Open Thoracoabdominal Aortic Aneurysms Research Articles

Tabular review of contemporary fenestrated-branched endovascular aortic repair experiences for treatment of thoracoabdominal aortic aneurysms.

Repair of thoracoabdominal aortic aneurysms (TAAAs) represents a technical challenge regardless of which technique is used. Open surgical repair (OSR) is the time-tested option against which novel techniques must be compared and it is still considered the gold standard option for younger, fit patients with heritable aortic diseases. Endovascular repair offers a less-invasive alternative in patients with suitable anatomy. This article aims to present a tabular review of the contemporary published data on endovascular repair of TAAAs using fenestrated-branched techniques. The published literature for single-center and multicenter studies evaluating the outcomes of FB-EVAR for TAAAs was searched using MEDLINE and Embase databases. Studies published between January 1st 2010 and July 11th 2024, in the English language which provided data on FB-EVAR of TAAAs with more than fifty reported cases were included. The average patient age at time of repair was 71 years old with majority of males (65.5%). Most patients presented with a Crawford Extent II TAAAs (21.6%), followed by Extent III (21.2%). Early mortality was 4.9% for the entire cohort. The most prevalent adverse event was acute kidney injury (9.4%), followed by spinal cord injury (8.0%). FB-EVAR of TAAAs continues to evolve. Pooled analysis of early mortality and morbidity is lower in this tabular review than historical outcomes of open TAAA repair.

Descending Thoracic and Thoracoabdominal Aortic Aneurysm Repairs: The Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis

BackgroundContemporary national outcomes of open and endovascular aortic repair for descending thoracic aortic aneurysms (DTAAs) and thoracoabdominal aortic aneurysms (TAAAs) are unclear. This study evaluated this issue by using The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD). MethodsFrom July 1, 2017 to June 30, 2022, study investigators identified 3522 adults who underwent planned DTAA repair (open, 328; endovascular, 1895) or TAAA repair (open, 870; endovascular, 429), after excluding ascending aorta or aortic arch aneurysms (zone 0, 1, or 2), interventions with a proximal extent in zone 0 or zone 1, juxtarenal or infrarenal aortic interventions, hybrid procedures, aortic trauma, and aortic infection. ResultsMost DTAA interventions (85.2%) were endovascular repairs, whereas most TAAA interventions were open repairs (66.9%). For DTAA interventions, the operative mortality, permanent stroke rate, and rate of spinal cord injury were 4.2%, 3.8%, and 2.4% for endovascular repairs and 9.2%, 8.5%, and 4.6% for open repairs, respectively (all P < .05). For TAAA interventions, the operative mortality, permanent stroke rate, and rate of spinal cord injury were 6.5%, 2.1%, and 3.0% for endovascular repairs and 11.7%, 6.0%, and 12.2% for open repairs, respectively (all P < .05). Increasing annual open TAAA repair volume was associated with lower odds of experiencing the composite of operative mortality, permanent stroke, or spinal cord injury. ConclusionsOn the basis of STS ACSD data, endovascular repair was the predominant approach for treating DTAA, whereas most patients undergoing TAAA interventions had an open surgical repair. Outcome differences between open and endovascular approaches may be related to patient selection. Increasing center experience with open TAAA repair is associated with improved outcomes.

Comparison of open thoracoabdominal repair for chronic aortic dissections and aneurysms

ObjectiveAortic dissection is common in patients undergoing open surgical repair of thoracoabdominal aortic aneurysms (TAAAs). Most often, dissection is chronic and is associated with progressive aortic dilatation. Because contemporary outcomes in chronic dissection are not clearly understood, we compared patient characteristics and outcomes after open TAAA repair between patients with chronic dissection and those with non-dissection aneurysm. MethodsWe retrospectively analyzed data from 3470 open TAAA repairs performed in a single practice. Operations were for non-dissection aneurysm in 2351 (67.8%) and chronic dissection in 1119 (32.2%). Outcomes included operative mortality and adverse events, a composite variable comprising operative death and persistent (present at discharge) stroke, paraplegia, paraparesis, and renal failure necessitating dialysis. Logistic regression identified predictors of operative mortality and adverse events. Time-to-event analyses examined survival, death, repair failure, subsequent progressive repair, and survival free of failure or subsequent repair. ResultsCompared with patients with non-dissection aneurysm, those with chronic dissection were younger, had fewer atherosclerotic risk factors, and were more likely to have heritable thoracic aortic disease and undergo extent II repair. The operative mortality rate was 8.5% (n = 296) overall and was higher in non-dissection aneurysm patients (n = 217; 9.2%) than in chronic dissection patients (n = 79; 7.1%; P = .03). Adverse events were less frequent (P = .01) in patients with chronic dissection (n = 145; 13.0%), 22 (2.0%) of whom had persistent paraplegia. Chronic dissection was not predictive of operative mortality (P = .5) or adverse events (P = .6). Operative mortality and adverse events, respectively, were independently predicted by emergency repair (odds ratio [OR], 3.46 and 2.87), chronic kidney disease (OR, 1.74 and 1.81), extent II TAAA repair (OR, 1.44 and 1.73), increasing age (OR, 1.04/year and 1.04/year), and increasing aortic cross-clamp time (OR, 1.02/minutes and 1.02/minutes). Patients with chronic dissection had lower 10-year unadjusted mortality (42% vs 69%) but more frequent repair failure (5% vs 3%) and subsequent repair for progressive aortic disease (11% vs 5%) than patients with non-dissection aneurysm (P < .001); these differences were no longer statistically significant after adjustment. ConclusionsOutcomes of open TAAA repair vary by aortic disease type. Emergency repairs and atherosclerotic diseases most commonly occur in patients with non-dissection aneurysm and independently predict operative mortality. Repair of chronic dissection is associated with low rates of adverse events, including operative mortality and persistent paraplegia, along with reasonable late survival and good durability. However, patients with chronic dissection tend to more commonly undergo subsequent repair to treat progressive aortic disease, which emphasizes the need for robust long-term imaging surveillance protocols.

Spinal cord injury after open and endovascular repair of descending thoracic aneurysm and thoracoabdominal aortic aneurysm: an updated systematic review and meta-analysis.

Spinal cord injury (SCI) is a rare but severe complication after open or endovascular repair of descending thoracic aneurysms (DTAs) or thoracoabdominal aortic aneurysms (TAAAs). This meta-analysis aims to provide a comprehensive assessment of SCI rates and factors associated with SCI. A systematic literature search was performed in September 2022 looking for studies on open and/or endovascular repair of DTA and/or TAAA published after 2018, to update the results of our previously published meta-analysis. The primary outcome was permanent SCI. Secondary outcomes were temporary SCI, 30-day and in-hospital mortality, follow-up mortality, postoperative stroke, and cerebrospinal fluid (CSF) drain-related complications. Data were pooled as proportions using inverse-variance weighting. A total of 239 studies (71 new studies and 168 from our previous meta-analysis) and 61,962 patients were included. The overall pooled rate of permanent SCI was 3.3% [95% confidence interval (CI), 2.9-3.8%]. Open repair was associated with a permanent SCI rate of 4.0% (95% CI, 3.3-4.8%), and endovascular repair was associated with a permanent SCI rate of 2.9% (95% CI, 2.4-3.5%). Permanent SCI was 2.0% (95% CI, 1.2-3.3%) after DTA repair, and 4.7% (95% CI, 3.9-5.6%) after TAAA repair; permanent SCI rate was 3.8% (95% CI, 2.9-5.0%) for Crawford extent I, 13.4% (95% CI, 9.0-19.5%) for extent II, 7.1% (95% CI, 5.7-8.9%) for extent III, 2.3% (95% CI, 1.6-3.5%) for extent IV, and 6.7% (95% CI, 1.7-23.1%) for extent V TAAA aneurysms. The pooled rate of CSF drain related complications was 1.9% (95% CI, 0.8-4.7%) for severe, 0.4% (95% CI, 0.0-4.0%) for moderate, and 1.8% (95% CI, 0.6-5.6%) for minor complications. Permanent SCI occurs after both endovascular and open DTA or TAAA repairs. Open repairs and TAAA repairs have higher risk of SCI compared with endovascular or DTA repairs. In particular, extent II aneurysms present the highest overall risk of SCI.

Open Treatments for Thoracoabdominal Aortic Aneurysm Repair.

Thoracoabdominal aortic aneurysms (TAAA) represent a unique pathology that is associated with considerable mortality if untreated. While the advent of endovascular technologies has introduced new modalities for consideration, the mainstay of TAAA treatment remains open surgical repair. However, the optimal conduct of open TAAA repair requires careful consideration of patient risk factors and a collaborative team effort to mitigate the risk of perioperative complications. In this chapter, we briefly outline the history of treating TAAA, preoperative preparation and postoperative care, and our operative techniques for treatment.

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.

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.

Perioperative and long-term outcomes after thoracoabdominal aortic aneurysm repair of chronic dissection etiology

ObjectiveOpen repair of thoracoabdominal aortic aneurysms (TAAAs) that have developed secondary to chronic dissection (CD) is often more complex than repair of degenerative aneurysms (DAs). However, the literature is conflicted regarding the effect of CD on perioperative and long-term outcomes after open TAAA repair. The goal of this study was to determine whether CD predicts negative outcomes after TAAA repair. MethodsAll open type I to type III TAAA repairs performed from 1987 to 2015 were evaluated using a single institutional database. End points included in-hospital death, spinal cord ischemia (SCI), major adverse events (MAEs), and long-term survival. Repairs performed for rupture or acute dissection were excluded. Univariate analysis was conducted using the Fisher's exact test for categorical variables and the Wilcoxon rank sum test for continuous variables. Logistic multivariable regression was used for the in-hospital end points, and survival analyses were performed with Cox proportional hazards modeling and Kaplan-Meier techniques. ResultsDuring the study period, 453 patients underwent an intact open type I to type III TAAA repair. Ninety (20%) were performed for patients with CD. Those with CD were more likely to be younger (59 years vs 72 years; P < .001), to have an extent II lesion (30% vs 16%; P < .001), and to have Marfan syndrome (18% vs 0.6%; P < .001) and less likely to have coronary artery disease (28% vs 25%; P = .01) or chronic obstructive pulmonary disease (12% vs 27%; P = .004) compared with patients with DA. Twelve percent of patients with CD died perioperatively compared with 6% of those with DA (P = .03). Eighteen percent of CD patients suffered from SCI compared with 12% of DA patients (P = .2). Fifty-nine CD patients suffered a MAE compared with 42% of those with DA (P = .006). Multivariable analysis revealed CD to be an independent predictor of perioperative death (adjusted odds ratio [AOR], 3.1; 95% confidence interval [CI], 1.2-8.0; P = .02) with adjustment for age and Crawford extent. CD was also found to be independently predictive of any MAE (AOR, 2.5; 95% CI, 1.4-4.6; P = .002). CD was not associated with increased risk of SCI (AOR, 1.4; 95% CI, 0.6-3.2; P = .4). There was a long-term survival advantage in the CD cohort in the unadjusted analysis (log-rank, P = .009) but not in the adjusted analysis (CD adjusted hazard ratio, 0.9; 95% CI, 0.6-1.4; P = .7). ConclusionsWhen analysis is limited to type I to type III TAAAs, open repair of patients with CD leads to increased perioperative mortality and morbidity compared with patients with DA. However, age-adjusted long-term survival is no different between the two cohorts.

Impact of Chronic Kidney Disease and Acute Kidney Injury on Survival After Fenestrated-Branched Endovascular Aneurysm Repair for Thoracoabdominal Aortic Aneurysms

Fenestrated-branched endovascular aneurysm repair (F/B-EVAR) has extended the treatment of thoracoabdominal aortic aneurysms (TAAAs) to “high surgical risk” patients, including patients with chronic kidney disease (CKD). Previous studies have demonstrated that both CKD and acute kidney injury (AKI) are associated with decreased survival after open TAAA repair. The purpose of this study was to assess the impact of CKD and AKI on survival after F/B-EVAR. A total of 105 patients with TAAAs, enrolled in a prospective physician-sponsored investigational device exemption study (G130193) from 2014 to 2019, were analyzed. Data were collected prospectively and audited by an independent external monitor. All patients were treated with Cook manufactured patient-specific F/B-EVAR devices or the Cook t-Branch device (Cook Medical, Bloomington, Ind). CKD was defined as CKD stage 3 to stage 5 without hemodialysis, and a single patient receiving hemodialysis preoperatively was excluded. AKI was determined within 48 hours and at 30 days postoperatively using RIFLE criteria (“risk” or “injury”). Survival was analyzed using Kaplan-Meier analysis, and associated factors were identified using Cox proportional hazards model. Risk factors for AKI were analyzed using logistic regression. Of 105 patients who underwent F/B-EVAR, 46 (43.8%) had CKD. Overall 30-day mortality was 3.81% (4/105). Whereas freedom from 30-day mortality was significantly lower in CKD patients (91.4% vs 100%; P = .02), 2-year survival was not different between CKD and non-CKD patients (78.3% vs 91.5%; P = .12). AKI occurred in 34 patients (32.4%), and there was no difference in survival at 30 days (94.1% vs 97.2%; P = .47) or at 2 years (73.5% vs 91.5%; P = .08) in patients with and without AKI, respectively. CKD patients who developed AKI after F/B-EVAR (CKD + AKI) had significantly lower 2-year survival in comparison to patients without AKI (±CKD; 58.8% vs 90.9%; P = .008; Fig). Multivariable analysis identified CKD + AKI (hazard ratio [HR], 3.2; 95% confidence interval [CI], 1.04-10.07; P = .04) and intraoperative blood loss (HR, 1.001; 95% CI, 1.00-1.001; P = .04) as risk factors for decreased 2-year survival. Increased procedure time was an independent risk factor for AKI (HR, 1.01; 95% CI, 1.00-1.001; P = .04). CKD, sex, renal artery diameter, renal artery stenosis ≥50%, contrast material volume, and intraoperative blood loss showed no significant correlation with AKI. Patients with CKD have increased perioperative mortality after F/B-EVAR but similar 2-year survival compared with patients without CKD. AKI occurs frequently after F/B-EVAR, and patients with pre-existing CKD who develop AKI after F/B-EVAR have markedly worse 2-year survival. Further studies focused on identification of risk factors for AKI and development of strategies to prevent AKI during F/B-EVAR are necessary and may significantly improve patient outcomes.

Comparative outcomes of open, hybrid, and fenestrated branched endovascular repair of extent II and III thoracoabdominal aortic aneurysms

ObjectiveOpen repair of extent II and III thoracoabdominal aortic aneurysms (TAAA) is associated with substantial morbidity. Alternative strategies, such as hybrid operations combining proximal thoracic endovascular aortic repair with either staged open distal TAAA repair or visceral debranching (hybrid), as well as fenestrated/branched endografts (FEVAR), have been increasingly reported; however, benefits of these approaches compared with direct open surgery remain unclear. The purpose of this study was to compare outcomes of these three different strategies in the management of extent II/III TAAA. MethodsAll extent II/III TAAA repairs (2002-2018) for nonmycotic, degenerative aneurysm or chronic dissection at a single institution were reviewed. The primary end point was 30-day mortality. Secondary end points included incidence of spinal cord ischemia (SCI), complications, unplanned re-operation, 90-day readmission, and out-of-hospital survival. To mitigate impact of covariate imbalance and selection bias, intergroup comparisons were made using inverse probability weighted-propensity analysis. Cox regression was used to estimate survival while cumulative incidence was used to determine reoperation risk. ResultsOne hundred ninety-eight patients (FEVAR, 92; hybrid, 40; open, 66) underwent repair. In unadjusted analysis, compared with hybrid/open patients, FEVAR patients were significantly older with more cardiovascular risk factors, but less likely to have a connective tissue disorder or dissection-related indication. Unadjusted 30-day mortality and complication rates were: 30-day mortality, FEVAR 4%, hybrid 13%, open 12% (P = .01); and complications, FEVAR 36%, hybrid 33%, open 50% (P = .11). Permanent SCI was not different among groups (FEVAR 3%, hybrid 3%, open 6%; P = .64). In adjusted analysis, 30-day mortality risk was greater for open vs FEVAR (hazard ratio, 3.6; 95% confidence interval, 1.4-9.2; P = .01) with no difference for hybrid vs open/FEVAR. There was significantly lower risk of any SCI for open vs FEVAR (hazard ratio, 0.3; 95% confidence interval, 0.09-0.96; P = .04); however, no difference in risk of permanent SCI was detected among the three groups. There was no difference in complications or unplanned reoperation, but open patients had the greatest risk of unplanned 90-day readmission. There was a time-varying effect on survival probability, with open repair having a significant survival disadvantage in the first 1 to 6 months after the procedure compared with hybrid/FEVAR patients (Cox model P = .03), but no difference in survival at 1 and 5 years (1- and 5-year survival: FEVAR, 86 ± 3%, 55 ± 8%; hybrid, 86 ± 5%, 60 ± 11%; open 69 ± 7%, 59 ± 8%; Cox-model P = .10). ConclusionsExtent II/III TAAA repair, regardless of operative strategy, is associated with significant morbidity risk. FEVAR is associated with the lowest 30-day mortality risk compared with hybrid and open repair when estimates are adjusted for preoperative risk factors. These data support greater adoption of FEVAR as first-line therapy to treat complex TAAA disease in anatomically suitable patients who present electively.

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.

Comparative Outcomes of Open, Hybrid, and Fenestrated Branched Endovascular Repair of Extent II and III Thoracoabdominal Aortic Aneurysms

Open repair of Crawford extent II and III thoracoabdominal aortic aneurysms (TAAA) is associated with substantial perioperative risk. In an effort to decrease this risk, endovascular technologies are increasingly used and include either a hybrid operation combining proximal thoracic endovascular aortic repair followed by staged open distal TAAA repair (hybrid) or a total endovascular approach using fenestrated/branched endografts (FEVAR). However, the benefits of these alternative approaches compared with open surgery remains unclear. The purpose of this study was to compare outcomes of these three different strategies in the management of extent II/III TAAA. All patients undergoing extent II/III TAAA repair (2002-2018) for nonmycotic, degenerative aneurysm or chronic dissection related indications by the division of vascular surgery at a single institution were identified. The primary end point was 30-day mortality. Secondary end points included incidence of spinal cord ischemia (SCI), complications, unplanned reoperation and/or 90-day readmission, and survival. To mitigate impact of covariate imbalance and selection bias, intergroup comparisons were made using inverse probability weighted propensity analysis. Cox regression was used to estimate survival while cumulative incidence was employed to determine re-operation risk. There were 198 patients (FEVAR, 92; hybrid, 40; open, 66) underwent extent II/III TAAA repair. Seven hybrid patients (18%) were excluded in adjusted analysis because they never underwent the second stage operation (death, 5; lost follow-up, 2). In an unadjusted analysis, compared with hybrid/open repair patients, FEVAR patients were significantly older with more cardiovascular risk factors, but less likely to have a connective tissue disorder or a dissection-related indication. The unadjusted 30-day mortality and complication risks were as follows: 30-day mortality—4% FEVAR, 13% hybrid, 12% open (P = .01); complications—36% FEVAR, 33% hybrid, 50% open (P = .11); and permanent SCI—3% FEVAR, 3% hybrid, 6% open (P = .64). In adjusted analysis, the 30-day mortality risk was significantly greater for open vs FEVAR (hazard ration, 3.6; 95% confidence interval, 1.4-9.2; P = .008) with no difference for hybrid versus open or hybrid versus FEVAR (Table). There was significantly lower risk of any SCI for FEVAR patients compared with open repair (open: FEVAR, 3.4; 95% confidence interval, 1.0-11.3; P = .04); however, there was no difference overall in the risk of permanent SCI. There was no difference in risk of major complications or unplanned reoperation, but hybrid repair patients had a greater risk of unplanned 90-day readmission compared with FEVAR/open repair patients (Table). There was a time-varying effect of procedure type on survival probability between 30 and 90 days with open repair having greater mortality risk. This difference led to a significant 1-year but not 5-year survival disadvantage compared with hybrid/FEVAR patients (1- and 5-year survival: FEVAR, 86 ± 3%, 55 ± 8%; hybrid, 86 ± 5%, 60 ± 11%; open 69 ± 7%, 59 ± 8%; Cox model P = .03; Fig). Extent II/III TAAA repair, regardless of operative strategy, is associated with significant morbidity risk. FEVAR is associated with the lowest 30-day mortality risk compared with hybrid and open repair when patients are matched based on preoperative risk factors. These data support greater adoption of FEVAR as first-line therapy to treat complex TAAA disease in anatomically suitable patients who present electively.TableInverse probability weighted propensity analysis for inter-group comparison of outcomes after Crawford Extent II/III thoracoabdominal aneurysm (TAAA) repairaGroupHazard ratio95% Confidence intervalP value30-day Death Hybrid:FEVAR1.650.57-4.79.36 Open:FEVAR3.61.4-9.2.008 Hybrid:open0.460.18-1.15.10Permanent SCIb Hybrid:FEVAR0.830.07-10.2.89 Open:FEVAR0.720.14-3.65.68 Hybrid:open1.170.09-13.8.9030-Day death and/or SCIb Hybrid:FEVAR0.640.12-3.42.60 Open:FEVAR0.240.07-0.86.03 Hybrid:open2.680.48-14.84.28Any SCI Hybrid:FEVAR2.930.50-17.1.23 Open:FEVAR3.431.05-11.27.04 Hybrid:open0.850.13-5.46.87Any major complication Hybrid:FEVAR1.720.38-7.89.48 Open:FEVAR0.520.21-1.26.15 Hybrid:open3.330.67-16.47.1490-Day readmission Hybrid:FEVAR6.001.25-28.85.03 Open:FEVAR0.750.24-2.38.63 Hybrid:open7.961.59-39.79.01Any unplanned reoperationb Hybrid:FEVAR1.230.42-3.65.71 Open:FEVAR2.070.66-6.46.21 Hybrid:open0.640.23-1.76.38FEVAR, Fenestrated/branched endografts; SCI, spinal cord ischemia.aInverse probability weighted propensity analysis accounted for age, body mass index, gender, procedure urgency, pathologic indication, American Society of Anesthesia score, and all other cardiopulmonary risk factors.bDeath modeled as a competing risk. Open table in a new tab

Late patency of reconstructed visceral arteries after open repair of thoracoabdominal aortic aneurysm

BackgroundIn the era of rising endovascular treatment of thoracoabdominal aortic aneurysms (TAAAs), the analysis of visceral vessel (VV) patency after open surgical repair is crucial to provide a future benchmark between these different approaches. This study reports the late outcomes of a single-center experience with open TAAA repair, focusing on the results of different techniques adopted for renal and splanchnic revascularization. MethodsData were analyzed for 382 consecutive open TAAA repairs performed between January 2009 and July 2015 (284 men; mean age, 66 ± 10 years). Follow-up of surviving patients was carried out by computed tomography angiography and office checkups at 3 and 12 months and yearly afterward. Kaplan-Meier analysis was performed for overall survival, patency of reconstructed VVs (celiac trunk, superior mesenteric artery, right renal artery, left renal artery), and reinterventions on visceral arteries. Furthermore, VV long-term patency was analyzed in subgroups of patients according to the revascularization strategy (patch inclusion of all vessels, group 1; one-vessel separate reattachment and patch inclusion of the remaining vessels, group 2; separate reattachment of all VVs, group 3). ResultsIn-hospital mortality and paraparesis/paraplegia occurred in 7.6% and 8.1% of patients, respectively. Among the 353 survivors, 338 complied with the follow-up protocol, and adequate computed tomography angiography images were available in 247 patients (952 VVs were analyzed). Overall follow-up survival was 94%, 91%, and 70% at 1 year, 2 years, and 5 years, respectively. At the same time points, VV patency was 99%, 98%, and 98% for celiac trunk; 100%, 100%, and 100% for superior mesenteric artery; 100%, 96%, and 96% for right renal artery; and 91%, 87%, and 82% for left renal artery (log-rank test, P < .0001). Estimates for reinterventions on VVs were 1.2%, 6.3%, and 17% at the same time points. Freedom from occlusion of any VV at 1 year and 3 years was 95% and 87% for group 1, 89% and 79% for group 2, and 92% and 92% for group 3, respectively (log-rank test, P = .13). ConclusionsLong-term patency of VVs after open TAAA repair performed in high-volume centers is high, regardless of the technique employed for revascularization. The left renal artery appears to be most prone to occlusion over time.

Improved outcomes and value in staged hybrid extent II thoracoabdominal aortic aneurysm repair

ObjectiveComplex Crawford extent II thoracoabdominal aortic aneurysms (TAAAs) can be treated in a hybrid manner with proximal thoracic endovascular aneurysm repair, followed by staged distal open thoracoabdominal repair. This study evaluated the outcomes and health care-associated value of this new method compared with traditional open repair over 10 years. MethodsA prospectively collected database was used to identify all patients with an extent II TAAA undergoing repair at a single institution between 2005 and 2015. Patient characteristics, postoperative outcomes, and incidence of major adverse events (MAEs; renal failure, spinal cord ischemia, death) were compared. After adjusting for time since surgery, value was analyzed looking at quality (1/MAE) divided by cost (total health system cost). This was multiplied by a constant to set the value of open TAAA repair to 100. ResultsA total of 113 consecutive patients underwent extent II TAAA repairs, of whom 25 (22.1%) had a staged hybrid approach with a median of 129 days between procedures. No baseline differences in demographic or comorbidity variables existed between groups (P > .05). The hybrid group had shorter operative time (255 vs 306 minutes; P = .01), shorter postoperative length of stay (10.1 vs 13.3 days; P = .02), and reduced blood loss (1300 vs 2600 mL; P = .01) at the time of open operation. Despite higher rates of acute kidney injury in the hybrid group (76.0% vs 51.1%; P = .03), there was no difference in renal failure (8.0% vs 4.5%; P = .84). The incidence of MAEs was lower in the staged hybrid group (20.0% vs 48.9%; P = .01), without a difference in hospital mortality (4.0% vs 3.4%; P = .89). Median total cost was higher in the hybrid group ($112,920 vs $72,037; P = .003). Value was improved in the hybrid group by 56% using mean cost and 178% by median cost. ConclusionsThe 20% MAE rate associated with staged hybrid repair of extent II TAAA was significantly decreased compared with open repair, with a relative reduction of >50%. Despite higher total hospital costs, staged hybrid repair had 56% to 178% higher health care-related value compared with standard open repair. In an era of increasing focus on costs and quality, staged hybrid repair of extensive TAAAs is associated with fewer complications than open TAAA repair, resulting in a good value investment from a resource utilization perspective.

Evolving Approaches to Thoracoabdominal Aortic Aneurysm Repair: Open Surgical and Endovascular Treatment Using Fenestrated/Branched Endografts

ABSTRACT Open repair remains the standard of care for the treatment of patients with thoracoabdominal aortic aneurysms. However, due to the magnitude of the operation and a typically older patient population with extensive comorbidities, less invasive methods of repair have received increasing acceptance—despite lack of long-term data on durability when compared with open surgical repair. One of the most dreaded complications of both open and endovascular thoracoabdominal aortic aneurysms repair (for patient and surgeon alike) remains the development of paraplegia, a complication that can be minimized with the techniques described herein.

Patency of renal and visceral vessels after open thoracoabdominal aortic replacement

In thoracoabdominal aortic aneurysms (TAAAs), a paradigm shift is observed from open surgery toward total endovascular aortic repair using fenestrated and branched endografts. Whereas outcome after open replacement in terms of mortality and paraplegia has been evaluated extensively, no studies exist addressing long-term patency of visceral and renal vessels. To enable comparison of target vessel patency between open and endovascular treatment, we analyzed our series of open TAAA replacements. Our vascular surgery database was screened for patients who received open TAAA replacement between 1998 and 2012, and patient records were analyzed retrospectively. All available imaging scans (computed tomography and magnetic resonance angiography: preoperative, postoperative, and follow-up) were evaluated for graft and vessel patency. We identified 62 patients (mean age, 66 ± 10 years; 40 men) who had been operated on for aneurysms of Crawford types I (8), II (13), III (13), and IV (24) and Safi type V (4). A total of 181 vessels were revascularized by either patch inclusion (n = 147) or selective revascularization (bypass or transposition, n = 34); 48 survived the procedure, resulting in a number of vessels available for follow-up of 154 (patch, 126; selective revascularization, 28). The respective patency rates for overall, patch, and selective revascularization were 95.2%, 94.2%, and 100% at 5 years and 83.7%, 81.3%, and 100% at 10 years, respectively. In addition, a trend for better performance of selective revascularization (bypass or transposition) was evident as all vessel occlusions were observed in cases of patch inclusion, whereas all selectively revascularized vessels were patent. The respective patency rates for the celiac trunk, superior mesenteric artery, and left and right renal artery were 100%, 97.5%, 92.3%, and 90.3% at 5 years. In our series of open thoracoabdominal aortic replacement, excellent patency rates for revascularized renal and visceral vessels were observed during long-term follow-up. We were able to provide a reference value of long-term target vessel patency that can and should be taken into account to judge the efficacy of endovascular repair in TAAA.

Visceral Debranching for the Treatment of Thoracoabdominal Aortic Aneurysms: Based on a Presentation at the 2013 VEITH Symposium, November 19-23, 2013 (New York, NY, USA).

Surgical repair of thoracoabdominal aortic aneurysms (TAAA) is associated with significant morbidity and mortality. Hybrid approaches that involve visceral debranching and aortic endografting allow for an alternative approach in certain high-risk patients. In most circumstances the visceral vessels can be bypassed in a retrograde manner from the iliac arteries via a midline laparotomy, and the aortic aneurysm subsequently excluded with standard aortic endografts. These procedures avoid the extensive two-cavity exposure, aortic cross-clamping, and mechanical circulatory support that comprise open TAAA repair, and offer the theoretical advantage of being less invasive. Despite this, outcomes have been mixed with reported perioperative mortality rates of 0% and 34% and permanent paraplegia rates of 0% to 13% in most major series. The reported outcomes, as well as the variation between centers, highlight the importance of patient selection in undertaking hybrid repair. In practice, the best outcomes are achieved in patients who have high-risk anatomy, rather than high-risk comorbidities.

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.

Open repair of intact thoracoabdominal aortic aneurysms in the American College of Surgeons National Surgical Quality Improvement Program

Open surgical repair of thoracoabdominal aortic aneurysms (TAAAs) is uncommon. Mortality rates of 20% are reported in studies using national data and are 5% to 8% in single-institution studies. Clinical trials are currently evaluating branched and fenestrated endografts. The purpose of this study is to establish a benchmark for future comparisons with endovascular trials using open repair of TAAAs in the National Surgical Quality Improvement Program (NSQIP) database. We identified all patients undergoing open elective and emergency surgical repair of intact TAAAs in NSQIP (2005 to 2010) using Current Procedural Terminology (American Medical Association, Chicago, Ill) and International Classification of Diseases, 9th Edition codes. We analyzed demographics, comorbidities, 30-day mortality, postoperative complications, and length of stay. Multivariable logistic regression was used to identify predictors of mortality. We identified 450 patients who underwent open surgical repair (418 elective, 32 emergent) of an intact TAAA. Mean age was 69.4 years, 60.7% were male, and 85.6% were white. Comorbidities included hypertension (87.1%), chronic obstructive pulmonary disease (27.3%), prior stroke or transient ischemic attack (16.7%), diabetes (11.6%), and peripheral vascular disease (9.6%). Thirty-day mortality was 10.0%. Pulmonary complications were the most common: failure to wean from ventilator (39.1%), pneumonia (23.1%), and reintubation (13.8%). Acute renal failure requiring dialysis occurred in 10.7% of patients. Multivariable analysis (odds ratio [95% confidence interval]) showed predictors of mortality were emergent repair (3.3 [1.03-10.83]; P = .04), age >70 years (3.5 [1.03-7.56], P = .001), preoperative dialysis (8.4 [1.90-37.29], P = .005), cardiac complication (2.9 [1.05-8.21], P = .04), and renal complications (8.4 [3.41-20.56], P < .001). In this study of NSQIP hospitals, the first to analyze open surgical repair of TAAAs, the 30-day mortality rate of 10.0% is similar to single-institution reports. However, morbidity and mortality after open TAAA repair remain high, confirming the need for less invasive procedures.

Staged hybrid approach using proximal thoracic endovascular aneurysm repair and distal open repair for the treatment of extensive thoracoabdominal aortic aneurysms

Repair of patients with extent I and II thoracoabdominal aortic aneurysms (TAAAs) is associated with significant morbidity and mortality, whereas repair of more distal extent III and IV TAAAs has a lower risk of paraplegia and death. Therefore, we describe an approach using thoracic endovascular aneurysm repair (TEVAR) as the index operation to convert extent I and II TAAAs to extent III and IV TAAAs amenable to subsequent open aortic repair to minimize patient risk. Between July 2007 and March 2012, 10 staged hybrid operations were performed to treat one extent I and nine extent II TAAAs. Aortic aneurysm pathology included five chronic type B dissections, three acute type B dissections, and two penetrating aortic ulcers. Initially, the proximal descending thoracic aorta was repaired with TEVAR for coverage of the most proximal fenestration or penetrating ulcer, with seven elective and three emergent repairs. Interval open distal aortic replacement was performed in a short-term planned setting or for progressive dilation of the distal aortic segment. In the open repair, the proximal end of the graft was sewn directly to the distal end of the TEVAR and outer wall of the aorta. Average patient age was 48 years, and 60% were men. Risk factors included hypertension (80%), current tobacco use (50%), and Marfan syndrome (30%). Complications after TEVAR included type IA (n=1) and type II (n=3) endoleaks, pleural effusions (n=3), and acute kidney injury (n=1). Three patients required endovascular reinterventions. In patients with dissection, persistent filling of the false lumen was common and associated with distal thoracic aortic dilation. Complications of open repair included acute kidney injury in two patients, but no cardiac, pulmonary, or neurologic morbidity. Median time between TEVAR and open repair was 14 weeks. Most importantly, no deaths or neurologic deficits occurred after either procedure during a median follow-up of 35 weeks. A staged hybrid approach to extensive TAAAs combining proximal TEVAR, followed by interval open distal TAAA repair, is safe and appears to be an effective alternative to traditional open repair. This approach may decrease the significant morbidity associated with single-stage open extent I and II TAAA repairs and may be applicable to multiple TAAA etiologies.