Aortic Arch Branch Vessels Research Articles

Long-term outcomes of total arch replacement with bilateral antegrade cerebral perfusion using the "arch first" approach.

To report outcomes of total arch replacement (TAR) with hypothermic circulatory arrest and bilateral antegrade cerebral perfusion (bACP) using an "arch first" approach for acute Type A aortic dissection (ATAAD). The "arch first" approach involved revascularization of the aortic arch branch vessels with uninterrupted ACP, before lower body circulatory arrest, while the patient was cooling. This was an observational study of aortic surgeries from 2010 to 2021. All patients who underwent TAR with bACP for ATAAD were included. Short-term and long-term outcomes were reported utilizing descriptive statistics and Kaplan-Meier survival estimation. A total of 215 patients were identified who underwent TAR + bACP for ATAAD. Age was 59.0 [49.0-67.0] years and 35.3% were female. 73 patients (34.0%) underwent a concomitant aortic root replacement, 188 (87.4%) had aortic cannulation, circulatory arrest time was 37.0 [26.0-52.0] minutes, and nadir temperature was 20.8 [19.4-22.5] degrees Celsius. 35 patients (16.3%) had operative mortality (STS definition), 17 (7.9%) had a new stroke, 79 (36.7%) had prolonged mechanical ventilation (>24h), 35 (16.3%) had acute renal failure (by RIFLE criteria), and 128 (59.5%) had blood product transfusions. One-year survival was 77.1%, while 5-years survival was 67.1%. During follow-up, there were 23 (10.7%) reinterventions involving the descending thoracic aorta - either thoracic endovascular aortic repair or open thoracoabdominal aortic replacement. Among patients with ATAAD, short-term postoperative outcomes after TAR + bACP using the "arch first" approach are acceptable. Moreover, this operative strategy may furnish long-term durability, with a reasonably low reintervention rate and satisfactory overall survival.

Extra-anatomic revascularization and a new cannulation strategy for preoperative cerebral malperfusion due to severe stenosis or occlusion of supra-aortic branch vessels in acute type A aortic dissection

ObjectivesAcute type A aortic dissection (ATAAD) with severe stenosis or occlusion of the true lumen of aortic arch branch vessels often leads to an increased incidence of severe postsurgical neurological complications and mortality rate. In this study, we aimed to introduce our institutional extra-anatomic revascularization and cannulation strategy with improved postoperative outcomes for better management of patients with cerebral malperfusion in the setting of ATAAD. MethodsTwenty-eight patients with ATAAD complicated by severe stenosis or occlusion of the aortic arch branch vessels, as noted on combined computed tomography angiography of the aorta and craniocervical artery, between January 2021 and June 2022 were included in this study. Basic patient characteristics, surgical procedures, hospitalization stays, and early follow-up results were analyzed. ResultsThe median follow-up duration was 16.5 months (interquartile range: 11.5–20.5), with a 100% completion rate. The 30-day mortality rates was 7.1% (2/28 patients); two patients had multiple cerebral infarctions on preoperative computed tomography and persistent coma. Postoperative transient neurological dysfunction occurred in 10.7% (3/28) of the patients, and no new permanent neurological dysfunction occurred. Of all the patients, 3.6% (1/28) had novel acute renal failure. No other deaths, secondary surgeries, or serious complications occurred during the early follow-up period. ConclusionsUse of extra-anatomic revascularization and a new cannulation strategy before cardiopulmonary bypass is safe and feasible and may reduce the high incidence of postoperative neurological complications in patients with ATAAD and cerebral malperfusion.

Laser Fenestration in TEVAR: Perspectives and Future Directions

Endovascular aortic repair has been increasingly used to treat a multitude of thoracic aorticpathologies. When placement of a thoracic endograft necessitates coverage of one or more of the great vessels, in situ laser fenestration is a safe and effective option for supra-aortic trunk revascularization. Certain anatomic factors may render laser fenestration more technically challenging, particularly depending on aortic arch type and branch vessel characteristics. Short-term and mid-term outcomes have shown promising results for mortality, stroke, and complication rates. Future developments may extend the utility of this approach and allow it to be applied to a more widespread set of patients with challenging anatomy.

One year follow-up outcomes of endovascular treatment for aortic dissection with a partial micropore stent graft in which fixation of the stent is done in zone 0: A pivotal trial first in human

ObjectiveThis study aimed to verify the efficacy and safety of the treatment for patients diagnosed with DeBakey type I and type III thoracic aortic dissections using a partial micropore stent graft. MethodsWe conducted a retrospective analysis of 32 patients who suffered from thoracic aortic dissection and underwent endovascular repair using a partial micropore stent graft at our center between December 2018 and January 2020. ResultsThe technical success rate for 32 patients was 100 %, while no 30-day mortality was observed. In the 30 patients finished follow-ups, 30 (mean: 1 per patient) micropore stents were implanted, while the openings of 90 (mean: 3 per patient) aortic arch branches were covered by the stents. After more than 12 months follow-up, 26 (86.7 %) of the 30 patients presented with a complete thrombosis in the false lumen, and 4 (13.3 %) patients presented with a partial thrombosis in the false lumen. All 90 aortic arch branches were patent. No aortic arch branch artery stenosis or occlusion was observed. ConclusionsThe outcomes obtained during 12 months of follow-up suggested that performing endovascular repair for thoracic aortic dissection patients with a partial micropore stent graft is safe and effective, maintaining the patency of aortic arch branch vessels.

Aortic and arch branch vessel cannulation in acute type A aortic dissection repair.

ObjectiveTo evaluate central aortic cannulation and arch branch vessel (ABV) cannulation in acute type A aortic dissection repair.MethodsFrom 2015 to April 2020, 298 patients underwent open repair of an acute type A aortic dissection. Patients undergoing femoral cannulation for cardiopulmonary bypass (n = 34) were excluded. Patients were then divided based on initial cannulation for cardiopulmonary bypass into central aortic cannulation (n = 72) and ABV cannulation (n = 192) groups. ABV sites included cannulation of the axillary, innominate, right/left common carotid, and intrathoracic right subclavian arteries.ResultsThe aortic cannulation group was younger (59 vs 62 years; P = .02), more likely to be men (76% vs 60%; P = .02), and had more peripheral vascular disease (60% vs 37%; P = .0009). ABV dissection was similar between central and ABV cannulation groups (53% vs 60%; P = .51). The aortic cannulation group underwent less aggressive arch replacement, had shorter cardiopulmonary bypass times (200 vs 222 minutes; P = .01), less utilization of antegrade cerebral perfusion (93% vs 98%; P = .04), and received less blood transfusion (0 vs 1 U; P = .001). Postoperative outcomes were similar between aortic and ABV cannulation groups, including stroke (5.6% vs 5.2%; P = 1.0) and operative mortality (4.2% vs 6.3%; P = .77). In addition, postoperative strokes were similar in location (right-brain, left-brain, or bilateral), etiology (embolic vs hemorrhagic), and presence of permanent deficits. Aortic cannulation was not a risk factor for postoperative stroke (odds ratio, 0.94; P = .91) or operative mortality (odds ratio, 0.70; P = .64). Short-term survival was similar between central and ABV cannulation groups.ConclusionsBoth aortic and ABV cannulation were safe and effective cannulation strategies in acute type A aortic dissection repair.

Update on Trials & Devices for Endovascular Management of the Ascending Aorta and Arch

Thoracic endovascular aortic repair (TEVAR) may treat a variety of acute and chronic aortic diseases as described in several articles in this issue of TVIR. A major challenge to endovascular treatment in the thoracic aorta is disease involving or in close proximity to the aortic valve, coronary arteries, or aortic arch branch vessels. Disease involving the ascending aorta in particular has significant limitations based on its distance from the aortic root. The left subclavian artery (LSA) can be covered in the emergent setting to ensure an adequate landing zone, but patients may require later surgical revascularization, and any coverage of the carotid arteries would require definite pre-endograft revascularization. Open surgical repair continues to have high morbidity and mortality rates in the acute setting, and endovascular therapy is preferred if feasible. Ad hoc modifications of current endografts to maintain arch vessel patency include placement of chimney/snorkel stents or custom fenestrations. However, there is a need for commercially available "off-the-shelf" ascending arch stent-grafts and branched stent-grafts that allow for complete endovascular repair of the aortic arch. This review will focus on devices under investigation for the treatment of pathologies involving the ascending aorta and aortic arch.

Is hemiarch replacement adequate in acute type A aortic dissection repair in patients with arch branch vessel dissection without cerebral malperfusion?

ObjectiveThe study objective was to determine if hemiarch replacement is an adequate arch management strategy for patients with acute type A aortic dissection and arch branch vessel dissection but no cerebral malperfusion. MethodsFrom January 2008 to August 2019, 479 patients underwent open acute type A aortic dissection repair. After excluding those with aggressive arch replacement (n = 168), cerebral malperfusion syndrome (n = 34), and indeterminable arch branch vessel dissection (n = 1), 276 patients with an acute type A aortic dissection without cerebral malperfusion syndrome who underwent hemiarch replacement comprised this study. Patients were then divided into those with arch branch vessel dissection (n = 133) and those with no arch branch vessel dissection (n = 143). ResultsThe median age of the entire cohort was 62 years, with the arch branch vessel dissection group being younger (60 vs 62 years, P = .048). Both groups had similar aortic arch and descending thoracic aortic diameters, with significantly more DeBakey type I dissections (100% vs 80%) in the arch branch vessel dissection group. The arch branch vessel dissection group had more aortic root replacement (36% vs 27%, P = .0035) and longer aortic crossclamp times (153 vs 128 minutes, P = .007). Postoperative outcomes were similar between the arch branch vessel dissection and no arch branch vessel dissection groups, including stroke (10% vs 5%, P = .12) and operative morality (7% vs 5%, P = .51). The arch branch vessel dissection group had a significantly greater cumulative incidence of reoperation (8-year: 19% vs 4%, P = .04) with a hazard ratio of 2.89 (95% confidence interval, 1.01-8.27; P = .048), which was similar between groups among only DeBakey type I dissections (8-year: 19% vs 5%, P = .11). The 8-year survival was similar between the arch branch vessel dissection and no arch branch vessel dissection groups (76% vs 74%, P = .30). ConclusionsHemiarch replacement was adequate for patients with acute type A aortic dissection with arch branch vessel dissection without cerebral malperfusion syndrome, but carried a higher risk of late reoperation.

Isolation of arch vessels: Imaging characteristics and associations on multidetector computed tomography angiography.

To evaluate the imaging characteristics and associations in patients with isolation of arch vessels on multidetector computed tomography angiography (CTA). We retrospectively reviewed all multidetector CTA studies performed for the evaluation of congenital heart diseases (CHDs) at our institution from January 2014 to June 2020. Cases with isolation of arch vessels were identified. The isolated arch artery and its relationship with patent arterial duct, pulmonary artery, and aortic arch were characterized in addition to other associated intra- and extracardiac anomalies. Isolation of arch vessels was seen in 14/3926 (0.36%) patients. Left subclavian artery (SCA) was the commonest isolated arch vessel, involved in 7/14 (50%) cases. Isolation of right SCA, left brachiocephalic artery, and left common carotid artery was seen in 4 (28.6%), 2 (14.3%), and 1 (7.1%) patient, respectively. The isolated arch vessel was seen associated with right aortic arch in 10/14 (71.4%) cases and was on the opposite side of aortic arch in all 14 (100%) patients. Right-sided nonrestrictive patent arterial duct was seen in 3/14 (21.4%) cases, left-sided nonrestrictive patent arterial duct was seen in 1/14 (7.1%) while a left-sided restrictive patent arterial duct was seen in 3/14 (21.4%) cases. Tetralogy of Fallot (ToF) was the commonest associated anomaly seen in 8/14 (57.1%) patients. Isolation of aortic arch branch vessels is rare, seen most commonly associated with ToF. Left SCA is the commonest involved vessel. CTA is useful not only in the diagnosis of isolation of arch vessels, but also in the presence or absence of associated anomalies which may impact the symptomatology, prognosis, and surgical management.

TRANSAXILLARY INTRA-AORTIC BALLOON PUMP MIGRATION MINIMIZED WITH A LONG INTRODUCER SHEATH

Intra-aortic balloon pump (IABP) is a treatment for cardiogenic shock and bridge to advanced therapies. Femoral IABP limits mobility and results in pre-transplant debility. Due to the anatomy of aortic arch branch vessels and patient ambulation, transaxillary IABPs may migrate. This can cause

An Observational Study of Sex Differences in Takayasu Arteritis in China: Implications for Worldwide Regional Differences

This study analyzes the demographics of patients affected by Takayasu arteritis (TA). The study further explores the correlation and other contributory factors to the regional differences between the ratios of females to males (sex ratio). This was a retrospective study using 1,011 clinical cases diagnosed with TA (as per 1990 American College of Rheumatology criteria) between 1982 and 2015 collected from the Peking Union Medical College Hospital (PUMCH) database. Literature review of TA studies published from 1992 to 2016 via the PubMed search was also conducted with exclusion of the studies less than 50 cases. General characteristics, sex ratios and regional differences worldwide, sex ratio variation in different age group, relationship between sex ratio and gross domestic product (GDP) per capita, and main lesion involved in different sexual group were statistically analyzed. The average age of these 1,011 patients was 32.5±15.1years, with 763 women comprising 75.5% of the cohort, giving a female-to-male ratio (F:M ratio) of 3.1:1. The F:M ratio of TA patients at PUMCH was equal to that of a previous study from China, but significantly lower than that in Japan, Italy, Turkey, Mexico, Korea (all P<0.05), but higher than that in India (P<0.05), and Thailand (although not statistically significant at P=0.08). The sex ratio of TA patients between PUMCH and Japanese databases significantly differed at all age groups (P<0.05), with the exception of the youngest (≤9years; P=0.57) and oldest (≥70years; P=0.32) patients. A significant correlation between the TA F:M ratio and GDP per capita was observed, with a correlation coefficient of ρ=0.730 (P=0.04). A sex difference in lesion distribution was also observed: women had significantly more aortic arch involvement (P=0.02), whereas lower limb artery involvement was more frequent in men (P<0.001). The sex ratio of patients with TA in China significantly differed from that in many other countries. Genetics, dietary habits, and environmental conditions may affect the incidences of TA in female versus male patients. Aortic arch branch vessels are involved more frequently in women; renal artery and iliac artery involvements are more common in men.

Complete Occlusion of Aortic Arch Branch Vessels Diagnosed by Intraoperative Point-of-Care Ultrasonography: A Case Report

Complete Occlusion of Aortic Arch Branch Vessels Diagnosed by Intraoperative Point-of-Care Ultrasonography: A Case Report

Dissected Aorta Repair Through Stent Implantation trial: Canadian results

ObjectivesWe describe the Canadian results of the Ascyrus Medical Dissection Stent (AMDS), a novel partially uncovered aortic arch hybrid graft implanted antegrade during hypothermic circulatory arrest to promote true lumen expansion and enhance aortic remodeling. MethodsFrom March 2017 to February 2018, 16 consecutive patients (66 ± 12 years; 38% female) presented with acute type A aortic dissections and underwent emergent surgical aortic repair with AMDS implantation. All patients presented with DeBakey I aortic dissection, with evidence of malperfusion in 50% (n = 8) of patients. All cases were performed under hypothermic circulatory arrest with an additional average duration for AMDS implantation time of 2.1 minutes. ResultsAll 16 device implantations were successful. Overall 30-day mortality was 6.3% (n = 1) and stroke occurred in 6.3% (n = 1) of cases. There was no incidence of device-related aortic injury or aortic arch branch vessel occlusion. During the follow-up period, 12 patients had completed at least 1 postoperative computed tomography scan. At initial follow-up computed tomography scan, complete or partial thrombosis, and remodeling of the aortic arch occurred in 91.7% of cases (n = 11/12) and in the proximal descending thoracic aorta, complete or partial thrombosis, and remodeling occurred in 91.7% (n = 11/12). ConclusionsPreliminary results suggest that the AMDS is a safe, feasible and reproducible adjunct to current surgical approaches for acute DeBakey I aortic dissection repair. Further, the AMDS manages malperfusion and promotes early positive remodeling in the aortic arch and distal dissected segments, with favorable FL closure rates at follow-up. Ongoing follow-up will provide additional insight into the long-term effects of the AMDS.

A computational framework for adjusting flow during peripheral extracorporeal membrane oxygenation to reduce differential hypoxia

Peripheral veno-arterial extra corporeal membrane oxygenation (VA-ECMO) is an established technique for short-to-medium support of patients with severe cardiac failure. However, in patients with concomitant respiratory failure, the residual native circulation will provide deoxygenated blood to the upper body, and may cause differential hypoxemia of the heart and brain. In this paper, we present a general computational framework for the identification of differential hypoxemia risk in VA-ECMO patients. A range of different VA-ECMO patient scenarios for a patient-specific geometry and vascular resistance were simulated using transient computational fluid dynamics simulations, representing a clinically relevant range of values of stroke volume and ECMO flow. For this patient, regardless of ECMO flow rate, left ventricular stroke volumes greater than 28 mL resulted in all aortic arch branch vessels being perfused by poorly-oxygenated systemic blood sourced from the lungs. The brachiocephalic artery perfusion was almost entirely derived from blood from the left ventricle in all scenarios except for those with stroke volumes less than 5 mL. Our model therefore predicted a strong risk of differential hypoxemia in nearly all situations with some residual cardiac function for this combination of patient geometry and vascular resistance. This simulation highlights the potential value of modelling for optimising ECMO design and procedures, and for the practical utility for personalised approaches in the clinical use of ECMO.

Natural history of aneurysmal aortic arch branch vessels in a single tertiary referral center

ObjectiveLittle is known about the natural history and management of aneurysmal aortic arch branch vessels (AABVs). The objectives of this study were to assess the natural history of aneurysmal AABVs and to examine the outcomes of operative intervention. MethodsA retrospective review of the Yale radiologic database from 1999 to 2016 was performed. Only those patients with an aneurysmal AABV and a computed tomography scan were selected for review. Patients' demographics, aneurysm characteristics, management, and follow-up information were collected. ResultsThere were 105 patients with 147 aneurysmal AABVs; 76 were male (72%), with a mean age of 70 years (range, 17-93 years). We identified 63 innominate, 50 left subclavian, 30 right subclavian, and 4 common carotid artery aneurysms. On computed tomography, 65 (62%) had aortic aneurysms and six (6%) had suffered an aortic dissection. Most were asymptomatic (104 [99%]); one had chest pain and an enlarging swollen mass. Twelve (11%) patients underwent operative repair (OR) for 12 aneurysmal AABVs because of symptoms, growth, or concomitant aortic operations; 93 (89%) were observed in the no operative repair (NOR) group with cross-sectional imaging. The overall mean vessel diameter was 2.08 ± 0.68 cm. The mean diameters in the OR and NOR groups were 3.32 ± 1.24 cm and 1.97 ± 0.46 cm, respectively (P = .002). OR included nine bypasses with resection, two stent grafts, and one resection without reconstruction. Two patients developed postoperative hemorrhage requiring re-exploration, one patient developed stent thrombosis, and one patient required pseudoaneurysm repair 20 years after index operation. Mean follow-up was 52 ± 51 months for the NOR group, with no ruptures or emboli. The growth rate was 0.04 ± 0.10 cm/y. On multivariable regression analysis, a descending aortic aneurysm (P = .041) and a left subclavian artery aneurysm (P = .016) were associated with higher growth rates, whereas height was associated with a lower growth rate (P = .001). ConclusionsAneurysmal AABVs tend to have a benign natural history with slow growth rates and low rates of complications, including rupture and embolization. We recommend expectant observational management for small, incidentally detected aneurysms.

Natural History of Aneurysmal Aortic Arch Branch Vessels in a Single Tertiary Referral Center

Little is known about the natural history and management of aneurysmal aortic arch branch vessels (AARBVs). The objectives of this study were to assess the natural history of AARBVs and the AARBV’s risk of rupture and to examine the outcomes of operative intervention. A retrospective review of the Yale radiologic database from 1999 to 2016 was performed. Only those patients with AARBV and a computed tomography scan were selected for review. Patient demographics, aneurysm characteristics, management, and follow-up information were collected. There were 111 patients with 153 AARBVs identified; 79 were male (71%), with mean age of 70 years (range, 17-93 years). There were 65 brachiocephalic, 51 left subclavian, 33 right subclavian, and 4 common carotid artery aneurysms. On computed tomography, 68 (61%) had aortic aneurysms, 32 (29%) bovine arch, and 8 (7%) aortic dissections. Most were asymptomatic (105 [95%]); four had arm pain and one had chest pain, shortness of breath, and dysphagia, respectively. One patient presented with a ruptured brachiocephalic pseudoaneurysm (size, 6.5 cm). Nineteen (17%) patients underwent operative repair (OR); 92 (83%) were followed up with cross-sectional imaging (NOR). The overall mean vessel diameter was 2.22 ± 0.96 cm. The diameter of OR and NOR was 3.94 ± 1.61 cm and 1.97 ± 0.46 cm, respectively (P < .00001). OR included 13 bypasses, 5 stent grafts, and 1 resection without reconstruction. Two patients developed postoperative hemorrhage requiring re-exploration. One patient required pseudoaneurysm repair 20 years after index operation. Mean follow-up was 52 ± 51 months for NOR without any ruptures. Four patients underwent elective repair of AARBV because of either growth or other aortic operation. The growth rate was 0.04 ± 0.10 cm/y. On multivariable regression analysis, age (P = .011), the presence of ascending (P = .011) or descending aortic aneurysms (P =.005), and a left subclavian artery aneurysm (P = .038) were associated with higher growth rates, whereas height was associated with a lower growth rate (P = .0005). Few patients with AARBVs require an operation. Operative intervention is safe and has a low index of complications. In the presence of other aortic abnormalities, open repair would be favored. When feasible, an endovascular option can be pursued. Given that we observed no true AARBV rupture, patients can be observed safely with imaging, accepting a growth rate of 0.04 ± 0.10 cm/y.

Management of the vertebral artery during thoracic endovascular aortic repair with coverage of the left subclavian artery

The application of thoracic endovascular aortic repair (TEVAR), a minimally invasive operation, in the aortic arch has been a challenge of cardiovascular surgery in recent years. This study aimed to investigate management of the vertebral artery with coverage of the left subclavian artery (LSA) during TEVAR. From January 2007 to September 2014 in the Department of Cardiothoracic Surgery at Wuhan General Hospital of Guangzhou Military Region, 160 patients underwent LSA closure or partial coverage during TEVAR of an aortic lesion near the LSA. The vertebral artery treatment, the reason for the surgical approach selection, and the prognosis were analyzed. In 94 patients with partial LSA coverage during TEVAR, no treatment was provided for the vertebral arteries, revealing blood flow of the left vertebral artery forward into the skull after surgery. For 66 patients with full LSA coverage (closure) during TEVAR, right carotid artery-left common carotid artery bypass surgery was performed before TEVAR in ten patients, without any treatment for the vertebral artery, showing reverse blood flow of the left vertebral artery after surgery. Left common carotid artery-LSA bypass surgery was performed before TEVAR in four patients; right common carotid artery-left common carotid artery-LSA bypass surgery was performed before TEVAR in three cases, and 6 out of these 7 patients underwent proximal LSA ligation, showing no obvious blood flow in the left vertebral artery. The closure of the LSA aortic arch opening using an occluder was performed in one patient, preserving the forward blood flow in the left vertebral artery. Among the 160 patients in this study, postoperative recurrent laryngeal nerve injury occurred in one patient after right common carotid artery-left common carotid artery-LSA bypass surgery, and the remaining 159 patients had no significant severe complications or death within 1 postoperative month. Appropriate management of the aortic arch branch vessels may expand the application of TEVAR to the aortic arch and reduce complications, especially for high-risk patients who have a difficult time tolerating thoracotomy.

Role of cardiovascular echo in patients with Takayasu arteritis.

Takayasu arteritis is an important differential diagnosis in young female patients presenting with fever, fatigue, hypertension, and/or neck pain. Aortic arch branch vessels are frequently affected and the carotid artery can have diffuse, homogeneous wall thickening, known as the 'macaroni sign'. The descending aorta can be stenotic with 'pseudo-coarctation'. Cardiovascular echo plays an important role in the screening and characterization of arterial lesions in patients with Takayasu arteritis.

Neurological Complications of Thoracic Endovascular Aortic Repair

Thoracic endovascular aortic repair (TEVAR) has decreased the morbidity and mortality associated with open surgical repair of descending thoracic aortic diseases, but important complications unique to the procedure remain. Spinal cord ischemia and infarction is a recognized complication caused by endovascular coverage or injury to spinal cord collateral vessels. Stroke is a consequence of thromboembolism or coverage of aortic arch branch vessels with insufficient collateral circulation. Understanding the risk factors and the pathophysiology of neurological complications of TEVAR are important for the successful anesthetic and surgical management and treatment of patients undergoing endovascular procedures involving the thoracic aorta.

The Hostile Landing Zone in Endograft Repair of the Thoracic Aorta: The Next Frontier

Objective: Thoracic endo-vascular repair of the aorta (TEVAR) is gaining popularity in the treatment of thoracic aortic pathologies. One of the limitations to the use of this treatment modality is unfavorable landing zone (LZ) anatomy proximally and distally involving the aortic arch and visceral branch vessels. We report our experience with extending the LZs using endobranching and an on-table modified device design to offer a treatment option to these high-risk patients.

Hybrid Repair of Thoracoabdominal Aortic Aneurysms Involving the Visceral Vessels: Comparative Analysis Between Number of Vessels Reconstructed, Conduit, and Gender

Thoracoabdominal aortic aneurysm (TAAA) repairs are technically challenging. The advent of endovascular aneurysm repair in combination with visceral/renal artery bypasses has allowed for hybrid endovascular repair of these aneurysms. The purpose of this study was to evaluate whether outcomes were affected by the number of visceral/renal artery reconstructions, conduit, or gender. All patients who underwent visceral/renal bypass associated with an endovascular aortic aneurysm repair were prospectively studied in a vascular registry and retrospectively reviewed between the years 2004 and 2009. Patients undergoing standard open TAAA repair and those with aortic arch branch vessel reconstructions associated with thoracic endovascular repair were excluded from this analysis. Patients were segregated into two groups on the basis of number of vessels bypassed. Group 1 (n = 9) consisted of patients who required one or two bypasses, whereas group 2 (n = 15) consisted of patients who required three or four bypasses. A total of 64 TAAA repairs were performed. In all, 22 patients with hybrid repair and aortic arch vessel reconstructions and 18 patients with open TAAA repair were excluded from this analysis. A total of 24 (38%) patients with hybrid endovascular repair were evaluated in this study. The 30-day mortality was found to be 12.5% (3/24) and the incidence of spinal cord ischemia was 8.3% (2/24). Preoperative comorbidities and American Society of Anesthesia (ASA) scores were reported to be similar between the two groups. As compared with group 2, patients in group 1 were reported to be younger (69.7 ± 10.6 vs. 76.0 ± 5.7 years [p = 0.074]), had less blood loss (1,200 ± 1,088 mL vs. 3,119 ± 2,188 mL, [p = 0.06]), required fewer blood transfusions (5.33 ± 2.31 vs. 9.09 ± 7.06 units packed red blood cells (PRBC) [p = 0.39]), and had a shorter length of stay (11.4 ± 5.6 vs. 21.9 ± 15.1 days, [p = 0.090]). There was no difference in 30-day mortality rates between the two groups. The incidence of perioperative morbidity, including bowel ischemia (11%[1/9] vs. 27% [4/15], [p = 0.39]), myocardial infarction (11% [1/9] vs. 13% [2/15], [p = 0.88]), wound infection (0% vs. 27% [4/15], [p = 0.09]), and pneumonia (11% [1/9] vs. 40% [6/15], [p = 0.14]) was found to be less in group 1 than group 2, but this difference was not significant. Patients with three or four bypasses had a significantly greater requirement for a skilled nursing facility or a rehabilitation facility after discharge (79% [11/14] vs. 29% [2/7], p = 0.026). There were no statistically significant differences in postoperative outcomes when comparing choice of conduit (autogenous or prosthetic) or gender. Results from the Cox-proportional hazards regression showed that bowel ischemia was the only postoperative complication associated with decreased survival (p = 0.037, confidence interval [0.1328-4.3075]). Hybrid aortic aneurysm repair carries a significant risk of patient morbidity with an acceptable mortality for patients considered to be at a high risk for standard thoracoabdominal repair. In patients requiring fewer visceral/renal reconstructions, there is a trend toward fewer postoperative complications and a significantly shorter length of stay. Moreover, there is a significantly lower need for skilled nursing facility requirements after discharge from the hospital. Bowel ischemia is associated with significantly worse outcome and better attempts at avoiding this complication and aggressive management is indicated.