Repair Of Thoracic Aortic Disease Research Articles

Long-Term Outcomes of Endovascular Repair of Thoracic Aortic Aneurysms.

The thoracic aorta is a dynamic structure composed of the aortic root, ascending aorta, aortic arch, and descending aorta. It is subject to the pressure and volume of the cardiac cycle and susceptible to atherosclerotic and aneurysmal changes. With these changes, the risk for acute aortic syndromes increases, thus creating the impetus for earlier interventions. The previous standard of open surgical repair has undergone a transition in recent years toward endovascular repair being favored in the descending and abdominal aortas with ongoing investigation into approaches for the ascending and aortic arch. These therapies have been shown to improve early mortality and morbidity outcomes with the caveat of more interventions compared with open surgery. We undertook this review to analyze the current data available regarding long-term outcomes in patients undergoing endovascular repair for thoracic aortic disease. The data support long-term benefit of endovascular repair for thoracic aortic disease. The primary indications identified for reintervention are endoleak and further aneurysmal degeneration. As the devices available for endovascular repair evolve, ongoing review of these outcomes will be necessary. It will also be important to trend the results as further techniques become available for endovascular repair of the ascending aorta and aortic arch.

Endovascular repair of thoracic aortic disease with isolated left vertebral artery and unfavorable proximal landing zone using fenestrated castor stent-graft.

The main purpose of this study was to evaluate the safety and efficacy of Castor single-branched stent-graft combined with fenestrated technique in treatment of thoracic aortic disease (TAD) with unfavorable proximal landing area (PLZ) and isolated left vertebral artery (ILVA). From January 2018 to March 2022, 8 patients with TAD (6 patients with type B aortic dissections, 1 patient with type B intramural hematomas, and 1 patient with thoracic aortic aneurysm) underwent thoracic endovascular aortic repair with fenestrated Castor stent-graft due to the existence of ILVA and unfavorable PLZ. Demographic characteristics, surgical details, postoperative complications, follow-up and postoperative CTA imaging results were collected and analyzed. The primary technical success rate was 100%. The mean operation time was 115 min (range, 70-180 min). All the left subclavian arteries (LSAs) and ILVAs of the eight patients were revascularized by fenestrated Castor stent-grafts. During the follow-up period, no deaths and complications were observed. No internal leakage, aortic rupture, retrograde type A dissection were found on computed tomography angiography. All of the LSAs and ILVAs maintained patency without stenosis. Castor single-branched stent-graft implantation combined with fenestration technique may be safe and feasible for TAD patients with ILVA and unfavorable PLZ.

Risk Factors for Stroke Development After Thoracic Aortic Surgery

Stroke after thoracic aortic surgery is a complication that is associated with poor outcomes. The aim is to characterize the intraoperative risk factors for stroke development. A retrospective analysis. Tertiary, high-volume cardiac surgery center. Patients who had surgical repair of thoracic aortic diseases from January 1, 2017, through December 31, 2021. None. A total of 704 patients were included, of whom 533 had ascending aortic aneurysms, and 171 had type A aortic dissection. The incidence of postoperative stroke was 4.5% (95% CI 2.9%-6.6%) for ascending aortic aneurysms compared with 12.3% (95% CI 7.8%-18.16%) in type-A aortic dissections. Patients who developed postoperative strokes had significantly lower intraoperative hemoglobin median (7.5 gm/dL [IQR 6.8-8.6] v 8.55 gm/dL [IQR 7.3-10.0]; p < 0.001). The median cardiopulmonary bypass time was 185 minutes (IQR 136-328) in the stroke group versus 156 minutes (IQR 113-206) in the nonstroke group (p=0.014). Circulatory arrest was used in 57.8% versus 38.5% of the nonstroke patients (p=0.017). The initial temperature after leaving the operating room was lower, with a median of 35.0°C (IQR 34-35.92) in the stroke group versus 35.5°C (IQR 35-36) in the nonstroke cohort (p=0.021). This single-center study highlighted the potential importance of intra-operative factors in preventing stroke. Lower hemoglobin, longer duration of cardiopulmonary bypass, deep hypothermic circulatory arrest, and postoperative hypothermia are potential risk factors for postoperative stroke. Further studies are needed to prevent this significant complication in patients with thoracic aortic diseases.

A prebifurcated axillobifemoral polytetrafluoroethylene graft simplifies carotid to carotid to subclavian bypass.

The use of thoracic endovascular aortic repair for thoracic aortic disease will necessitate cervical debranching in cases involving the proximal arch. We have presented the case of a 57-year-old athletic woman who had developed a type A dissection that extended to the bilateral iliac arteries. After hemiarch repair, she underwent staged cervical debranching with carotid–carotid–subclavian bypass using a prebifurcated axillobifemoral graft and subsequent thoracic endovascular aortic repair. We have detailed her successful clinical course and described the benefits of using a prebifurcated graft for cervical debranching in hybrid repairs of aortic arch pathology.

Paraplegia After Open Surgical Repair Versus Thoracic Endovascular Aortic Repair for Thoracic Aortic Disease: A Retrospective Analysis of Japanese Administrative Data

To comparatively examine the risk of postoperative paraplegia between open surgical descending aortic repair and thoracic endovascular aortic repair (TEVAR) among patients with thoracic aortic disease. Retrospective cohort study. Acute-care hospitals in Japan. A total of 6,202 patients diagnosed with thoracic aortic disease. None. The main outcome of this study was the incidence of postoperative paraplegia. Multiple logistic regression models, using inverse probability of treatment weighting and an instrumental variable (ratio of TEVAR use to open surgical repair and TEVAR uses), showed that the odds ratios of paraplegia for TEVAR (relative to open surgical descending aortic repair) were 0.81 (95% confidence interval: 0.42-1.59; p=0.55) in the inverse probability of treatment-weighted model and 0.88 (0.42-1.86; p=0.75) in the instrumental-variable model. There were no statistical differences in the risk of paraplegia between open surgical repair and TEVAR in patients with thoracic aortic disease. Improved perioperative management for open surgical repair may have contributed to the similarly low incidence of paraplegia in these two surgery types.

Aortic endovascular stenting in patients with systemic connective tissue disorders: does the prohibitive dogma still stand tall?

Endovascular repair of thoracic aortic diseases can provide satisfactory outcomes in elective and certain emergency cases involving the descending thoracic and aortic arch. However, open repair remains the gold standard method of aortic root pathologies and certain aortic arch pathologies, such as extended dissection. Nevertheless, the use of endovascular stenting in patients with connective tissue disorders has not been fully explored because the aortic tissues are fragile and the likelihood of keeping the stent in place is low because of its progressive dilatation and subsequent requirement for open repair at a later stage when the stent graft fails. Our brief review focuses on current evidence of the use of stents in patients with connective tissue disorders and whether such practice can be expanded further.

Prospective Multicenter Study of the Low-Profile Relay Stent-Graft in Patients with Thoracic Aortic Disease: The Regeneration Study

To evaluate the early safety and clinical performance of the new low-profile RelayPro Thoracic Stent-Graft System in patients with thoracic aortic disease. This was an international, prospective, single-arm study in patients diagnosed with thoracic aorta disease (aneurysm, pseudoaneurysm, dissection, penetrating atherosclerotic ulcer, or intramural hematoma) and treated with a RelayPro stent-graft (in bare stent and/or nonbare stent configurations). The primary endpoints were freedom from aneurysm or dissection-related mortality and stent-graft performance. A total of 31 patients were treated with the RelayPro thoracic stent-graft between 2014 and 2015 at 8 sites in Italy and Spain. Mean age was 72.1 (±10.2) years and 77% were male, 74% with hypertension, and 42% with a history of smoking. Twenty-four (77%) had aneurysms (fusiform in 46%, saccular in 42%, pseudoaneurysm in 12%); 5 (16%) had penetrating atherosclerotic ulcer; and 2 (6%) had chronic Type B dissection. Mean vascular access diameter was 9.1mm (6-13mm); 7 patients (23%) had vascular access of 7mm or less. Technical success was 100% (primary, 90%; assisted primary, 10%). Freedom from aneurysm/dissection-related mortality through 30days was 100%. Freedom from device-related major adverse events through 30days was 94%. At 1year, there was 1 (3%) type Ib and 1 (3%) type II endoleak, 1 (3%) nonaneurysm-related late death, and 1 (3%) secondary intervention (to correct type Ib endoleak). The RelayPro has a 3-4 French profile reduction to allow endovascular repair ofthoracic aortic disease in patients with smaller anatomies. This study shows good initial stent-graft performance and a favorable early safety profile.

Does BioGlue contribute to anastomotic pseudoaneurysm after thoracic aortic surgery?

Although bovine serum albumin-glutaraldehyde glue (BioGlue®) has been successfully used as a hemostatic adjunct in aortic surgical procedures, there are reports that it may lead to anastomotic pseudoaneurysm formation. We seek to examine if the use of BioGlue is associated with a high incidence of anastomotic pseudoaneurysm formation following surgical repair of thoracic aortic disease. We reviewed the medical records and follow-up computed tomography (CT) scans of patients from 2001 to 2015 in whom BioGlue was used during surgical repair of thoracic aortic disease to detect postoperative anastomotic pseudoaneurysm formation. A total of 233 patients with BioGlue use were identified. Mean age was 63.5±14.0 years (median 66; range 14-88; 25-75%, IQR 54-74 years) and 149 were male (63.9%). Surgical indication was thoracic aortic aneurysm in 169 (72.5%) patients, aortic dissection in 49 (21.0%), intramural hematoma in 9 (3.9%), penetrating aortic ulcer in 3 (1.3%) and other in 3 (1.3%). Emergency/urgent surgery was performed in 68 cases (29.2%). Operative mortality was 7.3% (17/233). Re-exploration for bleeding and neurologic deficits occurred in 24 (10.3%) and 21 (9.0%) patients respectively. All operative survivors were followed (100%, 216/216) and CT follow-up was available in 81.9% (177/216) for a mean duration of 2.4 years (median 0.6; 25-75% IQR 0.2-3.6 years). Anastomotic pseudoaneurysm was detected in 1 patient (0.6%) at 3 years postoperatively. This was an elderly female with extremely frail tissues who underwent a reoperative ascending and arch replacement for dissection. The use of BioGlue in thoracic aortic surgery was not associated with excess incidence of anastomotic pseudoaneurysm formation following surgical repair of thoracic aortic disease. Its use need not be discouraged on this basis.

How to prevent spinal cord injury during endovascular repair of thoracic aortic disease

The incidence of spinal cord injury in thoracic endovascular aortic repair (TEVAR) has been 3-5 % from recent major papers where sacrifice of the critical intercostal arteries is inevitable by a stent graft. Hemodynamic stability, which depends on a network of blood vessels around the cord is most important not only during but also after stent-graft deployment. High risk factors of spinal cord injury during endovascular aortic repair are (1) coverage of the left subclavian artery, (2) extensive coverage of long segments of the thoracic aorta, (3) prior downstream aortic repair, (4) compromising important intercostal (T8-L1), vertebral, pelvic and hypogastric collaterals, and (5) shaggy aorta. Preoperative, intraoperative, and postoperative managements have been required to prevent spinal cord injury with TEVAR. For imaging assessment of blood supply to spinal cord including Adamkiewicz artery, prophylactic cerebrospinal fluid drainage is mandatory, and monitoring motor-evoked potential is recommended for high risk factors of spinal cord injury. Mean arterial pressure should be maintained over 90 mmHg after stent-graft placement for a while to prevent delayed spinal cord ischemia in high-risk patients of spinal cord ischemia. Finally, because spinal cord injury during TEVAR is not rare and negligible, perioperative care during TEVAR should be strictly performed according to the protocol proposed by each cardiovascular team.

Endovascular Aortic Repair of Thoracic Aortic Disease:Early and 1-Year Results From a German Multicenter Registry

To report a "real-world" multicenter experience in the use of thoracic endovascular aortic repair (TEVAR) for diseases of the descending thoracic aorta. A prospective, multicenter, German TEVAR Registry was established in October 2008 and enrolled 191 patients (134 men; mean age 64.5±13.2 years) from 7 hospitals up to March 2011. Stent-graft implantation was performed for Stanford type B aortic dissection (104, 55.3%), true thoracic aortic aneurysm (91, 48.7%), intramural hematoma (20, 10.7%), penetrating aortic ulcer (16, 8.6%), and traumatic aortic rupture (6, 3.2%). Per patient, a mean of 1.2±0.7 stent-grafts were implanted. Technical success was 92.1% (164/178); 15 (8.5%) endoleaks (types I-III) were reported. Intervention duration was a mean 107±122 minutes. During the hospital stay, stroke occurred in 3.9% of patients (7/180) and paraplegia in 1.7% (3/180). Reintervention was performed in 3.3% (6/180). The mortality was 5.5% (10/181) in-hospital and 5.6% at 30 days. The mean follow-up was 24.5±27.7 months. The Kaplan-Meier estimates of 1-year reintervention and death rates were 7.2% and 11.4%, respectively. In this real-world TEVAR registry for acute or chronic descending aortic diseases, technical success was high and the short-term complication rate was acceptable. However, the high reintervention rate observed in the present study mandates thorough clinical and imaging follow-up after an initially successful procedure.

Early experience of thoracic endovascular aortic repair: a local single hospital experience

PurposeThe purpose of this retrospective study was to evaluate the short- to mid-term results of thoracic endovascular aortic repair (TEVAR) in Wonkwang University School of Medicine & Hospital.MethodsBetween February 2009 and May 2011, 8 consecutive patients had undergone endovascular stent-grafting for thoracic aortic diseases. Five patients were treated for traumatic thoracic aortic injuries, two patients were treated for thoracic aneurysms and one patient was treated for a pseudoaneurysm due to penetrating aortic ulcers. Attempted stent-graft deployment was performed electively in 6 patients and emergently in 2. Follow-up was performed at 1-month, 6-month, 1-year, and annually thereafter.ResultsTechnical success rates were achieved in 87.5% and the 30-day mortality rate was 0%. Mean hospital length of stay after TEVAR was 30 days in traumatic thoracic aortic injuries and 10 days in thoracic aneurismal diseases. Intra-operative Type I endoleak due to migration at deflation was visualized in 1 patient, which was treated by insertion of another stent-graft. During follow-up, a major complication was encountered in one patient who received carotid-subclavian bypass to relieve left arm ischemia. After 5 months he was treated with arch replacement for aortic arch aneurysm with type I endoleak at proximal site after endovascular treatment. The 30-day mortality rate was 0%. However, 1 case of mortality (12.5%) was observed during the follow-up period.ConclusionThe short and mid-term results of endovascular repair of thoracic aortic diseases are promising. TEVAR is an effective procedure in the management of thoracic aortic diseases.

Endovascular repair of thoracic aortic pathology

Endovascular repair of thoracic aortic pathology is an evolving and increasingly attractive alternative to open repair. Endograft technology and delivery systems have improved rapidly since their introduction in the 1990s, and early and mid-term results for currently available devices are promising. No individual device has proven to be superior as no comparative trials have been performed. However, each available device is unique in its characteristics to treat aortic disease: GORE® TAG® (WL Gore and Associates, AZ, USA), Zenith® (TX1® and TX2®, Cook, IN, USA), and Talent™ (Medtronic Vascular, CA, USA). In addition to a prerequisite set of endovascular skills, a detailed knowledge of different graft designs and an understanding of aortic pathology significantly affect the efficacy of endovascular repair of thoracic aortic disease. This article focuses on the currently available devices, their characteristics and pivotal clinical trial results.

RR1. Selective Cerebrospinal Fluid Drainage Protocole Is Effective to Prevent Spinal Cord Ischemia during Endovascular Repair of Thoracic Aortic Diseases: Results of a Comparative Study

RR1. Selective Cerebrospinal Fluid Drainage Protocole Is Effective to Prevent Spinal Cord Ischemia during Endovascular Repair of Thoracic Aortic Diseases: Results of a Comparative Study

Early and Midterm Results of Hybrid Endovascular Repair for Thoracic Aortic Disease

Background: A hybrid procedure using an open surgical extra-anatomic bypass of aortic arch vessels and thoracic endovascular aortic repair (TEVAR) is less invasive than open surgery, and provides a suitable proximal landing zone. Here we report our experience with a hybrid TEVAR procedure at a single center. Material and Method: We retrospectively reviewed consecutive patients with thoracic aortic disease who received a hybrid TEVAR procedure between August 2008 and January 2010. Patients’ data were prospectively collected and mean follow-up was 10.8±5.5 months (range 3~20). Result: Nine patients (7 males and 2 females) with a mean age of 63.8±15.8 years (range 38~84) underwent a hybrid procedure. Five patients had an arch or a proximal descending aortic aneurysm, two had a dissecting aneurysm of the descending aorta, and two had an aneurysm of the ascending arch and descending aorta. Mean expected mortality calculated by logistic EuroSCORE was 21%. Six patients underwent debranching and rerouting from ascending aorta to arch vessels, 2 had carotid-carotid bypass grafting, and 1 underwent carotid-axillary bypass grafting. Mean operation time was 221.4±84.0 min (range 94~364). Deployment success of endovascular stent grafting was 100% with no endoleak on completion angiography. There was no mortality, and a small embolism in the branch of the right opthalmic artery in one patient. During follow-up, one intervention was required for the endoleak. Actuarial survival at 20 months was 100%. Conclusion: Early and mid-term results are encouraging and suggest that hybrid TEVAR procedures are less invasive and safer and represent an effective technique for treating thoracic aortic disease.

Arterial Access for Thoracic Endograft Placement

Endovascular repair of thoracic aortic disease continues to evolve since FDA approval of the first thoracic endograft in the United States in March 2005. Certain anatomic characteristics, including adequacy of arterial access, remain a significant limiting factor in thoracic endovascular repair. In clinical trials evaluating thoracic endografts, vascular access complications occurred in >20% of cases. The purpose of this study is to evaluate the arterial access and the selective use of the ascending aorta for thoracic endograft placement. A retrospective review was performed for patients who underwent thoracic endograft placement between May 2005 and April 2009 (4 years since FDA approval of the first thoracic endograft). Patient records were reviewed for the indication for the procedure, type of arterial access, technical success, and access-related complications. Seventy-nine thoracic endografts were placed during the study period. The indications for endograft placement included 53 aneurysms, 10 traumatic lesions, 6 endoleaks, 4 dissections, 3 penetrating ulcers, 2 bleeding aortic fistulas, and 1 thoracic diverticulum. Retrograde access was used in 70 cases (89%): 60 femoral (76%) and 10 aortoiliac (13%). Antegrade access through a 10-mm polyester graft anastomosed to the ascending aorta was used in nine cases (11%). These procedures included endograft placement with proximal elephant trunk creation in six cases, endograft-alone in two cases, and combination with proximal arch reconstruction/debranching in one case. There was 100% technical success for all cases. The overall access-related complication rate was 6%. There were no complications with antegrade access through the ascending aorta or with aortoiliac access. There were five complications in the femoral access group (three iliac artery dissection, one iliac artery injury, and one femoral artery injury). Access selection is an important part of the preoperative planning of endovascular procedures. Choosing the most appropriate access for a patient will decrease the access-associated complication rate. In addition, selected patients with poor aortoiliac access and those that require debranching or elephant trunk procedures may benefit from antegrade access.

Quality assessment in open surgical repair of thoracic aortic disease

Risk-prediction and quality-assurance models facilitate comparison of surgeons, institutions, and emerging alternative technologies. With comparative context, the most meaningful outcomes for thoracic aortic (TA) repair can be identified, evaluated, and adopted to improve open TA repair among a variety of providers; moreover, open TA repair can be more accurately compared to endovascular TA repair. Although the EuroSCORE risk-stratification model was not specifically designed for TA repair, it is largely suitable for this purpose despite the aged dataset from which it was developed. However, such prediction models could be improved by expanding their end points to include not only mortality but other life-altering adverse events, such as paraplegia, stroke, and renal failure. Population-based studies may be useful in establishing trends and should be conducted in a fashion that will enhance their external applicability; procedure-volume studies are often limited as comparative benchmarks. Additionally, experienced centers have great value because they can report the outcomes of large numbers of cases. Despite a tendency to take on challenging cases, centers of excellence consistently report better outcomes than those observed in population studies. Stratifying reported outcomes for risk level and urgency of repair may have value, because it would avoid penalizing surgeons for taking on complex repairs. For the average patient with few comorbidities, the most durable and established repair should be offered, and the best contemporary success rates should be presented to facilitate that choice.

Endovascular repair of the thoracic aorta in the post-FDA approval era

Endovascular repair of thoracic aortic disease is rapidly progressing as an alternative to open surgical therapy. In March of 2005, the Gore TAG thoracic endoprosthesis (W. L. Gore & Associates, Inc, Flagstaff, Ariz) received Food and Drug Administration (FDA) approval for the treatment of descending thoracic aortic aneurysms. Subsequently, off-label use of the technology expanded to include additional thoracic aortic diseases. The purpose of this study was to examine whether the outcomes with this device changed after the inclusion and exclusion criteria of FDA-controlled trials no longer governed patient selection. A retrospective analysis was performed on all patients who underwent endovascular repair of the thoracic aorta with the Gore TAG device at our institution between March 23, 2005, and September 8, 2006. Fifty consecutive patients with a broad range of aortic pathologic conditions were included in the study. The results in this group compared with those of the phase II trial included the following: length of stay, 7.5 versus 7.6 days (P = .97); intensive care unit stay, 3.7 versus 2.6 days (P = .61); 30-day mortality, 2.0% versus 1.5% (P = .68); spinal cord injury, 2% versus 3% (P = .89); stroke, 4% versus 4% (P = .67); early endoleaks, 26% versus 4% (P < .01); and late endoleaks, 18% versus 7% (P = .08). At 1 year, overall survival was 92% compared with 82% in the phase II trial. In the post-FDA approval era, endovascular stent-graft therapy is frequently applied to patients with more challenging thoracic aortic anatomy and a wide range of pathologic conditions. Our results in this group are similar to outcomes reported for patients with descending thoracic aortic aneurysm exclusively.

Endovascular Repair of Thoracic Aortic Disease With the EndoFit Stent-Graft:Short and Midterm Results From a Single Center

To analyze the outcomes of endovascular treatment of thoracic aortic pathologies performed at a single center with the EndoFit thoracic stent-graft system. From January 2002 to January 2007, 41 patients (33 men; mean age 69.3+/-9.7 years, range 48-84) were treated for thoracic aortic disease with the EndoFit stent-graft system. Patient data were retrieved from a retrospective review of hospital records. Indications for treatment were progression of aneurysm size in atherosclerotic aneurysms (n = 24, mean aneurysm diameter 7.19+/-1.48 cm), acute contained aortic rupture (n = 5), aortic dissection (n = 6), penetrating atherosclerotic ulcers (n = 4), post-traumatic pseudoaneurysm (n = 1), and post coarctation repair aneurysm (n = 1). The EndoFit stent-graft was successfully deployed in all 41 patients. The in-hospital and 30-day mortality rate was 7.3% (3 patients). Three (7.3%) postoperative endoleaks were recorded: a proximal type Ia and a distal Ib both resolved spontaneously at 1 and 3 months, respectively. The third patient had a persistent type Ia endoleak; conversion was necessary after 1 year. There was only 1 case of spinal ischemia, with consequent lower extremity weakness; no paraplegia was observed. During a mean 24.8-month follow-up, 2 secondary type Ia endoleaks were treated with additional stent-grafts. There were 7 (17%) deaths during follow-up. At 2 years, overall patient survival by Kaplan-Meier analysis was 70%; aneurysm-related survival was 89%. Endovascular treatment of vascular disease involving the descending thoracic aorta can be safely performed with the EndoFit thoracic stent-graft system.

Noninvasive imaging for planning endovascular aortic procedures

Objective: One of the most fundamental differences between open surgical repair of thoracic aortic disease and treatment by endograft exclusion is the dependency on imaging for all critically important aspects of the endovascular approach. Patient selection and pre-procedure planning for device selection and sizing depend on imaging. Therefore aim of this study was to evaluate the accuracy of the 64-slice MDCT for aortic stent-graft planning.

Invited commentary

Invited commentary