Perioperative Complications in Patients with A “Shaggy Aorta” Undergoing EVAR and Open Aortic Surgery – A Retrospective Case Series and Case Discussion

Abstract

Introduction: Shaggy aorta is defined by diffuse, ulcerated plaques arising in the descending thoracic aorta and often extending through the abdominal and visceral segment. Two types of emboli originating from atherosclerotic plaques can be distinguished: Thrombemboli and atheroemboli (cholesterol crystal emboli). These plaques may lead to visceral, pelvic or peripheral embolization syndromes and have been shown to be associated with a higher 30-day mortality after endovascular (EVAR) and open (OR) aortic repair. Appropriate planning of endovascular procedures should include the calculation of these potential embolic risks for EVAR and OR as well as an adequate informed consent of the patients. Methods: All patients who underwent aortic repair with a shaggy aorta since 2015 were retrospectively analyzed. Patients' data, intra- and perioperative complications were collected. One fatal case will be described in detail including preoperative evaluation and intraoperative pictures. Results: Seven patients with complex EVAR (re-operation, transbrachial approach) and shaggy aorta were retrospectively evaluated since 2015. Due to high cardiac risk profiles (previous coronary bypass operation, bad general condition, aneurysm of the ascending aorta), re-EVAR was performed in 6 patients and OR in one patient. In 5 patients, atheroembolisation manifested and lead to dialysis requirement in 2 patients. One patient developed a multiple embolic syndrome (posterior stroke, multi-segmental bowel ischemia, liver necrosis), resulting from a complex transbrachial extension for cannulation of a left iliac branch device after contralateral hypogastric occlusion. Distal iliac extension for an endoleak Ib after EVAR without cannulating the descending aorta was associated with an uneventful course. In 2 patients (standard EVAR and EVAR with iliac branch device), renal function deteriorated, requiring permanent hemodialysis in 1 patient. ORlead to acute renal failure due to cholesterol emboli after clamping in perirenal aneurysm repair. Conclusion: Shaggy aorta represents an important risk factor for EVAR and OR. Prophylactic administration of corticoids and therapeutic anticoagulation during the procedure do not reduce the risk for embolic events. Plaques protruding >4 cm of thickness are highly likely to enhance the risk of cholesterol crystal embolism. Shaggy aorta remains an important risk factor for EVAR and OR and should influence our treatment strategies in complex aortic aneurysm surgery. Disclosure: Nothing to disclose