Editor's Choice – Open Thoracic and Thoraco-abdominal Aortic Repair After Prior Endovascular Therapy

Abstract

The aim was to present current results of open thoracic and thoraco-abdominal aortic repair as secondary procedure after prior endovascular therapy. This was a retrospective cross border single centre study. From 2006 to July 2017 45 open thoracic aortic (TAA) or thoraco-abdominal aortic aneurysm (TAAA) operations were performed on 44 patients (median age 58 [15-80] years) as secondary surgery after previous endovascular therapy comprising TEVAR (n=38; 86%), EVAR (n=3; 7%), fenestrated EVAR (n=1; 2%) and TEVAR plus EVAR (n=1; 2%). Eleven patients (25%) had had previous open aortic surgery at the secondary surgery site. Indications for TAA(A) repair were Type I endoleak (n=10; 23%), post-dissection aneurysm progression due to persisting false lumen perfusion (n=8; 18%), proximal/distal disease progression (n=16; 36%), device fracture/dislocation (n=4; 9%), infection (n=5; 11%), and initial endograft misplacement (n=1; 2%). The operations included descending thoracic aortic repair (n=13, 29%), TAAA Type I (n=4; 9%), Type II (n=5; 11%), Type III (n=13; 29%), Type IV (n=7; 16%), and Type V repair (n=3; 7%) with simultaneous arch repair in 18% (n=8). The median time to secondary surgery was 36 (2-168) months. The median follow up was 39 (3-118) months. In hospital mortality was 20% (n=9) due to intra-operative aneurysm rupture, pneumonia induced sepsis, hemorrhagic cerebellar infarction, mesenteric ischaemia, broncho-esophageal fistula, and multiorgan failure (1/9) as well as haemorrhage (3/9). Estimated survival was 73% at 1 year and 71% overall. The most frequent complications were pneumonia (n=19; 43%), bleeding requiring revision (n=11; 25%) and sepsis (n=14; 32%). Transient dialysis was required in 32% (n=14), permanent dialysis in 6% (n=2). Permanent spinal cord deficit (paraparesis) occurred in 6% (n=2). Estimated freedom from aortic re-intervention was 86%. Open TAA(A) repair as a secondary procedure after previous endovascular aortic therapy is an important treatment option even in the endovascular era. It represents a durable treatment that can produce respectable outcomes. Yet the peri-operative morbidity and mortality are relevant and a specialised team and infrastructure are mandatory for these complex procedures. Therefore, centralisation is required.