Hybrid Procedures in the Treatment of Thoracoabdominal Aortic Aneurysms:

Single Stem Visceral Debranching for Complex Aortic Disease

Objective

The treatment of complex aortic disease has been described with various retrograde visceral bypass techniques. An original technique with a single stem retrograde visceral graft (SSRVG) is presented.

Methods

This was a single centre retrospective study including 16 patients between 2015 and 2019. Patients were treated for aortic dissection (AD; type A and acute or chronic type B), thoraco-abdominal aortic aneurysms (TAAAs), and visceral occlusive disease. Surgery consisted of visceral vessel debranching from the native infrarenal aorta or from an aortic graft. In the case of AD, surgical fenestration was performed. Additional thoracic endovascular aneurysm repair (TEVAR) completed the treatment when indicated, during the same procedure or later. Patient outcomes and reconstruction patency were studied.

Results

The mean patient age was 64 years (median 68 ± 12.6). Ten (62%) patients were treated for AD, three (19%) for TAAA, and three (19%) for occlusive disease. Sixty-nine target vessels were debranched with this SSRVG technique. Aortic surgical fenestration was performed in eight cases and TEVAR in four. During their hospital stay, three (19%) TAAA patients died, seven cases of renal insufficiency (44%), four cases of pneumonia (25%), and three colonic ischaemia cases (19%) were noted. After a mean follow up of 21 months, no other deaths occurred. All vessels (except two inferior mesenteric arteries) were patent and no endoleak was noted.

Conclusion

The SSRVG technique can be offered in various complex aortic diseases. The use of a single graft is feasible and reduces the volume of multiple branch assembly in the retroperitoneal space. The observed patency rate is high.

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Not all patients with complex aortic disease are amenable to open surgery or total endovascular repair.

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Hybrid surgery with visceral vessel debranching may represent an alternative.

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Various techniques using several grafts to debranch visceral vessels have been published.

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The use of a single conduit for total visceral debranching is relatively straightforward and provides excellent patency results.

[Visceral debranching in hybrid surgery of thoracoabdominal aortic aneurysms]

Presented herein is a review of the literature dedicated to the method of visceral debranching, i. e., switching of the visceral and renal branches of the abdominal aorta to its intact portion, using synthetic vascular prostheses as the first stage of hybrid surgical treatment of thoracoabdominal aortic aneurysms prior to endovascular aortic aneurysm repair. This is accompanied and followed by describing the history of the problem, operative technique, results of studies, as well as the data from registries and meta-analyses. Also discussed are the main complications of the method and measures of their prevention. We conclude that hybrid surgery of the thoracoabdominal portion of the aorta is a promising method in a particular cohort of patients, especially those at high surgical risk of 'open' aortic surgery.

Unusual hybrid repair of a thoracoabdominal and mesenteric aneurysm with aberrant right hepatic artery

Hybrid approaches for the treatment of thoracoabdominal aortic aneurysms that combine visceral debranching and endovascular repair are feasible alternatives to open surgery for certain high-risk patients. A 70-year-old man was admitted with a rapidly expanding thoracoabdominal aneurysm involving the superior mesenteric artery, associated with an aberrant hepatic artery. An iliovisceral debranching was performed, followed by the endovascular repair of the thoracoabdominal aorta with a standard thoracic device. The ostial aneurysm was excluded by retrograde implantation of a covered stent from the superior mesenteric artery. Such approach can be considered as a viable alternative in the management of complex thoracoabdominal aneurysms.

[Staged approach for hybrid thoracoabdominal aortic replacement]

AIM

To generalize our experience of step-by-step hybrid thoracoabdominal aortic replacement.

MATERIAL AND METHODS

Twenty-three patients were enrolled who underwent staged hybrid treatment of thoracoabdominal aortic aneurysm. There were 5 (21.7%) women and 18 (78.3%) men aged 61.4±8.3 years (37-74 years). The first stage was proximal debranching, the second - distal (abdominal) procedure and the third - stenting of the thoracoabdominal aorta.

RESULTS

There were no any complications after proximal debranching and aortic stenting. Abdominal debranching was followed by lethal outcome in 3 (13.0%) patients and early postoperative occlusion of the prosthesis brunch in 3 out of 87 cases.

CONCLUSION

Staged approach for hybrid surgical treatment is optimal solution, especially in high risk patients. In our opinion no necessity for cardiopulmonary bypass is the main advantage of this technique.

Thoracoabdominal Aortic Aneurysm in a HIV-positive Patient

Advent of antiretroviral therapy has increased survival of patients with human immunodeficiency virus (HIV) infections, with the result that some of these patients now develop degenerative diseases, such as atherosclerotic aneurysms. Degenerative thoracoabdominal aortic aneurysm is rare in HIV patients. In this report, a 63-year-old male patient with HIV submitted to open repair of thoracoabdominal aortic aneurysm. The patient did not suffer any type of complication in the perioperative period and remained well in a 28-month follow-up period. In summary, open repair still remains a good alternative for aortic complex aneurysms even in HIV patients.

Multibranched Stent-Grafts for the Treatment of Thoracoabdominal Aortic Aneurysms

Purpose: To evaluate the available literature on endovascular repair of thoracoabdominal (TAAA) and pararenal aortic aneurysms (PRAA) using multibranched stent-grafts. Methods: MEDLINE, EMBASE, and Cochrane databases were searched between January 2001 and June 2015 to identify articles related to the use of multibranched stent-grafts for the treatment of TAAA and PRAA. Articles with <4 cases and those on juxtarenal aortic aneurysms were excluded. Meta-analyses were conducted to evaluate 30-day mortality, all-cause mortality, spinal cord ischemia, renal insufficiency, endoleak, target vessel patency, and reintervention. Of 370 articles screened, only 4 articles encompassing 185 patients (mean age 71.1 years; 137 men) were aligned with the inclusion criteria. There were 23 PRAAs; the mean aneurysm diameter was 64.5 mm. The Crawford TAAA classification was 10 type I, 47 type II, 37 type III, 58 type IV, and 9 type V; there was 1 Stanford type B dissection in association with a large TAAA. Results of the meta-analyses are reported as proportions and 95% confidence interval (CI). Results: Pooled analysis indicated a technical success rate of 98.9%. As study heterogeneity was significant, random effects models were used for meta-analysis. The rate for 30-day mortality was 9% (95% CI 3% to 19%), for all-cause mortality 27% (95% CI 17% to 38%), endoleaks 10% (95% CI 1% to 25%), target vessel patency 98% (95% CI 95% to 99%), SCI 17% (95% CI 1% to 26%), irreversible SCI 6% (95% CI 3% to 10%), renal insufficiency 15% (95% CI 0.8% to 41%), and reinterventions 21% (95% CI 4% to 47%). Conclusion: Use of multibranched stent-grafts in the treatment of TAAAs and PRAAs appears to be feasible and safe based on satisfactory early outcomes in the limited literature available to date. Long-term surveillance and further studies are essential to determine the durability of this technique.

["Debranching" -- a new surgical option for the aortic arch and thoracoabdominal aorta hybrid interventions]

INTRODUCTION

Endovascular techniques in vascular surgery are frequently applied to treat aortic diseases. These minimally invasive procedures changed aortic interventions remarkably. We have to be familiar with new terminology and methods.

METHOD

New and old surgical procedures gained new role in preparation of endograft implantations. Transforming anatomy of aortic branches - "debranching" - is aimed to create a sufficient fixation of the endografts at safe "landing zones".

CONCLUSIONS

Knowing the option of hybrid procedures is a fundamental requirement for the vascular surgeon. Equally important is to know the biomechanical characteristics of the available endografts, the possible complications during and after implantation and the treatment options. We have to be aware of the limitations of these new methods and the role of traditional open surgery in the new era. Our intention in this paper is to summarize methods of debranching.

Contemporary outcomes of open repair of thoracoabdominal aortic aneurysm in young patients

Background

Endovascular technology now permits total endovascular thoracoabdominal aortic aneurysm (TAAA) repair with high volume centres reporting encouraging results. The long-term durability of such stent grafts is unknown, leading to concerns regarding their use in younger patients. This study reports contemporary outcomes of open repair in young patients.

Methods

Outcomes for patients age 60 or younger undergoing open TAAA repair between June 1999 and August 2013 with prospective collected data were analysed retrospectively.

Results

Thirty-seven patients (31 men, 84%) with a median age of 56 (range 22–60) were identified with a median TAAA diameter of 6.9 cm (range 5.6-11). Aneurysm aetiology included degenerative change (18), dilation of chronic dissection (10), connective tissue disease (7) and mycotic degeneration (2). Crawford Type IV TAAA were most commonly treated (17), followed by Type II (10), Type III (7) and Type I (3). Two (5%) patients died in hospital, one from multiple organ failure and one from respiratory failure. Three patients (8%) developed temporary paraplegia, all of whom made a complete recovery and 4 (11%) patients required temporary renal replacement therapy. Median critical care stay was 5 days (range 2–28) with an in-hospital stay of 14 days (range 7–83). During a median follow-up of 72 months (range 13–171), no patient subsequently required any further aneurysm related surgical or radiological intervention. The mean (SEM) survival time was 138.5 (11) months. The 5 year survival was 79.7% (8.3) including early deaths, with no aneurysm related complications.

Conclusions

The outcome of open TAAA repair in patients aged less than 60 years is favorable. It is against these results that evolving endovascular interventions must be compared.

Electronic supplementary material

The online version of this article (doi:10.1186/s13019-014-0195-4) contains supplementary material, which is available to authorized users.

Renal interventions during endovascular aneurysm repair

Renal insufficiency is a risk factor for mortality and morbidity during endovascular aneurysm repair. Multiple changes in practice have occurred to mitigate renal injury and renal dysfunction. Transrenal fixation does carry an increased risk of a decline in renal function in the medium term. Renal stenting for athero-occlusive disease during endovascular aneurysm repair needs careful consideration, as indications have changed and there are unexpected consequences with early vessel occlusion. The growing number of renal interventions during complex endovascular aneurysm repair with the advent of chimney snorkel/periscope techniques and the introduction of fenestrated grafts has shown the resilience of the intervention with relatively low renal issues (approximately 10%), but has also illustrated the need for additional device development.

Subacute anterior spinal cord ischemia with lower limb monoplegia: a clinical dilemma and challenging scenario

A 70-year-old woman presented with crescendo right lower limb monoplegia. Magnetic resonance imaging depicted anterior spinal artery syndrome with an 8.5 cm Crawford type II thoracoabdominal aortic aneurysm (TAAA). A staged hybrid procedure was performed, following which she had total exclusion of her TAAA and full resolution of her monoplegia. Clinical presentations of TAAAs can be diverse and require detailed clinical knowledge and lateral thinking to unearth unorthodox presentations. This erratic presentation of a TAAA with anterior spinal artery syndrome outlines particular challenges with management and portrays the need for tailored utilization of contemporary techniques to deal with the growing complexity of TAAAs.

Hybrid one-stage approach to extensive atherosclerotic aneurysm of thoracoabdominal aorta

We report a 62-year-old man with an atherosclerotic Crawford type II aneurysm involving both common iliac arteries who underwent surgical revascularization of the visceral vessels and renal arteries from the ascending aorta and subsequent endovascular aneurysmal exclusion. Computed tomography imaging at 2 years showed complete exclusion of the aneurysm throughout the thoracoabdominal aorta, confirming the successful antegrade revascularization of visceral vessels and renal arteries. A hybrid approach to thoracoabdominal aneurysms using antegrade visceral and renal revascularization from the ascending aorta before endovascular repair is technically feasible and might constitute an attractive alternative to conventional surgical treatment.

Continued favorable results with open surgical repair of type IV thoracoabdominal aortic aneurysms

OBJECTIVES

Type IV thoracoabdominal aortic aneurysm (TAAA) repair, despite low risk of spinal cord ischemia (SCI), is reported to have significant morbidity and mortality. This has led some to apply adjuncts (eg, extracorporeal circulation) used in more extensive TAAA repair or to consider alternative approaches, such as hybrid operations. We have used a consistent, simplified surgical approach to type IV TAAA, and the goal of the present study is to review experience over 2 decades with such treatment and to identify correlates of surgical morbidity.

METHODS

All type IV repairs at Massachusetts General Hospital from January 1989 through September 2009 were evaluated for clinical features, technical operative details, and 30-day outcomes. Logistic regression identified predictors of morbidity. Survival was assessed using Kaplan-Meier analysis.

RESULTS

A total of 179 patients underwent type IV repair, with elective repair in 156 (87%) and urgent in 23 (13%). The clamp-and-sew technique was used for all operations, with routine hypothermic renal perfusion. Clinical features were age 73 ± 8 years, coronary artery disease in 89 (50%), and creatinine level >1.8 mg/dL defining chronic renal insufficiency (CRI) in 32 (18%). Operative reconstruction in 166 (93%) consisted of one beveled proximal anastomosis incorporating the descending thoracic aorta, celiac, superior mesenteric artery, and right renal arteries origins (mean visceral clamp time, 36 ± 12 minutes) and a side-arm graft to the left renal artery. Technical details included previous abdominal aortic aneurysm (AAA) repair in 52 (29%), operative time of 290 ± 90 min, estimated blood loss of 2.7 ± 1.4 L, and splenectomy in 57 (32%). The 30-day outcomes were death in 5 (2.8%), myocardial infarction in 6 (3.4%), hemodialysis in 5 (2.8%), and any degree of SCI in 4 (2.2%). Regression analysis identified a history of CRI as an independent predictor of postoperative complication or death (odds ratio, 3.4; 95% confidence interval, 1.4-8). Survival rates at 1, 5, and 10 years were 89% ± 2%, 62% ± 4%, and 36% ± 5%, respectively.

CONCLUSIONS

A simplified operative approach for type IV TAAA repair is associated with favorable perioperative results. These data refute the need for surgical adjuncts commonly applied in more extensive TAAA and indicate that the hybrid operation is an illogical posture. CRI should figure prominently in clinical decision making. Long-term survival equates that observed after routine AAA repair.

Multiple aneurysm repair: hybrid approach to chronic dissection around visceral branches

The present case report details our experience with the hybrid approach for multiple aneurysms in the aortic arch, thoracoabdominal aorta, and around the aortic bifurcation. Total arch replacement for the arch aneurysm under hypothermic cardiopulmonary bypass with antegrade cerebral perfusion was the first stage of aneurysm repair. Five months later, bifurcated graft replacement with debranching of four abdominal branches was undertaken as the second stage of treatment. Finally, stent-graft repair for chronic dissection of the thoracoabdominal aorta was performed utilizing a Gore-Tex Tag endovascular prosthesis. Over 7 months of treatment, all aneurysms were excluded from the aortic blood flow and pressure without abdominal organ dysfunction except a transiently elevated total bilirubin level. Although the patient had an episode of minor gastrointestinal bleeding after discharge, he is currently leading a normal life without limitations at home 5 months after the stent-graft repair.