Management of Visceral Artery Patch Aneurysms and Segmental Artery Patch Aneurysms Following Open Thoracoabdominal Aortic Aneurysm Repair

Abstract

Segmental intercostal/lumbar and visceral arteries are often reimplanted as a patch with surrounding native aortic tissue during open thoracoabdominal aortic aneurysm (TAAA) repair to preserve perfusion of the spinal cord and expedite visceral revascularization. However, late aneurysmal degeneration of the aortic tissue in the patch is a known, albeit infrequent, complication of this technique. The objective of this study was to describe our experience with management of visceral artery patch (VAP) aneurysms and segmental artery patch (SAP) aneurysms following TAAA repair. We retrospectively identified 57 patients (median age, 62 years; range, 50-73 years) who underwent VAP aneurysm and/or SAP aneurysm repair in our single practice (1986-2021). Median time from initial TAAA repair to patch aneurysm repair was 9 years (range, 5-12 years). Of these 57 repairs, 37 were for VAP aneurysm, 13 were for SAP aneurysm, and 7 were for both (Table). All 37 VAP aneurysms were repaired with open TAAA reoperations, while SAP aneurysms were addressed with either open repair (n = 13) or endovascular exclusion with thoracic aortic endografts (n = 7). Twenty-three patients (40%) had heritable thoracic aortic disease, of whom 17 had Marfan syndrome (30%). Crawford extent II repair was the most common preceding TAAA repair (n = 35, 61%). Patients presenting with patch aneurysm were often symptomatic (n = 41; 72%). Additionally, eight patients (14%) presented with patch aneurysm rupture. Early outcomes included operative mortality and adverse event, a composite variable comprised of operative death or persistent renal failure necessitating dialysis, paraplegia, paraparesis, or stroke. Operative mortality was 9% (n = 5); however, no operative deaths occurred in those treated with endovascular repair. The adverse event rate was 11% (n = 6), including four patients (7%) who developed persistent renal failure requiring dialysis following their repair. Only one patient (2%) experienced a stroke postoperatively. No patients experienced persistent paraplegia, including those who had endograft coverage of their intercostal patch without intercostal revascularization. Of 13 open SAP aneurysm repairs, 7 were performed with subsequent intercostal artery reimplantation. Left heart bypass was not used in any repairs; however, other adjuncts such as cerebrospinal fluid drainage (n = 27; 47%) and cold renal perfusion (n = 38; 67%) were used frequently. Most patients were discharged home (n = 49; 86%) (median length of hospital stay, 10 days; range, 9-14 days). Reoperative open VAP and SAP aneurysm repair is technically challenging; however, it can be performed with reasonable outcomes. Isolated SAP aneurysms can be safely managed with endovascular exclusion with promising results.TablePreoperative characteristics, operative details, and early outcomes in 57 visceral artery patch (VAP) aneurysm and segmental artery patch (SAP) aneurysm repairsVariablePatch aneurysm (n = 57)Age, years62 [50-73]Male sex30 (53)Time from initial TAAA repair to patch aneurysm repair, years9 [5-12]Heritable thoracic aortic disease23 (40)Tobacco use39 (68)Symptomatic41 (72)Rupture8 (14)Prior extent II repair35 (61)Urgent or emergency repair13 (23)Pseudoaneurysm at site of patch aneurysm15 (26)Open repaira50 (88) VAP aneurysm only37 (74) SAP aneurysm only6 (12) Both7 (14)Endovascular repair7 (12) VAP aneurysm0 SAP aneurysm7 (100)Cerebrospinal fluid drainage27 (47)Left heart bypass0Adverse event6 (11)Operative death5 (9)Persistent paraplegia0Persistent renal failure4 (7)Length of intensive care unit stay, days4 [3-6]Length of hospital stay, days10 [9-14]Discharged home49 (86)Values are number (%) or median (quartile 1-quartile3 [Q1-Q3]). Variables with missing data are clarified by available sample size.aPercentages in the open and endovascular repair subgroups are expressed as percentage of total open or endovascular repairs, respectively. Seven open repairs were performed in patients who had both VAP and SAP aneurysms repaired simultaneously. Open table in a new tab