Complex Thoracoabdominal Aneurysms Research Articles

Outcomes following Management of Complex Thoracoabdominal Aneurysm by an Open Approach.

In the last decade, advances in surgical techniques, and the introduction of adjuncts for organ protection, have modified the approach for thoracoabdominal aortic aneurysm (TAAA) surgical repair. The aim of this study is to determine whether the contemporary approach influenced the outcomes. From 1989 to 2022, patients who had received elective open surgical repair (OSR) for TAAA at our institution were retrospectively analyzed. This series has been divided in two groups: Group 1 (1989-2009), and Group 2 (2010-2022). Patients included in Group 1 were those treated with a selective use of adjuncts, and Group 2 included patients treated with the systematic use of adjuncts. A total of 1107 patients were treated (Group 1: 455; Group 2: 652). The surgical management was significantly different between the two groups. The in-hospital mortality was significantly different between the two groups (Group 1: 13.4%, Group 2: 8.1%; p 0.004), as was the rate of permanent spinal cord ischemia (Group 1: 11.9%, Group 2: 7.8%; p 0.023). Renal and respiratory failure were reduced in Group 2, but not significantly. The use of the adjuncts enabled the achievement of improvement in mortality and SCI prevention in TAAA OSR. Although a refined surgical technique, mortality and morbidity are still noteworthy in this complex aortic field.

TH4.5 The introduction of a custom made endograft service for patients with complex thoracoabdominal aneurysm

Abstract Introduction Custom made endografts represents a technological advance that has been widely adopted across vascular centres in the United Kingdom. The most recent National Vascular Registry report describes in-hospital mortality for complex as 2.3%. We have reviewed the outcome associated with the introduction of a custom made endograft program in a single Scottish Health Board. Methods Index cases were identified from a prospective radiology database with cases identified from 2008 to 2021. We collected patient demographics, pre-operative assessment, peri-operative and procedure related details and information on surveillance and re-intervention. Results There have been 49 cases performed. Most patients were males over the age of 70-years with significant medical co-morbidity. The mean AAA size was 5.8cm. Most of the procedures have been performed under general anaesthesia with percutaneous common femoral access. Procedural complications have included inability to stent target arteries (coeliac axis twice and right renal artery twice). Other complications have included limb ischaemia and haemorrhagic complications from access. Two critical care bed days have been used. The mean duration of hospital stay is 9-days. There have been no deaths on the index admission. During the follow-up period there have been 6 deaths. One of these deaths was from rupture of abdominal aortic aneurysm (secondary to Type III endoleak). Conclusion These data suggest that the case selection for custom made endografts is good. The cost of the device may be off set by a reduction in critical care utilization/hospital bed stay.

Outcomes and complications after fenestrated-branched endovascular aortic repair

ObjectiveTo report the outcomes of patients enrolled in a physician-sponsored investigational device exemption trial for endovascular treatment of complex thoracoabdominal aortic aneurysms with fenestrated and/or branched devices. MethodsThis study represents a retrospective analysis of a prospectively maintained database of patients enrolled in a physician-sponsored investigational device exemption trial for endovascular treatment of complex thoracoabdominal aneurysms between July 2012 and July 2017. Subjects included high-risk patients for open repair and patients with unsuitable anatomy for either standard endovascular aneurysm repair or Zenith (Cook Medical, Bloomington, Ind) fenestrated device. Aneurysm classification was based upon Crawford classification. We included the pararenal and paravisceral aneurysms in the type IV aneurysm group, because the repair of these aneurysms usually involved treatment of all four visceral branches. The endografts implanted were custom manufactured devices or off-the-shelf devices based on the Cook Zenith platform. Variables analyzed included preoperative demographics and comorbidities, anatomic aneurysmal characteristics, procedural details, and perioperative complications. ResultsOne -hundred fifty patients with a mean age of 71 ± 7.9 years were treated; 69% were male. Tobacco use (93%) and hypertension (91%) were the most common risk factors. Fifty-seven patients (38%) had a history of previous aortic repair. The mean aneurysm diameter was 62 ± 12 mm and 14 (9%) aneurysms were associated with chronic dissection. A total of 573 visceral vessels were incorporated (celiac artery/superior mesenteric artery [287 vessels], renal arteries [275 vessels], and 11 additional vessels) and 539 were stented. The celiac artery/superior mesenteric artery received a fenestrated design in 76.1% of cases. Branch designs were used in the renal artery in 13.2%, with the remainder treated with fenestrations. Spinal cord drainage was used in 51% of patients (76/150). The mean operative time, fluoroscopy time, and estimated blood loss were 283 ± 89 minutes, 83 ± 38 minutes, and 417 ± 404 mL, respectively. There were five patients (3.3%) with intraoperative complications, resulting in one intraoperative death. The early mortality was 2.7% (4/150). Major complications included respiratory failure in 7% (10/150), stroke and myocardial infarction in 0.7% each (1/150), and paraplegia in 2.7% (4/150). Acute kidney injury occurred in 4.7% of patients (7/150), two of whom required temporary dialysis. Thirty-nine percent of patients experienced at least one complication. Early branch vessel patency was 99.8% (525/526). Survival, primary, and primary-assisted branch patency at 2 years of follow-up were 79%, 97%, and 99%, respectively. ConclusionsEndovascular repair of complex aneurysms is safe and effective when performed in a high-volume center experienced in aortic disease management. Branch vessels patency and the low incidence of paraplegia and mortality support expanded use to treat most complex thoracoabdominal aortic aneurysms.

A clinical review of early outcomes from contemporary flow modulation versus open, fenestrated and branch technologies in the management of thoracoabdominal aortic aneurysm.

Traditional therapeutic options for complex thoracoabdominal aneurysm include open repair, hybrid repair or endovascular repair (involving fenestrated or branched endografts). The Streamliner Multilayer Flow Modulator has been available for treatment of thoracoabdominal aneurysms since 2010. Its design permits blood flow to perfuse through the mesh in a modus that preserves collateral branch patency, while modulating turbulent to laminar flow within the device. The flow then stagnates over time within the surrounding aneurysm sac. Significant complications, including paraplegia, renal failure and cerebrovascular accident, are much lower with Streamliner Multilayer Flow Modulator treatment. Application of the Streamliner Multilayer Flow Modulator to complex aortic pathologies presents a novel solution to an, as of yet, unmet clinical need, and has resulted in promising clinical outcomes when compared to existing solutions. The Streamliner Multilayer Flow Modulator offers potential for treatment of thoracoabdominal aortic pathologies in patients and is not just confined to those with complexity that dictates no other management options. While current literature illustrates that there is a decreased risk of mortality and associated complications when this new disruptive technology is utilised, there is still a need for prospective, long-term clinical trials, as well as comparative trials to accurately assess outcomes of Streamliner Multilayer Flow Modulator treatment that are both precise and reproducible. This article is a review of current clinical literature regarding contemporary flow modulating technology compared with open, branched and fenestrated managements, presenting early outcomes.

Aortenaneurysma 2012 – offen, hybrid oder total endovaskulär?

During the past two decades, minimally invasive endovascular procedures have changed therapeutic strategies. Such techniques have now become the method of choice for practically all vascular and aortic pathologies. This development is especially apparent in the treatment of aortic aneurysms. The purpose of this report is to provide a critical review about the current standard of care of abdominal and thoracic aorta based on an electronic Medline literature search. For elective infrarenal aneurysms, endovascular aneurysm repair (EVAR) has become a widely accepted alternative to open repair in cases with appropriate morphology. Currently, fenestrated (FEVAR) or branched endografts offer promising short- and mid-term results in juxtarenal aneurysms, however, these techniques are complex, technically challenging, and expensive. The alternative chimney or sandwich graft technique are becoming more common because they are feasible using standard endografts. Thoracic endovascular aortic repair (TEVAR) is already the gold standard for some descending pathologies. Complex thoracoabdominal aneurysms still require open surgery in centres of excellence, whereby, total endovascular repair or hybrid procedures have proved to be feasible in such specialist centres for selected patients.

The role of robotic endovascular catheters in fenestrated stent grafting

Fenestrated stent grafting has allowed the treatment of complex thoraco-abdominal aneurysm disease via a totally endovascular approach, but the procedure can be technically challenging and time consuming. We investigated whether this procedure may be enhanced by remotely steerable robotic endovascular catheters. A four-vessel fenestrated stent graft partially deployed within a computed tomography (CT)-reconstructed pulsatile thoraco-abdominal aneurysm silicon model was used. Fifteen operators were recruited to participate in the study and divided into three groups, based on their endovascular experience: group A (n = 4, 100-200 endovascular procedures, group B (n = 5, 200-300), and group C (n = 6, >300). All operators were asked to cannulate the renal and visceral vessels under fluoroscopic guidance, using conventional and robotic techniques. Quantitative (catheterization times and wire/catheter tip movements) and qualitative metrics (procedure-specific-rating scale [IC3ST]), which grades operators on catheter use, instrumentation, successful cannulation/catheterization, and overall performance were compared. Median procedure time for cannulation of all four vessels was reduced using the robotic system (2.87 min, interquartile range [IQR; 2.20-3.90] versus 17.24 min [11.90-19.80]; P < .001) for each individual operator, regardless of the level of endovascular experience. The total number of wire/catheter movements taken to complete the task was also significantly reduced (38, IQR [29-57] versus 454 [283-687]; P < .001). There were significant differences in time and movement for cannulation of each individual vessel in the phantom. Robotic catheter operator radiation exposure was negligible as the robotic workstation is remote and away from the radiation source. Overall performance scores significantly improved using the robotic system, despite minimal operator exposure to this technology (IC3ST score 29/35, IQR [22.8-30.7] versus 19/35 [13-24.3]; P = .002). Each group of operators demonstrated an improvement in performance with robotic cannulation. For group A, median IC3ST score was 28/35, IQR (22-33) versus 15/35 (11-20); P = .04; for group B, 30/35 (27-31) versus 19/35 (18-24); P = .07; and for group C, 28.8/35 (28.5-29) versus 22/35 (16-24); P = .06. For groups B and C, these differences did not reach statistical significance. Robotic catheterization of target vessels during this procedure is feasible and minimizes radiation exposure for the operator. Steerable robotic catheters with intuitive control may overcome some of the limitations of standard catheter technology, enhance target vessel cannulation, reduce instrumentation, and improve overall performance scores.

Customised Stent Graft for Complex Thoraco-abdominal Aneurysm Associated with Congenital Pelvic Kidney

The association of aortic aneurysm with congenital pelvic kidney is an uncommon condition and has been described in association with abdominal aortic aneurysm (AAA) open repairs. We present a case of a patient with a type IV thoraco-abdominal aortic aneurysm (TAAA) extending into the left common and internal iliac arteries associated with a congenital pelvic kidney who was treated with a customised endovascular prosthesis involving proximal fenestrations, bifurcation fenestration and a left internal deep iliac branch device. Although branch technology continues to evolve, cases such as this are encouraging for future widespread use. This approach allowed us to offer TAAA repair without compromising renal function in a patient with multiple co-morbidities who probably would not have withstood conventional open treatment.

A staged replacement of the entire aorta from the ascending arch to the hypogastric arteries using a hybrid approach

Combined open and endovascular hybrid procedures can be used to treat complex aortic pathology. This article reports a five-stage hybrid repair for a complex thoracoabdominal aneurysm with dissection in a 57-year-old man. To our knowledge, this is the first reported case of replacement and exclusion of the entire native human aorta from the root to the iliac bifurcations using a combined open and endovascular approach without neurologic complication. Bilateral hypogastric and femoral circulation was preserved. Aggressive spinal protective measures, including spinal drainage, motor-evoked potentials, and prevention of intraoperative and perioperative hypotension, were used during this staged approach.

Complex thoracoabdominal aortic aneurysms: Endovascular exclusion with visceral revascularization

We review our ongoing experience with a transabdominal stent repair of complex thoracoabdominal aneurysms (Crawford type I, II, and III) with surgical revascularization of visceral and renal arteries. A retrospective review was conducted of prospectively collected data from 29 consecutive patients who underwent an attempted visceral hybrid procedure between January 2002 and April 2005. Twenty-two patients were elective, four were urgent (symptomatic), and three were emergent (true rupture). The median patient age was 74 years (range, 37 to 81 years). The aneurysms were Crawford type I in 3, type II in 18, type III in 7, and type IV in 1. Previous aortic surgery had been performed in 13 (45%) of 29 and included aortic valve and root replacement in 3, TAA repair in 1, type I repair in 1), type IV repair in 3, type B dissection in 2, infrarenal aneurysm in 5, and right common iliac aneurysm in 1. Severe preoperative comorbidity was present in 23 (80%) of 29: chronic renal impairment in 5, severe chronic obstructive pulmonary disease in 6, myocardial disease in 11 at New York Heart Association grade II (6) and grade III (5), and Marfan's syndrome in 6. Twenty-six patients (90%) had a completed procedure. In two patients, myocardial instability prevented completion of the procedure despite extensive preoperative cardiac assessment, and in one, poor flow in the true lumen of a chronic type B dissection prevented anastomosis of the revascularization grafts. Exclusion of the full thoracoabdominal aorta was achieved in all 26 completed procedures and extended to include the iliac arteries in four, with revascularization of coeliac in 26, superior mesenteric artery in 26, left renal artery in 21, and right renal artery in 21). There was no paraplegia < or =30 days or during inpatient admission, and elective and urgent mortality was 13% (3/23). All of the patients with ruptured thoracoabdominal aneurysms died < or =30 days. Major complications included prolonged respiratory support (>5 days) in 9, inotropic support in 4, renal impairment requiring temporary support in 2 and not requiring support in 2, prolonged ileus in 2, resolved left hemispheric stroke in 1, and resection of an ischemic left colon in 1. Median blood loss was 3.9 liters (range, 1.2 to 13 liters). The median ischemia time was 15 minutes (range, 13 to 27 minutes) for the superior mesenteric and coeliac arteries and 15 minutes for the renal arteries (range, 13 to 21 minutes). The median hospital stay was 27 days (range, 16 to 84 days). Follow-up was a median of 8 months (range, 2 to 31 months), with 92 of 94 grafts patent. Six patients were found to have a type I endoleak. In four, this was a proximal leak, and stent extension in three reduced, but did not cure, the endoleak. One patient with a distal type I endoleak was successfully treated by embolization. Four type II endoleaks resolved without intervention, and one was treated by occlusion coiling of the origin of the left subclavian artery. A single late type III endoleak was found. Early results of visceral hybrid stent-grafts for types I, II, and III thoracoabdominal aneurysms are encouraging, with no paraplegia in this particularly high-risk group of patients. These results have encouraged us to perform the new procedure, in preference to open surgery, in Crawford type I, II, and III thoracoabdominal aortic aneurysms.

Staged Open and Endovascular Repair of Thoracoabdominal Aneurysms Using the Common Carotid Artery

The purpose of this study was to demonstrate the feasibility of staged open and endoluminal repair of complex thoracoabdominal aneurysms. We report the management of two patients with a staged, open abdominal and endoluminal thoracic repair of Crawford extent II aneurysms, where iliofemoral access was impossible and thoracic repair effected by endograft deployment via a common carotid artery. From this experience we conclude that staged open and endovascular repair for both ruptured and elective Crawford extent II thoracoabdominal aneurysms can be performed using the common carotid artery, when anatomy is favorable.