A Case Report on the Open Surgical Repair of Thoracoabdominal Aortic Aneurysm With Severe Thoracic Vertebral Body Erosion. Experience in LMIC

Invited commentary

Open repair of intact thoracoabdominal aortic aneurysms in the American College of Surgeons National Surgical Quality Improvement Program

To compare target artery (TA) outcomes after fenestrated or branched endovascular aortic repair (FB-EVAR) versus open surgical repair (OSR) of thoracoabdominal aortic aneurysms (TAAAs). Few studies have compared TA outcomes after endovascular incorporation and open reconstruction. Among consecutive patients who underwent elective OSR or FB-EVAR of TAAAs (2008-2020), we reviewed those who had postoperative imaging studies evaluating TA. Data of FB-EVAR patients were obtained from a prospectively maintained institutional database. TAs included celiac, superior mesenteric, right and left renal arteries treated during TAAA repairs. Primary endpoint was TA patency (primary and secondary). There were 131 patients (487 TAs) treated by OSR and 350 (1,300 TAs) by FB-EVAR. In the OSR group, 440 TAs (90.3%) were reconstructed by bypasses, and 47 (9.7%) by reimplantation. In the FB-EVAR group, 841 TAs (64.7%) were incorporated by fenestrations, and 459 (35.3%) by DBs. Thirty-day TA primary patency rates were not significantly different between FB-EVAR and OSR (99.4%% vs. 99.0%, P=0.36), but secondary patency rate was higher after FB-EVAR (99.8% vs. 99.0%, P=0.02). Three-year primary patency rates were 95.9% (95% confidence interval [CI], 94.7-97.2%) and 94.7% (95% CI, 92.2-97.2%), respectively; secondary patency rates were 98.5% (95% CI, 97.7-99.2%) and 94.7% (95% CI, 95.7-99.2%), respectively. There were no significant differences in late primary patency and secondary patency between groups (each P<0.05). Target artery primary and secondary patency rates following elective OSR or FB-EVAR were high. Endovascular repair was not associated with loss of primary patency and late secondary patency.

The use of left heart bypass in the repair of thoracoabdominal aortic aneurysms: current techniques and results

Surgical thoracoabdominal aortic aneurysm (TAAA) repair remains challenging. Apart from mortality, spinal cord injury (SCI) is a dreaded complication. We analyzed our experience to identify predictors for SCI in a nonhigh-volume institution. All patients who underwent TAAA repair between February 1996 and November 2016 (n = 182) were enrolled. Most were male (n = 121; 66.4%), median age was 68 years (range: 21-84). Elective operations were performed in 153 instances (84.1%). Our approach to minimize SCI includes distal aortic perfusion, mild hypothermia, identification of the Adamkiewicz artery, and sequential aortic clamping. Cerebrospinal fluid drainage was introduced in 2001 and liberal use of selective visceral perfusion in 2006. Early mortality was 12.1%; it was 8.5% after elective procedures. Reduced left ventricular function, nonelective setting, older age, and longer bypass time were identified as independent predictors for mortality in multivariable logistic regression model. Permanent SCI was observed in nine patients (4.9%), of whom seven (3.8%) developed paraplegia. In a multivariable logistic regression model for paraplegia, peripheral arterial disease (PAD), Crawford type II repair, smaller body surface area, and era before 2001 were identified as independent predictors, whereas only PAD was significant for SCI. The incidence of paraplegia was 13.8% in extensive repair out of the first 91 cases, whereas it was improved up to 2.7% thereafter. Using an integrated approach, acceptable outcome of TAAA repair can be achieved, even in a nonhigh-volume center. PAD and extensive involvement of the aorta are strong independent predictors for spinal cord deficit after TAAA repair.

Perioperative care after thoracoabdominal aortic aneurysm repair: The Baylor College of Medicine experience. Part 1: Preoperative considerations

Chronic-contained aortic aneurysm rupture with vertebral erosion is a rare entity with fatal complications. Multidetector computed tomography (CT) angiography is an important diagnostic method for the evaluation of the aortic aneurysms, their complications, and also the relationship between aneurysm and branching vessels and adjacent structures. We present the multidetector CT angiography findings of a 62-year-old patient with chronic-contained thoracoabdominal aortic aneurysm rupture causing severe vertebral body erosion.

Severe cardiac disease is a major risk for early death following thoracoabdominal aortic aneurysm (TAAA) repair. Proximal aortic cross-clamping during TAAA repair dramatically increases left ventricular afterload risking myocardial ischemia. Although preoperative myocardial revascularization helps protect myocardium at risk during these periods of hemodynamic stress, in some patients myocardial revascularization is not feasible. Similarly, intraoperative shunting or bypass is not always practical. Under these circumstances we employ a modified multigraft technique during TAAA repair to reduce the risk of early death in high-risk cardiac patients. Case #1 is a 59-year-old male with end-stage ischemic cardiomyopathy (ejection fraction 15%), and recurrent admission for CHF, diagnosed with a 6 cm type III TAAA during evaluation for cardiac transplantation. Because of the potential need for intraaortic balloon support, he was not accepted for transplantation unless the TAAA could be repaired first. He underwent successful modified TAAA repair and subsequently had a successful cardiac transplant. He remains alive and well 3 years after TAAA repair. Patient #2 is a 70-year-old male who presented with an 8 cm type III TAAA. Cardiac evaluation revealed a history of prior myocardial infarction, severe nonreconstructable three-vessel coronary artery disease and inducible angina, left ventricular aneurysm, and ischemic wall motion abnormalities during dobutamine stress echocardiogram. Aneurysm size and multiple episodes of radiating central abdominal and back pain suspicious for aneurysm expansion precluded delays inherent to myocardial revascularization. He remains alive and well 10 months following successful modified TAAA repair. Patients with severe cardiac disease are at risk for early death following TAAA repair. Aortic cross-clamping contributes to this risk. The modified, multigraft technique of TAAA repair avoids aortic cross-clamping, minimizes myocardial risk, and may reduce early death.

To assess the safety and efficacy of off-pump technique with normothemia to extend thoracoabdominal aortic aneurysm replacement compared with traditional hypothermic circulatory arrest. From January 2004 to December 2013, 128 consecutive patients underwent surgical repair of thoracoabdominal aortic aneurysm (type Crawford Ⅱ) in Fuwai Hospital. The mean age was (37±11) years. The patients included 74 cases (57.8%) with chronic Stanford A dissection, 34 cases (26.6%) with chronic Stanford B dissection, 20 cases (15.6%) with thoracoabdominal aortic true aneurysm. There were 71 patients who underwent hypothermic circulatory arrest surgery (cardiopulmonary bypass (CPB) group) and 57 patients who underwent off-pump surgery with normothermia (off-pump group). The clinic data was compared between the 2 groups using paired t tests and χ(2) test. Kaplan-Meier survival analysis was used for postoperative survival stays. The mean CPB time in CPB group was (251 ±87) minuets and the circulatory arrest time was (45±24) minuets. Spinal cord ischemia time in the two groups was (21±12) minuets and (18±10) minuets (t=5.68, P=0.51). The operation time, ventilator time, length of ICU stay and length of hospital stay of off-pump group were shorter than CPB group ((408±114) minuets vs.(630±156) minuets, t=-7.67, P=0.05; (18±13) hours vs. (113±89) hours, t=-3.86, P=0.00; (4±2) days vs.(10±9) days, t=-4.19, P=0.00; (15±7) days vs.(25±14) days, t=-4.47, P=0.00). The intraoperative blood loss in off-pump group and CPB group was (900±750) ml and (1 400±400) ml (t=-2.23, P=0.04). The mortality was 1.7% and 9.8% in the off-pump group and CPB groups (χ(2)=3.544, P=0.05). The cerebral complication rate in the normal temperature group was 1.7% vs. 22.6% in extracorporeal group (χ(2)=9.35, P<0.05). A total of 113 patients were followed up, with a follow-up rate of 88.2%. Duration of follow-up was (78±54) months. Five patients died during the follow-up period, including 2 who died of cerebral infarction and 3 paraplegia patients who died of infection. Eight patients had phase Ⅱ aortic arch replacement after a mean time of 6 months. The overall postoperative survival rate was 97%, 93% and 87% at 3 years, 5 years and 7 years, respectively. Off-pump technique with normothemia was associated with a lower risk of a composite outcome of mortality and major adverse cardiac and cerebrovascular events during repair of extensive thoracoabdominal aortic aneurysm.

Invited Commentary

Commentary: Modified branch-first technique in thoracoabdominal aortic aneurysm repair: Does simpler mean safer?

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

Adjunctive Therapy for Spinal Cord Protection During Thoracoabdomina Aortic Aneurysm Repair

Minimally Invasive Segmental Artery Occlusion Prior to Endovascular Repair of Thoraco-Abdominal Aortic Aneurysm to Reduce the Risk of Spinal Cord Injury

Cardiac Arrhythmia After Open Thoracoabdominal Aortic Aneurysm Repair