Long-term Outcomes of Endovascular Repair for Blunt Thoracic Aortic Injury: A 10 Year Multi-center Experience

OBJECTIVE

This study aimed to assess the long-term outcomes in patients treated by thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injuries (BTAI).

MATERIALS AND METHODS

From January 2010 to December 2019, this retrospective observational study was conducted at 3 centers, involving 62 consecutive BTAI patients who underwent TEVAR. Computed tomography angiography scans were planned to be conducted at 6 months post-procedure, and annually thereafter.

RESULTS

Technical success was achieved in all 62 procedures (100%), which included cases of dissection (n=35, 56.45%), pseudoaneurysm (n=20, 32.26%), and rupture (n=7, 11.29%). Mean injury severity score was 31.66±8.30. A total of 21 supra-arch branches were revascularized by chimney technique, with 12 cases involving the left subclavian artery (LSA) and 9 cases involving the left common carotid artery. In addition, 11 LSAs were covered during the procedure. The in-hospital mortality rate was 1.61% (n=1). The mean follow-up time was 86.82±30.58 months. The all-cause follow-up mortality rate was 3.28% (n=2). Stenosis or occlusion of 3 supra-arch branches (4.92%) was identified at follow-up, with 2 cases (3.28%) requiring re-intervention. No spinal cord ischemia, endoleak, or migration was observed.

CONCLUSIONS

Despite only including patients with long-term follow-up, this study confirms the long-term safety and effectiveness of TEVAR for BTAI. For young BTAI patients, as the thoracic aorta increases with age, longer follow-up is needed to observe the potential mismatch between the endograft and the aorta.

CLINICAL IMPACT

This study confirms the long-term safety and effectiveness of endovascular treatment for blunt thoracic aortic injury (BTAI). For young BTAI patients, as the thoracic aorta increases with age, longer follow-up is needed to observe the potential mismatch between the endograft and the aorta. Through a remarkably extended follow-up period (86.82±30.58 months) conducted at multiple centers in China, this study confirms the long-term safety and effectiveness of endovascular treatment for BTAI.

Weekend Admission is Associated with Higher Kidney Failures after Thoracic Endovascular Aneurysm Repair for Stanford Type B Aortic Dissection

BACKGROUND

Weekend effect characterized by worse perioperative outcomes has been demonstrated in some surgery patients admitted on weekends, as opposed to weekdays. This study aimed to examine weekend effect on open surgical repair or thoracic endovascular aneurysm repair (TEVAR) for Stanford Type B Aortic Dissection (TBAD).

METHODS

Patients who underwent TBAD repair were identified in National/Nationwisde Inpatient Sample from Q4 2015-2020. Open surgery and TEVAR were examined separately. Multivariable analyses were performed comparing in-hospital perioperative outcomes of patients under weekday and weekend admission. Adjusted preoperative variables included sex, age, race, socioeconomic status, hospital characteristics, clinical symptoms, comorbidities, and elective/non-elective admission. Also, length of stay, days from admission to operation, and total hospital charge were compared.

RESULTS

Among patients who underwent open TBAD repair, 1321 were admitted on weekdays and 340 on weekends. Among patients who underwent TEVAR for TBAD, 2018 were admitted on weekdays and 440 wereadmitted on weekends. There was no difference in open repair outcomes between those admitted on weekdays vs weekends. In TEVAR, weekend admission was associated with higher post-procedural kidney failure (1.14% vs .20%, aOR = 4.11, P = .04) and superficial wound complications (2.73% vs 1.49%, aOR = 2.2, P = .03) but lower respiratory complications (5.80% vs 3.64%, aOR = .47, P = .01). Also, in TEVAR, weekend admission was associated with longer time from admission to operation (3.92 ± .27 vs 2.35 ± .09 days, P < .01).

CONCLUSIONS

Renal malperfusion was a common indication for TBAD repair. TBAD patients admitted over the weekend and underwent TEVAR had higher post-procedural kidney failure, which may be due to delayed diagnosis and treatment.

Coil embolization of asymptomatic left gastric artery aneurysm: Case report and literature review

Patients with visceral artery aneurysms are rare, and the reported incidence of left gastric aneurysm (LGA) is only 4%. At present, although there is little knowledge about such disease, it is generally believed that appropriate treatment should be planned to prevent some dangerous aneurysms from rupturing. We introduced a case of 83-year-old patient with LGA who underwent endovascular aneurysm repair. The 6-month follow-up computed tomography angiography showed complete thrombosis in the aneurysm lumen. In addition, to insight the management strategy on LGAs deeply, a literature review concerning this entity published in recent 35 years was performed.

Hybrid Management of an Aortobronchial Fistula after Patch Aortoplasty for Aortic Coarctation in a Patient with SARS-CoV-2 Pneumonia: Case Report and Review of the Literature

Aortobronchial fistula is a rare cause of repeated hemoptysis and a potentially fatal condition if left untreated. We present the case of a 40-year-old man with repeated hemoptysis, excessive cough, and epistaxis ongoing for several days after SARS-CoV-2 pneumonia diagnosis. The patient had a history of patch aortoplasty for aortic coarctation and aortic valve replacement with a mechanical valve for aortic insufficiency due to bicuspid aortic valve at the age of 24. Computed tomography scan performed at presentation revealed a severely dilated ascending aorta, a thoracic aorta pseudoaneurysm at the site of the former coarctation, an aortobronchial fistula suggested by the thickened left lower lobe apical segmental bronchus in contact with the pseudoaneurysm and signs of alveolar hemorrhage in the respective segment. The patient was treated with thoracic endovascular aneurysm repair (TEVAR) after prior hemi-aortic arch debranching and transposition of the left common carotid artery and subclavian artery through a closed-chest surgical approach. Our case report together with a systematic review of the literature highlight the importance of both considering an aortobronchial fistula in the differential diagnosis of hemoptysis in patients with prior history of thoracic aorta surgical intervention, regardless of associated pathology, and of taking into account endovascular and hybrid techniques as an alternative to open surgical repair, which carries a high risk of morbidity and mortality.

Right-Sided Chylothorax: A Case Report of an Uncommon Manifestation After Cervical Debranching Thoracic Endovascular Aneurysm Repair

A 70-year-old man was admitted to our hospital with a thoracic aortic aneurysm. He underwent elective thoracic endovascular aneurysm repair with left common carotid artery-left subclavian artery bypass via the left supraclavicular approach. During the bypass, the thoracic duct was injured and ligated. On postoperative day 3, the patient complained of dyspnea. Chest radiography revealed a massive right-sided pleural effusion. On postoperative day 5, he was diagnosed with right-sided chylothorax and underwent chest tube insertion. The next day, a left-sided chylothorax was noted, and chest tube drainage was performed. Conservative management, including nil per os and subcutaneous octreotide (300 μg/day) injection, was carried out for 2 weeks; subsequently, the chylothorax improved. This report highlights the diagnostic challenge of right-sided chylothorax after debranching thoracic endovascular aneurysm repair.

Transesophageal Echocardiography Guided Partial Right Atrial Inflow Occlusion - A Case Study

Deployment of stent-grafts and other endovascular devices is a common technique for various vascular repair procedures. Induced, transient, periods of hypotension are essential to the precise deployment of a device as this minimizes displacement that can result from high pressure aortic flow. Partial inflow occlusion of the right atrium is a reliable, precise, and safe method of achieving this. We present a case where intraoperative transesophageal echocardiography (TEE) was used to guide and confirm balloon placement for right atrium inflow occlusion during a thoracic endovascular aneurysm repair (TEVAR) procedure for repair of an aortic dissection in a 67 year old male. This highlights a novel use of TEE in the context of endovascular surgery, and showcases an alternative method of reliably achieving transient hypotension.

An unusual case of type IIIB endoleak after repeat thoracic endovascular aortic repair at acute-angled arch: A case of fabric tear by bare-metal stent

We report a case of an unusual case of type IIIB endoleaks after repeat thoracic endovascular aortic repair that was not visualized on computed tomography, first diagnosed during open conversion surgery, and successfully treated. A 69-year-old man had undergone repeat thoracic endovascular aortic repair for an enlarged thoracic aortic aneurysm six months before. His repeat computed tomography showed an acutely enlarged aneurysm, which had expanded from 80 to 96 mm in diameter, without any endoleaks. A type IIIB endoleak resulted from a small tear in fabric caused by a bare-metal stent of the previous endograft. The tip of the bare-metal of smaller outer endograft had penetrated a fabric portion of the inner larger endograft. The aneurysmal sac pressure was 58/46 mmHg, compared with a systemic pressure of 79/35 mmHg. The endografts were explanted and replaced with a vascular graft.

A scoping review to identify competencies for transcatheter cardiovascular procedures

OBJECTIVES

Transcatheter procedures are increasingly being recognized as a priority for cardiac surgeons and cardiac surgery trainees. The optimal method of teaching these procedures during residency training has not been established. We used an evidence-based approach to systematically review the literature and identify competencies to inform future paradigms of transcatheter training in cardiac surgery.

METHODS

A scoping review was conducted to retrieve relevant literature on the performance of transcatheter cardiovascular procedures, identify competencies required by surgical residents learning to perform these procedures, and develop a preliminary list of competencies for consideration during transcatheter training. MEDLINE, Scopus, and ERIC were queried until April 1, 2020, using a systematic search strategy. No limitations were placed on publication date or type.

RESULTS

A total of 1456 sources of evidence were retrieved. After deduplication and screening, there remained 33 that were included in the scoping review, published between 2006 and 2020. The distribution of publication types included 10 comparative studies (30.3% of total), 8 societal statements (24.2% of total), 5 surveys and 5 opinion articles (each 15.2% of total), 2 editorials and 2 descriptions of a simulator (each 6.1% of total), and 1 narrative review (3.0% of total). From these, a total of 400 items were identified and organized into 97 competencies.

CONCLUSIONS

Evidence on the competencies required to perform transcatheter cardiovascular procedures is available from a variety of sources. The identified competencies may be a useful resource for developing curricula and teaching transcatheter procedures to cardiac surgery residents.

Frozen elephant trunk repair of aortic aneurysms: How to reduce the incidence of endoleak and reintervention

Background

Frozen elephant trunk (FET) enables treatment of arch and proximal descending thoracic aorta aneurysms. In treating patients with single-stage FET, the relationship of distal stent size to endoleak and reintervention has remained unexamined.

Methods

In this retrospective analysis of 63 cases in which FET was used to repair aneurysms between 2008 and 2019, 36 were intended as single-stage procedures. Effective sizing and sealing of distal stents were analyzed by preoperative and postoperative computed tomography angiography (CTA).

Results

During a mean of 25.8 ± 5.7 months of CTA follow-up, 10 of 36 (28%) experienced endoleak, and 3 of 36 (8%) had sac expansion. Ultimately, 5 of 13 (38%) underwent thoracic endovascular aneurysm repair. Patients without endoleak or sac expansion were more likely to have stents with >10% oversize and a >30-mm seal in healthy aorta compared with those experiencing these complications (11 of 23 vs 0 of 13; P = .0031). Conversely, 11 of 36 patients (31%) with adequately oversized and sealed stents developed fewer endoleaks compared with those without (0 of 11 vs 10 of 14; P < .0004). Patients with endoleak or sac expansion had smaller mean distal stent oversize and shorter mean sealing length compared with those without endoleak or sac expansion (2.3 ± 3.9% vs 18 ± 2.9% [P = .0023] and 1 ± 0.7 mm vs 34 ± 6 mm [P = .0005], respectively).

Conclusions

We recommend >10% distal stent oversize and >30-mm sealing length to minimize endoleak and reintervention. Increasing multidisciplinary collaboration with endovascular surgeons will improve distal stent planning.

Reversal of Spinal Cord Ischemia Following Endovascular Thoracic Aortic Aneurysm Repair With Hyperbaric Oxygen and Therapeutic Hypothermia

BACKGROUND

Neurological adverse events with spinal cord ischemia (SCI) remain one of the most feared complications in patients undergoing thoracic endovascular aortic repair (TEVAR). These patients can develop irreversible paraplegia with lifelong consequences with physical and psychological agony.

CASE PRESENTATION

We herein present a patient who developed SCI with bilateral lower leg paraplegia on the third postoperative day following TEVAR. Spinal catheter was inserted for spinal fluid drainage. A hyperbaric oxygen therapy was initiated for 90 minutes for 2 days, which was followed by therapeutic hypothermia for 24 hours with a target temperature of 33°C. The patient exhibited significant neurological recovery following these treatments, and he ultimately regained full neurological function without spinal deficit.

DISCUSSION

This represents the first reported case of full neurological recovery of a patient who developed complete SCI following TEVAR procedure. The neurological recovery was due in part to immediate therapeutic hypothermia and hyperbaric oxygen therapy which reversed the spinal ischemia.

Thoracic Aorta Aneurysm Repair in a Patient with a Solitary Kidney: Hybrid Surgery as a Bailout Procedure

Thoracic endovascular aortic repair (TEVAR) is an emerging treatment option for thoracic aorta aneurysms (TAA). Endovascular access is a challenge. We present a novel TEVAR technique in a patient with single kidney and a 6.4 cm TAA. Attempting to place a sheath through iliac arteries was unsuccessful. The decision to proceed to hybrid TEVAR was made. The protection of the solitary kidney was achieved through axillo-femoral bypass, followed by an end-to-side anastomosis between the aorta and a bifurcated graft. Through the graft, a stent was introduced in the thoracic aorta. With the use of contrast material, the right position of the graft was confirmed.

Bridging thoracic endovascular aneurysm repair for a late rupture following aortic coarctation angioplasty

Introduction Thoracic endovascular aneurysm repair has been employed to treat late complications after aortic coarctation correction. However, its use in children has seldomly been reported. Case report We present the case of a 15-year-old child who presented with a ruptured aneurysm of the descending aorta complicated later by an aortic-oesophageal fistula following aortic coarctation stenting that was managed with multiple bridging endovascular interventions until a definitive repair was performed.

CONCLUSION

Thoracic endovascular aneurysm repair may be used successfully as a bridging intervention to a definitive repair in children with life-threatening aortic complications following aortic coarctation repair.

Case Report: En Bloc Resection of Pancoast Tumor with Adjuvant Aortic Endograft and Chemoradiation

"Pancoast" tumors frequently require a multidisciplinary approach to therapy and are still associated with high morbidity and mortality. Due to their sensitive anatomic location, complex resections and chemoradiation regimens are typically required for treatment. Those with signs of aortic invasion pose an even greater challenge, given the added risks of cardiopulmonary bypass for aortic resection and interposition. Placement of an aortic endograft can facilitate resection if the tumor is in close proximity to or is invading the aorta. Prophylactic endografting to prevent radiation-associated aortic rupture has also been described. This case describes a 60-year-old female who presented with a stage IIIa left upper lobe undifferentiated non-small-cell carcinoma encasing the subclavian artery with thoracic aorta and bony invasion. Following carotid-subclavian bypass with Dacron, en bloc resection of the affected lung, ribs, and vertebral bodies was performed. The aorta was prophylactically reinforced with a Gore TAG thoracic endograft prior to adjuvant chemoradiation. The patient remains disease-free at more than 5 years follow-up after completing her treatment course. Endovascular stenting with subsequent chemoradiation may prove to be a viable alternative to palliation or open operative management and prevention of aortic injury during tumor resection and/or adjuvant therapy in select patients with aortic involvement.

Hybrid repair of right aortic arch aneurysm with a Kommerell's diverticulum

We describe the case of a 74-year-old man who underwent a hybrid open and endovascular approach for repair of dissecting thoracic aortic aneurysm of a right aortic arch with aberrant left subclavian artery arising from a Kommerell's diverticulum. Total debranching using a tailored quadrifurcated graft and thoracic endovascular aneurysm repair for the transverse aortic lesion were performed. The procedures were successfully accomplished with complete exclusion of the aneurysm. This hybrid procedure for complex aortic arch disease may reduce perioperative complications compared to challenging conventional open approaches.

Customized CT angiogram planning for intraoperative transesophageal echography-guided endovascular exclusion of thoracic aorta penetrating ulcer

The technique is demonstrated in a 78-year-old man; the preoperative CT angiogram showed a descending thoracic aorta ulcer of 5.9 cm in maximum diameter and 3.8 cm longitudinal extension. A ZTEG-2P-36-127-PF (Cook Medical) single tubular endograft was planned to be deployed. From the preoperative CT angiogram we planned to land 4.7 cm above the midline of the descending thoracic aorta ulcer and 8.0 cm below. In the operating room, under radioscopic vision the centre of the transesophageal echography probe was used as marker to identify the correspondent midline of the descending thoracic aorta ulcer and a centimeter-sized pigtail catheter in the aorta was used to calculate the desired length above and below the ulcer midline. The endograft was introduced and placed in the desired position compared to the transesophageal echography probe and the catheter; under transesophageal echography vision the graft was finally deployed. The CT angiogram at 1 month showed the correct endograft position, descending thoracic aorta ulcer exclusion with no signs of endoleak. In selected cases, this method allows planning in advance safe stent graft positioning and deployment totally assisted by transesophageal echography, with no risk of periprocedural contrast-related renal failure and reduced radiation exposure for the patient and operators.

Update on aneurysm disease: current insights and controversies: peripheral aneurysms: when to intervene - is rupture really a danger?

Peripheral artery aneurysms are rarer than abdominal aortic aneurysms (AAA), although the true prevalence is not well known. They often coexist with aortic and other peripheral artery aneurysms. In contrast to AAA, where the principal risk is that of rupture, thromboembolism is more common, contributing a bigger risk in the more common lesions. Although rupture does occur, with incidence related to anatomical site, aneurysm diameter cannot be used to guide management with the same confidence as in AAA. In addition, the rarity of these lesions results in a paucity of evidence with which to guide intervention. Consequently they are difficult lesions to manage, and numerous aneurysm and patient factors must be considered to provide treatment individualised for each case. We discuss popliteal, femoral, carotid, subclavian, upper limb, visceral and false aneurysms, focussing on the risk of rupture and thromboembolism, and current thresholds for intervention, based on the available published literature.

Thoracic endovascular aortic repair with the chimney technique for blunt traumatic pseudoaneurysm of the aortic arch in a no-option patient

A 42-year-old man was involved in a motor vehicle collision. Imaging studies revealed the presence of a post-traumatic aortic pseudo-aneurysm (about 34 × 26 cm) arising from the descending thoracic aorta at the level of the left subclavian artery (LSA), prone to rupture. Thoracic endovascular aneurysm repair (TEVAR) was the only feasible option due to his poor overall medical status. In this case, LSA needed to be covered in order to extend the proximal landing zone. Eventually, modified TEVAR was successfully performed by means of the chimney technique to preserve flow to the LSA and to prevent flow into the pseudoaneurysmal sac.

Staged hybrid debranching and thoracic endovascular aneurysm repair for multiple aortic aneurysms after conventional open repair of the descending aorta: a case report

Endovascular repairs of thoracic and thoracoabdominal aortic aneurysm have recently been proposed as a less invasive alternative to conventional open surgical repair. In selective cases, adjunctive bypass surgery may be required to provide an adequate landing zone. We describe a case of staged hybrid debranching and thoracic endovascular aneurysm repair for distal aortic arch and thoracoabdominal aortic aneurysms after conventional open repair of the descending aorta.