Primary Thoracic Endovascular Aortic Repair Research Articles

Thoracic Endovascular Aortic Repair for Metachronous Thoracic Aortic Aneurysms Following Prior Infrarenal Abdominal Aortic Aneurysm Repair

Thoracic endovascular aortic repair (TEVAR) for metachronous thoracic aortic aneurysms (M-TAA) after prior abdominal aortic aneurysm repair has been shown to be associated with higher risk of spinal cord ischemia compared with primary TEVAR. However, data regarding the impact of the type of prior repair on outcomes are scarce. In this study, we examined perioperative outcomes and long-term mortality after TEVAR for M-TAA compared with primary TEVAR for TAA. We identified all patients who underwent TEVAR for TAA of the descending thoracic aorta in the Vascular Quality Initiative from 2013 to 2022. Only patients undergoing primary TEVAR or TEVAR after infrarenal open (iOAR) or endovascular (EVAR) repair were included. We performed univariate analyses to identify differences in baseline and procedural characteristics, and multivariable analyses for perioperative outcomes and 5-year mortality using logistic and Cox regression models. We included 1493 patients who underwent primary TEVAR (n = 1213; 81%) or TEVAR after prior iOAR (n = 135; 9%) or prior EVAR (n = 145; 10%). Compared with primary TEVAR, patients undergoing TEVAR for metachronous aneurysms were older, more commonly male, White, and more frequently had a history of genetic disorders and other comorbidities. Patients with M-TAA were more often asymptomatic at repair, presented with larger diameters, and required higher contrast volume and longer procedural time, relative to patients undergoing primary TEVAR. After risk adjustment, compared with primary TEVAR, prior EVAR was associated with higher perioperative mortality (10% vs 3.9%; odds ratio [OR]: 4.5, 95% confidence interval [CI]: 2.0-9.9; P < .001) (Table) and 5-year mortality (40% vs 24%; hazard ratio: 1.9, 95% CI: 1.3-2; P = .001) (Fig), along with higher odds of acute kidney injury (10% vs 6.2%; OR: 2.0, 95% CI: 1.0-3.8; P = .04). However, other in-hospital complications including spinal cord ischemia were not notably different. On the other hand, TEVAR after prior iOAR was associated with similar perioperative mortality (4% vs 4%; OR: 0.8, 95% CI: 0.3-2.0; P = .75), 5-year mortality (28% vs 24%; hazard ratio: 1.2, 95% CI: 0.72-1.9; P = .54), and in-hospital complication and reintervention rates, relative to primary TEVAR. Type of prior repair has a significant impact on outcomes in patients undergoing intervention for M-TAA. Further efforts should aim to identify the reasons behind these differences in outcomes to help improve care of patients with M-TAA.TablePerioperative outcomes and 5-year mortality after primary TEVAR and TEVAR after prior iOAR or EVARPrimary TEVARPrior iOARPrior EVARPrimary TEVAR vs prior iOARPrimary TEVAR vs prior EVARUnadjusted event rates, %Odds ratio (95% CI)P valueOdds ratio (95% CI)P valuePerioperative mortality3.94.49.71.2 (0.32-3.7).754.5 (2.0-9.9)<.001Any complication1814230.92 (0.50-1.6).771.5 (0.89-2.3).13 AKI6.26.7101.3 (0.56-2.9).492.0 (1.0-3.8).04 Postoperative dialysis1.01.51.42.1 (0.24-1.2).461.4 (0.07-9.1).78 Spinal cord ischemia2.60.72.80.22 (0.01-1.2).161.3 (0.35-3.5).69 Leg ischemia1.90.72.11.2 (0.06-7.2).862.0 (0.42-7.0).33 Bowel ischemia0.501.4NANA3.0 (0.40-15).22 Stroke3.11.54.10.63 (0.10-2.3).541.3 (0.40-3.3).58 Pulmonary complication5.06.76.91.8 (0.72-4.0).181.9 (0.83-3.8).11 Cardiac complication2.53.02.81.7 (0.45-5.2).971.02 (0.23-3.2).97Reintervention4.93.76.21.2 (0.38-3.0).761.5 (0.64-3.3).30Unadjusted estimatesHazard ratio (95% CI)P valueHazard ratio (95% CI)P value5-year mortality2325401.2 (0.72-1.9).541.9 (1.3-2.8).001AKI, Acute kidney injury; CI, confidence interval; iOAR, infrarenal open aortic repair; TEVAR, thoracic endovascular aortic repair.Boldface P values represent significance P < .05.*Adjusted for age, gender, diameter, race, saccular, presentation, prior myocardial infarction, prior congestive heart failure, hypertension, diabetes, chronic obstructive pulmonary disease, smoking, renal dysfunction, prior medication use (aspirin, statin, and β-blocker), and genetic history. Open table in a new tab

The surgical management of retrograde type A aortic dissection after thoracic endovascular aortic repair.

Our goal was to review the surgical treatment of retrograde type A aortic dissection (RTAD) after thoracic endovascular aortic repair (TEVAR) in our centre. From January 2014 to April 2018, 22 patients with RTAD after TEVAR were operated on in our centre. The mean age at operation was 52.0 ± 8.0 years old. The median interval between the primary TEVAR procedure and RTAD was 4.6 months (range 0-120 months). The postoperative mortality and morbidity rates were calculated to evaluate the early and long-term results. Twenty patients received total arch replacement with the frozen elephant trunk technique and 2 patients received total arch replacement alone. The mean cardiopulmonary bypass time, aortic cross-clamp time and selective cerebral perfusion time were 172.4 ± 39.3, 100.1 ± 30.3 and 19.7 ± 10.5 min, respectively. The incidence of major adverse events was 18.6% (4/22), including stroke in 1 patient, myocardial dysfunction in 1 patient and renal failure necessitating dialysis in 3 patients. Death within 30 days was 13.6% (3/22 patients). The follow-up data were available for all 19 survivors. The mean follow-up period was 32.2 ± 16.2 months (range 10-62 months). No deaths or aortic-related events occurred during the follow-up period. Total arch replacement with or without the frozen elephant trunk technique was suitable for the management of RTAD after TEVAR, with acceptable early and long-term results.

Primary thoracic endovascular aortic repair to aortic coarctation complicating with spontaneous epidural hemorrhage

Development of collateral circulation belongs among the typical signs of aortic coarctation (CoA) and can lead to the growth of ectatic, fragile spinal neurovascular malformations. Spontaneous spinal epidural hemorrhage (SSEH) as a complication of CoA is exceptionally rare, with only few case reports proposed up to date. At our institute, we had two experiences of SSEH complicated by CoA. The first case had been published in 2016, with disappointing neurologic outcome. As for the second case, presenting with extremely sharp upper back pain followed by paraplegia and anal sphincter impairment, we chose immediate surgical intervention with thoracic endovascular aortic repair (TEVAR), aiming at amelioration of the pressure gradient across the juxtaductal coarctation in the aorta, to ensure the safety and the completeness of following surgical decompression of the spinal epidural hematoma. To our knowledge, this case is the first one featuring TEVAR to the CoA immediately followed by surgical decompression of SSEH in this kind of emergent setting. This case recovered satisfactorily without neurologic deficit. Conservative treatment for SSEH caused by CoA may not succeed at all times. Emergent TEVAR to CoA immediately followed by surgical decompression is achievable, making following surgical decompression of the epidural hematoma easier and safer.

Distal Stent Graft-Induced New Entry After TEVAR of Type B Aortic Dissection: Experience in 15 Years

Experience is limited with distal stent graft-induced new entry (SINE) after thoracic endovascular aortic repair (TEVAR) of type B dissection (TBAD). We report the management strategy and outcomes in such patients. Clinical data were analyzed for 95 patients (age, 53.2 ± 10.9 years; 82 men) who presented with distal SINE after TEVAR for TBAD. Follow-up was 100% for 7.2 ± 3 years after primary TEVAR. Distal SINE occurred at a mean of 2.7±2.4 years. Re-TEVAR was performed for 78, with routine stent grafts in 64 and a more tapered graft in 14. Three patients were managed surgically and 14 medically. Two patients died after re-TEVAR. During follow-up at 5.8 ± 2.9 years, late death occurred in 19 patients, 7 with medical therapy and 12 with re-TEVAR. Distal SINErecurred in 11 at 3.5 ± 1.7 years after re-TEVAR. Reintervention significantly improved survival up to 8years compared with medical therapy (88.3% vs 63.5%, p= 0.001). In 64 patients with routine stent grafts, mortality was 24%, distal SINE recurred in 20%, and recurrence-free survival was 56% at 6 years. Neither death nor recurrence of SINE occurred in 14 patients with a more tapered stent graft. Predictors for distal SINE after primary TEVAR were stent graft length (hazard ratio, 0.984; p= 0.037) and chronic phase (hazard ratio, 1.725; p= 0.049). In TBAD patients with distal SINE after TEVAR, reintervention with re-TEVAR could improve long-term survival significantly. Recurrence of distal SINE was high after re-TEVAR using routine stent grafts. More tapered stent grafts may be helpful in preventing the recurrence of distal SINE.

The frozen elephant trunk technique for the treatment of acute complicated Type B aortic dissection

Our goal was to report our preliminary results in patients with acute complicated Type B aortic dissection without a suitable landing zone for primary thoracic endovascular aortic repair who were treated with the frozen elephant trunk (FET) technique. Within a 25-month period, 14 patients with acute complicated Type B aortic dissection underwent surgical repair using the FET technique. The reasons to perform the FET procedure were an ectatic ascending aorta/arch in 6 patients and the lack of an adequate landing zone in 8 patients. No deaths were observed. A non-disabling stroke occurred in 2 patients. Symptomatic spinal cord injury was not observed. The closure of the primary entry tear was successfully achieved in all patients. In 3 patients, a secondary distal thoracic endovascular aortic repair extension was performed during the same hospital stay. The median follow-up period was 6 ± 5 months. The FET technique is an attractive method for the repair of acute complicated Type B aortic dissection without a suitable landing zone for primary thoracic endovascular aortic repair. It should be considered as an alternative in patients who are at high risk for retrograde Type A aortic dissection, in patients with an unfavourable anatomy or in patients with connective tissue disease.

Treatment of serious complications following endovascular aortic repair for type B thoracic aortic dissection.

ObjectiveThis study aimed to describe treatment of serious complications after primary thoracic endovascular aortic repair (TEVAR) in type B aortic dissection.MethodsFrom June 2008 to March 2016, serious complications occurred in 58 patients without Marfan syndrome who received TEVAR for type B aortic dissection.ResultsComplications included endoleak, distal true lumen collapse, retrograde dissection, stroke, stent–graft (SG) migration and mistaken deployment, lower limb ischaemia, and SG fracture. Treatment included endovascular repair, surgical procedures, or conservative medication. Forty-six patients recovered from complications. Twelve patients were not cured. The median follow-up time was 29.5 months (2–61 months). The overall 30-day mortality rate was 1.7% (1/58) and the total mortality rate following secondary complications was 8.6% (5/58). The causes of death were stroke and aortic rupture.ConclusionSome treatments need to be performed after TEVAR because of severe complications. A reduction in these complications can be achieved by optimal evaluation of patients, selection of SGs, and specialized endovascular manipulation.

Outcomes of secondary procedures after primary thoracic endovascular aortic repair†.

The purpose of this study is to retrospectively evaluate, with an 'all-comers' approach, the survival and outcome of patients following secondary surgical or interventional procedures after thoracic endovascular aortic repair (TEVAR). Between October 2002 and December 2013, 371 patients with different aortic pathologies underwent primary TEVAR at our institution. Fifty-six out of the 371 patients (15.1%, 18 females, mean age 62.3 ± 13.7 years) required secondary procedures, either interventionally (N = 31; 55.4%) or surgically (N = 25; 44.6%), due to stent graft-related complications. After TEVAR complications comprised endoleaks (N = 28; 7.5%), organ malperfusion (N = 9; 2.4%), aorto-oesophageal/-bronchial fistulae (N = 9; 2.4%), stent graft infections (N = 4; 1.1%), aneurysm progression (N = 3; 0.8%), retrograde type A aortic dissection (N = 2; 0.5%) and aortic regurgitation (N = 1; 0.3%). The overall in-hospital mortality rate was 10.7% (N = 5): open surgery (N = 1; 4%) versus reintervention (N = 5; 16%; P = 0.14). The cumulative survival rates after secondary procedures at 6 months, 1 year and 3 years were 80.4, 73.5 and 69.3%, respectively. Postoperative complications either for open surgery or reintervention comprised stroke (8 vs 9.6%; P = 0.82), paraplegia (4 vs 6.4%; P = 0.68), renal failure (16 vs 3.2%; P = 0.09), respiratory failure (12 vs 0%; P = 0.04), sepsis (16 vs 3.2%; P = 0.87), organ malperfusion (4 vs 3.2%; P = 0.87) and need for a tertiary procedure (8 vs 6.4%; P = 0.82). Stent graft complications after primary TEVAR were not infrequent and often required secondary procedures for definite treatment. Endoleaks (type Ia), organ malperfusion, stent graft infections, fistula formation and expanding aneurysm occurred predominantly during early and mid-term follow-up. Despite the high-risk nature of the complications, secondary open surgical or interventional procedures may be successfully performed with an acceptable outcome.

Early and Midterm Outcomes of Open Surgical Correction After Thoracic Endovascular Aortic Repair

We present a single center's experience of secondary interventions after thoracic endovascular aortic repair (TEVAR). One hundred and forty-seven patients underwent TEVAR at our institution between 2000 and 2012. A total of 26 patients (19 male, mean age 68.4 ± 12.7 years), including 7 patients with primary TEVAR at other centers, underwent secondary interventions. The median interval to secondary intervention was 17.2 months (range, 0.22 to 36.1). The indications for secondary interventions included procedure-related dissection (n= 1), collapse of the endovascular device (n= 1), aortoesophageal fistula (n= 1), residual dissection (n= 3), and endoleaks causing dilation of the sac (n= 17) or aortic rupture (n= 3). Sixteen patients underwent open conversion including total arch replacement (n= 2), extensive replacement of the aortic arch or descendingaorta (n= 10), and thoracoabdominal aortic replacement (n= 4). Second-time TEVAR was performed in the remaining 10 patients. The in-hospital mortality rate was 11.5% (3 patients; 1 case of multiorgan failure after open conversion, and 1 case of mesenteric ischemia and 1 case of aortic rupture after second-time TEVAR). Postoperative stroke after second-time TEVAR occurred in 1 patient. The cumulative survival rate of the 26 patients was 80.0% ± 8.0% at 5 years after secondary intervention. Short proximal neck (p= 0.0036), steep angulation of landing zones (p=0.033), and nonuse of commercially available devices (p= 0.011) were significantly correlated with incidence of TEVAR failure. Secondary surgical procedures after TEVAR can be performed with low mortality and morbidity, despite the precarious preoperative conditions and complex aortic pathologies of patients.

Thoracic endovascular aortic repair as emergency therapy despite suspected aortic infection

To evaluate thoracic endovascular aortic repair (TEVAR) as emergency therapy despite suspected aortic infection. Within a 5-year period, we treated 6 patients with a strategy of primary TEVAR despite suspected aortic infection in patients with symptomatic or already ruptured thoracic aortic pathology. In-hospital mortality was 16.7%. The reason for death was septic multiorgan failure. During follow-up, 2 patients were converted to secondary open surgery in a stable elective setting. The median follow-up was 42.5 months. All surviving patients are not receiving continuing antibiotic therapy. Freedom from infection is 100% to date. TEVAR as emergency therapy despite suspected aortic infection is feasible and may well serve as a definite treatment option in selected cases. As recurring infection cannot be entirely excluded, life-long clinical and morphological surveillance remains mandatory.

Stent graft-induced new entry after endovascular repair for Stanford type B aortic dissection

Stent graft-induced new entry (SINE), defined as the new tear caused by the stent graft and excluding those arising from natural disease progression or iatrogenic injury from the endovascular manipulation, has been increasingly observed after thoracic endovascular aortic repair (TEVAR) for Stanford type B dissection in our center. SINE appears to be remarkably life threatening. We investigated the incidence, mortality, causes, and preventions of SINE after TEVAR for Stanford type B dissection. Data for 22 patients with SINE were retrospectively collected and analyzed from 650 patients undergoing TEVAR for type B dissection from August 2000 to June 2008. An additional patient was referred to our center 14 months after TEVAR was performed in another hospital. The potential associations of SINE with Marfan syndrome, location of SINE and endograft placement, and the oversizing rate were analyzed by Fisher exact probability test or t test. We found 24 SINE tears in 23 patients, including SINE at the proximal end of the endograft in 15, at the distal end in 7, and at both ends in 1. Six patients died. SINE incidence and mortality reached 3.4% and 26.1%, respectively. Two SINE patients were diagnosed with Marfan syndrome, whereas there were only 6 Marfan patients among the 651 patients. The 16 proximal SINEs were evidenced at the greater curve of the arch and caused retrograde type A dissection. The eight distal SINEs occurred at the dissected flap, and five caused enlarging aneurysm whereas three remained stable. The endograft was placed across the distal aortic arch during the primary TEVAR in all 23 patients. The incidence of SINE was 33.33% among Marfan patients vs 3.26% among non-Marfan patients (P = .016). There was no significant difference in mortality between proximal and distal SINE (25% vs 28.6%, P > .99), incidence of SINE between endograft placement across the arch and at the straight portion of descending thoracic aorta (23 of 613 vs 0 of 38, P = .39), and the oversizing rate between SINE and non-SINE patients (13% ± 4.5% vs 16% ± 6.5%, P = .98). SINE appears not to be rare after TEVAR for type B dissection and is associated with substantial mortality. The stress yielded by the endograft seems to play a predominant role in its occurrence. It is important to take this stress-induced injury into account during both design and placement of the endograft.

Quality of life after acute type b dissection in the era of thoracic endovascular aortic repair

Conservative management of acute type B aortic dissection is currently being challenged by primary thoracic endovascular aortic repair. Aim was to assess outcome and quality of life after these different approaches using an adjusted standard population as benchmark. Observational study of a prospectively collected (January 2000 to December 2005) consecutive series of 87 patients with acute type B aortic dissection. Patients were 63 +/- 13 years old and 68 were men (78.2 %). Seventy-two were managed conservatively (83 %) and 15 invasively (12 by endovascular aortic repair). Follow-up was 36 +/- 19 months. Endpoints were early and late morbidity and mortality, and long-term quality of life as assessed by the Short Form health survey questionnaire. Patient cohorts were similar regarding age, risk profile and local disease. In the conservative cohort, four patients died during early (5.6 %) and eight during long-term follow-up (cumulative four years survival rate 79 %). Thirty-two patients needed secondary surgical management (44 %), i.e. delayed aortic repair (n = 11), or interventions on adjacent aortic sections or major branches (n = 21). In the surgical cohort no patient died, and no repeated interventions were necessary after the peri-operative period. Long-term quality of life scores were 100 (69-115) in conservatively and 94 (75-124) in invasively managed patients. Normal scores range from 85 to 115. Primary endovascular management of uncomplicated acute type B dissection is safe and leads to excellent long-term results, whereas secondary interventions were required with high incidence after initial conservative management. Long-term quality of life, however, returned to normal with any successful treatment strategy.