Endovascular Repair Of Thoracoabdominal Aortic Aneurysms Research Articles

Geometric and hemodynamic analysis of fenestrated and multibranched aortic endografts

ObjectiveThe objective of this study was to determine the influence of hemodynamic force on the development of type III endoleak and branch thrombosis after complex endovascular thoracoabdominal aortic aneurysm repair. MethodsPatients with thoracoabdominal aortic aneurysm, within surgical range, treated with a fenestrated or branched endovascular aneurysm repair from 2014 to 2018 and with 3-month control computed tomography angiography were selected. Demographic variables, aneurysm anatomy, and endograft conformation were analyzed retrospectively from a prospective registry. The hemodynamic force was calculated using the mass and momentum conservation equations. ResultsTwenty-eight patients were included; the mean follow-up period was 24.7 ± 19.3 months. There were 102 abdominal vessels successfully catheterized (19 celiac arteries, 29 superior mesenteric arteries, 27 right renal arteries, 26 left renal arteries, and 1 polar renal artery). The rate of type III endoleak was 11.5% (n = 12); six cases were associated with branches that received two stents (P < .001). A higher rate of endoleak was observed with wider stents (8.50 ± 1.0 mm vs 7.17 ± 1.3 mm; P = .001) but not with longer stents (P = .530). All cases of type III endoleak affected visceral arteries (eight celiac arteries and four superior mesenteric arteries). The freedom from type III endoleak at 24 months was 86%. The rate of thrombosis was 5.9% (n = 6). A higher rate of thrombosis was observed in smaller vessels (5.00 ± 1.3 mm vs 7.16 ± 1.8 mm; P = .001), with higher stent oversizing (36.87% ± 23.6% vs 5.52% ± 15.0%; P < .001), and with a higher angle of curvature (124.33 ± 86.1 degrees vs 57.71 ± 27.9 degrees; P < .001). All cases of thrombosis were related to renal arteries (two left renal arteries, two right renal arteries, and two polar renal arteries). The freedom from thrombosis at 24 months was 92%. The area under the curve for the angle of curvature was 0.802 (95% confidence interval, 0.661-0.943; P = .013), and the cutoff point was established at 59.5 degrees (sensitivity, 100%; specificity, 60.4%). The receiver operating characteristic curve for the stent oversize showed an area under the curve of 0.903 (95% confidence interval, 0.821-0.984; P = .001), and the cutoff point was 14.5% (sensitivity, 100%; specificity, 77.1%). A higher hemodynamic force was associated with thrombosis (23.35 × 10−3 N ± 18.7 × 10−3 N vs 12.31 × 10−3 N ± 6.8 × 10−3 N; P = .001) but not with endoleak (P = .796). The freedom from endoleak and thrombosis at 24 months was 86% and 90%, respectively. ConclusionsLonger stents should be preferred to avoid type III endoleak. A higher angle of curvature leads to a higher hemodynamic force that results in a higher rate of thrombosis. Accordingly, we recommend maintaining the angle of curvature under 59.9 degrees. Small vessels and excessive stent oversizing entail a higher risk of thrombosis; as such, we advise a maximum stent oversize of 14.5%. Renal arteries are more susceptible to thrombosis, whereas visceral arteries are more prone to endoleak.

SLPI - a Biomarker of Acute Kidney Injury after Open and Endovascular Thoracoabdominal Aortic Aneurysm (TAAA) Repair

Acute kidney injury (AKI) is a relevant complication following thoracoabdominal aortic aneurysm repair (TAAA). Biomarkers, such as secretory leucocyte peptidase inhibitor (SLPI), may enable a more accurate diagnosis. In this study, we tested if SLPI measured in serum is an appropriate biomarker of AKI after TAAA repair. In a prospective observational single-center study including 33 patients (51.5% women, mean age 63.0 ± 16.2 years) undergoing open and endovascular aortic aneurysm repair in 2017, SLPI was measured peri-operatively (until 72 h after surgery). After surgery, the postoperative complications AKI, as defined according to the KDIGO diagnostic criteria, sepsis, death, MACE (major cardiovascular events) and, pneumonia were assessed. In a subgroup analysis, patients with preexisting kidney disease were excluded. Of 33 patients, 51.5% (n = 17) of patients developed AKI. Twelve hours after admission to the intensive care unit (ICU), SLPI serum levels were significantly increased in patients who developed AKI. Multivariable logistic regression revealed a significant association between SLPI 12 hours after admission to ICU and AKI (P = 0.0181, OR = 1.055, 95% CI = 1.009–1.103). The sensitivity of SLPI for AKI prediction was 76.47% (95% CI = 50.1–93.2) and the specificity was 87.5% (95% CI = 61.7–98.4) with an AUC = 0.838 (95% CI = 0.7–0.976) for an optimal cut-off 70.03 ng/ml 12 hours after surgery. In patients without pre-existing impaired renal function, an improved diagnostic quality of SLPI for AKI was observed (Sensitivities of 45.45–91.67%, Specificities of 77.7–100%, AUC = 0.716–0.932). There was no association between perioperative SLPI and the incidence of sepsis, death, MACE (major cardiovascular events), pneumonia. This study suggests that SLPI might be a post-operative biomarker of AKI after TAAA repair, with a superior diagnostic accuracy for patients without preexisting impaired renal function.

Occlusion of the Celiac Artery during Endovascular Thoracoabdominal Aortic Aneurysm Repair Is associated with Increased Perioperative Morbidity and Mortality

Some studies suggest that celiac artery coverage during elective endovascular thoracoabdominal aortic aneurysm (TAAA) repair is safe given sufficient collateralization of visceral organ perfusion from the superior mesenteric artery. However, there is concern that celiac artery coverage may lead to increased risk of foregut or spinal cord ischemia with an attendant increased risk of mortality. We sought to investigate rates of bowel ischemia, spinal cord ischemia, and 30-day mortality associated with celiac artery coverage during TEVAR and complex EVAR. The Society for Vascular Surgery Vascular Quality Initiative database was queried for TEVAR and complex EVAR cases from 2012 to 2018. Inclusion criteria included TAAA pathology and endograft extension to aortic zone 6. Patients with aortic rupture, trauma, prior thoracic aortic surgery, known preoperative occlusion of the left subclavian superior mesenteric, or celiac arteries were excluded. Cases with intraoperative celiac artery occlusion (CAO) were compared retrospectively to cases with celiac artery preservation (CAP). Primary outcomes included 30-day mortality and a composite end point of 30-day mortality, spinal cord ischemia (transient or permanent lower extremity neurologic deficit), and bowel ischemia (colonoscopic evidence of ischemia, bloody stools in a patient who dies prior to colonoscopy or laparotomy, or other documented clinical diagnosis). Univariable comparisons were performed using chi-squared tests and Student's t-tests, as appropriate. Multivariable logistic regression analyses were employed to identify independent predictors of outcome. There were 628 cases identified for inclusion in the study. Patients undergoing CAO (n=44) were more likely to be female or to have higher rates of preoperative spinal drain use, American Society of Anesthesiologists score ≥3, low preop hemoglobin, and/or symptomatic presentation, but fewer mean number of aortic zones covered. CAO was associated with higher 30-day mortality (5 of 44, 11%) compared to CAP (23 of 584, 4%), P=0.039. The composite end point occurred at a significantly greater proportion for those who had CAO (10 of 44, 23%) compared to CAP (53 of 584, 9%, P=0.008), driven by higher rates of 30-day mortality and bowel ischemia (9% vs. 2%, P=0.026). By multivariate analysis, CAO was predictive of 30-day mortality (odds ratio [OR]=3.9, 95% confidence interval [CI]=1.1-13.8, P=0.04) and the composite endpoint (OR=3.0, 95% CI=1.1-8.5, P=0.03). Increasing procedure time was also associated with 30-day mortality (OR=1.4, 95% CI=1.1-1.7, P<0.001) and the composite end point (OR=1.4, 95% CI=1.1-1.6, P<0.001). For those treated for TAAAs, CAO was independently predictive of increased 30-day mortality and a composite end point of perioperative mortality, spinal cord ischemia, and bowel ischemia. When treating patients with extensive aortic aneurysmal disease, physicians should attempt to preserve the celiac artery, by revascularization or avoiding ostium coverage, whenever feasible.

Postoperatively increased bioactive adrenomedullin is related to adverse outcome after complex aortic surgery.

Background: Open and endovascular thoracoabdominal aortic aneurysm repair is related to major complications and increased mortality rates. Up to now, specific biomarkers for adverse outcome are scarce, although routine usage of such biomarkers could enable an earlier and more appropriate treatment of complications during the postoperative course after complex aortic aneurysm repair. Patients and methods: In a prospective single-center study including 33 patients (48.5% women, mean age 63.0±16.2years) undergoing elective complex open and endovascular aortic aneurysm repair, bioactive adrenomedullin (bio-ADM) was measured for 72h perioperatively and an association with clinical endpoints, namely cardiogenic shock, death and the combined endpoint of the two aforementioned parameters was assessed. Furthermore, the association between bio-ADM and baseline characteristics and perioperative details including sepsis biomarkers score were assessed. Results: 51.5% (n=17) of patients developed postoperative acute kidney injury, 21.2% (n=7) pneumonia and 18.2% (n=6) sepsis. Cardiogenic shock was observed in 12.1% (n=4) patients. The in-hospital mortality rate was 18.2% (n=6), and 24.2% (n=8) of patients developed cardiogenic shock and/or died in hospital. A significant correlation of bio-ADM concentrations from all available time points was observed with leukocytes (r = 0.37, P < 0.0001), C-reactive protein (r = 0.56, P < 0.001) and serum creatinine levels (r = 0.52, P < 0.001). Increased bio-ADM at 12h, 24h, 48h and 72h after admission to ICU was associated with both, in-hospital death and cardiogenic shock, with an area under the curve for the combined endpoint of 0.598, 0.720, 0.880 and 0.967. Bio-ADM concentrations at 48h and 72h after admission to ICU were predictive for in-hospital death and cardiogenic shock (both P<0.01). Conclusions: Bio-ADM may serve as postoperative biomarker for cardiogenic shock and death after complex open and endovascular aortic aneurysm repair, potentially enabling an earlier and by that more adequate treatment of adverse outcome after major surgery.

Outcomes of a novel upper extremity preloaded delivery system for fenestrated-branched endovascular repair of thoracoabdominal aneurysms

ObjectiveThe aim of this study was to evaluate the feasibility and outcomes of endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) using a novel low profile (LP) device with upper extremity preloaded guidewire system (PGS) and compare procedural metrics and outcomes with a standard multibranch stent graft (t-Branch; Cook Medical, Bloomington, Ind). MethodsWe reviewed the clinical data of 232 consecutive patients treated by fenestrated-branched endovascular aortic repair for TAAA and enrolled in a prospective nonrandomized trial between 2014 and 2017. Patients who had repair using t-Branch or patient-specific TAAA devices using upper extremity LP-PGS were included. End points were technical success, operative and fluoroscopic time, patient radiation exposure, time from arterial access to complete device deployment, total contrast volume, and 30-day rates of major adverse events (MAEs) and mortality. ResultsThere were 54 patients, including 33 males (67%) and 21 females (33%), with a mean age of 73 ± 9 years old. Forty-nine patients (91%) had extent I-III and five patients (9%) had extent IV TAAAs. Device design was t-Branch in 24 patients (44%) and LP-PGS in 30 patients (56%). A total of 206 renal-mesenteric arteries were incorporated with no difference between groups (mean, 3.8 ± 0.6 target vessels/patient; P = .92). Patients treated by t-Branch device had larger mean aneurysm diameter (79 ± 16 vs 66 ± 10 mm; P = .0006). All patients had transbrachial approach. Technical success was achieved in all patients in both groups. Patients treated by LP-PGS devices had lower radiation dose (1250 ± 849 vs 3154 ± 2421 mGy; P = .003) and shorter operating time for complete device deployment (105 ± 42 vs 123 ± 34 minutes; P = .043). There was no difference in mean operative time (252 ± 69 vs 273 ± 56 minutes; P = .23), fluoroscopy time (82 ± 29 vs 96 ± 35 minutes; P = .08) or contrast volume (163 ± 59 vs 197 ± 75 mL; P = .07) comparing LP-PGS and t-Branch respectively. There was no 30-day or in-hospital mortality. There were no differences in MAEs, which occurred in 18 patients (33%) in both groups (P > .05). ConclusionsEndovascular TAAA repair using the standard or LP-PGS multibranch stent graft was associated with high technical success, no mortality, and a low rate of MAEs in this study. Patients treated by upper extremity LP-PGS had shorter time to complete device deployment, suggesting decreased technical demand with preloaded systems.

Assessment of Neurone-Specific Enolase, Glial Fibrillary Acidic Protein and S100 B as Spinal Cord Ischemia Biomarkers in Patients Undergoing Open and Endovascular Complex Aortic Surgery: A Single-Center Experience

Despite all efforts, spinal cord ischemia (SCI) is a relevant and feared complication after open and endovascular thoracoabdominal aortic aneurysm (TAAA) repair. Besides the established correlation of motor evoked potentials (MEPs) and SCI, the usage of biomarkers for early detection of SCI intraoperatively and postoperatively after TAAA surgery is scarcely described in literature. The methods include retrospective assessment of 33 patients (48.48% male) undergoing open and endovascular TAAA repair between January 2017 and January 2018. Levels of the biomarkers neurone-specific enolase (NSE), glial fibrillary acidic protein (GFAP), and S100B were correlated with a decrease of the amplitude of the MEPs of more than 50%, indicating SCI. Linear mixed models were applied to test for differences in the biomarker levels between open and endovascular surgery and between different times of measurement. Post hoc analyses were performed using Tukey's multiple comparisons test. Logistic regression models were used to investigate the association between GFAP, NSE, and S100B levels at different times and a significant decrease in MEP or in-hospital mortality. Altogether, 19 patients were treated by endovascular repair; 14 patients were treated by open repair; 5 patients were treated because of a type I TAAA; 7 received treatment because of a type II TAAA; 7, 10, and 4 patients received type III, IV, or V TAAA repair, respectively. In-hospital mortality was 18.18% (n=6); 5 of these patients were treated because of symptomatic TAAA. MEP decrease could be observed in 18 cases (54.5%), with 16 (48.4%) recovering during the intervention. SCI could be observed in 9.09% (n=3), 2 endovascular repairs leading to paraplegia and one open repair leading to paraparesis. All biomarkers showed increasing levels over time, with no statistically significant difference between open and endovascular repair. The difference in NSE and S100B levels between the different times of measurements was statistically significant (P<0.0001, P=0.0017, respectively). In a univariable logistic regression analysis, no correlation with the end points "significant decrease in MEP" or "in-hospital mortality" was observed for any of the assessed biomarkers. SCI-related biomarkers, namely NSE and S100B, show a relevant increase directly after open and endovascular TAAA surgery, while no clear association between these biomarker levels and an intraoperatively measurable indicator for SCI could be observed.

Minimally Invasive Segmental Artery Occlusion Prior to Endovascular Repair of Thoraco-Abdominal Aortic Aneurysm to Reduce the Risk of Spinal Cord Injury

Introduction - Minimal invasive segmental artery occlusion (MISAO) has been clinically introduced as an entirely endovascular approach to stage the segmental artery (SA) sacrifice in several sessions prior to total endovascular repair (ER) of thoraco-abdominal aortic aneurysm (TAAA) and thereby reduce ischemic spinal cord injury (iSCI) (1,2). The aim of our study was to report on our initial clinical experience and the SCI rates after MISAO and endovascular repair of TAAA. Methods - A cohort of 39 patients (28 men, mean age 68.92±7.56 years) with extensive nonruptured TAAAs and no previous neurological deficit were treated by MISAO followed by fenestrated and multibranched endografting between October 2014 and March 2017. MISAO was performed in local anesthesia with clinical surveillance of the patients ‘neurological functions and hemodynamic stability for at least 48 hours. Final ER was performed after a minimum of one week after the last MISAO session. The main outcomes were the 30-day mortality and the onset of the SCI after ER. Results - The majority of patients (n=36) were treated for atherosclerotic aneurysm, whereas three patients were treated for post-dissection aneurysm. The TAAA distribution was as follow: type I, n= 5; type II, n=9; type III, n=20; type IV, n=5. The maximum aortic diameter was in average 62.74 ± 8.77mm. The mean number of patent SAs per patient was 11±4.5. A total of 245 SAs were occluded by MISAO with each patient having in median 6 coiled SAs (range: 1-19), occluding 75% of direct segmental arterial inflow (Range: 38.89% - 100%). MISAO preconditioning was completed in one (n=15), two (n=17), three (n=3), four (n=3) and five (n=1) sessions prior to TAAA-ER. The maximum number of coiled SAs per session was six and the maximum number of coiled SAs per patient was nineteen. In seventeen patients the inferior mesenteric artery was also coiled. The average interval time between sessions was 63.56 ± 70.69 days. No SCI and no other major complications developed. Minor complications were temporary back pain in eleven patients. After a mean of 77 ± 61.56 days thirty-eight of the patients received total ER of their TAAA. One patient died waiting for ER of TAAA. At 30 days postoperatively, thirty-seven patients were alive and none developed SCI. Conclusion - In our experience, minimal invasive segmental artery occlusion to precondition the paraspinous collateral network is clinically feasible and safe. MISAO followed by aneurysm exclusion may eliminate paraparesis and paraplegia after total endovascular repair of extensive TAAA.

Relevance of Slpi as Biomarker of Acute Kidney Injury After Open and Endovascular Complex Aortic Surgery

Introduction: Open and endovascular repair of thoracoabdominal aortic aneurysm (TAAA) is related to a relevant rate of postoperative complications such as acute kidney injury (AKI), which is in turn closely linked with poor patients` outcome. Hence an early detection of AKI may enable an immediate start of specific treatment bundles. In this context, the necessity of clinically available early and reliable biomarkers for AKI becomes evident. Secretory leukocyte proteinase inhibitor (SLPI) is a protease inhibitor and regulator of innate and adaptive immunity. It is synthesized predominantly in immune cells and epithelial cells of mucosal surfaces, such as the pancreas and kidney. Patients with AKI showed significantly increased SLPI plasma and urine levels when compared with patients without AKI. The aim of this study was to evaluate SLPI as a potential predictive biomarker of postoperative AKI in patients undergoing complex open and endovascular aortic aneurysm repair. Methods: Between January and December 2017 33 patients have been enrolled in this prospective, non-randomized single-center study. Serum samples were collected at six defined time points until 72 hours after surgery. AKI was defined according to the KDIGO criteria. In a subgroup analysis, patients with preexisting kidney disease (defined as preoperative serum creatinine > 1.2 mg/dl according to the Cleveland clinic foundation score) were excluded. Results: The mean patients' age was 66 ± 16 years. A total of 13 patients (53.3 %) developed postoperative AKI. Serum SLPI showed an early and significant increase within the first 12 hours after surgery until 72 hours after surgery. Patients suffering from AKI showed significantly higher serum SLPI 12 hours after surgery when compared to patients without AKI (p=0.008). The ROC analysis revealed a prognostic accuracy with an Area under Curve [AUC]=0.783 for SLPI as a biomarker of AKI 12 hours after surgery (p=0.009). After exclusion of patients with underlying kidney disease, 20 patients were further analyzed from which 11 patients (55%) showed postoperative AKI. In this group, an even stronger correlation between serum SLPI and AKI was evident: Significantly increased serum SLPI 12, 24, and 48 h after surgery could be observed (12 h: p=0.0002, 24 h: p=0.0016, 48 h: p=0.025). Besides, the respective ROC analysis showed an AUC=0.949 for 12 hours after surgery (p=0.0001), AUC=0.899 for 24 hours after surgery (p=0.0003), and AUC=0.795 for 48h after surgery (p=0.025). Conclusion: The present findings highlight SLPI as a reliable and promising marker for the early detection of postoperative AKI after open and endovascular TAAA repair, Besides, these results potentially suggest a general applicability of SLPI as a biomarker of AKI. Disclosure: Nothing to disclose

Hospital Volume Impacts the Outcomes of Endovascular Repair of Thoracoabdominal Aortic Aneurysms

Few centers in the United States have the expertise to manage patients with a thoracoabdominal aortic aneurysm (TAAA). The purpose of this study is to use a nationally representative vascular database to assess the role of hospital volume on outcomes in patients undergoing endovascular repair for TAAA. All patients undergoing complex endovascular repair (cEVAR) for TAAA were identified in the Vascular Quality Initiative (VQI) database (2012-2018). The total mean number of cases per year was identified at each center and were used to group into three quantiles containing an equal number of patients (Low [LVH], Medium [MVH], High [HVH]). Standard univariate and multivariable (logistic regression) analyses were performed to evaluate the patient's characteristics and short-term outcomes. A total of 2,115 patients from 118 centers (Low - 92, Medium - 19, High - 7) were identified in VQI from 2012 to 2018. The annual mean (S.D.) number of cases at HVH, MVH, LVH were 22.7 (4.7), 9.6 (3.0), 3.6 (1.4), respectively. The repair of Type III TAAA was slightly higher in HVH versus MVH versus LVH (22.5% vs. 21.0% vs. 15.1%), while Type I was more common among LVH versus MVH versus HVH (13.7% vs. 11.5% vs. 3.7%) (Both P<0.001). Custom/modified devices were more likely to be used in HVH versus MVH versus LVH (67.9% vs. 27.6% vs. 27.2%) (P<0.001). Additionally, HVH and MVH utilized fenestrated/branched or chimney/snorkel options more frequently, whereas surgical bypasses were common in LVH for revascularization of visceral arteries. In univariate analysis, HVH were associated with significantly lower mortality (2.2% vs. 5.1% and 6.5%), failure to rescue [FTR] (3.5% vs. 11.6% and 12.1%) and any complication (24.6% vs. 27.1% and 31.2%) compared to LVH and MVH (All P<0.001). After adjusting for potential confounders, both LVH and MVH were associated with 2-4 fold increase in the odds of mortality [OR (95% CI): 2.30 (1.20-4.41) and 2.14 (1.16-3.93)] and FTR [OR (95% CI): 4.42 (1.86-10.54) and 4.08 (1.73-9.62)] compared to HVH. Our study demonstrates significantly lower morbidity and mortality in high volume hospitals performing cEVAR for TAAA, despite operating on older patients with more complex TAAA types. This is likely due to better rescue phenomenon in addition to more experienced operators. Complex endovascular repair of TAAA can be performed safely in high volume aortic centers of excellence.

Health Care Costs of Endovascular Compared With Open Thoracoabdominal Aortic Aneurysm Repair

To compare 1-year health care costs of open and endovascular thoracoabdominal aortic aneurysm (TAAA). Population-based administrative health databases were used to capture TAAA repairs performed in Ontario, Canada, between January 2006 and March 2017. All health care costs incurred by the Ministry of Health were included. Costs of the aortic endografts and devices for the index procedure were C$44,000 per case versus C$1000 for open cases. Costs (2017 Canadian $) were calculated in phases (1, 1-3, 3-6, 6-12 months) with censoring for death. Propensity score matching based on 26 preoperative characteristics was used. The association between preoperative characteristics and 1-month cost were characterized through multivariable analysis. Overall 664 TAAA repairs were identified (open, n = 361 [54.5%] and endovascular, n = 303 [45.6%]) and 241 open/endovascular propensity score-matched pairs were formed. At 1 month, the mean [median] total cost for the pre propensity score matched open TAAA group was C$46,575 [C$36,647] (77% hospital cost, 14% physician billings, 3% graft cost, 6% other), whereas for the endovascular group, total cost was C$72,581 [C$64,892] (67% graft cost, 27% hospital cost, 5% physician billings, 1% other; P < .01). At 1 to 3 months, 3 to 6 months, and 6 months to 1 year postprocedure intervals, there were no significant difference in health care costs between groups (Table). The mean [median] cumulative cost for patients alive at 1-year were C$91,571 [C$52,003] versus C$103,740 [C$83,242]; P < .01 for open (n = 264) and endovascular (n = 206) TAAA repair, respectively. On multivariable analysis, older age (P < .01), nonelective procedures (P < .01), and preoperative stroke (P = .05) were associated with increased costs at 1 month. While devices led to higher 1-month costs of endovascular TAAA repair, total cumulative health care costs after the first month and up to 1 year were not significantly different, including re-interventions. Higher 1-month costs occurred with older age, preoperative stroke, and nonelective procedures.TableHealth care costs of endovascular versus open thoracoabdominal aortic aneurysm (TAAA) repairCostBefore propensity score matchingAfter propensity score matchingOpenEndovascularP valueOpenEndovascularP valueMean [median]Mean [median]Mean [median]Mean [median]1 month46,575 [36,647]72,581 [64,892]<.0146,556 [33,605]72,786 [64,892]<.011-3 months19,826 [2024]11,292 [1977].6218,828 [1832]11,454 [1992].613-6 months12,289 [1173]11,453 [1508].169456 [1144]12,153 [1298].846 months-1 year11,985 [2427]12,087 [2998].978840 [2524]12,016 [3050].34 Open table in a new tab

Treatment of High Surgical Risk Thoracoabdominal Aortic Aneurysms with Stent Graft and Multilayer Bare Stents Joint Technique: Mid-Long-Term Clinical Results

This study aims to present the performance data on stent-graft and multilayer bare stents (MBS) joint technique in the treatment of high-risk thoracoabdominal aortic aneurysm (TAAA). From May 2012 to December 2015, 8 selective TAAA cases (ages 46-75years) ineligible for surgical repair underwent the stent-graft and MBS joint procedure, and were closely followed up for a median of 32months (range 14-58). Using computed tomography images, the aneurysm size, luminal blood flow diameter, and the covered visceral branches were analyzed. Technical success was achieved in all patients (100%, 8/8). Twenty-four visceral branches were covered by MBS in total. There was no complication or death during hospital stay. During follow-up period, no death or complication occurred. Aneurysm shrinkage (maximum diameter decrease ≥5mm) was observed in 7 patients. No aneurysm expansion was observed. Total aneurysm sac thrombosis was observed in all patients. The majority of covered side branches (23/24) were successfully preserved. No visceral ischemia or bleeding complications was observed during follow-up. Total endovascular repair of TAAA using stent-graft and MBS joint technique may be a safe and effective alternative in high surgical risk patients. More approving clinical evidences about the safety and efficacy of this procedure are anticipated.

Women undergoing endovascular thoracoabdominal aortic aneurysm repair differ significantly from their male counterparts preoperatively and postoperatively

ObjectiveA rational approach to the management of aortic aneurysm disease relies on weighing the risk of aneurysm rupture against the complications and durability of operative repair. In men, seminal studies of infrarenal aortic aneurysm disease and its endovascular management can provide a reasoned argument for the timing and modality of surgery, which is then extrapolated to the management of thoracoabdominal aortic aneurysms (TAAAs). In contrast, there is less appreciation for the natural history of TAAA disease in women and its response to therapy. MethodsWe used a retrospective cohort design of women, all men, and matched men, fit for complex endovascular thoracoabdominal aneurysm repair at two large aortic centers. We controlled for preoperative anatomic and comorbidity differences, and assessed technical success, postoperative renal dysfunction, spinal ischemia, and early mortality. Women and matched men were reassessed at follow-up for long-term durability and survival. ResultsAssessing women and all men undergoing complex endovascular aortic reconstruction, we demonstrate that these groups are dissimilar before the intervention with respect to comorbidities, aneurysm extent, and aneurysm size; women have a higher proportion of proximal Crawford extent 1, 2, and 3 aneurysms. Matching men and women for demographic and anatomic differences, we find persistent elevated perioperative mortality in women (16%) undergoing endovascular thoracoabdominal aneurysm repair compared with matched men (6%); however, at the 3-year follow-up, both groups have the same survival. Furthermore, women demonstrate more favorable anatomic responses to aneurysm exclusion, with good durability and greater aneurysm sac regression at follow-up, compared with matched men. ConclusionsWomen and unmatched men with TAAA disease differ preoperatively with respect to aneurysm extent and comorbidities. Controlling for these differences, after complex endovascular aneurysm repair, there is increased early mortality in women compared with matched men. These observations argue for a careful risk stratification of women undergoing endovascular thoracoabdominal aneurysm treatment, balanced with women's good long-term survival and durability of endovascular aneurysm repair.

Impact of Renal Function on Early and Late Survival After Endovascular Thoracoabdominal and Pararenal Aortic Aneurysm Repair

Renal dysfunction can be a prohibitive risk for open repair of complex thoracoabdominal aortic aneurysms (TAAAs) and pararenal aneurysms (PRAs). However, the impact of renal dysfunction from branched/fenestrated aneurysm repair (B-FEVAR) on outcomes is poorly defined. The objective was to review the association of renal function with early and long-term mortality after B-FEVAR. This study reviewed the clinical data of consecutive patients enrolled in a prospective nonrandomized study to investigate B-FEVAR for PRAs and TAAAs at a single institution with 1-year follow up (2013-2017). Patients were categorized by preoperative chronic kidney disease (CKD) classification, and early and long-term mortality was assessed. During the study interval, 231 patients underwent B-FEVAR, including 80 PRAs, 89 type I to type III TAAAs, and 62 type IV TAAAs. Mean age was 74.6 years (standard deviation, 6.7 years), and 71% were male. There were 126 CKD stage 1/2 patients, 96 CKD stage 3 patients, and 9 CKD stage 4/5 patients (all with baseline creatinine concentration >2.0 mg/dL). No patients were on dialysis at time of procedure. Patients with CKD stage 4/5 had similar demographics to those with normal renal function but had slightly larger aneurysms (6.5 vs 7 cm; P = .15). Early 30-day mortality was 1.35% (n = 3) for those with CKD stage 1 to stage 3 vs 0% in CKD stage 4/5 (P = .73). Similarly, 1-year survival was similar (95% vs 88%; log-rank, P = .98) for CKD stage 1 to stage 3 patients vs CKD stage 4/5 patients, respectively. Median follow-up time was 2.6 years (interquartile range, 1.5-3.7 years). Two CKD stage 4/5 patients died in follow-up. CKD stage 4/5 patients had similar survival during follow-up (hazard ratio, 1.02; 95% confidence interval, 0.2-4.2). Although it was a small sample size for evaluation, selected patients with CKD stage 4/5 may have similar short- and long-term mortality to that of patients with normal/moderate renal dysfunction after B-FEVAR. Although it is a major contraindication to open repair, renal dysfunction may not be as prohibitive for endovascular repair in well-selected patients.

Anatomic Eligibility for Commercial Branched Endograft Repair of Thoracoabdominal Aortic Aneurysms

Background 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. Methods 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. Results 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 Conclusions 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.

Safety and Effectiveness of Percutaneous Axillary Artery Access for Complex Aortic Interventions

The aim of this study is to evaluate the safety and effectiveness of percutaneous axillary artery access in patients requiring upper extremity large sheath access during complex aortic interventions. Consecutive patients who had percutaneous axillary artery access with a large-bore sheath during endovascular thoracoabdominal aortic artery aneurysm repair within an Food and Drug Administration-approved, physician-sponsored investigational device exemption study or visceral artery interventions during other complex aortic interventions were included in the study. All patients had percutaneous axillary artery ultrasound-guided access and deployment of 2 Perclose ProGlide devices (Abbott Vascular, Santa Clara, CA) prior to introduction of a large sheath. Completion angiography was performed to assess technical success of percutaneous access site closure, which was defined as hemostatic arterial closure without evidence of axillary artery stenosis or occlusion requiring intervention. Follow-up computed tomography scans and patient records were also reviewed for access site associated complications. A total of 46 patients underwent percutaneous axillary artery access. Largest sheath profile was 16F in 1 (2%), 12F in 42 (91%), 10F in 1 (2%), 9F in 1 (2%), and 8F in 1 (2%) patient. Technical success was achieved in 41 of 46 patients (89%). Five patients required endovascular covered stent placement during the index operation to control persistent access site bleeding. Two of 46 patients (4%) suffered access-related complications; both patients experienced ipsilateral upper extremity paresthesias without motor weakness, with persistent digit numbness in one. There was no incidence of conversion to open axillary artery repair and no additional access site complications (stenosis, occlusion, or dissection) but neurologic complications were observed during follow-up. Percutaneous axillary artery access can be used to provide upper extremity arterial access during complex aortic interventions with high rates of safety and technical success. Overall complication rates are low and occurred mainly during the early experience, indicating that there is an associated learning curve effect. Elimination of surgical cutdown incisions and arterial conduits by using percutaneous axillary access may reduce operative times and wound-related complications during complex aortic interventions requiring large-bore upper extremity access.

Validation of endovascular and open thoracoabdominal aortic aneurysm repair in Ontario health administrative databases.

The positive predictive value (PPV) of endovascular and open thoracoabdominal aortic aneurysm (TAAA) repair coding was assessed in Ontario health administrative databases. Between 1 January 2006 and 31 March 2016, a random sample of 192 patients was identified using Canadian Classification of Health Intervention (CCI) procedure codes and Ontario Health Insurance Plan (OHIP) billing codes from administrative data. Blinded chart reviews were conducted at two cardiovascular centers to assess the level of agreement between the administrative records and the corresponding patients' hospital charts. The PPV was calculated with 95% confidence intervals using hospital charts as the gold standard. The PPV for the single endovascular TAAA repair code, 1ID80GQNRN, was 0.90 (0.78, 0.97). A combination of all nine CCI open TAAA repair codes was performed, with a PPV of 0.62 (0.47, 0.76). The combination of any one of the nine CCI codes AND the single OHIP code for open TAAA repair (R803) rendered a PPV of 0.98 (0.90, 1.00). Endovascular TAAA repair may be identified using a single CCI code (1ID80GQNRN). Open TAAA repair may be identified using a combination of CCI and OHIP codes. Researchers may therefore use administrative data to conduct population-based studies of endovascular and open repair of TAAA.

PC020. Health Care Costs of Endovascular Compared With Open Thoracoabdominal Aortic Aneurysm Repair

The objective of this study was to compare 1-year health care costs of open and endovascular thoracoabdominal aortic aneurysm (TAAA) repair within a single-payer, public health care system. Population-based administrative health databases were used to capture TAAA repairs performed in Ontario, Canada, between January 2006 and March 2017. Health care costs to the Ministry of Health for these patients included those attributable to hospital stay, emergency department visits, inpatient rehabilitation, physician billing, outpatient nursing, and allied health care as well as outpatient medications, investigations, and all subsequent interventions. Costs of the aortic endografts and ancillary devices for the index procedure were determined to be C$44,000 per case vs C$1000 for open cases. Costs (2017 Canadian dollars) were calculated in phases (1 month, 1-3 months, 3-6 months, 6 months-1 year) with censoring for death. Propensity score matching based on 26 preoperative characteristics was employed to account for confounding by indication. The association between preoperative characteristics and 1-month cost was characterized through multivariable analysis. A total of 664 TAAA repairs were identified (open, n = 361 [54.5%]; endovascular, n = 303 [45.6%]), and 241 open and endovascular propensity score-matched pairs were identified. At 1 month, mean (median) total cost for the unmatched open TAAA group was C$46,575 (C$36,647; 77% hospital cost, 14% physician billings, 3% graft cost, 6% other), whereas for the endovascular group, total cost was C$72,581 (C$64,892; 67% graft cost, 27% hospital cost, 5% physician billings, 1% other; P < .01. On multivariable analysis, older age (P < .01), nonelective procedures (P < .01), and preoperative stroke (P = .05) were associated with increased costs at 1 month. At intervals of 1 to 3 months, 3 to 6 months, and 6 months to 1 year after the procedure, there were no significant differences in health care costs between groups (Table). Mean (median) cost for patients alive at 1 year were C$91,571 (C$52,003) vs C$103,740 (C$83,242; P < .01) for open (n = 264) and endovascular (n =206) TAAA repair, respectively. Similar costs were observed in the matched groups. Device costs were the primary driver of the higher costs of endovascular TAAA repair compared with open repair during the initial month. Increasing age, preoperative stroke, and nonelective procedures were associated with higher 1-month cost. Total health care costs after the first month and up to 1 year, which includes reinterventions, were not significantly different. Reducing device costs will help balance the costs of open and endovascular TAAA repair.TableHealth care costs (in Canadian dollars) of endovascular vs open thoracoabdominal aortic aneurysm (TAAA) repairCostUnmatchedPropensity score matchedOpenEndovascularP valueOpenEndovascularP valueMean (median)Mean (median)Mean (median)Mean (median)1 month46,575 (36,647)72,581 (64,892)<.0146,556 (33,605)72,786 (64,892)<.011-3 months19,826 (2024)11,292 (1977).6218,828 (1832)11,454 (1992).613-6 months12,289 (1173)11,453 (1508).169456 (1144)12,153 (1298).846 months-1year11,985 (2427)12,087 (2998).978840 (2524)12,016 (3050).34 Open table in a new tab

RS10. Occlusion of the Celiac Artery During Endovascular Thoracoabdominal Aortic Aneurysm Repair Is Associated With Increased Perioperative Morbidity and Mortality

RS10. Occlusion of the Celiac Artery During Endovascular Thoracoabdominal Aortic Aneurysm Repair Is Associated With Increased Perioperative Morbidity and Mortality

Endovascular repair of thoraco-abdominal aortic aneurysms by fenestrated and branched endografts†.

Our objective was to report the outcomes of fenestrated/branched endovascular aneurysm repair of thoraco-abdominal aortic aneurysms (TAAAs) with endografts. Between January 2010 and April 2018, patients with TAAAs, considered at high surgical risk for open surgery and treated by Cook-Zenith fenestrated/branched endovascular aneurysm repair, were prospectively enrolled and retrospectively analysed. The early end points were 30-day/hospital mortality rate, spinal cord ischaemia and 30-day cardiopulmonary and nephrological morbidity. Follow-up end points were survival, patency of target visceral vessels and freedom from reinterventions. Eighty-eight patients (male: 77%; mean age: 73 ± 7 years; American Society of Anesthesiologists 3/4: 58/42%) were enrolled. Using Crawford's classification, 43 (49%) were types I-III and 45 (51%) were type IV TAAAs. The mean aneurysm diameter was 65 ± 15 mm. Custom-made and off-the-shelf endografts were used in 60 (68%) and 28 (32%) cases, respectively. Five (6%) patients had a contained ruptured TAAA. The procedure was performed in multiple steps in 42 (48%) cases. There was 1 (1%) intraoperative death. Five (6%) patients suffered spinal cord ischaemia with permanent paraplegia in 3 (3%) cases. Postoperative cardiac and pulmonary complications occurred in 7 (8%) and 12 (14%) patients, respectively. Worsening of renal function (≥30% of baseline level) was detected in 11 (13%) cases, and 2 (2%) patients required haemodialysis. The 30-day and hospital mortality rates were 5% and 8%, respectively. The mean follow-up was 36 ± 22 months. Survival at 12, 24 and 36 months was 89%, 75% and 70%, respectively. The patency of target visceral vessels at 12, 24 and 36 months was 92%, 92% and 92%, respectively. Freedom from reinterventions at 12, 24 and 36 months was 85%, 85% and 83%, respectively. The endovascular repair of TAAAs with fenestrated/branched endovascular aneurysm repair is feasible and effective with acceptable technical/clinical outcomes at early/midterm follow-up.

Should endovascular approach be considered as the first option for thoraco-abdominal aortic aneurysms?

Open surgical repair has been the gold standard for treatment of thoracoabdominal aortic aneurysms (TAAAs). The technique of open TAAA repair has evolved from the use of "island" patch incorporation to separate branch vessel bypass, from "clamp and go" to routine use of distal perfusion, and towards more extensive repair in patients with connective tissue disorders. Open TAAA repair can be done with excellent results in highly specialized centers. However, these operations continue to carry excessive risk when performed outside large aortic centers, with 30-day mortality estimated on 20% according to statewide and national databases. In octogenarians, the mortality of elective open TAAA repair can be up to 40%. Endovascular repair was introduced as an alternative to open surgical repair in the elderly or higher risk patients using hybrid reconstruction, parallel grafts or fenestrated and branched endografts. Several large aortic centers have developed dedicated clinical programs to advance techniques of fenestrated-branched endovascular repair using patient-specific and off-the-shelf devices, offering a minimally invasive alternative to open repair allowing treatment of increasingly older and sicker TAAA patients. During the last decade, improvements in device design, patient selection, spinal cord injury protocols, and perioperative management have contributed to a continued decline in morbidity and mortality of fenestrated-branched endovascular aortic repair, challenging open surgical repair as the new "gold standard" for treatment of TAAAs. Despite the improved results, endovascular repair is a highly technical procedure that requires vast experience, involves a significant risk of complications, and also, has an impact on patients' physical quality of life. In this article, we review the current technical aspects of endovascular TAAA repair with the main focus on the evidence of open versus endovascular outcomes of TAAA repair.