Descending Thoracic Aortic Aneurysms Research Articles

Phase-specific survival after endovascular versus open surgical repair of descending thoracic aortic aneurysm.

Thoracic endovascular aortic repair (TEVAR) has gained preference over open surgical repair (OSR) as the intervention of choice for patients with descending thoracic aortic aneurysm (DTA). This study aimed to compare the outcomes of patients with DTA undergoing OSR and TEVAR with contemporary findings. A comprehensive search of MEDLINE and EMBASE databases was conducted to identify relevant randomized controlled trials or studies utilizing propensity-score analysis or reporting risk-adjusted outcomes. The search was performed up until March 2023. Eight studies met the inclusion criteria, including 4 studies using propensity-score matching and four studies reporting risk-adjusted outcomes, comprising 14,873 patients with DTA undergoing OSR (N.=10,882) and TEVAR (N.=3991). Operative mortality was similar between the two interventions (odds ratio 0.92, 95% CI 0.70-1.21, P=0.57, I2=0%). However, overall long-term mortality was significantly higher after TEVAR compared to OSR (Hazard Ratio [HR] 1.30, 95% CI 1.05-1.59, P=0.01, I2=0%). Phase-specific analysis revealed comparable risks of mortality within 1 year and between one and two years after interventions, while the risk of mortality was significantly higher after TEVAR compared to OSR beyond two years (HR 1.77, 95% CI, 1.19-2.63, P=0.01. I2=0%). This study demonstrated comparable operative mortality between OSR and TEVAR, but higher long-term mortality associated with TEVAR in patients with DTA. The phase-specific analysis highlighted the survival advantage of OSR beyond 2 years. These findings suggest a need for reconsidering OSR indications in the management of DTA.

Abstract 15289: Phase-Specific Survival After Endovascular versus Open Surgical Repair of Descending Thoracic Aortic Aneurysm

Background: Thoracic endovascular aortic repair (TEVAR) has gained preference over open surgical repair (OSR) as the intervention of choice for patients with descending thoracic aortic aneurysm (DTA). However, recent studies have suggested comparable or potentially favorable outcomes after OSR. This study aimed to compare the outcomes of patients with DTA undergoing OSR and TEVAR with contemporary findings. Methods: A comprehensive search of MEDLINE and EMBASE databases was conducted to identify relevant randomized controlled trials or studies utilizing propensity-score analysis or reporting risk-adjusted outcomes. The search was performed up until March 2023. All-cause mortality was analyzed in specific phases: within 1 year, 1-2 years, and beyond 2 years. Results: Eight studies met the inclusion criteria, including 4 studies using propensity-score matching and 4 studies reporting risk-adjusted outcomes, comprising 14,873 patients with DTA undergoing OSR (n=10,882) and TEVAR (n=3,991). No randomized controlled trials were identified. Operative mortality was similar between the two interventions (odds ratio 0.92, 95% CI 0.70-1.21, p = .57, I 2 = 0%). However, overall long-term mortality was significantly higher after TEVAR compared to OSR (hazard ratio (HR) 1.30, 95% CI 1.05-1.59, p = .01, I 2 = 0%). Phase-specific analysis revealed comparable risks of mortality within 1 year and between 1 and 2 years after interventions, while the risk of mortality was significantly higher after TEVAR compared to OSR beyond 2 years (HR 1.77, 95% CI, 1.19-2.63, p = .01. I 2 = 0%). Conclusion: This study demonstrated comparable operative mortality between OSR and TEVAR, but higher long-term mortality associated with TEVAR in patients with DTA. The phase-specific analysis highlighted the survival advantage of OSR beyond 2 years after surgery compared to TEVAR. These findings suggest a need for reconsidering OSR indications in the management of DTA.

Safety of cerebrospinal fluid drainage in descending and thoracoabdominal aortic replacement surgery.

Spinal cord injury (SCI) remains a significant morbidity of surgical repair of descending thoracic aortic aneurysms (DTAA) and thoracoabdominal aortic aneurysms (TAAA). We present our 17-year experience with cerebrospinal fluid drainage (CSFD) as a protective strategy during open surgical repair of descending and thoracoabdominal aortic disease. We conducted a retrospective chart review of 132 patients who underwent open surgical repair of DTAA and TAAA and dissections with concurrent use of CSFD for spinal cord protection. Information regarding survival, postoperative course, and complications related to CSFD use were extracted from electronic health records (EHR) and analyzed. Mean patient age was 65.4±13.0 years, and 82 (62.1%) were male. A CSFD was successfully inserted in all patients. The mean hospital length of stay after surgery was 12.2±11.2 days, and in-hospital mortality was 7.6%. Postoperative transient paresis was observed in 5 patients (3.8%), and permanent paraplegia was seen in 4 (3.0%). CSFD related complications were reported in 25 patients (19%). Complications included persistent cerebrospinal fluid (CSF) leakage, blood-tinged CSF (with subdural hematoma reported in 3 patients) and spinal cutaneous fistula in 9 (7%), 14 (11%), and 1 (1%), respectively. Long term survival was 50.9% at 15 years. CSFD is associated with minor complications, without major sequalae. It is a safe practice and likely contributes innocuously to decreased SCI in patients undergoing open repair of DTAA and TAAA.

Abstract 10215: Investigating Aortic Geometric Changes After Endovascular and Open Surgery Repair of Descending Thoracic Aortic Aneurysms

Introduction: Repair of descending thoracic aortic aneurysms (DTAA) by endovascular (TEVAR) or open aortic replacement alters aortic anatomical and biomechanical characteristics, which may result in adverse cardiac remodeling. The interplay between all these factors remains mostly unknown. Hypothesis: A robust and objective quantification of 3D geometrical changes to the treated aorta will help investigate long-term cardiovascular consequences of DTAA repair. Methods: Pre- and post-operative 3D modeling from CT angiography was obtained for 6 patients undergoing OPEN (n=3) or TEVAR (n=3). An automated analysis was conducted to extract aorta centerlines, register pre/post geometries based on anatomical landmarks, calculate the following features: length ( L ), curvature ( C ), torsion ( T ), tortuosity ( TT ), cross sectional area ( A ), and volume ( V ). Pre/post repair geometric analysis was conducted on the ascending (AscAo) and descending (DesAo) aorta, and in consecutive segments based on C / T profiles; rotations between segments modeled as osculating planes were calculated; TEVAR vs OPEN differences were investigated. Results: The age of patients was 65±15 years and 4 were female. All centerline and geometric features were calculated from the models. Fig 1 shows one case with registered C profiles. Main results between pre/post were: increase in A AscAo (mean 43.4±20.5 mm 2 ) and V AscAo (mean 31.3±9 cm 3 ); increase in TT DesAo (0.6±0.4 vs 1.4±0.5, p=0.01); TEVAR cases showed DesAo elongation (mean 17.8±4 mm); trends for increasing C max (AscAo) and decreasing C max (DesAo); inter-segment rotations show notable pre/post variations (Fig 1b). Conclusions: Our preliminary analysis automatically quantified relevant changes in aortic anatomy pre/post repair of DTAA with either open or endovascular repair. Complemented with fluid dynamics and biomechanical studies these investigations could clarify mechanisms affecting long-term consequences of DTAA repair.

Outcomes of descending and thoracoabdominal aortic repair in connective tissue disorder patients

Objectives Open surgical repair (OSR) of descending and thoracoabdominal aortic aneurysms carries risks of mortality and major complications. Patients with connective tissue disorders (CTD) are younger and require safe, efficient treatment with long-term durability. This study provides current outcome data to help inform treatment decisions. Methods All OSRs of descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) from January 2011 to July 2021 were included in a retrospective cohort study. Primary outcome measures were early and follow-up mortality and reintervention. Secondary outcome measures were major complications. Kaplan-Meier methods were used to estimate reintervention-free survival. Results A total of 26 OSRs (7 DTAA, 19 TAAA) were performed in 23 patients: 20 (77%) Marfan and 6 (23%) Loeys-Dietz syndrome; median age 43 years. Aortic dissection was present in 100% and 3/26 (12%) were urgent. Early mortality was 1/26 (3.8%). No patient suffered spinal cord ischemia, stroke, vocal cord paralysis, or re-exploration for bleeding. The transient respiratory failure occurred in 19% (5/26) and transient renal replacement therapy in 15% (4/26). Renal function normalized in all patients within 3 months. During follow-up (median 4.6, range 0–11 years) there were no deaths and only one re-intervention on a previously operated aortic segment, resulting in 92% reintervention-free survival at 5 years. Conclusions In dedicated units, open surgical DTAA and TAAA repair in patients with CTD can be performed with a very low risk of death, severe complications and, late re-intervention. For CTD patients with reasonable risk, OSR should remain the first line of treatment.

Impact of ethnicity and race on outcomes after thoracic endovascular aortic repair

Thoracic endovascular aortic repair (TEVAR) became the standard of care for treating Type B aortic dissections and descending thoracic aortic aneurysms. We aimed to describe the racial/ethnic differences in TEVAR utilization and outcomes. The National Inpatient Sample was reviewed for all TEVARs performed between 2010 and 2017 for Type B aortic dissection and descending thoracic aortic aneurysm (DTAA). We compared groups stratifying by their racial/ethnicity background in White, Black, Hispanic, and others. Mixed-effects logistic regression was performed to assess the relationship between race/ethnicity and the primary outcome, in-hospital mortality. A total of 25,260 admissions for TEVAR during 2010-2017 were identified. Of those, 52.74% (n = 13,322) were performed for aneurysm and 47.2% (n = 11,938) were performed for Type B dissection. 68.1% were White, 19.6% were Black, 5.7% Hispanic, and 6.5% were classified as others. White patients were the oldest (median age 71 years; p < .001), with TEVAR being performed electively more often for aortic aneurysm(58.8% vs. 34% vs. 48.3% vs. 48.2%; p < .001). In contrast, TEVAR was more likely urgent or emergent for Type B dissection in Black patients (65.6% vs. 41.1% vs. 51.6% vs. 51.7%; p < .001). Finally, the Black population showed a relative increase in the incidence rate of TEVAR over time. The adjusted multivariable model showed that race/ethnicity was not associated with in-hospital mortality. Although there is a differential distribution of thoracic indication and comorbidities between race/ethnicity in TEVAR, racial disparities do not appear to be associated with in-hospital mortality after adjusting for covariates.

Midterm Outcomes of Endovascular Versus Open Surgical Repair of Intact Descending Thoracic Aneurysms in Patients with Connective Tissue Disorders

Data on the efficacy of endovascular thoracic endovascular aneurysm repair (TEVAR) versus open surgical repair for chronic aortic pathology in patients with connective tissue disorders are limited. In particular, few studies have examined outcomes of TEVAR versus open repair for intact descending thoracic aortic aneurysms (DTAA) in this subset of patients beyond index hospitalization. Therefore, we investigate 5-year outcomes of TEVAR and open surgical repair of intact DTAAs in patients with known connective tissue disorders. Using the TriNetX Data Network, a global federated database of over 75 million patients, we conducted a retrospective cohort study of patients with connective tissue disorders and intact DTAAs, treated initially with either TEVAR or open surgery. Eligible patients were 1:1 propensity score-matched for several preoperative co-variates including demographics, surgical history, and comorbidities. We calculated and compared 5-year cumulative incidence and hazards of death, re-intervention, aortic dissection, renal failure, stroke, intracranial hemorrhage, paraplegia, and limb ischemia using the Kaplan-Meier method and Cox proportional hazards models. We identified 55 patients treated with TEVAR and 200 treated with open surgery. After matching, we compared 46 patients in each cohort. After matching, only incidence of re-intervention via endovascular approach was significantly higher among patients in the TEVAR cohort (27.1% vs. 4.8%, P=0.009). Rates and hazards of other outcomes were higher in the TEVAR group, however, differences were not statistically significant. Patients treated with TEVAR had numerically higher rates of adverse outcomes compared to open surgical patients, however only the difference in re-intervention rate was statistically significant. Given the evolving landscape of endovascular intervention, greater-powered studies are needed to determine the safety and efficacy of TEVAR for intact DTAAs in a select subset of connective tissue disorder patients.

Differences in Mid-Term Outcomes Between Patients Undergoing Thoracic Endovascular Aortic Repair for Aneurysm or Acute Aortic Syndromes: Report From the Global Registry for Endovascular Aortic Treatment

A retrospective review of the Global Registry for Endovascular Aortic Treatment between August 2010 and October 2016. Of 575 patients who underwent thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm (DTAA) (305) or acute aortic syndrome (AAS) (270), patients with DTAAs were older and had significantly higher comorbidities than patients with AAS. Between 1 month and 1 year after TEVAR, patients with AAS experienced higher all-cause mortality (7.5% vs 5.0%), aorta-related deaths (2.3% vs 0%), and reintervention rates (4.9% vs 3.0%) than those with DTAA. However, between 1 year and 3 years, all-cause mortality was higher for DTAA (11.8%) than for AAS (7.3%). Patients who underwent TEVAR for DTAA or AAS experienced different mortality and reintervention rates during early and mid-term follow-up.

Differences in Mid-Term Outcomes Between Patients Undergoing Thoracic Endovascular Aortic Repair for Aneurysm or Acute Aortic Syndromes: Report From the Global Registry for Endovascular Aortic Treatment

Purpose: To analyze differences in baseline characteristics, overall mortality, device-related mortality, and re-intervention rates in patients who underwent thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm (DTAA) with atherosclerotic/degenerative cause or acute aortic syndrome (AAS), using the Global Registry For Endovascular Aortic Treatment (GREAT). Materials and Methods: Patients submitted to TEVAR for AAS or DTAA, included in GREAT, were eligible for this analysis. Primary outcome was 30-day all-cause mortality rate. Secondary outcomes were 30-day aorta-related mortality and re-intervention rate, 1-year and 3-year all-cause mortality, aorta-related mortality and re-intervention rate. Results: Five-hundred and seventy-five patients were analyzed (305 DTAA and 270 AAS). Thirty-day mortality rate was 1.3% and 1.8% for DTAA and AAS, respectively (p=0.741). One-year and 3-year mortality rates were 6.2% versus 9.3 and 17.3% versus 15.9% for DTAA and AAS, respectively (p=0.209 and p=0.655, respectively). Aorta-related mortality rates at 30 days, 1 year and 3 years were 1.3%, 1.3%, and 2.6% for DTAA, 1.8%, 4.2%, and 4.2% for AAS (p=ns). Re-intervention rates at 30 days, 1 year, and 3 years were 1.3%, 4.3%, and 7.5% for DTAA, 3.3%, 8.1%, and 10.7% for AAS (p=ns). Furthermore, a specific analysis with similar outcomes was performed dividing follow-up in 3 periods (1-30 days, 31-365 days, 366-1096 days) and describing mutual differences between 2 groups and temporal trends in each group. Conclusion Patients who underwent TEVAR for DTAA or AAS experienced different mortality and re-intervention rates among years during mid-term follow-up. Although all-cause related deaths within 30 days were TEVAR-related, aorta-related deaths were more common for AAS patients within 1 year. A greater re-intervention rate was described for AAS patients, although only 1 year after TEVAR.

Risk calculator predicts 30-day mortality after thoracic endovascular aortic repair for intact descending thoracic aortic aneurysms in the Vascular Quality Initiative

ObjectiveThoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm (DTAA) is associated with high perioperative survival, although mortality is a possible outcome. However, no risk score has been developed to predict mortality after TEVAR for intact DTAA to aid in risk discussion and preoperative patient selection. Our objective was to use a multi-institutional database to develop a 30-day mortality risk calculator for TEVAR after DTAA repair. MethodsThe Vascular Quality Initiative database was queried for patients treated with TEVAR for intact DTAA between August 2014 and August 2020. Univariable and multivariable analyses aided in developing a 30-day mortality risk score. Internal validation was done with K-fold cross-validation and calibration curve analysis. ResultsOf 2141 patients included in the analysis, 90 (4.2%) died within 30 days after the procedure. Clinically relevant variables identified to be independently associated with 30-day mortality and therefore used to derive the predictive model included age 75 years or greater (odds ratio [OR], 2.27; 95% confidence interval [CI], 1.50-3.44; P < .001), coronary artery disease (OR, 1.60; 95% CI, 1.03-2.47; P = .036), American Society of Anesthesiologists class IV/V (OR, 2.39; 95% CI, 1.39-4.10; P = .002), urgent vs elective procedure (OR, 3.47; 95% CI, 1.90-6.33; P < .001), emergent vs elective procedure (OR, 5.27; 95% CI, 2.36-11.75; P < .001), prior carotid revascularization (OR, 3.24; 95% CI, 1.64-6.39; P = .001), and proximal landing zone <3 (OR, 2.51; 95% CI, 1.65-3.81; P < .001). The model showed an area under the receiver operating characteristic curve of 0.75. Internal validation demonstrated a bias-corrected area under the receiver operating characteristic curve of 0.73 (95% CI, 0.66-0.79) and a calibration slope of 1.00 with a corresponding intercept of 0.00. ConclusionsThis study provides a novel clinically relevant risk prediction model to estimate 30-day mortality risk after TEVAR for DTAA. The TEVAR Mortality Risk Calculator provides useful prognostic information to guide patient selection and facilitate preoperative discussions and shared decision making. An easily accessible online version of the TEVAR Mortality Risk Score is available to facilitate ease of use.

Association of body mass index with outcomes after thoracic endovascular aortic repair in the vascular quality initiative

ObjectiveAlthough several studies have evaluated the impact of obesity on outcomes after abdominal aortic aneurysm repair, literature examining this association in thoracic endovascular aortic repair (TEVAR) is sparse. Here, we use a multi-institutional, international database to assess the role of body mass index (BMI) on adverse outcomes in patients who underwent TEVAR for descending thoracic aortic aneurysms (DTAA) and type B dissections (TBD). MethodsA retrospective review of all patients who underwent TEVAR for DTAA or TBD from August 2014 to August 2020 was performed. Patients who were underweight (BMI <18.5 kg/m2) or obese (BMI ≥30 kg/m2) were compared with those of normal weight (≥18.5 to <30 kg/m2). Adjustment for confounding was done with multivariable logistic regression or Cox proportional hazards regression as appropriate for studying postoperative or 1-year outcomes. Primary outcomes were 30-day and 1-year mortality. Other outcomes included any postoperative complication, stroke, and spinal cord ischemia. ResultsA total of 3423 participants were included in the study, of whom 3.3% (n = 113) were underweight, 65.9% (n = 2253) had normal weight, and 30.8% (n = 1053) were obese. Compared with normal weight, there was no significant difference in 30-day mortality in underweight patients (odds ratio [OR], 1.81; 95% confidence interval [CI], 0.80-4.14; P = .156). Obese patients who underwent TEVAR for TBD had a 2.7-fold increase in the odds of 30-day mortality compared with normal weight (OR, 2.67; 95% CI, 1.52-4.68; P = .001). Obese and normal weight patients with DTAA had equivalent odds of 30-day mortality (OR, 1.32; 95% CI, 0.79-2.23; P = .292). The adjusted hazard of 1-year mortality was 2-fold higher in underweight patients compared with normal weight (hazard ratio, 2.15; 95% CI, 1.41-3.29; P < .001), driven by a higher risk of mortality among patients with thoracic aortic aneurysm (OR, 2.62; 95% CI, 1.63-4.21; P < .001). There was no significant difference in 1-year mortality risk between normal weight and obesity in both DTAA (OR, 0.77; 95% CI, 0.54-1.09; P = .146) and TBD (OR, 1.26; 95% CI, 0.85-1.86; P = .248). ConclusionsIn this study, obese patients who underwent TEVAR for DTAA had comparable 30-day and 1-year mortality risk as normal weight individuals. Obese patients who underwent TEVAR for TBD demonstrated a 2.7-fold increase in the odds of 30-day mortality, but equivalent mortality risk as normal weight patients at 1 year. TEVAR represents a safe minimally invasive option for treatment of DTAA in obese patients. Future work should be directed toward minimizing perioperative mortality among patients with TBD to optimize TEVAR outcomes.

A Risk Calculator Predicting Thirty-day Mortality After Thoracic Endovascular Aortic Repair

Thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm (DTAA) is associated with high perioperative survival. However, no risk score has been developed to guide discussions with patients prior to surgery. We developed a 30-day mortality risk calculator for TEVAR after DTAA repair.

Endovascular repair of descending thoracic aortic aneurysms-a mid-term report from the Global Registry for Endovascular Aortic Treatment (GREAT).

The aim of this study was to evaluate the short- to mid-term outcomes of descending thoracic aortic aneurysm (DTAA) repair from the Gore Global Registry for Endovascular Aortic Treatment (GREAT). This is a multicentre sponsored prospective observational cohort registry. The study population comprised those treated for DTAA receiving GORE thoracic aortic devices for DTAA repair between August 2010 and October 2016. Major primary outcomes were early and late survival, freedom from aorta-related mortality and freedom from aorta-related reintervention. There were 180 (58.1%) males and 130 (41.9%) females: the mean age was 70 ± 11 years (range 18-92). The median maximum DTAA diameter was 60 mm (interquartile range 54-68.8). Technical success was achieved in all patients. Operative mortality, as well as immediate conversion to open repair, was never observed. At the 30-day window, mortality occurred in 4 (1.3%) patients, neurological events occurred in 4 (1.3%) patients (transient ischaemic attacks/stroke n = 3, paraplegia n = 1) and the reintervention rate was 4.5% (n = 14). Estimated survival was 95.6% [95% confidence interval (CI) 92.6-97.4] at 6 months, 92.7% (95% CI 89.1-95.2) at 1 year and 57.3% (95% CI 48.5-65.1) at 5 years. Freedom from aorta-related mortality was 98.3% (95% CI 96.1-99.3) at 6 months, 98.3% (95% CI 96.1-99.3) at 1 year and 92.2% (95% CI 83.4-96.4) at 5 years. Freedom from thoracic endovascular aortic repair (TEVAR)-related reintervention at 5 years was 87.2% (95% CI 81.2-91.4). TEVAR for DTAAs using GORE thoracic aortic devices is associated with a low rate of device-related reinterventions and is effective at preventing aorta-related mortality for up to 5 years of follow-up. NCT number: NCT01658787. 161, 164.

Hybrid Surgery for Thoracic Aneurysm Rupture: An Effective Alternative in a Case Without Distal Neck

Introduction: Endovascular treatment of descending thoracic aortic aneurysms (DTAA) is associated with low rates of morbidity and mortality and is currently the first line of therapeutic intervention. Endoleaks are a well known complication of this technique, with the consensus that the identification of type I endoleak implies its prompt correction. Report: This is the report of a patient who underwent TEVAR for the treatment of DTAA, with exclusion of the aneurysm on follow up angiography. Follow up CTA showed type Ib endoleak with aneurysm sac growth, so treatment was proposed which the patient refused. The patient was subsequently admitted urgently with rupture of the aneurysm and was immediately subjected to debranching of the visceral trunks, followed by distal TEVAR extension. Discussion: Hybrid treatment of thoracic aneurysms without a distal landing zone through debranching of the visceral trunks and TEVAR is an alternative to conventional surgery and complex endovascular surgery, which presents good results in patients with high surgical risk and also allows treatment of patients urgently as it does not depend on the manufacture of fenestrated and/or branched endoprostheses. Keywords: Debranching, Descending thoracic aortic aneurysm, Endoleak, Hybrid surgery, TEVARView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Application of deep hypothermic circulatory arrest in open left chest aortic aneurysm repair

ObjectivesDeep hypothermic circulatory arrest (DHCA) is often required for patients undergoing repair of descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm via left thoracotomy when proximal crossclamping is not feasible or when aneurysmal disease extends into the transverse aortic arch. Historical literature suggests higher complications rates due to the technical complexity of this approach; we examined outcomes with this approach at our center. MethodsBetween January 2008 and May 2018, 84 patients with DTAA or Crawford extent I thoracoabdominal aortic aneurysm underwent open repair. DHCA was employed in 46 of 84 (55%) patients, of which 33 (72%) required repair of distal arch and DTAA, and 13 (28%) required repair of the distal arch and extent I thoracoabdominal aortic aneurysm. Patients who underwent DHCA had more chronic dissections than those in the non-DHCA group (70% vs 34%; P ≤ .05). ResultsMajor adverse outcomes for the DHCA group versus non-DHCA group were as follows: early mortality 3 out of 46 (7%) versus 4 out of 38 (11%) (P = .70), stroke 3 out of 46 (7%) versus 1 out of 38 (3%) (P = .62), permanent spinal cord deficit 2 out of 46 (4%) versus 3 out of 38 (8%) (P = .65), permanent renal failure necessitating dialysis 1 out of 46 (2%) versus 2 out of 38 (5%) (P = .59). Freedom from major adverse outcomes was 38 out of 46 (83%) versus 31 out of 38 (82%) for DHCA versus non-DHCA (P = 1). ConclusionsDHCA can be employed via left thoracotomy for combined arch and DTAA or extent I thoracoabdominal aortic aneurysm open repair.

Safety of perioperative cerebrospinal fluid drain as a protective strategy during descending and thoracoabdominal open aortic repair.

ObjectiveWe present our experience with routine application of the cerebrospinal fluid (CSF) drain (CSFD) during open aortic repair.MethodsWe retrospectively reviewed 100 patients with descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) or who underwent CSFD insertion before open repair between 2006 and 2017. All CSFDs were inserted by the cardiovascular anesthesia team. The goal was to keep intracranial pressure <10 mm Hg during the surgical procedure by draining CSF at a rate of 20 to 30 mL/h. Postoperatively, CSFD was set to maintain the lumbar pressure <10 mm Hg to reduce the risk of postoperative paraplegia. CSFD was part of our standard cord protection regimen.ResultsThe mean patient age was 65.4 ± 11.7 years, and 60 (60%) were male. A CSFD was successfully inserted in all patients. The mean hospital length of stay was 11.9 ± 11.8 days, and hospital mortality was 6%. Postoperative transient paresis was observed in 4 patients (4%), and permanent paraplegia was seen in 2 (2%). CSFD-related complications were reported in 14 patients (14%). Complications included persistent CSF leakage and blood-tinged CSF with and without intracranial hemorrhage and spinal cutaneous fistula in 7 (7%), 9 (9%), and 1 (1%), respectively. Long-term survival was excellent (68.4% at 10 years).ConclusionsCSFD is a safe practice when applied routinely as an adjunct strategy to prevent paraplegia in surgical management of DTAA and TAAA. We feel that this contributed to good early and late clinical results.

Endovascular Treatment of a Ruptured Pseudoaneurysm of the Intercostal Patch after Descending Aortic Aneurysm Repair.

Anastomotic pseudoaneurysm and patch aneurysm are life-threatening complications following thoracoabdominal and descending thoracic aortic aneurysm (DTAA) repair. The aortic wall tissue is fragile in patients with Marfan syndrome, who are at high risk of anastomotic pseudoaneurysm and patch aneurysms. We experienced a rare case of ruptured pseudoaneurysm of the intercostal patch after DTAA repair in a patient with Marfan syndrome. A hematoma was separated from the pseudoaneurysm caused by adhesion of the left lung after DTAA repair, which made diagnosis difficult. To prevent type II endoleak and achieve thoracic endovascular aortic repair, we treated the patent intercostal arteries by embolization.

Early and Long-term Results of ePTFE (Gore TAG®) versus Dacron (Relay Plus® Bolton) Grafts in Thoracic Endovascular Aneurysm Repair

The aim of this study is to compare early and late results of an expanded polytetrafluoroethylene (ePTFE-Gore TAG®, group A) mesh structured endograft versus a Dacron one (Relay Plus® Bolton, group B) in thoracic endovascular aneurysm repair (TEVAR). A prospective database was used to extract information from anonymous patients who underwent TEVAR for descending thoracic aortic aneurysms (DTAAs) between February 2005 and February 2019 at 3 referral university hospitals. Cases treated by means of ePTFE endograft (Gore TAG, group A) and Dacron graft (Relay Plus Bolton, group B) in elective and urgent settings were included. Early and late outcomes were compared. A total of 129 consecutive patients were included (115 men and 14 women). ePTFE-Gore TAG® and Dacron-Relay Plus® Bolton were used in 56 (43.4%) and 73 (56.5%) patients, respectively. Preoperative characteristics of patients were similar. Technical success was 100%. Urgent procedures were 22.4%. Mean aortic coverage and partial debranching were 217.5±91.3 and 37.2%, respectively. Early mortality and spinal cord ischemia (SCI) were 8.5% and 2.3%, respectively, without differences between the 2 groups. Early reintervention was required in 5.4% (group A) and 11% (group B), P=0.29. Median follow-up was 32months (interquartile range 12-55 months, range 1-156 months), similar between the 2 groups. Type I endoleak (EL), type II EL, and type III EL were observed in 16.3%, 10.9%, and 3.1% of cases, respectively, without significant differences between the groups. The rate of sac shrinkage was 28.6% in group A vs. 39.7% in group B (P=0.19). Freedom from reintervention in group A versus group B at 6, 12, 24, and 36months was 94.0% vs. 97.1%, 94.0% vs. 95.5%, 90.8% vs. 86.9%, and 81.1% vs. 80.4%, respectively (log-rank 0.35, Breslow 0.54). Rate of survival at 6, 12, 24, and 36months was 96.0% vs. 94.2%, 89.3% vs. 86.8%, 76.5% vs. 77.5%, and 63.3% vs. 64.2%, respectively (log-rank 0.30, Breslow 0.57). ePTFE-Gore TAG and Dacron-Relay Plus Bolton in DTAA presented similar early and late results in terms of mortality, SCI, EL, and TEVAR-related reinterventions. Effectiveness of TEVAR procedure was confirmed by the high rate of sac shrinkage and it was not influenced by endograft fabric.

Respiratory Failure after Open Descending Aortic Aneurysm Repair: Risk Factors and Outcomes.

Purpose: This study was conducted to identify predictors of respiratory failure after open repair of descending thoracic aortic aneurysm (DTAA), and to identify any relationship between respiratory failure and long-term survival.Methods: A total of 75 patients undergoing elective open DTAA repair at the Shiga University of Medical Science Hospital were included in the study. Univariate and multivariate logistic regression analyses were performed to assess the odds ratios for incident postoperative respiratory failure after open DTAA repair. Survival over time was estimated by the Kaplan–Meier method.Results: Respiratory failure, defined as ventilation dependence for longer than 48 hours, occurred in 11 patients (14.7%). Independent predictors of respiratory failure after DTAA included prolonged operation time and reduced preoperative forced expiratory volume in 1 second/forced vital capacity × 100 (FEV1%). In-hospital mortality was higher (p = 0.020) among patients with respiratory failure (18.2% of those who suffered respiratory failure) than among those without (0%). The survival rates at 8 years were significantly lower (p = 0.010) in the respiratory failure group (at 44.2%) than in the group without respiratory failure (at 89.0%).Conclusion: Lower FEV1% and longer operation time were risk factors of postoperative respiratory failure after open repair of DTAA, which in turn is associated with significantly reduced long-term survival.

Proteomic Analysis of Descending Thoracic Aortic Aneurysms and Dissections to Identify Biomarkers for Surgical Management

Biomarkers may improve risk assessment and potential timing of intervention in patients with thoracic aortic aneurysms and dissections. Our aim was to identify molecular signatures unique to descending thoracic aortic aneurysms (DTAA), type B aortic dissection (TBAD) and cases of initially stable TBAD that progressed into aneurysm (BDTAA).