Endovascular Repair Of Thoracoabdominal Aortic Aneurysms Research Articles

Role of In Situ Fenestration as the Technique of Choice for Endovascular Repair of Ruptured Thoracoabdominal and Suprarenal Aortic Aneurysms at a Regional Aortic Center

Emergent endovascular repair of suprarenal aortic aneurysms (SRAAs) and thoracoabdominal aortic aneurysms (TAAA) poses a significant challenge owing to branch vessel incorporation, time constraints, and the lack of dedicated devices. At our center, techniques to incorporate branch vessels have included parallel grafting, physician modified endografts, double-barrel/reversed iliac branch endoprosthesis, and in situ fenestration (ISF; Fig 1). We have described our experience using these techniques to repair ruptured SRAAs and TAAAs and their associated outcomes. A retrospective review of patients who had undergone endovascular repair of ruptured SRAAs and TAAAs from 2014 to 2021 with branch vessel incorporation was performed. The clinical presentations, intraoperative details, and postoperative outcomes of ISF were compared against the other techniques. Forty-two patients had undergone endovascular repair for ruptured SRAAs and TAAAs, 18 of whom had undergone ISF. Of the 18 ISF patients, 72% were hypotensive before surgery compared with the patients (58%) who had received the other techniques (ie, physician modified endografts, parallel grafting, double-barrel/reversed iliac branch endoprosthesis). The procedural times, fluoroscopy times, and interval from admission to surgery were similar between the two groups despite ISF incorporating more branch vessels than the other techniques (3.1 vs 2.2 per patient). The rate of serious complications was 57% across all techniques, with postoperative renal dysfunction the most frequent. In-hospital mortality was 19% for all ruptures and 25% for ruptures with hypotension. In-hospital mortality was the lowest with ISF (11% vs 25%), and this advantage was more pronounced for the patients with hypotension (8% vs 45%). Later in the study period, ISF became more commonly used owing to the improved outcomes for patients with ruptured aneurysms (Fig 2). Although emergent endovascular repair of SRAAs and TAAAs remains a challenge, a number of techniques are available for expeditious treatment. Of these, ISF has become an attractive technique owing to the improved mortality and the ability to rapidly achieve hemorrhage control before branch vessel incorporation. These advantages were especially apparent for ruptures with hypotension. Further experience is required to validate these encouraging initial results and assess the durability of ISF repair.Fig 2Endovascular techniques used for ruptured thoracoabdominal aortic aneurysm (TAAA) and suprarenal aortic aneurysm (SRAA) over time. DB/rIBE, Double barrel excluded/reversed iliac branch endoprosthesis; ISF, in situ fenestration; PG, parallel grafting; PMEG, physician modified endograft.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Extensive Aortic Stent Graft Coverage for Thoracoabdominal Aortic Aneurysm is Associated With Hemorrhagic Complications Induced by Disseminated Intravascular Coagulation

Hybrid endovascular repair for thoracoabdominal aortic aneurysm (TAAA) is a less invasive alternative treatment than conventional open repair. However, disseminated intravascular coagulation (DIC) and hemorrhagic complications can occur postoperatively. We investigated risk factors for hemorrhagic complications after hybrid endovascular TAAA repair. Sixty-one patients who underwent elective hybrid endovascular TAAA repair between 2007 and 2020 were included. Laboratory data before and after placing stent graft were collected, and DIC was diagnosed using a scoring system established by the Japanese Association for Acute Medicine. The length of the stent graft used to cover the aorta was defined as the aortic coverage length, which was measured using the first postoperative computed tomography image. Predictors of unexpected hemorrhagic complications were evaluated. Postoperative thrombocytopenia was observed in 57 (93%) patients, and their platelet count decreased significantly after stent graft placement (14.3 [9.5-18.0] vs. 8.2 [5.4-10.9]×104/µL, P < 0.001). Fifteen (25%) and 45 patients (74%) were diagnosed with DIC before and after stent graft placement, respectively. Hemorrhagic complications were observed in 21 patients (34%). Multivariate logistic regression analysis revealed that aortic coverage length was an independent risk factor for hemorrhagic complications (odds ratio 1.441/50 mm increase; 95% confidence interval, 1.041-1.994, P=0.027). The cutoff value for aortic coverage length obtained from the receiver operating characteristic curve (area under the curve=0.72) was 304.4 mm (sensitivity 0.76, specificity 0.70). Aortic coverage length is a risk factor for hemorrhagic complications. Patients undergoing extensive aortic coverage greater than 304 mm should be closely monitored.

Innovative approaches and new endograft designs to perform complex endovascular thoracoabdominal aortic aneurysm repair

I would like to congratulate and thank Said Abisi et al1 for their thorough description of a new endograft design for the endovascular repair of complex aortic aneurysms, its possible indications, and their early experience in its use. They are further to be commended for the reported technical and clinical results, which are certainly impressive and reflect clinical practice in a very experienced high-volume aortic center.

Total abdominal debranching hybrid thoracoabdominal aortic aneurysm repair versus chimneys and snorkels

Open thoracoabdominal aortic aneurysm (TAAA) repair remains a surgical challenge. Hybrid and total endovascular repair have emerged as alternatives in treating TAAA. Total endovascular TAAA repair may be best performed with branched/fenestrated stent grafts. However, these technologies are not yet widely available. Thus, currently total endovascular TAAA repair using the chimney/snorkel techniques is considered a viable option in many centers.In this article, we briefly review 2 readily available techniques with off-the-shelf devices, hybrid procedure using total abdominal debranching, and total endovascular repair using chimney/snorkel procedures. The hybrid TAAA repair avoids thoracotomy but requires laparotomy and carries high morbidity and mortality (eg, operative mortality, 4%-26% and renal failure, 4%-26%), comparable to traditional open repair. The staged hybrid approach has been proposed to minimize the invasiveness of the procedure, whereas the associated risk of interval aortic deaths is not negligible. Total endovascular repair reduces the morbidity and mortality after TAAA repair (eg, operative mortality, 3%-20% and renal failure, 0%-20%). However, it is technically demanding and the risks of future reinterventions—and need for repetitive surveillance—is inevitable (eg, immediate type I endoleak, 7%-16% and 1-year branch patency, 93%-98%). Currently, there are not enough data to determine which less-invasive option for open repair in patients with TAAA is superior. These alternatives should complement each other and be applied to carefully selected populations as a part of the overall toolbox in treating TAAA.

Pre-operative platelet reactivity is a strong, independent predictor of bleeding complications after branched endovascular thoracoabdominal aortic aneurysm repair

Endovascular aortic repair (EVAR) an alternative to open surgical repair of thoracoabdominal aortic aneurysm (TAAA). The effect of EVAR on platelet reactivity is unknown. We prospectively determined the effect of branched EVAR (bEVAR) on platelet reactivity in patients with TAAA, and evaluated the predictive value of preoperative platelet reactivity for post-operative bleeding in 50 consecutive patients undergoing elective bEVAR (mean age 70.9 ± 5.7 years, 66% male). Blood samples were collected within 24 hours before bEVAR, after bEVAR and at hospital discharge. Platelet reactivity was assessed with impedance aggregometry using ASPI, ADP and TRAP tests. Platelet reactivity decreased within 24 hours after bEVAR compared to the measurement before bEVAR in all tests (p ≤ 0.04), with a further decrease in hospital discharge in the ADP test (p = .004). Twenty-three patients experienced post-operative bleeding complications (transfusion ≥2 red blood cell [RBC] units). Preoperative platelet reactivity below the cutoff value of 30 AUC units predicted post-operative bleeding with 78% sensitivity and 59% specificity (p = .045). In the multivariable analysis, platelet reactivity was the only independent predictor of postoperative bleeding (OR 6.507, 95% CI 1.227–34.506, p = .028). We conclude that platelet reactivity decreases following bEVAR of TAAA and is a strong and independent predictor for postoperative bleeding complications.

Incidence of Acute and Chronic Renal Failure Following Branched Endovascular Repair of Complex Aortic Aneurysms

Background:The purpose of this study was to examine the incidence of acute kidney injury and chronic renal impairment following branched endovascular aneurysm repair (BEVAR) of complex thoracoabdominal aortic aneurysms (TAAA) using the Medtronic Valiant Thoracoabdominal Aortic Aneurysm stent graft system (MVM), the physician-modified Visceral Manifold, and Unitary Manifold stent graft systems. The objective was to report the acute and chronic renal function changes in patients following complex TAAA aneurysm repair.Methods:This is an analysis of 139 patients undergoing branched endovascular repair for complex TAAAs between 2012 and 2020. Patient renal function was evaluated using serum creatinine and estimated glomerular filtration rate at baseline, 48 hr, discharge, 1 month, 6 months, and annually to 2 years. Patients on dialysis prior to the procedure were excluded from data analysis.Results:A total of 139 patients (mean age 71.13; 64.7% male) treated for TAAA with BEVAR met inclusion criteria and were evaluated. A total of 530 visceral vessels were stented. A majority of patients (n = 131, 94.2%) underwent a single procedure while 8 required staged procedures. Thirty-day, 1-year and 2-year all-cause mortality rates were 5.8%, 25.2%, and 32.4%, respectively. Primary and secondary patency rates at a median follow-up of 26.9 months (95% CI; 21.1 – 32.7) were 96.2% and 97.5% for all vessels and 95.4% and 96.9% for renal arteries, respectively. Postoperative acute kidney injury (AKI) was identified in 22 (15.8%) patients. At discharge, 16 patients (11.6%) had an increase in CKD stage with 3 requiring permanent dialysis. Five additional patients required permanent dialysis over the 2-year follow-up period for a total of 8 (5.8%). Increasing age (HR = 1.0327, P = 0.0477), hemoglobin < 7 prior to procedure (HR = 2.4812, P = 0.0093), increasing maximum aortic diameter (HR = 1.0189, P = 0.0084), presence of AKI (HR = 2.0757, P = 0.0182), and increase in CKD stage (HR = 1.3520, P = 0.002) at discharge were significantly associated with decreased patient survival.Conclusions:Postoperative AKI and a chronic decline in renal function continue to be problematic in endovascular repair of complex aortic aneurysms. This study found that BEVAR using the manifold configuration resulted in immediate and mid-term renal function that is comparable to similar analyses of branched and/or fenestrated grafts.

Long-term survival after descending thoracic and thoracoabdominal aortic aneurysm repair

ObjectivePatients with descending thoracic aortic aneurysms (dTAA) or thoracoabdominal aortic aneurysms (TAAA) often have a variety of medical comorbidities. Those that are deemed acceptable for intervention undergo complicated repairs with good early outcomes. The purpose of this study was to identify variables that were associated with mortality over time. MethodsThis was a retrospective review of a prospectively maintained database at our institution from 1983 to 2015. Patients were included if they underwent open or endovascular repair for dTAA or TAAA. Patients were excluded if they were intervened on for traumatic transections. The primary outcome for the study was long-term survival. Secondary outcomes included aortic-related mortality. We had mortality and survival data on all patients. ResultsA total of 946 patients met our study criteria with a median follow-up of 102.8 months (interquartile range [IQR], 58.9-148.2 months). The median age of the cohort was 71 years (IQR, 63-77 years) with the majority of patients being male (58.1%). The extent of TAAA pathology was as follows: type I (14.2%), type II (21.2%), type III (17.1%), type IV (26.2%), and dTAA (21.2%). A total of 147 patients (15.5%) had a prior dissection. The median diameter of aneurysm was 6.4 cm (IQR, 6.0-7.0 cm). A total of 158 patients (16.7%) underwent endovascular repair over the study period. Variables associated with mortality over time were age, surgical era, acute pathology, dissection, preoperative creatinine, and type IV TAAAs. In addition, experiencing the following complications in the postoperative period was associated with mortality over time: neurological, cardiac, and pulmonary. Aortic-related mortality was 2.1% (n = 20) over the study period. Patients who underwent endovascular repair for acute conditions had better long-term survival when compared with open repair. However, there were no differences in long-term survival between open and endovascular repair for nonacute cases. In addition, repair in the more modern era was associated with improved survival. ConclusionsTAAAs can be repaired with reasonable perioperative mortality rates. Once patients undergo repair of their aneurysm, aortic-related mortality remains low. The addition of endovascular options has dramatically changed management of patients with dTAA and TAAA. Further, endovascular repair was associated with decreased perioperative mortality and significantly increased long-term survival in acute patients. Patients undergoing TAAA repair are generally considered high risk and therefore require extensive long-term follow-up for management of their comorbidities and complications, because these are the main contributors to mortality over time.

Single Center Experience with Endovascular Repair of Acute Thoracoabdominal Aortic Aneurysms.

PurposeTo investigate feasibility and outcomes of endovascular repair for acute thoracoabdominal aortic aneurysms (TAAA).Materials and MethodsData from a single center were retrospectively analyzed. Patients who underwent endovascular repair for acute TAAA between January 2010 and April 2020 were included. Perioperative and mid-term follow-up outcomes were analyzed. Survival, freedom from reintervention, and target vessel patency were calculated by Kaplan–Meier analysis.ResultsA total of 30 patients (18 men, 67.5 ± 6.9 years) underwent endovascular repair for acute symptomatic (n = 15) or contained ruptured (n = 15) TAAA. An off-the-shelf four-branched stent-graft (T-Branch) was used in 19 (63.3%) patients, a custom-made device (CMD) with expedite order in 5 (16.7%) patients, a CMD with short anticipated delivery time in 3 (10.0%) patients, and a CMD available in the hospital in 3 (10.0%) patients. Technical success was 90.0% (n = 27). Thirty-day mortality was 10% (n = 3). There was no complete persistent paraplegia, but one (3.3%) patient suffered permanent limb weakness. Estimated survival at 1 and 2 years was 86.3% ± 6.4%, and 82.3% ± 7.2%, respectively. Estimated freedom from reintervention at 1 and 2 years was 81.4% ± 7.6% and 73% ± 8.8%. Estimated target vessel patency at 1 and 2 years was 96.6% ± 2% and 92.6% ± 2.9%.ConclusionEndovascular treatment of acute TAAA in this selected group of patients was associated with low early mortality and excellent mid-term survival. The off-the-shelf stent-graft option (T-Branch) was used in the majority of patients. Endovascular repair should be considered the first option for suitable acute TAAA.

Lateral Axillary Exposure for Antegrade Access during Endovascular Repair of Complex Abdominal Aortic and Thoracoabdominal Aneurysms

During endovascular treatment of pararenal aortic aneurysms (PAA) and thoracoabdominal aortic aneurysms (TAAA), our antegrade vascular access of choice is a lateral axillary exposure (LAE). We directly access the axillary artery with multiple sheaths followed by primary closure of the axillary artery at case completion. The aim of this study is to describe our technique and to report our results with this approach. This study is a single-institution, retrospective review of 53 patients who were treated with parallel grafts for endovascular repair of PAA and TAAA from 2006 to 2018. The aortic repairs requiring LAE included: 9 cases of endo-leaks from prior endovascular repair, 20 TAAAs, and 24 PAAs. The axillary artery was exposed with a vertical axillary skin incision followed by retraction of the lateral border of the pectoralis major to expose the axillary artery distal to the pectoralis minor. A 5-French (F) through 12F sheaths were used to directly access the axillary artery for delivery of endovascular devices. Two hundred and sixty reno-visceral stents were delivered through 125 axillary sheaths in an antegrade fashion to 114 arteries without intraoperative complications or technical failures. Two postoperative complications included an access-site hematoma managed conservatively (1.9%) and a left brachial vein thrombosis treated with anticoagulation (1.9%). There were no cases of cerebrovascular or peripheral neurologic events, upper extremity ischemia, or reoperation related to LAE. LAE is a valid approach for upper extremity access during the endovascular repair of complex aortic aneurysms requiring simultaneous delivery of multiple reno-visceral devices. It does not require the use of a prosthetic conduit. There were no neurologic events or upper extremity ischemia in our series.

Effect of renal function on patient survival after endovascular thoracoabdominal and pararenal aortic aneurysm repair

BackgroundRenal dysfunction can be a prohibitive risk for open repair of complex thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms (PRAAs). However, the effect of renal dysfunction from fenestrated and branched endovascular aneurysm repair (FB-EVAR) on outcomes is poorly defined. Our objective was to review the association of renal function on patient survival after FB-EVAR. MethodsThe present study reviewed the clinical data of consecutive patients enrolled in a prospective nonrandomized study to investigate FB-EVAR for PRAAs and TAAAs at a single institution with 1 year of follow-up (2013-2017). The patients were categorized by preoperative chronic kidney disease (CKD) classification, and the early- and long-term mortality was assessed. ResultsDuring the study period, 231 patients had undergone FB-EVAR for 80 PRAAs, 89 type I-III TAAAs, and 62 type IV TAAAs. The mean age was 74.6 ± 6.7 years, and 71% were men. Of the 231 patients, 126 had had CKD stage 1-2, 96 CKD stage 3, and 9 CKD stage 4-5 (all with baseline creatinine >2.0 mg/dL). Patients with CKD stage 4-5 had demographic data similar to those with normal renal function but had had slightly larger aneurysms (6.5 vs 7 cm; P = .15). The 30-day mortality was 0.5% (n = 1) for those with CKD 1-3 vs 0% for those with CKD 4-5 (P = .73). The 1- and 3-year survival analysis showed no major hazards (95% vs 88% and 84% vs 75%, respectively; log-rank P = .98) between the CKD 1-3 and CKD 4-5 groups. The median follow-up period was 2.6 years (interquartile range, 1.5-3.7 years). Two patients with CKD 4-5 had died during the follow-up period. ConclusionsAlthough a small sample size for evaluation, selected patients with CKD 4-5 might have similar short- and long-term mortality compared with those with normal to moderate renal dysfunction after FB-EVAR. Although a major contraindication for open repair, renal dysfunction might not be as prohibitive for endovascular repair in well-selected patients.

Kidney protection in thoracoabdominal aortic aneurysm surgery

Acute kidney injury (AKI) is a common complication of both open and endovascular repair of thoracoabdominal aortic aneurysms (TAAA). Its definition varies across difference studies, some standardized definitions (RIFLE, AKIN, KDIGO) have been proposed but still not uniformly employed in published papers. Acute kidney injury is multifactorial and is associated with increased in-hospital mortality, long-term mortality and late renal function decline. In addition, AKI is also associated with perioperative spinal cord ischemia. No specific pharmacological strategy has received a strong recommendation with high level of evidence as a protective measure. Fenoldopam, methylprednisolone or mannitol use to prevent AKI is commonly employed, but not supported by literature data. Avoiding nephrotoxic drugs and maintaining an adequate MAP, during and after the procedure plays a key role in preserving kidney function. During open TAAA surgery, renal arteries may be reimplanted using different techniques. The choice of the best option must be tailored to the patient, to reduce ischemic time and guarantee long-term patency. Current experience suggests that cold crystalloid solutions are the best substrates in preventing ischemia-reperfusion injury. Renal perfusion using Custodiol® (Dr Franz-Kohler Chemie GmbH; Bensheim, Germany) 4 °C, even if currently considered off-label, represents an encouraging organ protection tool. In endovascular TAAA repair, techniques such as fusion imaging, use of diluted contrast, and CO<inf>2</inf> subtraction angiography have the potential to reduce postoperative AKI. Visceral vessels patency is closely related to the anatomy. Therefore, accurate endograft design according to these characteristics is crucial for long-term preservation of renal function.

In-hospital mortality and organ failure after open and endovascular thoraco-abdominal aortic surgery can be predicted by increased levels of circulating dipeptidyl peptidase 3.

Endovascular and open thoraco-abdominal aortic aneurysm (TAAA) repair is associated with specific complications. Circulating dipeptidyl peptidase 3 (cDPP3) is a novel biomarker that shows a strong association with organ failure which has not been assessed in surgical settings. Therefore, the objective of this study was to assess the prognostic capabilities of cDPP3 for predicting patient survival and organ failure following open and endovascular TAAA repair. Thirty-three patients undergoing TAAA repair were assessed in this prospective observational single-centre study. cDPP3 levels were serially measured perioperatively until 72 h after admission to the intensive care unit (ICU). In-hospital mortality and any organ failure were the clinical end points. Postoperative organ failure was detected in 17 patients (51.5%), and 6 patients died after surgery (18.2%). At 12 h after admission to the ICU, cDPP3 levels were significantly increased in patients who died or developed organ failure (P < 0.001). cDPP3 levels after surgery demonstrated a remarkable predictive accuracy for in-hospital mortality [12 h area under the receiver operating characteristic curve (AUC): 0.907 (P < 0.001), 24 h AUC: 0.815 (P = 0.016), 48 h AUC: 0.914 (P = 0.003)] and the development of organ failure [12 h AUC: 0.882 (P < 0.001), 24 h AUC: 0.850 (P < 0.001), 48 h AUC: 0.846 (P < 0.001)]. Additionally, a significant correlation between cDPP3, the sequential organ failure assessment score and procalcitonin, C-reactive protein and interleukin-6 levels (P < 0.001, P < 0.001, P = 0.011, P = 0.007, respectively) based on all available measurements and time points was observed. The present findings highlight the role of cDPP3 as an early, highly specific postoperative biomarker for prediction of in-hospital mortality and organ failure after TAAA repair.

Association between thoracoabdominal aneurysm extent and mortality after complex endovascular repair

ObjectiveTraditional open surgical repair of thoracoabdominal aortic aneurysms (TAAAs) has historically resulted in 30-day mortality rates ranging from 6% to 20%, depending on the Crawford anatomic extent. Although short-term survival is important, long-term survival is essential for patients to benefit from these often elective and potentially morbid procedures. The aneurysm extent affects the long-term survival after open repair; however, effect on endovascular repair is unknown and could influence the decision process for repair. We evaluated the association between aneurysm extent and survival and identified patient and perioperative factors associated with mortality after endovascular repair. MethodsA retrospective cohort of patients treated for TAAAs recorded in the Society for Vascular Surgery Vascular Quality Initiative thoracic and complex endovascular aneurysm repair registry were evaluated. All patients treated for asymptomatic degenerative aneurysms from 2010 to 2019 were included. Crawford extent I to V was defined according to the proximal and distal landing zones documented in the registry. Patients without extension into the visceral aorta were used for comparison and categorized as having extent 0a or 0b, depending on the distal landing zone in the thoracic aorta. Kaplan-Meier plots were used to estimate survival, and Cox proportional hazard regression models were created to identify the predictors of mortality. ResultsFrom 2010 to 2019, 15,333 patients were entered into the registry, of whom 2062 met the inclusion criteria. The Crawford extent was 0a for 379, 0b for 848, I for 81, II for 98, III for 130, IV for 454, and V for 72. Three groups were created in accordance with the similar outcomes noted on a preliminary analysis: (1) extent 0a and 0b; (2) extent I, II, and III; and (3) extent IV and V. The mean survival time for the extent 0a and 0b group was 70.7 ± 1.43 months and was 48.6 ± 1.65 months for the extent I, II, and III group and 57.6 ± 1.24 months for the extent IV and V group. The corresponding 1-year mortality was 8.4%, 18.4%, and 7.8%. Cox regression analysis identified the following preoperative factors were associated with mortality: chronic obstructive pulmonary disease (odds ratio [OR], 1.70; P < .001), Crawford extent I to III (OR, 1.64; P = .015), preexisting chronic kidney disease (OR, 1.37; P = .024), and age per year (OR, 1.03; P < .001). A number of postoperative factors were also associated with mortality. ConclusionsSimilar to open TAAA repair, patients with more extensive aortic disease treated with endovascular repair had worse 1-year and long-term survival. The extent of aortic disease and anticipated postoperative survival should factor prominently into the surgical decision-making process for elective endovascular TAAA repair.

Health care costs of endovascular compared with open thoracoabdominal aortic aneurysm repair

ObjectiveTo compare 1-year health care costs between endovascular and open thoracoabdominal aortic aneurysm (TAAA). MethodsPopulation-based administrative health databases were used to capture TAAA repairs performed in Ontario, Canada, between January 2006 and February 2017. All health care costs incurred by the Ministry of Health from a single-payer universal health care system were included. Costs of the aortic endografts and ancillary devices for the index procedure were estimated as C$44,000 per endovascular case vs C$1000 for open cases, based on previous reports. Costs (2017 Canadian dollars) were calculated in phases (1, 1-3, 3-6, and 6-12 months from surgery) with censoring for death. For each phase, propensity score matching of endovascular and open cases based on preoperative patient and hospital characteristics was used. The association between preoperative characteristics (including repair approach) and the first month postprocedure cost was characterized through multivariable analysis. ResultsOverall 664 TAAA repairs were identified (open, n = 361 [54.5%] and endovascular, n = 303 [45.6%]). At 1 month, the median cost was higher for endovascular TAAA repair in the prematching cohort (C$64,892 vs C$36,647; P < .01). Similarly, in 241 well-balanced endovascular/open patient pairs after propensity score matching, the median health care costs were higher in endovascular TAAA cases during the first month (C$62,802 vs C$33,605; P < .01). The 1- to 3-month median cost was not statistically different between endovascular and open TAAA cases either before matching (C$2781 vs C$2618; P = .71) or after matching (C$2762 vs C$2092; P = .58). Likewise, in the 3- to 6-month and 6- to 12-month postprocedure intervals, there were no significant differences in the median health care costs between groups. On multivariable analysis, older age (5-year increments) (relative change [RC] in mean cost, 1.05; 95% confidence interval [CI], 1.04-1.06; P = .01), urgent procedures (RC, 1.29; 95% CI, 1.10-1.52; P < .01), and history of stroke (RC, 1.34; 95% CI, 1.00-1.78; P = .05) were associated with higher costs in the first postoperative month, whereas open relative to endovascular TAAA repair was associated with a decreased 1-month cost (RC, 0.65; 95% CI, 0.56-0.74; P < .01). ConclusionsTAAA repair is expensive regardless of technique. Compared with open TAAA repair, endovascular repair was associated with a higher early cost, owing to the upfront cost of the endograft and aortic ancillary devices. There was no difference in cost from 1 to 12 months after repair. A decrease in the cost of endovascular devices might allow equivalent costs between endovascular and open TAAA repair.

The Role of Ribonuclease 1 and Ribonuclease Inhibitor 1 in Acute Kidney Injury after Open and Endovascular Thoracoabdominal Aortic Aneurysm Repair.

Acute kidney injury (AKI) is one of the most common post-operative complications and is closely associated with increased mortality after open and endovascular thoracoabdominal aortic aneurysm (TAAA) repair. Ribonuclease (RNase) 1 belongs to the group of antimicrobial peptides elevated in septic patients and indicates the prediction of two or more organ failures. The role of RNase 1 and its antagonist RNase inhibitor 1 (RNH1) after TAAA repair is unknown. In this study, we analyzed RNase 1 and RNH1 serum levels in patients undergoing open (n = 14) or endovascular (n = 19) TAAA repair to determine their association with post-operative AKI and in-hospital mortality. Increased RNH1 serum levels after open TAAA repair as compared with endovascular TAAA repair immediately after surgery and 12, 48, and 72 h after surgery (all p < 0.05) were observed. Additionally, elevated RNase 1 and RNH1 serum levels 12, 24, and 48 h after surgery were shown to be significantly associated with AKI (all p < 0.05). RNH1 serum levels before and RNase 1 serum levels 12 h after TAAA repair were significantly correlated with in-hospital mortality (both p < 0.05). On the basis of these findings, RNase 1 and RNH1 may be therapeutically relevant and may represent biomarkers for post-operative AKI and in-hospital mortality.

Open vs. endovascular thoracoabdominal aortic aneurysm repair: tale of the tape.

Open surgical repair persists as the gold-standard operation for thoracoabdominal aortic aneurysm; however, endovascular repair has become commonplace. Technical considerations in thoracoabdominal aortic aneurysm treatment are particularly complex, insofar as it involves critical branching arteries feeding the visceral organs. Newer, low-profile devices make total endovascular thoracoabdominal aortic aneurysm repair more feasible and, thus, appealing. For younger and low-risk patients, the choice between open and endovascular therapy remains controversial. Despite the advantages of a minimally invasive procedure, data suggest that endovascular aortic repair incurs a greater risk of spinal cord deficit, and the durability of endovascular aortic repair remains unclear. It is difficult to compare outcomes between endovascular and open thoracoabdominal aortic aneurysm repair, primarily because of the current investigational status of endovascular devices, the variety of approaches to endovascular repair, differing patient populations, lack of prospective randomized studies, and minimal medium- and long-tern follow-up data on endovascular repair. When deciding between open and endovascular approaches, one should consider which is more suitable for each patient. Older patients generally benefit from a less invasive approach. Open repair should be considered for young patients and those with heritable thoracic aortic disease. Infection and fistulae are best treated by open repair, although endovascular intervention as a lifesaving bridge to definitive repair has evolved to become a critical component of initial treatment. It is crucial to have technical expertise in both open and endovascular procedures to provide the best aortic repair for the patient. This may require dedicated aortic programs at tertiary institutions.

Anatomic Eligibility for Commercial Branched Endograft Repair of Thoracoabdominal Aortic Aneurysms

First-generation "off-the-shelf" branched endovascular stent grafts are in development for treatment of thoracoabdominal aortic aneurysms (TAAAs). Prior studies have assessed eligibility rates among highly selected cohorts of patients referred for endovascular treatment, and the broader applicability of these devices to all patients with TAAA is unknown. The aims of this study were to assess the overall suitability of the 3 commercial 4-branched devices with or without adjunct procedure(s) in an unselected cohort of patients with TAAA and to identify areas for improvement in the next generation of devices. A retrospective review of three-dimensional centerline reconstructions of contrast-enhanced computed tomography (CT) imaging was performed in consecutive patients with TAAA seen between 2013 and 2017. All patients with contrast-enhanced CT imaging were included, regardless of prior evaluation for suitability for endovascular repair. Eligibility for a device was assessed based on instructions for use (IFU) from the device manufacturer along with prespecified anatomic criteria. Adjunct procedures were defined as carotid-subclavian revascularization, target vessel endovascular intervention, and iliac conduit/revascularization. Of 165 patients with TAAA, 122 had CT scans adequate for study inclusion. Eighteen patients (14.8%) were eligible for at least 1 device by IFU, and 41 (33.6%) could have been made eligible for at least 1 device by an adjunct procedure. Sixty-three (51.6%) were not eligible for any device within IFU even with adjunct procedures, including 31 of 32 patients with TAAA due to dissection. The most common reasons for ineligibility were perivisceral flow channel diameter <20mm (n=43) and an inadequate proximal seal zone (n=29). Women were significantly less likely to be eligible for an off-the-shelf device (P=0.03) and were more likely to require an iliac procedure to become eligible (P=0.006). Almost none of the patients with dissection could receive a device even if adjunct procedures were used. Over half of patients with TAAA could not be made eligible for an off-the-shelf device based on manufacturers' criteria, even with adjunct procedures. Women and patients with TAAA due to dissection had higher rates of ineligibility. These data demonstrate that custom fenestrated devices and low-profile devices are needed to expand eligibility for endovascular repair of TAAA.

Long-term Follow-Up Following Advanced Endovascular Thoracoabdominal Aortic Aneurysm Repair: A Single-Center Experience

We reviewed our institutional outcomes of patients with thoracoabdominal aortic aneurysms (TAAA) repaired using branched or fenestrated endovascular devices for complications including TAAA life-altering events, a composite of mortality, permanent paraplegia, permanent dialysis, stroke, and long-term survival. Data were collected both prospectively and retrospectively with institutional ethics approval. Seventy-eight consecutive patients underwent endovascular TAAA repair using branched-fenestrated endovascular aneurysm repair stent grafts at our institution from June 2008 to July 2019 (47 male; mean age, 74 ± 7 years). Graft designs included 68 patient-customized devices and 9 off-the-shelf grafts. Median follow-up was 5.43 years. Mean aneurysm size at presentation was 70 ± 8 mm and Crawford extents were three type I (3.9%), 18 type II (23.4%), 22 type III (28.6%), 31 type IV (40.2%) and 3 type V (3.9%). The Table highlights patient baseline demographic characteristics. Graft deployment was successful in all patients. Target vessel revascularization was successful in 276 of 290 (95.2%) vessels: 57 of 65 celiac arteries, 76 of 76 superior mesenteric arteries, 74 of 76 right renal arteries, and 69 of 73 left renal arteries. Seventeen branches over 16 (20.5%) patients required reintervention for occlusion, endoleaks, and/or target vessel realignment during their hospital stay. Thirty-day mortality was observed in eight (10.3%) patients. In the surviving patients, 13 (18.6%) developed perioperative spinal cord ischemia: three (4.3%) patients with temporary paraparesis, three with temporary paraplegia, three with permanent paraparesis, and four (5.7%) patients with permanent paraplegia. Postoperative stroke occurred five 6.4%) patients, acute myocardial infarction in six (7.7%) patients, one (1.3%) patient suffered renal failure requiring permanent dialysis at discharge, and three (3.8%) patients suffered bowel ischemia requiring reintervention. At 5 and 9 years, freedom from all-cause mortality was 54% (95% confidence interval, 0.42-0.70) and 29.3% (95% confidence interval, 0.16-0.53), respectively (Figure). There were no deaths related to aneurysm rupture. Endovascular repair of TAAAs was associated with a high rate of technical success and prevented short and long-term rupture. While the rate of early mortality and morbidity is low, secondary reintervention rates indicate the need for further improvements and continuous patient follow-up. Our data include one of the longest median follow-up durations of endovascular TAAA repair, which highlights the durability of the procedure and compares favorably to survival Results to population-based outcomes and centers of excellence across the globe.TableClinical and aneurysm characteristics of the 78 patients in the studyVariableAge74 ± 6.9Male, n (%)47 (60.3)Urgent or emergent10 (12.8)Crawford classification extent I3 (3.9) II18 (23.4) IIII22 (28.6) IV31 (40.2) V3 (3.9)Staged procedure30 (38.5)Smoking (current or past)64 (82.1)Hypertension71 (91.0)Diabetes mellitus13 (16.7)Dyslipidemia42 (54.5)Chronic obstructive pulmonary disease36 (46.8)Cerebrovascular disease (stroke/TIA)15 (19.2)Peripheral vascular disease25 (32.9)Coronary artery disease30 (39.5)Previous coronary revascularization20 (25.6)Renal Insufficiency (GFR <30 mL/min)5 (6.4)Connective tissue disorder2 (2.6)Previous aortic surgery31 (39.7)GFR, Glomerular filtration rate; TIA, transient ischemic attack.Values are mean ± standard deviation or number (%). Open table in a new tab

Occlusion of the Celiac Artery During Endovascular Thoracoabdominal Aortic Aneurysm Repair Is Associated With Increased Perioperative Morbidity and Mortality

Occlusion of the Celiac Artery During Endovascular Thoracoabdominal Aortic Aneurysm Repair Is Associated With Increased Perioperative Morbidity and Mortality

Detrimental effects of cerebrospinal fluid pressure elevation on spinal cord perfusion: first-time direct detection in a large animal model.

Cerebrospinal fluid (CSF) drainage is routinely utilized to mitigate perioperative and postoperative spinal cord ischaemia in open and endovascular thoraco-abdominal aortic aneurysm repair to prevent permanent paraplegia. Clinical decision-making in the vulnerable perioperative period, however, is still based on limited clinical and experimental data. Our aim was to investigate the isolated effect of CSF pressure elevation on spinal cord perfusion in an established large animal model. Ten juvenile pigs with normal (native) arterial inflow (patent segmental arteries and collaterals) underwent iatrogenic CSF pressure elevation (×2, ×3, ×4 from their individual baseline pressure). Each pressure level was maintained for 30 min to mimic clinical response time. After the quadrupling of CSF pressure, the dural sac was slowly depressurized against gravity allowing CSF pressure to passively return to baseline values. Measurements were taken 30 and 60 min after normalization, and microspheres for regional blood flow analysis were injected at each time point. Spinal cord perfusion decreased significantly at all mid-thoracic to lumbar cord segments at the doubling of CSF pressure and declined to values <53% compared to baseline when pressure was quadrupled. Normalizing CSF pressure led to an intense hyperperfusion of up to 186% at the cervical level and 151% within the lumbar region. CSF pressure elevation results in a relevant impairment of spinal cord blood supply. Close perioperative and postoperative monitoring of CSF pressure is crucial for maintaining sufficient spinal cord perfusion. Radical and rapid withdrawal of CSF is followed by significant hyperperfusion in all spinal cord segments and may lead to 'drainage-related' iatrogenic reperfusion injury-aggravating the risk of delayed spinal cord injury-and should therefore be avoided.