Repair Of Thoracic Aortic Pathology Research Articles

Combined Endovascular Treatment of Complex Aortic Pathologies.

Multisegmented aortic pathologies present challenging issues independent of the treatment chosen. Whether open or endovascular, staged, or simultaneous, every treatment modality has its own pros and cons. We revealed our patients retrospectively with early and midterm results who had simultaneous endovascular thoracic and abdominal aortic repair for thoracic aortic pathologies and infrarenal abdominal aortic aneurysm (iAAA) as a single-center experience. Between January 2016 and January 2021, 16 patients were diagnosed with thoracic aortic pathology and iAAA was simultaneously repaired in an endovascular manner. All patients were operated on with the same cardiovascular surgeon team. The average age of the patients were 76.9 ± 6.2 (64-86) years. There was no early mortality. The technical success was 100%. In total, 18 thoracic endografts were deployed in 16 patients for thoracic aortic pathologies. Follow-up period was 21.85 ± 8.96 months, and in the follow-up period, two patients had a secondary intervention. One cardiac and one coronavirus disease 2019 mortality was detected in the follow-up period. There was no aneurysm-related mortality. The postoperative first-year survival was 84.6 ± 10.0. Simultaneous endovascular solution for complex multisegmented aortic pathologies provides a rapid, less-invasive approach with successful early and midterm morbidity, mortality with short intensive care unit period, and length of hospital stay. A combination of endovascular aortic aneurysm repair and thoracic endovascular aortic repair where anatomic suitability exists is a strong alternative over staged and hybrid therapies. Contrast-induced nephropathy, postimplantation syndrome, and spinal cord ischemia should be carefully monitored with this strategy.

Inferior Vena Cava—Balloon Occlusion and Its Effect on the Myocardium During Endograft Deployment in the Arch

Purpose: To evaluate the impact of cava balloon occlusion on the myocardium during endovascular repair of thoracic aortic pathologies. Material and methods: A prospective observational cohort study of 21 patients who underwent endovascular repair of aortic arch and thoracic aorta in a single tertiary referral center with use of inferior vena cava (IVC) balloon occlusion as a method of intraoperative cardiac output reduction. Pre-, intra-, and postoperative measurements of heart rate, blood pressure, stroke volume index, and central venous oxygen saturation were noted. High-sensitive serum troponin levels were also analyzed according to a pre-established protocol. Endpoints were cardiac troponin T levels after induced hypotension and left ventricular ejection fraction during follow-up. Secondary endpoints were procedure technical success and overall survival. Results: Twenty-one patients (18 male, median age 69, (62-75, IQR)) enrolled in the study between May 2015 and January 2019. Indication for endovascular treatment was an aortic arch aneurysm (n=10), descending aortic aneurysm (n=8), lusorian artery aneurysm (n=2), and thoracoabdominal aortic aneurysm (n=1). Median time to reach half mean arterial pressure was 60 seconds while median recovery time of blood pressure was 135 seconds. In 5 (24%) cases, we observed a > 50% change of Troponin T on the reference level. Technical success was achieved in all cases. Two (10%) patients developed new and persistent atrial fibrillation and 1 (5%) suffered a peri-operative ST-elevation myocardial infarction. Conclusion: The use of IVC balloon occlusion is a feasible technique for cardiac output reduction during endovascular repair of thoracic aortic pathologies. One fourth of the patients develop significant troponin leakage but the significance of the finding needs further studies.

Experience with Thoracic EndoVascular Aortic Repair (TEVAR) treatment of uncomplicated Stanford type B aortic dissection, 2022 Updates

There have been significant advances in the technique and application of endovascular repair of thoracic aortic pathology over the past 20 years. The Stanford type A and the complicated type B dissection patients require urgent/emergent intervention. In the last decade, earlier intervention has been pursued for uncomplicated type B dissections. The INvestigation of STent-grafts in Aortic Dissection (INSTEAD) Long term (XL) study showed that there was significant crossover from medical management to Thoracic EndoVascular Aortic Repair (TEVAR) at year 3, suggesting TEVAR might benefit this population long term. Today, the application of TEVAR, which was initially designed to address aneurysmal disease, has become a standard and Food and Drug Administrative (FDA) approved management option in dissections. Currently there are four FDA approved TEVAR devices in the United States for the treatment of the thoracic dissections, namely Gore, Medtronic, Cook, and Terumo. With each iteration, there are increased opportunities for customization and widespread use in individualized patient’s pathology. As the technology improves and the feasibility of the grafts expands, the complication rates continue to decline cementing the safety and efficacy of these thoracic aortic grafts. Two rare but catastrophic complications in spinal ischemia and retrograde Stanford type A aortic dissection are further discussed. With the success of the TEVAR, a new frontier of hybrid aortic surgery has developed. The debranching of the aortic arch vessels in order to advance the TEVAR proximal landing zones has been aggressively pursued. With the widespread growth of TEVAR technology it is apparent that complex aortic pathology can be safely repaired endovascularly. Article Details

Efficacy and cost-effectiveness of cell saver usage in the repair of thoracic aortic aneurysms and dissections.

A substantial amount of blood loss occurs during the open repair of aortic aneurysms or dissections. The aim of the present study is to determine the efficacy and cost-effectiveness of cell saver devices in blood conservation during the open repair of thoracic aortic pathologies. The present study prospectively collected the data pertaining to 25 patients who underwent surgical management of thoracic aortic aneurysms or dissections using a cell saver (Group 1, n = 25). The volume and cost of transfusion and postoperative outcomes were compared with the second group of patients who underwent surgery without the use of cell savers in the previous year (Group 2, n = 25); the data pertaining to the same were retrospectively collected from the hospital records. The patient characteristics and categorical variables were compared using the x2 test and Fisher's exact test. Transfusion volume and costs were compared using the independent samples t-test and Mann-Whitney U test. The patients in both the groups displayed similar characteristics and risk factors. The total volume of allogenic red blood cell (p < 0.001) and total blood product (p = 0.01) transfusions were significantly lower in Group 1. The cost of red blood cell (p < 0.001) and total transfusions (p = 0.03) were lower in Group 1. The two groups displayed similar in-hospital morbidity and mortality rates. There was a significant association between the use of cell savers and the decreased need for red blood cell and total blood product transfusions. Considering the cost of the cell saver set, transfusion costs in the two groups were comparable.

Outcomes of single physician-modified fenestrated stent grafts for endovascular repair of thoracic aortic lesions involving the distal aortic arch.

Our goal was to evaluate the outcomes of fenestrated thoracic endovascular aortic repair of thoracic aortic lesions involving the distal aortic arch using single physician-modified stent grafts. This single-centre, retrospective study included 58 consecutive patients (mean age, 57 ± 14 years; 11 women) who underwent fenestrated thoracic endovascular aortic repair for thoracic aortic pathologies involving the distal aortic arch using single physician-modified stent grafts between November 2015 and December 2018. Indications included complicated acute type B dissection or intramural haematoma with an unfavourable proximal landing zone (n = 49), type Ia endoleak subsequent to thoracic endovascular aortic repair due to acute type B dissection (n = 1) and distal arch degenerative aneurysms <15 mm from the left subclavian artery (n = 8). The technical success rate was 94.8%. The 30-day mortality was 1.7%, and the perioperative ischaemic stroke rate was 1.7%. The incidence of perioperative complications was 10.3%. At a mean follow-up of 26.3 months (range, 7-44), all target vessels were patent. All-cause mortality was 5.2%. Estimated 1-, 2- and 3-year survival was 98.3 ± 1.7%, 96.4 ± 2.5% and 93.2 ± 3.9%, respectively. The single fenestrated stent graft technique is feasible and effective for endovascular repair of thoracic aortic pathologies involving the distal aortic arch.

Transapical Endovascular Repair of Thoracic Aortic Pathology

Alternative access for thoracic endovascular aortic repair (TEVAR) has been explored for patients with unsuitable femoral and iliac access, but few cases of transapical access have been described. We report our experience with transapical access for various aortic pathologies. We reviewed 6 cases undergoing transapical access for endovascular repair of thoracic aortic pathology between December 2013 and August 2015. Five patients had an aortic arch aneurysm and 1 patient presented with Stanford type A subacute aortic dissection. Transapical access was indicated to avoid approach through the severely atherosclerotic thoracic descending aorta in 4 patients and severely kinked aorta in 1 patient and to treat an ascending aortic dissection lesion in 1 patient. Transapical endografting was completed in all patients. Significant aortic valve regurgitation occurred in 3 patients when a large bore sheath was placed across the aortic valve. There was 1 death attributed to global cerebral ischemia due to carotid dissection after carotid bypass and chimney stent-graft insertion. There were no access-related complications. Computed tomography revealed complete exclusion of the aortic aneurysm in 4 patients, and shrinkage of the false lumen in 1 patient with aortic dissection. Transapical access for TEVAR would be a potential alternative when the anatomy is unfit for routine retrograde approach. This method might have potential benefit of reducing the risk of embolism in patients with severe atherosclerotic thoracic descending aorta. However, certain safety concerns must be addressed, including maintenance of hemodynamics, wire exteriorization for navigation of the device tip, and rapid pacing during deployment.

Short- and Long-term Results of Hybrid Arch and Proximal Descending Thoracic Aortic Repair

Purpose: To evaluate the short- and long-term outcomes of hybrid repair of the arch and proximal descending aorta in a single tertiary center for aortic disease. Methods: A retrospective analysis was performed of 55 patients (median age 67 years; 36 men) who underwent hybrid repair of thoracic aortic pathology with involvement of the arch between January 2005 and May 2015 at a single tertiary center. The pathologies included 40 (73%) with aneurysmal disease, 10 (18%) acute type B aortic dissections, 2 with acute aortic syndrome, an acute type A dissection, and left and aberrant right subclavian artery aneurysms. Seven (13%) procedures were performed as an emergency. Demographics and procedure characteristics were collected for analysis of survival and reinterventions. Results: Complete aortic debranching was performed in 14 (25%) to facilitate endograft placement in zone 0; debranching was partial in 20 (36%) patients for zone 1 deployments and 21 (38%) for zone 2. Primary technical success was achieved in 51 (93%) cases. One patient died in-hospital from aneurysm rupture following aortic debranching prior to stent-graft repair. In another, the stent-graft procedure proved infeasible and was abandoned. The other 2 technical failures were due to type Ia endoleaks. Five (9%) patients died in-hospital (4 of 48 elective and 1 of 7 emergency cases); 2 of these patients died within 30 days (4%). Eight (14%) patients had a stroke, 6 of 48 elective and 2 of the 7 emergency patients. Spinal cord ischemia was reported in 3 (6%) patients. Mean follow-up was 74.6 months. Overall cumulative survival was 70% at 1 year, 68% at 2 years, and 57% at 5 years. Reintervention to the proximal landing zone for type Ia endoleak was required in 6% of cases. The overall rate of aortic reintervention was 18% at 1 year, 21% at 2 years, and 36% at 5 years. Overall extra-anatomic graft patency was 99%. Conclusion: Hybrid repair of the aortic arch and proximal descending thoracic aorta is technically feasible, with acceptable short-term mortality. There is a low rate of proximal landing zone reintervention when hybrid techniques are used to create an adequate proximal landing zone. Extra-anatomic bypass grafts have good long-term patency. Ongoing disease progression means that further distal aortic interventions are often necessary in patients with extensive disease.

Endovascular repair of thoracic aortic pathologies: Postoperative nursing implications

Endovascular stent grafting is increasingly used to manage descending thoracic aortic pathologies. The procedure was introduced at the study hospital in 2001. We sought to examine the short-term clinical outcomes of patients who underwent this endovascular stent grafting, with the aim of using the result as baseline for development of an in-center clinical management protocol. We undertook a single-center, retrospective review of health care records of patients managed with thoracic stent grafts from 2001 to 2009. Patient characteristics, in-hospital data, and procedural data were obtained. SPSS was used to analyze the data. A total of 30 patients were treated with thoracic stent; 23 were male, 7 were female, and the mean age was 55.0. Aortic pathologies treated were traumatic aortic dissection/transection (n=15), acute/chronic aortic dissection (n=9), and degenerative aneurysms (n=6). Endoleak occurred in 3 patients, with 1 requiring further endograft repair. Two patients underwent combined open and endovascular repair of acute thoracic aortic dissection; 1 died 4days after the procedure, and the other developed stroke and acute renal failure not requiring dialysis. Of the 28 patients who underwent endovascular repair, paraplegia and paraparesis occurred in 2 patients but resolved with cerebrospinal fluid drainage. Stroke occurred in 1 patient. Patients who underwent combined procedure of open and endovascular repair of thoracic aortic dissection had a greater risk of developing major adverse events than patients who underwent endovascular repair alone (Fisher's exact test P=.023). There was no association between the risk of stroke and the coverage of left subclavian artery in this series (P=.483). Graft stenting treatment for descending thoracic aortic pathologies has been shown to result in high in-hospital survival rates. It is essential for nurses who work in acute care settings to have knowledge of this procedure and potential complications associated with the procedure to enable postoperative assessment and immediate action if any deviation is observed.

The impact of bird-beak configuration on aortic remodeling of distal arch pathology after thoracic endovascular aortic repair with the Zenith Pro-Form TX2 thoracic endograft

Structural changes and incomplete endograft apposition to the aortic arch (bird-beak configuration) after thoracic endovascular aortic repair are poorly understood. The aim of this study was to analyze the morphologic changes, conformability, and angulation factors in patients who underwent stainless steel-based stent graft repair of thoracic aortic pathology. From March 2011 to March 2012, the study enrolled 19 patients with aortic pathology requiring proximal fixation in zones 2 and 3 who underwent stent graft repair using Zenith Pro-Form TX2 stent grafts (Cook Medical, Bloomington, Ind). For comparison, another 19 patients who received Zenith Z-Trak stent grafts were selected from December 2009 to February 2011. Chest computed tomography scans were analyzed at baseline, and then at 1, 6, and 12 months postoperatively. Arch angulation and bird-beak configuration were evaluated according to sealing zones of attachment by Aquarius iNtuition software (TeraRecon, San Mateo, Calif). The treated diseases included chronic type B aortic dissection in 17 patients and degenerative aneurysms in 21. Significant arch angle transformation was noted at the zone 2 level between the Pro-Form and Z-Trak treated groups (150° ± 11° vs 158° ± 6°; P = .033) and left subclavian artery level (152° ± 12° vs 160° ± 8°; P = .031) during 1 year of follow-up. The bird-beak configuration was detected in six patients (32%) in the Pro-Form group and in 11 (58%) in the Z-Trak group (P = .096) at 1 month, and in six (32%) in the Pro-Form group and in 14 (74%) in the Z-Trak group (P = .022) at 12 months. The mean bird-beak angle was significantly less in Pro-Form-treated patients at 1 month (5° ± 9° vs 15° ± 13°; P = .019) and at 1 year (6° ± 10° vs 18° ± 15°; P = .033). In the Pro-Form platform, a preoperative zone 2 angle <151.1° was a better estimation of the presence of a postoperative bird-beak configuration, with a sensitivity of 86% and specificity of 83%. Aortic remodeling after stainless steel stent graft repair of thoracic aortic pathology is a continuous process. Significant arch angle transformation was discovered over the zone 2 and left subclavian artery levels. TX2 Pro-Form stent grafts improved arch conformation after 1 year of follow-up. Furthermore, in the patients with dissection, a preoperative distal arch angle of zone 2 was predictive of postoperative bird-beak configuration, regardless of whether they were treated with a Pro-Form stent graft.

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.

Stenting of the descending thoracic aorta: a six-year single-center experience

The aim of this study was to review the six-year results of the endovascular repair of descending thoracic aortic pathologies, reporting the early perioperative outcomes as well as the mid-term follow-up of the treated patients. Fifty-five consecutive patients who underwent endovascular repair for thoracic aortic pathology (32 aneurysms, 17 acute thoracic aortic syndromes, and six traumatic aortic ruptures) during a six-year period were retrospectively reviewed. From these patients, 30 (54.5%) were treated electively and 25 (45.5%) on an emergency basis. In eight cases (14.5%) there was a need for left subclavian artery orifice overstenting. In seven patients (12.7%) an abdominal aortic lesion was simultaneously treated, while three more patients (5.5%) had previously had their abdominal aortic aneurysm repaired. The primary technical success was 92.7%. Seven patients (12.7%) underwent some operation related complication, while postoperative complications occurred in five patients (9.1%), namely four myocardial infarctions, one acute respiratory distress syndrome and two delayed parapareses resulting in an overall incidence of neurological complications of 3.6%. The combined 30-day and in-hospital mortality was 9.1%, exclusively related to patients treated emergently (P = 0.01). In a mean follow-up period of 34 months there were six deaths, and the overall cumulative survival at four years was estimated at 72.6%. Only one type II endoleak was observed one month after the procedure and it spontaneously disappeared 18 months later. The endovascular repair of descending thoracic aortic pathologies seems to be a well-established method, with favorable morbidity and mortality rates, at least for 30 days and in the mid-term. Taking into account the potential of a wide application of the endovascular technique in many vascular centers, stenting of the thoracic aorta might offer an overall better solution for patients suffering from these devastating pathologies.

Arch Debranching Versus Elephant Trunk Procedures for Hybrid Repair of Thoracic Aortic Pathologies

We compared outcomes of arch debranching (AD) and elephant trunk (ET) techniques when used with thoracic endovascular aortic repair. A review was performed of consecutive patients with proximal thoracic aortic pathologies repaired with a hybrid approach. Between 2005 and 2009, 58 patients underwent first-stage ET (n = 21) or AD (n = 37). Cardiopulmonary bypass was utilized in 100% of ET procedures and 68% of AD procedures (p < 0.01). Circulatory arrest was used in 86% of ET and 27% of AD cases (p < 0.01). The second stage was completed in 76% of ET and 76% of AD patients. Rates of spinal cord ischemia (ET 0 of 21, AD 0 of 37, p = 1.0), stroke (ET 2 of 21, AD 4 of 37, p = 1.0), and 30-day mortality (ET 4 of 21, AD 6 of 37, p = 1.0) were similar. Each group had one major aortic complication between the two stages. Type Ia endovascular leak at 1 and 12 months occurred in 13% ET patients and 4% AD patients at 1 month (p = 0.54) and in 0% ET patients and 4% AD patients at 12 months (p = 1.0). Kaplan-Meier estimates of survival at 1 and 12 months were 90.5% ± 6.4% and 73.1% ± 10% in the ET group, and 86.5% ± 5.6 and 71.6% ± 8.5 in the AD group, respectively (p = 0.68). The risk of a secondary procedure at 1 and 12 months was 76.2% ± 9.3% and 58.7% ± 12% in the ET group, and 71.0% ± 7.8% and 52.8% ± 10% in the AD group, respectively (p = 0.86). Arch debranching achieves equivalent results to standard elephant trunk repair but with a decreased need for cardiopulmonary bypass and circulatory arrest.

Predictors of Stroke and Paraplegia in Thoracic Aortic Endovascular Intervention

Background Endoluminal repair of thoracic aortic pathology has become established in clinical practice, but is associated with significant neurological complications. The aim of this study was to identify factors that were predictive of stroke and paraplegia. Methods Prospective data was collected for a cohort of 293 consecutive patients having thoracic aortic endovascular repair between August 1997 and September 2009. Patient and procedural characteristics were related to the incidence of stroke and paraplegia using multivariate logistic regression analysis. Results The median age was 68 years (18–87), there were 191 men and 102 women. Mortality was 5.1% for 195 elective and 13.4% for 98 urgent patients. Stroke affected 16 (5.5%) patients: 11 affected the anterior and 5 the posterior circulation. Coverage of the left subclavian artery with no revascularisation was the only significant factor predictive of stroke (OR 5.34 (1.42–20.40) P = 0.01). Paraplegia affected 16 patients (5.5%) but no independent risk factor was identified: 12 were identified perioperatively and 4 were delayed by up to 6 months. Conclusion Covering the left subclavian artery without revascularisation increases the risk of stroke following endoluminal repair of thoracic pathology. Paraplegia appears to be more complex and no independent precipitating factor was identified.

Endovascular Treatment of Late in—Stent-Graft Dissection After Thoracic Endovascular Aneurysm Repair

Complications after endovascular repair of thoracic aortic pathologies may be devastating. We report the case of endovascular treatment of late in-stent-graft dissection after thoracic endovascular aneurysm repair (TEVAR). A 25-year-old man was admitted to our hospital 2 years after endovascular treatment of posttraumatic aortic pseudoaneurysm using stent-graft implantation with an acute sudden onset of ischemia in both legs with absent femoral pulses, numbness, and renal functions deterioration. Multidetector computed tomography (MDCT) angiography showed an intimal flap in the distal part of the stent-graft with critical stenosis of the residual lumen. The patient was successfully treated with stent-graft implantation by way of percutaneous approach while under local anesthesia. The risk of this late complication after TEVAR should be considered during follow-up, especially in young patients with increased physical activity. Endovascular treatment can be the method of choice for these patients.

Spinal Cord Protection with a Cerebrospinal Fluid Drain in a Patient Undergoing Thoracic Endovascular Aortic Repair

Paralysis and paraparesis are dreaded complications of thoracic endovascular aortic repair (TEVAR) that occur with an incidence of 2%-6%. Risks factors include the type of thoracic aortic pathology treated, coverage of the left subclavian artery origin without revascularization, concomitant infrarenal abdominal aortic aneurysm repair, extent of stent graft coverage of the thoracic aorta, and renal failure. Cerebral spinal fluid (CSF) drains have been advocated as one of several protective strategies to prevent spinal cord ischemia. This case discussion briefly addresses the evidence supporting the use of CSF drains in patients undergoing TEVAR and offers an algorithm for managing CSF drains.

Hybrid repair of a symptomatic thoracic intra-mural haematoma

The repair of thoracic aortic pathology by open techniques is associated with high morbidity and mortality. We describe the first case of hybrid thoracic aortic repair performed in Ireland for a symptomatic thoracic intramural haematoma. Hybrid repair with extra-anatomical aortic visceral revascularisation and subsequent thoracic endograft exclusion offers an attractive alternative method of repair for thoracic aortic pathology.

Neurological complications associated with endovascular repair of thoracic aortic pathology. A single-centre experience

Neurological complications associated with endovascular repair of thoracic aortic pathology. A single-centre experience

Endovascular Approaches to Complex Thoracic Aortic Disease

Diseases of the thoracic aorta remain among the most lethal and difficult to treat conditions. In 2005, the US Food and Drug Administration approved the first endoprosthesis for the treatment of aneurysms of the descending thoracic aorta; at present, there are 3 thoracic devices approved by the US Food and Drug Administration. Although approved only for the treatment of descending aneurysms, thoracic endografting has other potential off-label applications, including acute and chronic aortic dissection and traumatic aortic transection. Endovascular repair of thoracic aortic pathology is emerging as the preferred treatment strategy in certain patients, as increasing data suggest that endovascular repair may be performed with lower peri-operative morbidity and mortality rates and similar midterm survival, when compared with standard open repair. However, because of anatomic constraints related to required endograft seal zones, a significant number of patients are excluded from standard endovascular repair. Hybrid techniques, including open aortic arch and thoracoabdominal debranching procedures, have been described to allow creation of proximal and/or distal landing zones for the stent graft seal. This review describes the surgical and anesthetic considerations relevant to thoracic endografting, with an emphasis on hybrid procedures used to treat more complex thoracic aortic pathology. Hybrid techniques may be performed with lower rates of morbidity and mortality than conventional open repair, and they appear to be a safe alternative to open repair for thoracoabdominal and aortic arch aneurysms in properly selected patients with significant comorbidity or prior open aortic surgery.

Abstract No. 239: Non-Aneursymal Acute Aortic Syndromes – 3D CT Imaging Features for Interventional Management

To review and audit our single institution experience to-date in endovascular repair of thoracic aortic pathology. A formal thoracic aortic stent programme was inititated in June 2006 by the radiology department in collaboration with the national cardiothoracic center and vascular surgery departments. Prior to this a number of stents had been performed electively by the cardiology and cardiothoracic services. We prospectively recorded the patients treated by radiology and retrospectively reviewed clinical, imaging and follow up data on all patients. A total of 29 patients were treated over 2 years. The underlying thoracic conditions included aneurysm, dissection, pseudoaneurysm, transaction and aorto-bronchial fistula. Radiology performed 10 stents in 9 patients over 12 months and all the emergency cases. 8 TAG (Gore), 2 Palmaz and 6 Valiant (Medtronic) stents were employed. Cardiology performed 14 Palmaz stents for Coarctations. All had pre-procedure and follow-up 2D and 3D CT angiography. All patients had successful stenting procedures. There was one death in a patient of high risk and multiorgan dysfunction pre-procedure. There were 2 stent foldings/kinks one of which required angioplasty and balloon mounted stent. There were no stent migrations or endoleaks. There was no paraparesis or paralysis from stent procedures. Non-stent complications included 1 surgical bypass which thrombosed requiring re-operation. Thoracic aortic stenting has been performed with consistent clinical success in our institution for a variety of non-aneurysmal aortic pathologies. Results compare favourably to international standards. The radiology department has provided a reliable diagnostic and therapeutic service over the last 12months with good results in the elective and emergency setting.

Neurologic complications associated with endovascular repair of thoracic aortic pathology: Incidence and risk factors. A study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) Registry

Endovascular treatment of thoracic aortic disease may be associated with severe neurologic complications. The current study used the data of a multicenter registry to assess of the incidence and the risk factors for paraplegia or paraparesis and intracranial stroke. The European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) database prospectively enrolled 606 patients. Thoracic pathologies with urgent or elective presentation, which included degenerative aneurysm in 291, aortic dissection in 215, traumatic rupture in 67, anastomotic false aneurysm in 24, and infectious or nonspecified disorders in 9. Study end points included evidence of perioperative spinal cord ischemia (SCI) or stroke. Univariate analysis and multivariate regression models were used to assess the significance of clinical factors that potentially influenced the occurrence of neurological sequelae. Paraplegia or paraparesis developed in 15 patients (2.5%) and stroke in 19 (3.1%); two patients had both complications. At multivariate regression analysis, independent correlation with SCI was observed for four factors: (1) left subclavian artery covering without revascularization (odds ratio [OR], 3.9; P = .027), (2) renal failure (OR, 3.6; P = .02), (3) concomitant open abdominal aorta surgery (OR, 5.5; P = .037) and (4) three or more stent grafts used (OR, 3.5; P = .043). In patients with perioperative stroke, two correlating factors were identified: (1) duration of the intervention (OR, 6.4; P = .0045) and (2) female sex (OR, 3.3; P = .023). A neurologic complication (paraplegia or stroke) developed in 8.4% of the patients in whom left subclavian covering was required compared with 0% of patients with prophylactic revascularization (P = .049). Perioperative paraplegia or paraparesis was significantly associated with blockage of the left subclavian artery without revascularization. The clinical significance of this source of collateral perfusion of the spinal cord had not been confirmed previously. Intracranial stroke was associated with lengthy manipulation of wires, catheters, and introducer sheaths within the aortic arch, reflected by a longer duration of the procedure.