Open Thoracoabdominal Aneurysm Repair Research Articles

Parallel intercostal artery stenting and exclusion of symptomatic bucket-handle intercostal patch aneurysm

Intercostal patch aneurysms after open thoracoabdominal aneurysm repair represent a challenging pathology, with highly variable patient anatomy and spinal cord ischemia risk. We present a case of a 51-year-old man with a large symptomatic “bucket-handle” loop graft intercostal patch aneurysm, which was treated with endovascular exclusion with concurrent parallel intercostal stent grafting. This case highlights specialized endovascular techniques to treat intercostal patch aneurysms and the necessity of meticulous operative case planning in both open and endovascular thoracoabdominal aneurysm repair.

Usefulness of the H-Reflex for Intraoperative Monitoring of Thoracoabdominal Aneurysms.

Intraoperative neurophysiologic monitoring in thoracoabdominal aneurysms (TAAA) is essential to avoid intraoperative spinal cord injury). Motor and somatosensory evoked potentials may be considered intraoperative tools for detecting spinal cord injury. H-reflex is a well-known neurophysiologic technique to evaluate L5-S1 root. Current evidence supports the observation that H-reflex changes may occur with spinal cord damage as high as the cervical level. This study aimed to evaluate the usefulness of the H-reflex in these surgeries. The use of intraoperative H-reflex in TAAA monitoring was evaluated in 12 patients undergoing open or endovascular repair of TAAA for a period of four years (2016-2020) using somatosensory evoked potentials (SSEPs) and transcranial motor evoked potentials (TcMEPs) and bilateral H-reflex. Six neurophysiologic alarms were recorded in five of the 12 patients. Summarizing the neurophysiologic changes of our series, we considered a peripheral change when we detected a unilateral loss of SSEPs, TcMEPs, and H-reflex. Instead, we assumed a central change when we detected a unilateral or bilateral loss of TcMEPs and H-reflex with normal SSEPs, which we considered a sign of spinal cord ischemia. Interestingly H-reflex always changed significantly in combination with TcMEPs in the same fashion. According to our series, H-reflex can detect intraoperative changes with the same sensitivity as TcMEPs in TAAA surgeries. With the support of other techniques, it can be useful to localize the origin of the lesion (peripheral or central spinal cord), to help in surgical decision-making to avoid postoperative neurologic damage. Based on our results, we recommend the systematic use of H-reflex in TAAA surgeries.

Retroaortic left renal vein in open thoracoabdominal aneurysm repair: A modified approach.

The incidence of retroaortic left renal vein (RLRV) is less than 6%. This anatomical variation hinders the exposure and anastomosis of visceral arteries during open thoracoabdominal aneurysm repair. This situation may warrant division and ligation of the RLRV using the conventional retroperitoneal approach. This report describes a modified approach wherein the vein is not divided, thereby improving its surgical exposure.

Results of open thoracoabdominal aneurysm repair with left partial cardiopulmonary bypass in a low-volume center

Results of open thoracoabdominal aneurysm repair with left partial cardiopulmonary bypass in a low-volume center

The long-term fate of renal and visceral vessel reconstruction after open thoracoabdominal aortic aneurysm repair

ObjectivesIn the ever-advancing era of endovascular thoracoabdominal aneurysm (TAAA) repair, understanding long-term patency of renovisceral reconstructions after open TAAA repair provides important benchmarks. MethodsInstitutional open TAAA repair patient data were queried. Patients dying during index admission or with incomplete operative detail were excluded. Visceral and renal reconstructions were categorized as bypass, incorporation into a proximal or distal beveled aortic anastomosis, inclusion button, Carrel patch, or hybrid stent along with endarterectomy/stent adjuncts. Axial imaging or angiography determined long-term patency. Vessel event was defined as new occlusion or reintervention after repair. Overall time-to-event analysis was performed as well as separate analyses for each vessel (celiac, superior mesenteric artery [SMA], right renal, left renal) by reconstruction type utilizing Kaplan-Meier methods. Log-rank testing was employed to compare reconstructive strategies. ResultsOver 28 years, 604 repairs (type I, 106 [18%]; type II, 73 [12%]; type III, 195 [32%]; and type IV, 230 [38%]) were identified. Follow-up (median, 500 days) was available in 410/570 (72%) celiac, 406/573 (71%) SMA, 379/532 (71.2%) right renal, and 370/515 (72%) left renal reconstructions. There were five celiac, one SMA, eight right renal, and 10 left renal events. No type of reconstruction or adjunct was significantly associated with event. Overall 5-year patency of all renal/visceral reconstructions was 94% (95% confidence interval, 90%-96%). Estimated 5-year patency of the celiac, SMA, left renal, and right renal were similar, and were 99%, 100%, 97%, and 96%, respectively (P = .09). ConclusionsVisceral and renal long-term patency after open TAAA repair is excellent regardless of reconstructive technique. No differences are appreciated even when target vessel disease is addressed at the time of reconstruction. These findings continue to substantiate the effective long-term durability of open TAAA repair and are particularly germane to the ongoing evolution of endovascular strategies.

Commentary: Thoracoabdominal aneurysm repair: Not for the faint of heart—or is it?

Ando and colleagues1 describe their management of a 16-year-old patient with Marfan syndrome and concomitant aneurysmal degeneration of the descending thoracic aorta (chronic dissection after mechanical Bentall repair) and dilated cardiomyopathy with very severely reduced ejection fraction (<10%). They successfully performed an extent II open thoracoabdominal aneurysm repair with the ultimate goal of candidacy for durable left ventricular assist device as a bridge to cardiac transplantation.

Effect of thoracoabdominal aortic aneurysm extent on outcomes in patients undergoing fenestrated/branched endovascular aneurysm repair

ObjectiveThe outcomes after open repair of thoracoabdominal aneurysms (TAAAs) have been definitively demonstrated to worsen as the TAAA extent increases. However, the effect of TAAA extent on fenestrated/branched endovascular aneurysm repair (F/BEVAR) outcomes is unclear. We investigated the differences in outcomes of F/BEVAR according to the TAAA extent. MethodsWe reviewed a single-institution, prospectively maintained database of all F/BEVAR procedures performed in an institutional review board-approved registry and/or physician-sponsored Food and Drug Administration investigational device exemption trial (trial no. G130210). The patients were stratified into two groups: group 1, extensive (extent 1-3) TAAAs; and group 2, nonextensive (juxtarenal, pararenal, and extent 4-5) TAAAs. The perioperative outcomes were compared using the χ2 test. Kaplan-Meier analysis of 3-year survival, target artery patency, reintervention, type I or III endoleak, and branch instability (type Ic or III endoleak, loss of branch patency, target vessel stenosis >50%) was performed. Cox proportional hazards modeling was used to assess the independent effect of extensive TAAA on 1-year mortality. ResultsDuring the study period, 299 F/BEVAR procedures were performed for 87 extensive TAAAs (29%) and 212 nonextensive TAAAs (71%). Most repairs had used company-manufactured, custom-made devices (n = 241; 81%). Between the two groups, no perioperative differences were observed in myocardial infarction, stroke, acute kidney injury, dialysis, target artery occlusion, access site complication, or type I or III endoleak (P > .05 for all). The incidence of perioperative paraparesis was greater in the extensive TAAA group (8.1% vs 0.5%; P = .001). However, the incidence of long-term paralysis was equivalent (2.3% vs 0.5%; P = .20), with nearly all patients with paraparesis regaining ambulatory function. On Kaplan-Meier analysis, no differences in survival, target artery patency, or freedom from reintervention were observed at 3 years (P > .05 for all). Freedom from type I or III endoleak (P < .01) and freedom from branch instability (P < .01) were significantly worse in the extensive TAAA group. Cox proportional hazards modeling demonstrated that F/BEVAR for extensive TAAA was not associated with 1-year mortality (hazard ratio, 1.71; 95% confidence interval, 0.91-3.52; P = .13). ConclusionsUnlike open TAAA repair, the F/BEVAR outcomes were similar for extensive and nonextensive TAAAs. The differences in perioperative paraparesis, branch instability, and type I or III endoleak likely resulted from the increasing length of aortic coverage and number of target arteries involved. These findings suggest that high-volume centers performing F/BEVAR should expect comparable outcomes for extensive and nonextensive TAAA repair.

Commentary: Success lies in attention to details when performing open repair of thoracoabdominal aneurysms

Chronic thoracoabdominal aortic aneurysm (TAAA) with dissection presents an interesting and complex challenge for surgeons owing to the high degree of variability in the anatomy of the dissected aorta and its branch vessels. Although some success has been made with endovascular interventions in a subset of highly selected patients, the applicability of endovascular solutions remains limited by anatomy. The locations of branch vessels, the primary tear, downstream fenestrations, and landing zones all need to be considered carefully.

Contemporary outcomes of open thoracoabdominal aneurysm repair: functional status is the strongest predictor of perioperative mortality

BackgroundOpen repair of thoracoabdominal and descending thoracic aneurysm (TAA) carries significant operative morbidity and mortality. Despite evolving operative techniques patient-level risk factors affecting mortality after open TAA repair, including patient functional status, remain to be fully understood. Materials and methodsWe identified all open TAA repair cases in the National Surgical Quality Improvement Program database between 2005 and 2013. Multivariable logistic regression was used to evaluate the effect of patients' age, gender, race, body mass index (BMI), comorbid conditions, functional status, ASA class, smoking, rupture, descending thoracic aneurysm versus Crawford types, dissection, and preoperative: transfusion, creatinine levels, on perioperative (30-d) mortality after open TAA repair. ResultsA total of 1048 patients underwent open TAA repair during the 9-y study period. Mean patient age was (mean ± SEM) 67 ± 0.4 y, mean BMI was 27 ± 6 kg m2, and most patients (60%) were male. Perioperative mortality was 14.0% (nonruptured 11.4% versus ruptured 34.2%, P < 0.01) and patients with postoperative renal failure requiring dialysis comprised 12.6%. On multivariable analysis, dependent status had the highest effect on operative mortality, tripling the risk of death (odds ratio [OR] = 3.18, 95% confidence interval [CI] = 1.49-6.81, P < 0.01). Ruptured aneurysms had more than double the operative mortality risk (OR = 2.49, 95% CI = 1.42-4.38, P < 0.01). Preoperative renal insufficiency added 23% mortality risk per unit increase in creatinine (OR = 1.23, 95% CI = 1.01-1.50, P = 0.04), whereas each year in patient age or unit increase in BMI increased the risk of death by 4% (OR = 1.04, 95% CI = 1.02-1.07, P < 0.01, OR = 1.04, 95% CI = 1.00-1.07, P = 0.04, respectively). ConclusionsPatients' functional status is the strongest independent predictor of perioperative death. Other patient-level factors, including increasing age, BMI, and renal dysfunction, also play a role. Appropriate patient selection for open TAA repair is essential for achieving good outcomes.

Extended Motor Evoked Potentials Monitoring Helps Prevent Delayed Paraplegia After Aortic Surgery

Motor evoked potentials (MEPs) monitoring can promptly detect spinal cord ischemia (SCI) from aortic clamping during open thoracoabdominal aneurysm repair (OTAAR) with distal aortic perfusion (DAP) and thus help decrease the risk of immediate postoperative SCI (IP-SCI). However, neither stable MEPs during aortic clamp interval (ACI) nor absence of IP-SCI eliminate the possibility of delayed postoperative SCI (DP-SCI). We hypothesized that extension of MEPs monitoring beyond ACI can also help decrease the risk of DP-SCI. We identified 150 consecutive patients at our institution between April 2005 and October 2014 who underwent OTAAR with DAP and MEPs monitoring and had no IP-SCI. Using logistic regression analysis, we studied the independent effect of extended MEPs monitoring on the risk of developing DP-SCI. We used a propensity score analysis to adjust for potential confounders, such as poorly controlled hypertension, previous aneurysm surgery, splenectomy, acute aortic dissection, aneurysm type, older age, and history of diabetes and smoking. From the 150 patients, 129 (86%) remained neurologically intact whereas 21 (14%) developed DP-SCI. Nineteen of these twenty-one patients (90%) had no extended monitoring. Fifty-seven of fifty-nine (97%) patients who benefited from extended monitoring had no DP-SCI (p = 0.003). Extended MEPs monitoring was independently associated with decreased risk of DP-SCI (odds ratio = 0.14; 95% confidence interval: 0.03, 0.65; p = 0.01). MEPs detect the lowest systemic blood pressure that ensures appropriate spinal cord perfusion in the postoperative period. Thus, they inform the hemodynamic management of patients post-OTAAR, particularly in the absence of a reliable neurological exam.

Intraoperative Motor Evoked Potentials (MEPs) Monitoring beyond the Aortic Clamp Period of Open Thoracoabdominal Aneurysm Repair (TAA) Further Decreases the Risk of Post-operative Paraplegia (S22.006)

Intraoperative Motor Evoked Potentials (MEPs) Monitoring beyond the Aortic Clamp Period of Open Thoracoabdominal Aneurysm Repair (TAA) Further Decreases the Risk of Post-operative Paraplegia (S22.006)

Validation of semiautomated and locally resolved aortic wall thickness measurements from computed tomography

Aortic wall thickness (AWT) is important for anatomic description and biomechanical modeling of aneurysmal disease. However, no validated, noninvasive method for measuring AWT exists. We hypothesized that semiautomated image segmentation algorithms applied to computed tomography angiography (CTA) can accurately measure AWT. Aortic samples from 10 patients undergoing open thoracoabdominal aneurysm repair were taken from sites of the proximal or distal anastomosis, or both, yielding 13 samples. Aortic specimens were fixed in formalin, embedded in paraffin, and sectioned. After staining with hematoxylin and eosin and Masson's trichrome, sections were digitally scanned and measured. Patients' preoperative CTA Digital Imaging and Communications in Medicine (DICOM; National Electrical Manufacturers Association, Rosslyn, Va) images were segmented into luminal, inner arterial, and outer arterial surfaces with custom algorithms using active contours, isoline contour detection, and texture analysis. AWT values derived from image data were compared with measurements of corresponding pathologic specimens. AWT determined by CTA averaged 2.33 ± 0.66 mm (range, 1.52-3.55 mm), and the AWT of pathologic specimens averaged 2.36 ± 0.75 mm (range, 1.51-4.16 mm). The percentage difference between pathologic specimens and CTA-determined AWT was 9.5% ± 4.1% (range, 1.8%-16.7%). The correlation between image-based measurements and pathologic measurements was high (R = 0.935). The 95% limits of agreement computed by Bland-Altman analysis fell within the range of -0.42 and 0.42 mm. Semiautomated analysis of CTA images can be used to accurately measure regional and patient-specific AWT, as validated using pathologic ex vivo human aortic specimens. Descriptions and reconstructions of aortic aneurysms that incorporate locally resolved wall thickness are feasible and may improve future attempts at biomechanical analyses.

Staged Hybrid Repair for Extent II Thoracoabdominal Aortic Aneurysms and Dissections

Thoracoabdominal aortic aneurysms (TAAAs) often require intervention to prevent catastrophic aortic rupture. Open TAAA repair techniques have been well described with excellent long-term results. Outcomes, however, vary according to the extent of aortic pathology. In particular, Crawford extent II TAAAs are associated with higher rates of paraplegia, renal failure, pulmonary complications, and death. In a contemporary series, despite the use of adjuncts, such as, cerebrospinal drainage, cardiopulmonary bypass, and mesenteric perfusion, mortality and paraplegia after extent II TAAA repair range from 10%42% and 7%-32%, respectively. Thoracic endovascular aneurysm repair (TEVAR) has reduced the operative risk of repair compared with open surgical approach for isolated thoracic aortic aneurysms. At present, TEVAR alone cannot be utilized for extent II TAAA owing to involvement of the abdominal visceral vessels. Hybrid approaches to extensive TAAA have the potential to reduce operative risk. In this articles, we describe a 2-stage hybrid repair technique for extent II TAAAs or dissections. In the first stage, TEVAR is performed to address the proximal descending thoracic aorta—effectively converting an extent II TAAA to an extent III or IV TAAA. In the second stage, an open thoracoabdominal aneurysm repair is performed to address the distal thoracic and abdominal aorta. The staged approach distributes spinal cord ischemia from repair over time, potentially allowing vascular remodeling and collateral formation. This potentially may decrease paralysis rates. The hybrid approach also obviates the need for a high proximal thoracic aortic anastomosis. This reduces the extent of the incision, eliminates dissection around the arch and recurrent laryngeal nerve, and allows a simpler thoracic aortic anastomosis. This may potentially reduce operative time and recurrent laryngeal nerve injury and prevent respiratory failure.

Hybrid Repair of Thoracoabdominal Aneurysm: A Two-Stage Approach

Despite higher standards of perioperative care and refinements in operative techniques, conventional open repair of thoracoabdominal aneurysms (TAAAs) is still associated with remarkable morbidity and mortality rates. Hybrid procedures as an option to traditional surgical procedures are still debated, especially in elderly patients with severe comorbidities. We report the experience of our institution using a hybrid technique ina subgroup of high-risk patients in an attempt to improve the results.

Open repair of thoracoabdominal aneurysm in the endovascular era

In this endovascular era, open repair of thoracoabdominal aneurysm is a rare operation in regional hospitals. Adjuncts to the repair including left heart bypass and spinal cord protection remain controversial. This is a

Extracorporeal Bypass Use Improves Outcomes of Open Thoracic and Thoracoabdominal Aneurysm Repair

Objectives: There is no consensus on the use or benefit of extracorporeal circulation (EC) during descending thoracic (DTA) or thoracoabdominal aneurysm (TAA) repair. We evaluated the role of EC during DTA or TAA repair using U.S. Medicare data. Methods: Medicare (2004-2007) patients undergoing intact open DTA or TAA repair were identified by ICD-9 code; specific exclusions included ascending/arch and hypothermic circulatory arrest (DHCA) operations. The impact of EC (ICD-9 39.61) on early and late outcomes was analyzed using standard statistical methods. Results: A total of 4230 patients had DTA or TAA repair, with EC used in 2433 (57%). Differences in baseline clinical features are presented in the Table. The 30-day mortality, any complication, and systemic complications were significantly reduced with EC use (Table). EC patients had shorter length of stay of 13.5 13 vs 17.2 18 days (P .01) and lower total hospital charges of $151,000 $140,000 vs $180,000 $190,000 (P .01). EC patients were more likely to be discharged home than to an extended care facility (67% vs 56%; P .01). Multivariable regression modeling (odds ratio [95% confidence interval] to adjust for baseline clinical differences showed EC to independently reduce operative mortality (0.80 [0.65-0.97]; P .02), any complication (0.67 [0.59-0.76]; P .01), pulmonary complications (0.68 [0.59-0.79]; P .01), and acute renal failure (0.52; [0.44-0.61]; P .01). Long-term survival was higher (log-rank P .01) in EC patients at 1 year (81% 0.8% vs 73% 1%) and 5 years (67% 1% vs 52% 1%). Risk-adjusted Cox proportional hazards regression also showed that EC was independently associated with improved long-term survival (odds ratio, 0.69; 95% confidence interval, 0.63-0.74; P .01). Conclusions: Although important clinical variables such as DTA/TAA extent and spinal cord ischemic complications cannot be assessed with the Medicare database, EC used during open DTA and TAA repair significantly reduces operative mortality, morbidity, and procedural costs, and improves late survival. These data indicate EC should be a more widely applied adjunct in DTA/TAA open surgery.

Aortic Aneurysmal Repair With Surtureless Visceral Revascularization Using Novel Hybrid Vascular Graft and a Gradual Funneling Technique

This article details a novel technique in the treatment of a symptomatic thoracoabdominal aneurysm (TAA) involving the visceral segment and an infrarenal abdominal aortic aneurysm. The patient was treated in a 2-staged hybrid approach combining an endovascular repair of the infrarenal segment, followed by open TAA repair. The large visceral arteries were revascularized using expanded polytetrafluoroethylene GORE Hybrid Vascular Graft (GHVG) and a Gradual Funneling Technique with Dacron graft. This method assured a complete hemostatic seal and minimized visceral ischemic time. To our knowledge, this is the first case of sutureless visceral artery revascularization using GHVG reported in the literature.

Best surgical option for thoracoabdominal aneurysm repair - the open approach.

Open thoracoabdominal aneurysm (TAAA) repair is a complex surgical procedure that requires efficient replacement of diseased aorta, limitation of ischemia to the various and multiple vascular beds, and intraoperative protection of the heart, central nervous system and abdominal viscera in a patient population with multiple comorbidities. Techniques of TAAA repair have evolved from the original “clamp and sew” technique to modern perfusion-assisted techniques with varying degrees of hypothermia. In experienced aortic centers, the morbidity and mortality of TAAA repair is quite good with mortality 5.0% to 8.0%, paralysis 2.3% to 3.8%, and renal failure requiring hemodialysis 1.5% to 5.6%. Open repair is durable and the long-term survival is well-defined and acceptable. In our hands, the 10 year survival of open descending thoracic and thoracoabdominal aneurysm repair is 53.5%. The applicability of open TAAA repair to the myriad of aortic pathologies, anatomy and connective tissue disorders (CTDs) is unlimited. Thoracic endovascular aortic repair (TEVAR) is a less invasive method for repairing descending thoracic and thoracoabdominal aneurysms. Currently, the approved indication is repair of descending thoracic atherosclerotic aneurysms with adequate proximal and distal landing zones, although these devices are used to treat all aortic pathologies. The applicability of TEVAR to the transverse arch and visceral abdominal aorta has been extended using extraanatomical bypasses (hybrid techniques) or branched and/or fenestrated devices. Long-term durability of these repairs extended beyond the descending thoracic aorta is unknown. Furthermore, the application of TEVAR in patients with CTDs is not recommended in the STS guidelines for thoracic and thoracoabdominal aneurysm repair. As the next generation of devices become available (some with FDA indications other than atherosclerotic descending thoracic aneurysm) and as more data accumulates regarding the long-term efficacy of TEVAR, we may gain more insight into the specific clinical scenarios in which TEVAR may be superior to open repair. Currently, we believe that open repair in the hands of experienced surgeons is superior to TEVAR for thoracoabdominal aneurysms in a variety of aortic pathologies including: chronic aortic dissection, aortic aneurysm or dissection in patients with CTDs, mycotic pseudoaneurysm and infected aortic grafts. TEVAR has distinct advantages in other aortic pathologies, including acute complicated type B aortic dissection, blunt traumatic aortic injury (BTAI) and anatomically suitable ruptured descending thoracic aneurysm. Intimate knowledge of and facility in applying both techniques is paramount in deciding how to intervene in specific patient scenarios. The remainder of this commentary will discuss our opinion on open vs. endovascular repair of specific pathologies of the thoracoabdominal aorta.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Some technical considerations of open thoracoabdominal aortic aneurysm repair in a transition country

A variety of operative approaches and protective adjuncts have been used in thoracoabdominal aneurysm (TAA) repair to minimize the major complications of perioperative death and spinal cord ischemia. There is no consensus with respect to the optimal approach. We present 118 surgically treated patients over a 10-year period. The present study reviews our experience as a transition country (Serbia) in the treatment and problems we have encountered during open operative treatment of TAAs. Between 1999 and 2009, the authors reviewed 118 consecutive patients who underwent thoracoabdominal aortic resection using a variety of spinal cord protection. Clinical data collected prospectively were analyzed retrospectively. The purpose of the current study was to review the results of a large series of TAA repairs and to present some technical considerations and complications of open TAA repair. There were seven operative deaths (5.9%): two in the setting of ruptured TAAs, three myocardial infarctions and two due to hemorrhage. All 30 (25.4%) postoperative deaths occurred during the initial hospitalization. Postoperative complications included paraplegia in 11 patients (9.3%); renal failure in eight patients (6.8%), with four patients (3.4%) requiring hemodialysis; pulmonary complications in 75 patients (63.5%); bleeding requiring reoperation in two patients (1.7%) and coagulopathic hemorrhage in five patients (4.2%); cardiac complications in six patients (5.1%); stroke in five patients (4.2%); wound dehiscence in six patients (5.1%); and subdural hemorrhage in one patient (0.87%). Open TAA repair intrinsically has substantial complications, of which spinal cord ischemia and renal failure are the most devastating, despite major progress in our understanding of the pathophysiology and operative strategy. Our current review of data clearly proves that the surgical repair of TAAs remains a challenge even in the 21st century, especially in a country in transition.