEF II) score with adverse events was analyzed.

RESULTS

After a median 3.4 years follow-up, 63 (10.4%) patients died. Multivariable analysis revealed that ACEF score was independently associated with long-term mortality (adjusted hazard ratio = 3.54; 95% confidence interval, 2.09-6.01; p < 0.001). ACEF, AGEF and ACEF II score had similar predictive ability for both in-hospital and long-term death. The in-hospital mortality (1.5% vs. 1.0% vs. 6.6%, p = 0.001) were significantly higher in Tertile 3. In addition, cumulative long-term mortality in Tertile 3 was significantly higher than that in Tertile 1 and 2 (Log-Rank = 23.74; p < 0.001).

CONCLUSION

ACEF score could be served as an useful and relatively simple tool for pre-TEVAR risk stratification in TBAD patients.

Endovascular treatment of complex diseases of the thoracic aorta-10 years single centre experience

BACKGROUND

Introduction of invasive endovascular techniques constituted a real a breakthrough in the treatment of aortic aneurysm dissection and rupture. We assessed the effectiveness and safety of thoracic endovascular aortic repair (TEVAR) in patients with thoracic aortic pathologies.

METHODS

Between 2007 and 2017, 118 patients with thoracic aortic pathology underwent TEVAR. Among them, 20 (16.9%) patients required hybrid procedures. Stent grafts indication were thoracic aortic aneurysm in 46 (39.0%) patients, type B dissection in 68 (57.6%) patients and other indications in 4 (3.3%). Procedural success rate, in-hospital and late mortality and morbidity were evaluated.

RESULTS

The patients were followed-up for a mean of 55 months (range, 6-118 months). The technical success rate was 96%. Five patients died during the first 30 days after procedure (mortality 4.2%), four due to ischemic stroke followed by multi-organ failure and another one hemodynamically significant type I endoleak. Most of them were noted in the first years of our study. Five others died during post-discharged period. Four patients developed neurological complications, including stroke (n=2; 1.7%) and paraparesis (n=2; 1.7%). There were 6 (5.1%) primary (5 type I and 1 type II) and 3 (2.5%) secondary endoleaks (1 type I and 2 type III). Secondary interventions were required in 8 subjects. There was one case of stent collapse and two retrograde aortic dissection.

CONCLUSIONS

Treatment of descending aortic diseases by using stent graft implantation has become the method of choice, decreasing the risk of open surgery, especially in patients with severe clinical state and comorbidities. However, effectiveness and safety may be achieved by experience team.

Prospective Multicenter Study of the Low-Profile Relay Stent-Graft in Patients with Thoracic Aortic Disease: The Regeneration Study

BACKGROUND

To evaluate the early safety and clinical performance of the new low-profile RelayPro Thoracic Stent-Graft System in patients with thoracic aortic disease.

METHODS

This was an international, prospective, single-arm study in patients diagnosed with thoracic aorta disease (aneurysm, pseudoaneurysm, dissection, penetrating atherosclerotic ulcer, or intramural hematoma) and treated with a RelayPro stent-graft (in bare stent and/or nonbare stent configurations). The primary endpoints were freedom from aneurysm or dissection-related mortality and stent-graft performance.

RESULTS

A total of 31 patients were treated with the RelayPro thoracic stent-graft between 2014 and 2015 at 8 sites in Italy and Spain. Mean age was 72.1 (±10.2) years and 77% were male, 74% with hypertension, and 42% with a history of smoking. Twenty-four (77%) had aneurysms (fusiform in 46%, saccular in 42%, pseudoaneurysm in 12%); 5 (16%) had penetrating atherosclerotic ulcer; and 2 (6%) had chronic Type B dissection. Mean vascular access diameter was 9.1 mm (6-13 mm); 7 patients (23%) had vascular access of 7 mm or less. Technical success was 100% (primary, 90%; assisted primary, 10%). Freedom from aneurysm/dissection-related mortality through 30 days was 100%. Freedom from device-related major adverse events through 30 days was 94%. At 1 year, there was 1 (3%) type Ib and 1 (3%) type II endoleak, 1 (3%) nonaneurysm-related late death, and 1 (3%) secondary intervention (to correct type Ib endoleak).

CONCLUSIONS

The RelayPro has a 3-4 French profile reduction to allow endovascular repair of thoracic aortic disease in patients with smaller anatomies. This study shows good initial stent-graft performance and a favorable early safety profile.

Emergent aortic surgery in octogenarians: is the advanced age a contraindication?

Surgery of both the ascending and descending aortic segments in the context of an acute aortic syndrome is one of the greatest challenges for the cardiac surgeon. In the case of surgery of the descending aorta, surgical risk increases due to the technical complexity, the required aggressive approach and because surgical indication is usually established as a result of complications and therefore involves, almost always, critically ill patients. The aging of the population is causing such surgery to be considered in an increasing number of octogenarians. The present review analyzes the available scientific evidence on the surgical indications and outcomes of these complex procedures in this population, particularly in the emergent scenario. Ascending and descending thoracic aortic diseases are reviewed separately, and the role of both the current risk scores and frailty assessments are comprehensively discussed.

Endovascular Repair in Acute Complicated Type B Aortic Dissection: 3-Year Results from the Valiant US Investigational Device Exemption Study

Acute complicated type B aortic dissection (TBAD) is a potentially catastrophic, life-threatening condition. If left untreated, there is a high risk of aortic rupture, irreversible organ or limb damage, or death. Several risk factors have been associated with acute complicated TBAD, including age and refractory hypertension. In the acute phase, even uncomplicated patients are more prone to develop complications if hypertension and pain are left medically untreated. Innovations in stent graft technologies have incrementally improved outcomes since their first use for this condition in 1999, though improvement is needed in mitigating periprocedural complications, adverse events, and mortality. In the past decade, endovascular repair has become the preferred treatment because of its superior outcomes to open repair and medical therapy. The Valiant Captivia Thoracic Stent Graft System is a third-generation endovascular stent graft with advancements in minimally invasive delivery, conformability to the anatomy, and the minimization of adverse sequelae. Herein, this stent graft is briefly reviewed and its 3-year outcomes are presented. Freedom from all-cause and dissection-related mortality was 79.1% and 90.0%, respectively. The Valiant Captivia Stent Graft represents a safe, effective intervention for acute complicated TBAD. Continued surveillance is needed to verify its longer-term durability.

Acute aorta, overview of acute CT findings and endovascular treatment options

Acute aortic pathologies include acute aortic syndrome (aortic dissection, intramural hematoma, penetrating aortic ulcer), impending rupture, aortic aneurysm rupture and aortic trauma. Acute aortic syndrome, aortic aneurysm rupture and aortic trauma are life-threatening conditions requiring prompt diagnosis and treatment. The basic imaging modality for "acute aorta" is CT angiography with typical findings for these aortic pathologies. Based on the CT, it is possible to classify aortic diseases and anatomical classifications are essential for the planning of treatment. Currently, endovascular treatment is the method of choice for acute diseases of the descending thoracic aorta and is increasingly indicated for patients with ruptured abdominal aortic aneurysms.

Initial clinical experience with the Zenith alpha stent-graft

PURPOSE

To assess safety and short-term efficacy of endovascular repair of the thoracic aorta with the new Zenith Alpha stent-graft.

METHODS

Between August 2010 and May 2014, 33 patients (21 men; mean age 73.2±9.0 years) were treated Zenith Alpha stent-graft (group ZA). Outcomes of this group were compared with those of 34 patients (25 men; mean age 70.3±8.5 years) treated contemporaneously with the Zenith TX-2 for the same pathologies (group TX). The primary outcome measure was technical success. Data on iliac tortuosity, minimum access vessel diameter, and previous unsuccessful treatment with other endografts was also recorded.

RESULTS

Technical success was 93.9% in group ZA and 91.2% in group TX (p=0.67). There was no case of surgical death or conversion to open repair in either group. Two (6%) type I endoleaks occurred in group ZA and 3 (9%) in group TX (p=0.67). Three patients died within 30 days in group ZA vs. none in group TX (p=0.07). Mean minimum access vessel diameter was significantly smaller (5.07 vs. 6.65 mm, p=0.002) and iliac tortuosity indices significantly higher in group ZA (1.34 vs. 1.25, p=0.02). Access vessel complications occurred in 1 (3%) patient in group ZA and 4 (12%) patients in group TX (p=0.17). Significantly more patients in group ZA (6, 18%) were unsuccessfully treated previously with other endografts vs. none in group TX (p=0.01).

CONCLUSION

The new Zenith Alpha appears to be equally as safe and efficacious as the Zenith TX-2 while being used in patients with demanding access vessel morphology.

Update in the management of type B aortic dissection

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

Biomechanical Changes After Thoracic Endovascular Aortic Repair in Type B Dissection

Thoracic endovascular aortic repair (TEVAR) has evolved into an established treatment option for type B aortic dissection (TBAD) since it was first introduced 2 decades ago. Morbidity and mortality have decreased due to the minimally invasive character of TEVAR, with adequate stabilization of the dissection, restoration of true lumen perfusion, and subsequent positive aortic remodeling. However, several studies have reported severe setbacks of this technique. Indeed, little is known about the biomechanical behavior of implanted thoracic stent-grafts and the impact on the vascular system. This study sought to systematically review the performance and behavior of implanted thoracic stent-grafts and related biomechanical aortic changes in TBAD patients in order to update current knowledge and future perspectives.

A Right Intercosto-Bronchial Artery Derived from the Thyrocervical Trunk: An Unusual Cause of Type II Endoleak Post Thoracic Aortic Stenting

The aetiology, incidence and management of type II endoleaks in standard infrarenal endovascular aortic aneurysm repair is well described. Far less data is available for thoracic stent grafting. We present a rare and interesting case of a type II endoleak post thoracic aortic stenting and highlight the aberrant anatomy that can cause this phenomenon in such cases.

Surgical and anesthetic considerations for the endovascular treatment of ruptured descending thoracic aortic aneurysms

PURPOSE OF REVIEW

Ruptured descending thoracic aortic aneurysm (rDTAA) is a life-threatening disease. In the last decade, thoracic endovascular aortic repair (TEVAR) has evolved as a viable option and is now considered the preferred treatment for rDTAAs. New opportunities as well as new challenges are faced by both the surgeon and the anesthesiologist. This review describes the impact of current developments and new modalities for the surgical and anesthetic management of rDTAAs.

RECENT FINDINGS

A collaborative approach between the anesthesiologist and surgeon during critical moments such as induction, moment of aortic occlusion and placement of the aortic stent-graft is mandatory. Important issues to consider on preoperative imaging evaluation are correct sizing of the aortic stent-graft and localization of the artery of Adamkiewicz. Emergency TEVAR should preferentially be started under local anesthesia and could be switched to general anesthesia after stent placement. Patients should be kept in permissive hypotension preoperatively and during the intervention before stent-graft deployment and relative hypertension after deployment. The use of a proactive spinal cord protection protocol could decrease the risk of spinal cord ischemia and/or paraplegia and consists of permissive hypertension after stent deployment, cerebrospinal fluid drainage to maintain adequate spinal cord perfusion, relative hypothermia and possibly use of mannitol.

SUMMARY

In order to improve outcomes of TEVAR for rDTAA, a close communication between the anesthesiologist and the surgeon and a thorough understanding of the events during the procedure is mandatory. The use of a proactive spinal cord protection protocol may decrease the rates of devastating spinal cord ischemia.

Clinical safety and efficacy of a next-generation stent-graft device for thoracic endovascular aortic repair

Thoracic endovascular aortic repair has significantly improved the treatment of patients with acute and chronic diseases of the descending thoracic aorta. Retrograde transarterial implantation of a membrane-covered stent graft aims at excluding the aortic pathology at risk for complications (e.g., aneurysm, dissection) from the circulation to prevent expansion and ultimately rupture. Today, several stent grafts from different manufacturers are approved by the respective authorities and thus commercially available. The Medtronic Talent® stent graft used to be one of the initially available devices and has been broadly used to become the world-wide market leader at its time. In 2005, it has been replaced by the second-generation Medtronic Valiant® device, which features several technical improvements. In this article, we evaluate a recent publication investigating the clinical performance of this second-generation stent graft device, and discuss the results in the view of the current literature and developments.

Clinical significance of type II endoleaks after thoracic endovascular aortic repair

BACKGROUND

To evaluate the clinical significance of type II endoleaks (ELII) after thoracic endovascular aortic repair (TEVAR).

METHODS

From January 1997 to June 2012, a total of 344 patients received TEVAR in our institution. ELII was diagnosed in 30 patients (8.7%; 13 males; median age: 65 years, range: 24 to 84 years), representing the study population of this retrospective, single-center analysis. Mean follow-up was 29.5 months (range, 8 months to 9.5 years).

RESULTS

Primary ELII was observed in all but two cases (28/30; 93.3%). The most common sources of ELII were the left subclavian artery (LSA; 13/30; 43.3%) and intercostal/bronchial vessels (13/30; 43.3%), followed by visceral arteries (4/30; 13.4%). Overall mortality was 33.3% (10/30). ELII-related death (secondary rupture) was observed in 20% (2/10). Reintervention (RI) procedures for ELII were performed in 9 of 30 patients (30.0%); 5 of 9 (55.6%) in cases with ELII via the LSA. Indications for RI were diameter expansion in five and extensive leakage in four cases. Treatment was successful in five patients (55.6%) but failed in four cases (44.4%). In 12 of 21 (57.1%) untreated patients, ELII sealed during follow-up. In conservatively treated patients, an increase in aortic diameter has been only observed in a patient with secondary ELII.

CONCLUSIONS

The results presented herein suggest that the clinical impact of ELII after TEVAR must not be underestimated. Albeit a transient finding in most cases, ELII is associated with a relevant RI rate, particularly in cases involving the LSA. RI seems indicated in patients with increasing aortic diameter and/or extensive leakage. Careful surveillance of all patients with ELII is recommended.