Previous Thoracic Endovascular Aortic Repair Research Articles

VS2. Open Repair of Distal Aortic Failure Following TEVAR for Type B Aortic Dissection

This case illustrates the management of distal aortic failure following previous proximal thoracic endovascular aortic repair (TEVAR) for type B aortic dissection via an open approach. The patient is a 59-year-old woman with chronic hypertension and multiple previous aortic interventions, including ascending and arch repair related to acute intramural hematoma. After many years of stability, she developed an acute type B dissection distal to her previous repair with right lower extremity malperfusion and was treated with TEVAR. On routine surveillance imaging, a 7.2-cm type V thoracoabdominal aneurysm distal to her stent grafts rapidly developed due to a new entry tear. Her anatomy was not suitable for Food and Drug Administration-approved endovascular therapy. After extensive counseling discussing the risks and benefits, she elected to proceed with definitive open aortic reconstruction. Our standard thoracoabdominal incision was made, and the aorta was exposed via retroperitoneal approach. The left inferior pulmonary vein and left femoral artery were cannulated to provide partial heart bypass and distal perfusion. The aorta was doubly clamped, and an aortotomy was made and extended appropriately, exposing the distal extent of the previous TEVAR. The distal portion of the TEVAR was resected, and reconstruction was performed using a Dacron graft. The proximal anastomosis was incorporated into the remaining distal TEVAR graft, and a beveled distal anastomosis was fashioned to the visceral aortic segment. The left renal artery was reimplanted as a Carell patch. The patient tolerated the procedure well, aside from brief need for hemodialysis therapy. By postoperative day 7, the patient had returned to her baseline renal function. She was discharged to a rehabilitation facility on postoperative day 12 for further convalescence.

Open Aortic Repair After Prior Thoracic Endovascular Aortic Repair

Background. Thoracic endovascular aortic repair (TEVAR) has been applied to increasingly complex aortic pathology, resulting in an increase in late complications. We characterized patients undergoing open repair after prior TEVAR including indications, operative techniques, and outcomes. Methods. Chart review and query of a prospectively collected database identified 50 patients who underwent thoracic aortic operation after prior TEVAR. Active follow-up was supplemented by Social Security information for vital status. Results. From July 2001 to January 2012 open arch (n [ 25), descending (n [ 6), thoracoabdominal (n [ 17), or extra-anatomic bypass (n [ 2) operations were performed after previous TEVAR (median interval from TEVAR to open surgical procedure: 13.9 months; interquartile range, 0.5 to 24 months). Indications for open operation included type 1 endoleaks (n [ 19), retrograde aortic dissection (n [ 9), chronic aortic dissection with persistent growth of

Chimney technique for aortic arch pathologies: an 11-year single-center experience.

To report our single-center experience with the chimney technique for aortic arch pathologies and the mid- to long-term results in these patients. From June 2002 to May 2013, 26 patients (18 men; mean age 71.2 years, 53-86) underwent thoracic endovascular aortic repair (TEVAR) combined with chimney technique. Indications for treatment were: a proximal landing zone <15 mm long distal to the left subclavian artery (LSA), thoracic aortic aneurysm (n=13), complicated type B aortic dissection (n=10), type I endoleak after previous TEVAR (n=2), and penetrating aortic ulcer (n=1). Treatment was performed in the emergency setting in 7 cases. The 28 chimney stent-grafts (double chimneys in 2 patients) were deployed in the innominate artery (n=7), left common carotid artery (n=10), and LSA (n=11). All patients underwent computed tomography before discharge, at 1, 6, and 12 months, and yearly thereafter. Technical success was 100%. One (3.8%) perioperative death was due to a cerebral hemorrhage. No major stroke was registered, but 3 (11.5%) minor strokes occurred (all resolved). Paraparesis developed in 2 (7.7%) patients. Median follow-up was 36.8 months (range 1-131), during which an additional 4 (15.4%) patients died, but only 1 death was aneurysm-related. Chimney graft patency was 89.3% (25/28); an asymptomatic fracture was found in a patent chimney stent-graft at the 18-month follow-up. The type I endoleak rate was 23% (n=6); 3 endoleaks associated with aneurysm sac enlargement were treated. The chimney technique for aortic arch pathologies is safe and feasible and may be an option in patients considered at high risk for surgery or who are ineligible for conventional TEVAR, especially in the emergency setting. Concern persists regarding type I endoleak, and long-term follow-up remains mandatory.

Strategies for the treatment of aorto-oesophageal fistula†

Presenting a surgical strategy for aorto-oesophageal fistula (AEF). From October 1999 to August 2013, 16 patients with AEF were treated at Kobe University Hospital. The mean age was 65.5 ± 10.2 years, and the male/female ratio was 13/3. Eight patients had non-dissecting thoracic aneurysm, 3 had chronic aortic dissection, 5 had oesophageal cancer and 1 had fish bone penetration. Five patients were in shock. Four patients had previous thoracic endovascular aortic repair (TEVAR) in the descending aorta and 1 had hemi-arch replacement. As treatment for AEF, 8 patients underwent TEVAR, 2 had a bridge TEVAR to open surgery, 2 had extra-anatomical bypass (EAB) and 5 had in situ reconstruction of the descending aorta. The oesophagus was resected in 8 patients, and an omental flap was installed in 7 patients. For the 4 most recent cases, simultaneous resection of the aorta and oesophagus, in situ reconstruction of the descending aorta using rifampicin-soaked Dacron graft and omental flap installation were performed. Hospital mortality was noted in 4 patients (25.0%; persistent sepsis n = 3 and pneumonia n = 1). However, since 2007, only 1 of 5 patients died (pneumonia). All patients with oesophageal cancer died during follow-up. Two patients underwent oesophageal reconstruction using a pedicled colon graft and one is on the waiting list for oesophageal reconstruction. Bridging TEVAR is a useful adjunct in treating AEF patients with shock. One-stage surgery consisting of resection of the aneurysm and oesophagus, in situ reconstruction of the descending aorta and omental flap installation provided a better outcome in the AEF surgical strategy compared with conservative treatment.

When Not to Implant the Multilayer Flow Modulator: Lessons Learned From Application Outside the Indications for Use in Patients With Thoracoabdominal Pathologies

To scrutinize registry data on thoracoabdominal repairs performed using the Multilayer Flow Modulator (MFM) outside the indications for use (IFU) and analyze the adverse outcomes. Of 380 patients from Europe registered in the MFM Global Registry after treatment for thoracoabdominal aortic aneurysm (TAAA) or dissection, 38 (10%) patients (30 men; median age 71 years, range 30-91) treated on a compassionate basis outside the IFU were analyzed. Thirteen patients had chronic Stanford type B dissection with aneurysmal dilatation >6 cm. There were 6 mycotic and 4 saccular aneurysms in addition to 15 primary TAAAs. The mean aneurysm diameter was 7.1 cm. Ten patients presented with rupture, and 23 patients had previous open or thoracic endovascular aortic repair (TEVAR). Although no death, paraplegia, stroke, or renovisceral compromise was documented during the initial hospital stay, technical success was zero. There were 31 (81.6%) cases in which there was failure to land the device in normal aorta. Other violations of the IFU included 12 with inadequate stent overlap and 11 cases involving a small MFM being deployed inside a larger one. Five of the 9 cases in which an undersized device was used resulted in a type I endoleak (failure mode I). During a mean follow-up of 10.0±6.9 months, all-cause mortality was 89.5% (34/38), of which 27 (71.1%) were aneurysm-related deaths. Overall survival, freedom from aneurysm-related death, and rupture-free survival estimates were 17.5%, 25.0%, 31.5%, respectively, at 18 months. There were 8 visceral branch complications; in all, 14 secondary endovascular interventions were required in 11 patients for endoleak (failure modes I and II) or stent foreshortening. No false lumen was completely thrombosed in the dissecting aneurysms. All aneurysms showed a mean sac growth rate of 0.12±0.16 cm/month. Factors having a significance influence on risk of aneurysm-related death included maximum aneurysm diameter (p=0.025, HR 1.37, 95% CI 1.04 to1.82), previous TEVAR (p=0.03, HR 2.44, 95% CI 1.10 to 2.08), and inadequate overlap between MFM devices (p<0.002, HR 4.02, 95% CI 1.70 to 9.49). There are clinical scenarios in which the MFM does not perform well. The MFM is not a solution for patients living on borrowed time and should not be used indiscriminately in patients in whom other modalities of aortic repair are not feasible. Its use must adhere to the IFU, and robust clinical data are required before constructing a randomized controlled trial.

Open Aortic Repair After Prior Thoracic Endovascular Aortic Repair

Thoracic endovascular aortic repair (TEVAR) has been applied to increasingly complex aortic pathology, resulting in an increase in late complications. We characterized patients undergoing open repair after prior TEVAR including indications, operative techniques, and outcomes. Chart review and query of a prospectively collected database identified 50 patients who underwent thoracic aortic operation after prior TEVAR. Active follow-up was supplemented by Social Security information for vital status. From July 2001 to January 2012 open arch (n = 25), descending (n = 6), thoracoabdominal (n = 17), or extra-anatomic bypass (n = 2) operations were performed after previous TEVAR (median interval from TEVAR to open surgical procedure: 13.9 months; interquartile range, 0.5 to 24 months). Indications for open operation included type 1 endoleaks (n = 19), retrograde aortic dissection (n = 9), chronic aortic dissection with persistent growth of the false lumen (n = 16), and graft infection (n = 6). Sixty percent had prior cardiovascular surgical procedures and 18% were done as emergencies. Circulatory support was required in 78% and hypothermic arrest in 48%. Hospital mortality occurred in 3 (6%) patients with no strokes and 1 patient with myocardial infarction; 5 (10%) patients required tracheostomy and 1 required dialysis. Survival was 67% at a median follow-up of 2.9 years. Conversion to open repair after thoracic stent-grafting may be indicated for type 1 endoleak, retrograde dissection, chronic aortic dissection with persistent false lumen growth, or graft infection. These salvage operations are complex but can be completed safely with good early outcomes and preservation of the stent-graft in most cases. Late outcomes are consistent with the chronic disease state of these patients.

Apicoaortic Valved Conduit Bypass for Progressing Aortic Graft Stenosis Due to Malformation of Repeated Thoracic Endovascular Aortic Repairs

Since the first report by Cooley and colleagues in 1975 [Cooley DA, Norman JC, Mullins CE, Grace R. Left ventricle to abdominal aorta conduit for relief of aortic stenosis. Cardiovasc Dis 1975;2:376-83], an apicoaortic valved conduit bypass has been usually administrated to selected patients presenting with certain clinical conditions or complications such as aortic stenosis associated with porcelain aorta, unclampable atherosclerotic aorta, resternotomy, or previous coronary bypass surgery. On the other hand, thoracic endovascular aortic repair for various aortic lesions has become a promising and less invasive therapy. We encountered a critical case of a patient suffering from aortic graft stenosis due to malformation of a previous thoracic endovascular aortic repair procedure originally performed for acute type A aortic dissection. Because of a deep sternal wound infection, apicoaortic valved conduit bypass from the left ventricular apex to the abdominal aorta was successfully performed.

Clinical competence statement on thoracic endovascular aortic repair (TEVAR)—multispecialty consensus recommendations: A Report of the SVS/SIR/SCAI/SVMB Writing Committee to Develop a Clinical Competence Standard for TEVAR

Clinical competence statement on thoracic endovascular aortic repair (TEVAR)—multispecialty consensus recommendations: A Report of the SVS/SIR/SCAI/SVMB Writing Committee to Develop a Clinical Competence Standard for TEVAR