Side-arm Graft Research Articles

Repair of pseudoaneurysm in extra-anatomic aortic arch bypass graft.

Repair of pseudoaneurysm in extra-anatomic aortic arch bypass graft.

Custom-Made Bifurcated Prosthetic Graft for Aortoiliac Aneurysm Repair.

Revascularization of the internal iliac artery during open repair of aortoiliac aneurysms can be challenging, especially if there is a significant distance between the orifices of the internal and external iliac arteries owing to common iliac aneurysmal dilatation. We describe a technique involving insertion of an 18-mm tube graft between the proximal aortic neck and aneurysmal common iliac artery bifurcation. Revascularization of the contralateral external iliac artery is accomplished through an 8-mm side arm graft.

Durability of open surgical repair of type I-III thoracoabdominal aortic aneurysm

ObjectiveEarly outcomes and late mortality after open repair of extent I to III thoracoabdominal aortic aneurysms (TAAAs) are described, but late graft and aortic events are seldom detailed. This study investigated long-term aortic and graft outcomes as these data are increasingly important as endovascular repair matures. MethodsDuring 28 years, 516 patients underwent repair (type I, n = 177 [34%]; type II, n = 100 [20%]; type III, n = 239 [46%]). Patients were monitored for late events. Late aortic events were defined as native aortic disease leading to death or further intervention. Planned secondary procedures were excluded. Graft complications included anastomotic aneurysm, graft infection, and branch occlusions. Variables were assessed for association with end points using log-rank methods and Cox proportional hazards regression. Time-to-event analysis was performed using Kaplan-Meier methods. ResultsIn-hospital death occurred in 40 patients (8%), leaving 476 for surveillance. Mean age was 69.8 ± 10.5 years. Mean follow-up was 4.9 ± 4.6 years. Repair conduct included distal aortic perfusion and motor evoked potential monitoring (n = 169 [35.5%]), clamp and sew (n = 307 [64.5%]), and selectively applied in-line mesenteric shunting (n = 172 [36.1%]). At the time of repair, 117 patients (24.6%) had 122 synchronous, noncontiguous aortic aneurysms. There were 98 late aortic and graft events in 89 patients (18.7%); 62 aortic-related events occurred in 56 patients (12%; elective repair, n = 47; emergent repair, n = 14; type A dissection, n = 1) at a mean of 4.4 ± 4.2 years after repair. Variables independently predictive of an aortic event were aortic clamp time (hazard ratio [HR], 1.02/min; P = .001), type III extent (HR, 2.5; P = .008), and expansion of retained aorta (HR, 10.4; P < .0005). There were 33 patients (7%) who experienced 36 graft-related events (anastomotic aneurysm, n = 14 [3% of cohort; aortic, n = 7; visceral patch, n = 6; side graft, n = 1]; graft infection, n = 12; renovisceral occlusion/repair, n = 9 [1.9%; side-arm graft, n = 8; native, n = 1]; and anastomotic stricture, n = 1) occurring at 4.7 ± 4.5 years. Variables predictive of graft-related complication were type II extent (HR, 3.4; P = .002) and distal aortic perfusion and motor evoked potential monitoring (HR, 3.6; P = .02). Freedom from aortic- or graft-related event was 80% at 5 years. Freedom from any aortic or graft reintervention was 84% at 5 years. Aortic-related mortality after discharge was 2.7% and estimated to be 3.1% at 5 years. Overall survival was 67% and 44% at 5 and 10 years, respectively. ConclusionsAfter type I-III TAAA repair, late aortic and graft-related events occur in 19% of patients. Native aortic disease sequelae are more common than graft complication. Aortic events are predicted by complex operation and degree of remaining aorta. Extensive reconstruction drives graft-related events. Ultimately, reintervention is rare and aorta-related mortality low. These findings verify durability of extensive TAAA repair, serving as benchmarks for endovascular repair.

Comparison of Direct Versus Side-Arm Graft Cannulation of the Axillary Artery in Patients With Acute Type A Aortic Dissection

Aim: In our unit, we use the axillary artery as an arterial cannulation site to reduce intraoperative malperfusion and facilitate antegrade cerebral perfusion in patients undergoing surgical management of acute type A aortic dissection (ATAAD). Two techniques used to achieve this are cannulation directly or through the use of a side-arm graft. The purpose of this study was to evaluate our unit's experience with both techniques and investigate cannulation-related morbidity and patient outcomes.

Direct axillary cannulation with open Seldinger-guided technique: is it safe?

Axillary artery cannulation is commonly used in thoracic aortic surgery, often utilizing a sidearm graft. Although our institutional preference is femoral cannulation, we use axillary cannulation in select cases with a 'dirty' aorta on computed tomography scan or intraoperative transoesophageal echocardiography. Since 2011, we have routinely used an open Seldinger-guided approach for axillary cannulation. Here, we report our experience with open Seldinger-guided technique, evaluating its safety and efficacy. A retrospective analysis of our institutional database from 2011 to 2016 was performed to find cases of peripheral arterial cannulation for thoracic aortic surgery. We identified 404 consecutive patients who underwent peripheral arterial cannulation. Of these, 352 were femoral and 52 were axillary cannulations. All axillary cannulations were performed for ascending and/or arch surgery. The technique involves a surgical exposure of the artery which is then cannulated by guidewire inside a purse string without arterial incision. Indications for surgery included aneurysm in 63.5% (33/52), dissection in 30.7% (16/52) and pseudoaneurysm in the remaining 5.8% (3/52). Hospital survival was 98.1% (51/52). There were no instances of axillary arterial injury or intraoperative malperfusion phenomena. No postoperative limb ischaemia or stroke was evident. No wound infections or late pseudoaneurysms were observed. The open Seldinger-guided technique for axillary artery cannulation is safe and effective. We strongly recommend this technique, given its speed and simplicity. The vessel is not snared, thereby preserving distal arterial flow and minimizing the risk of acute limb ischaemia. Furthermore, the limited manipulation of the artery lowers the risk of local complications.

Alternative peripheral perfusion strategies for safe cardiopulmonary bypass in atrial septal defect closure via a right minithoracotomy approach.

In cases of cardiac surgery via a minimally invasive right minithoracotomy approach, cardiopulmonary bypass is established with peripheral arterial cannulation, frequently with a single femoral artery. Occasionally, alternative perfusion access is required to prevent perfusion site-related complications. In this study, the feasibility of alternative perfusion strategies was verified by comparing the postoperative outcomes and complications. The records of 91 consecutive patients (68 women, 23 men; mean age 40.7±16.5years) who underwent atrial septal defect (ASD) closure via a right minithoracotomy approach between January 2009 and September 2014 were reviewed. Patients were divided into two groups: those with single femoral arterial access (SF group, n=84), and those with alternative perfusion access (ALT group, n=7, bilateral femoral arterial cannulation in 6, side-arm graft anastomosed to the femoral artery in 1). Femoral artery diameter was smaller in the ALT group than in the SF group (6.5±0.5 vs. 7.3±1.0mm, P=0.013). Operating time was longer in the ALT group than in the SF group (259.2±54.0 vs. 208.3±54.9min, P=0.031). One patient was converted to ascending aortic cannulation owing to high perfusion pressure. Postoperative major cardiac or cerebrovascular events, such as death, stroke, or myocardial infarction, did not occur in either group. Alternative perfusion access was safe in ASD closure via a right minithoracotomy approach. Precise preoperative evaluation of the iliofemoral artery is important for choosing the appropriate perfusion strategy.

Commentary on "Multibranched Frozen Elephant Trunk with Left Subclavian Artery Cannulation" by Martinelli, G.L. et al.

Dear Editor: The paper by Martinelli et al. [1] presents a variant of the frozen elephant trunk procedure for repair of pathology in the ascending aorta, aortic arch, and proximal descending aorta. The authors take the approach of performing the distal anastomosis in an extra-anatomic location proximal to the innominate artery. Their other modification involves a side-arm graft to the subclavian artery, which is used initially for perfusion and subsequently for permanent anastomosis to the main graft. This approach is well conceived and offers several potential advantages. First, this technique, like all frozen elephant trunk methods, aims to achieve thrombo-exclusion of the false lumen after introduction of an endoprosthesis into the descending aorta, with the purpose of reducing late aneurysm formation. However, this technique cannot overcome the impact of distal reentries below the bottom of the frozen elephant trunk, which can encourage late dilatation in those segments. Second, transposing the proximal anastomosis to a more proximal extra-anatomic location certainly facilitates the anastomosis, is likely to reduce the circulatory arrest time, and avoids trauma to the recurrent laryngeal nerve. A number of concerns arise regarding this technique, presented in this paper after experience in five patients: The early surgical results (20% mortality) are concerning, with one death and one dialysis-requiring renal failure in this small, early series. Late results are completely unknown. The patency and long-term fate of the multiple long grafts to the great vessels (innominate, left carotid, left subclavian) are entirely unknown. Especially, the patency over long intervals of the subclavian graft traversing the chest wall is entirely unknown. The idea that perfusing the left subclavian artery and, in this way, the left vertebral artery and the anterior spinal artery, is purely anatomical and speculative. There is no physiological or other evidence that this will produce actual benefit to the spinal cord. Since this series is so small, the argument that the authors had no spinal problems is not cogent. Reoperation on patients having had such an operation would be formidable when we look at Figure 2 [1], showing the end anatomic result. Despite the potential theoretical advantages of the proposed approach, strong caution is advised regarding its widespread adoption.

Open triple-branched stent graft applied to patient of acute type a aortic dissection with Aberrant Right Subclavian Artery

A 57-year-old Chinese male patient presented with Standford type A aortic dissection with an aberrant right subclavian artery (ARSA). At operation, the ascending aorta was replaced by a mono–branch vascular prosthesis with the branch bypassing to the ARSA; the triple-branched stent graft was inserted into the true lumen of the arch and proximal descending aorta (covering the origin of the ARSA) with each sidearm graft being positioned into the aortic branches; and then its proximal end was sutured to mono–branched vascular prosthesis. Follow-up computed tomography angiography showed false lumen of the dissection disappeared with satisfactory position of the triple-branched stent graft.

A simple technique for the management of bleeding from axillary cannulation site

A simple technique for the management of bleeding from the axillary cannulation site is described. We present this technique due to the fact that bleeding usually occurs in side-arm graft technique from axillary artery cannulation site during cardiopulmonary bypass in aortic surgery patients.

Open triple-branched stent graft placement for the surgical treatment of acute aortic arch dissection

BackgroundThe primary experience of open triple-branched stent graft placement for acute aortic arch dissection was reported.MethodsBetween January 2011 and October 2011, 13 well-selected patients (mea age, 46±8.2 years; approximate range, 30~58 years) with acute aortic arch dissection underwent open triple-branched stent graft placement for total arch reconstruction. The triple-branched stent graft was a branched 1-piece graft consisting of a self-expandable nitinol stent and polyester vascular graft fabric (Yuhengjia Sci Tech Corp Ltd, Beijing, China).During hypothermic circulatory arrest, through the transverse incision of the ascending aorta, the main graft of the triple-branched stent graft was inserted into the true lumen of the arch and proximal descending aorta, and then each sidearm graft was positioned one by one into the aortic branch. Once the main graft and sidearm grafts were properly positioned, the restraining strings were withdrawn and then the main graft and sidearm grafts were deployed. Enhanced electric beam computed tomography was performed in each patient before discharge to evaluate the postoperative time course of the residual false lumen.ResultsOpen triple-branched stent graft placement was technically successful in all patients. The mean cardiopulmonary bypass time, aortic cross-clamp time and arrest time were 138.40±47.75 min, 70.60±28.94 min and 28.60±12.48 min, respectively. All patients were discharged from hospital. Their computed tomographic scans postoperatively showed that all stent grafts were fully opened and not kinked, there was no blood flow surrounding the triple-branched stent graft.ConclusionOpen triple-branched stent graft placement is a new effective technique for total arch reconstruction in acute arch dissection.

Endovascular Aneurysm Repair

Since first described by Parodi in 1991, endovascular aortic repair (EVAR) has progressively and dramatically changed the approach to treating abdominal aortic aneurysm (AAA) disease.1 Whereas historically developed to treat patients unfit for open repair, EVAR now represents the primary paradigm by which most infrarenal AAAs are managed. This paradigm shift has occurred in the setting of long-term clinical uncertainty and increased expense, largely secondary to the costs of the endograft itself. EVAR is currently performed by multiple interventional and surgical specialties. Outcomes are associated with lower in-hospital mortality rates compared with open repair, often permitting successful discharge of patients within 24 hours. Because the market share of EVAR has increased, the endograft industry has also seen tremendous growth and development. Cross-sectional imaging with 3-dimensional reconstructions has become paramount to the appropriate and timely management of aortic aneurysms. At present, even in the setting of aortic rupture, EVAR is preferred because it has been associated with lower mortality rates compared with open repair. Despite the rampant increase in EVAR, not all patients are anatomic candidates for EVAR as defined by industry-issued instructions for use. Therefore, alternative treatment strategies, such as altering endografts with fenestrations or sidearm grafts, snorkeling stent grafts alongside endografts, or performing hybrid debranching procedures with open bypasses to the viscerals and renals followed by endografting have been developed. Although the data supporting EVAR as the primary treatment option for infrarenal AAA is robust, its superiority over open repair can be questioned until the long-term outcomes (>10 years) from landmark randomized controlled trials begin to surface. Parenthetically, the indications for EVAR seem to be increasing because clinical equipoise remains ambiguous and fewer trainees are required to perform open AAA repair. Although early use of EVAR was primarily at centers of excellence, currently it has become the most …

Side-Arm Grafts for Femoral Extracorporeal Membrane Oxygenation Cannulation

Lower extremity ischemia is an important source of morbidity with femoral venoarterial extracorporeal membrane oxygenation support. We describe our experience with the use of a side-arm graft sewn to the femoral artery that facilitates adequate extracorporeal membrane oxygenation flow while preventing lower extremity ischemia.

Continued favorable results with open surgical repair of type IV thoracoabdominal aortic aneurysms

Type IV thoracoabdominal aortic aneurysm (TAAA) repair, despite low risk of spinal cord ischemia (SCI), is reported to have significant morbidity and mortality. This has led some to apply adjuncts (eg, extracorporeal circulation) used in more extensive TAAA repair or to consider alternative approaches, such as hybrid operations. We have used a consistent, simplified surgical approach to type IV TAAA, and the goal of the present study is to review experience over 2 decades with such treatment and to identify correlates of surgical morbidity. All type IV repairs at Massachusetts General Hospital from January 1989 through September 2009 were evaluated for clinical features, technical operative details, and 30-day outcomes. Logistic regression identified predictors of morbidity. Survival was assessed using Kaplan-Meier analysis. A total of 179 patients underwent type IV repair, with elective repair in 156 (87%) and urgent in 23 (13%). The clamp-and-sew technique was used for all operations, with routine hypothermic renal perfusion. Clinical features were age 73 ± 8 years, coronary artery disease in 89 (50%), and creatinine level >1.8 mg/dL defining chronic renal insufficiency (CRI) in 32 (18%). Operative reconstruction in 166 (93%) consisted of one beveled proximal anastomosis incorporating the descending thoracic aorta, celiac, superior mesenteric artery, and right renal arteries origins (mean visceral clamp time, 36 ± 12 minutes) and a side-arm graft to the left renal artery. Technical details included previous abdominal aortic aneurysm (AAA) repair in 52 (29%), operative time of 290 ± 90 min, estimated blood loss of 2.7 ± 1.4 L, and splenectomy in 57 (32%). The 30-day outcomes were death in 5 (2.8%), myocardial infarction in 6 (3.4%), hemodialysis in 5 (2.8%), and any degree of SCI in 4 (2.2%). Regression analysis identified a history of CRI as an independent predictor of postoperative complication or death (odds ratio, 3.4; 95% confidence interval, 1.4-8). Survival rates at 1, 5, and 10 years were 89% ± 2%, 62% ± 4%, and 36% ± 5%, respectively. A simplified operative approach for type IV TAAA repair is associated with favorable perioperative results. These data refute the need for surgical adjuncts commonly applied in more extensive TAAA and indicate that the hybrid operation is an illogical posture. CRI should figure prominently in clinical decision making. Long-term survival equates that observed after routine AAA repair.

Extensive Primary Repair of the Thoracic Aorta in Acute Type A Aortic Dissection by Means of Ascending Aorta Replacement Combined With Open Placement of Triple-Branched Stent Graft

To simplify extensive primary repair of the thoracic aorta in acute type A aortic dissection, we developed the open triple-branched stent graft placement technique. The early results of this new technique are reported. Between June 2008 and November 2009, 30 patients with acute Stanford type A aortic dissection underwent extensive primary repair of the thoracic aorta by means of ascending aorta replacement combined with open placement of triple-branched stent graft. Placement of the triple-branched stent graft into the true lumen of the descending aorta, arch, and 3 arch vessels was technically successful in all patients. The mean cardiopulmonary bypass time, aortic cross-clamp time, and lower body arrest time were 151.8 ± 16.69, 84.1 ± 6.97, and 31.17 ± 5.34 minutes, respectively. The postoperative mechanical ventilation support period and duration of intensive care unit stay were 17.93 ± 2.35 and 62.10 ± 9.24 hours, respectively. All implanted stent grafts were fully opened and not kinked; there was no space or blood flow surrounding the triple-branched stent graft and no sidearm graft stenosis or occlusion. The false lumen of the descending aorta distal to the stent graft closed with thrombus in 25 of 30 patients at their first postoperative scans and in 26 of 30 at the 3-month postoperative scan. Open triple-branched stent graft placement is an effective technique with satisfactory early results. With this technique, extensive primary repair of the thoracic aorta may become easier and safer for acute type A aortic dissection.

Comparison of Right Internal Thoracic Artery and Right Gastroepiploic Artery Y Grafts Anastomosed to the Left Internal Thoracic Artery

Early and 1-year results of arterial Y composite grafts anastomosed to the in situ left internal thoracic artery were studied. Three hundred twelve patients who underwent off-pump coronary artery bypass using arterial Y composite grafts for revascularization of the left coronary artery territory were analyzed. A skeletonized right internal thoracic artery (RITA) or right gastroepiploic artery (RGEA) was anastomosed to the side of the left internal thoracic artery to construct a Y composite graft. Propensity-matched analysis was used to match patients using RITA (RITA group, n = 102) with patients using RGEA (RGEA group, n = 102). Postoperative coronary angiographies were performed early (200 of 204; 1.8 +/- 1.7 days) and 1 year (171 of 204, 11.3 +/- 2.5 months) postoperatively. There were no differences in postoperative mortalities (1 of 102 versus 2 of 102; p = 1.000) and morbidities including atrial fibrillation, mediastinitis, and perioperative myocardial infarction between the RITA and RGEA groups (not significant). Early and 1-year postoperative angiographies showed that there were no significant differences in patency rate between the two groups (early, 99.4% versus 99.3%; p = 1.000; 1-year, 95.4% versus 97.4%; p = 0.251). When the early and 1-year patency rates were compared based on the side-arm graft used, there were no differences in patency rates of RITA versus RGEA grafts between the two groups (early, 99.4% versus 100%; p = 1.000; 1-year, 96.5% versus 97.7%; p = 0.724). Construction of Y composite grafts using the RITA or RGEA showed comparable results including patency rates early and 1 year postoperatively.

Invited Commentary

Transient or permanent neurologic deficits remain the major cause of morbidity and mortality after complex aortic arch reconstruction. Neuroprotective strategies during aortic arch surgery include hypothermic arrest (HCA) alone, HCA in conjunction with retrograde cerebral perfusion (RCP), or antegrade cerebral perfusion (ACP), moderate hypothermia with ACP, and even normothermic complete arch replacement without circulatory arrest. The ideal method of arterial cannulation and cerebral and systemic protection remain undefined. Several reports document the safety and efficacy of these various approaches. However, large clinical series and laboratory data have suggested several limitations of RCP in aortic arch surgery. Svensson and colleagues [1Svensson L.G. Nadolny E.M. Penney D.L. et al.Prospective randomized neurocognitive and S-100 study of hypothermic circulatory arrest, retrograde brain perfusion, and antegrade brain perfusion for aortic arch operations.Ann Thorac Surg. 2001; 71: 1905-1912Abstract Full Text Full Text PDF PubMed Scopus (108) Google Scholar] have documented that the brain is incompletely perfused when using RCP. Okita and colleagues [2Okita Y. Minatoya K. Tagusari O. et al.Prospective comparative study of brain protection in total aortic arch replacement: deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion.Ann Thorac Surg. 2001; 72: 72-79Abstract Full Text Full Text PDF PubMed Scopus (203) Google Scholar] found that the prevalence of transient neurologic dysfunction was significantly higher using RCP when compared with ACP. A recent survey of major aortic centers found 50% preferred selective ACP, 38% used a combination of techniques, and 6% used both HCA and RCP [3Stein L.H. Elefteriades J.A. Protecting the brain during aortic surgery: an enduring debate with unanswered questions.J Cardiothorac Vasc Anesth. 2009 July 29; ([Epub ahead of print])Google Scholar]. Numerous arterial perfusion techniques have been described that allow ACP during aortic arch surgery. These techniques include selective cannulation of the ostium of the innominate artery (IA) or left carotid artery (or both of these arteries), cannulation of the axillary artery, cannulation of the innominate artery, and construction of an arch first graft. Huang and colleagues [4Huang F.J. Wu Q. Ren C.W. et al.Cannulation of the innominate artery with a side graft in arch surgery.Ann Thorac Surg. 2010; 89: 800-804Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar] have described a method of innominate artery perfusion using an 8-mm vascular graft in conjunction with the use of HCA for aortic arch surgery. The majority of patients in this series had type A dissections (34 of 46 patients), 4 patients required surgery for type B dissection, and the remainder had aneurysmal disease of the ascending aorta and arch. The operative mortality rate for this complex set of patients was a respectable 6.5%. Interestingly, there were no reported neurologic complications of either transient or permanent neurologic dysfunction. Although the methods and techniques used by Huang and colleagues [4Huang F.J. Wu Q. Ren C.W. et al.Cannulation of the innominate artery with a side graft in arch surgery.Ann Thorac Surg. 2010; 89: 800-804Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar] have largely been described elsewhere for ACP during aortic arch surgery, the novel idea of attaching a side-arm graft to the innominate artery is unique. The authors suggest that a side-arm graft is preferential to direct cannulation for the following reasons: less risk of damage to the innominate artery, less requirement for manipulation of a cannula, and less risk of stenosis of the IA after tying down the pursestring sutures after de-cannulation. Perhaps these reasons are based more on surgeon preference, as many centers report excellent results with direct cannulation. Indeed, the main benefit of direct IA perfusion is the rapidity in which it may be accomplished in an urgent or emergent situation, which requires aortic arch reconstruction (ie, dissection surgery). In addition, the use of a side-biting clamp, as the authors describe, may be more traumatic to the IA than direct cannulation. Therefore, a side-arm graft may be an over complicated method for ACP for most patients. The authors did illustrate one example in which a side-arm graft would be necessary (ie, those patients with small IA diameters). The authors should be commended on their early series of a unique method to supply ACP during complex aortic arch reconstruction. The absence of any neurologic complications is remarkable in this challenging patient population, and the authors' work contributes to the expanding experience of refining aortic arch surgery. Cannulation of the Innominate Artery With a Side Graft in Arch SurgeryThe Annals of Thoracic SurgeryVol. 89Issue 3PreviewThe purpose of this study was to examine the safety and efficacy of cannulation of the innominate artery with a side graft in arch surgery. Full-Text PDF

Reversal of delayed-onset paraplegia with thrombectomy of an interposed graft for the intercostal artery after thoracic descending aortic aneurysm repair

A 78-year-old woman who had previously undergone prosthetic graft replacement of the total aortic arch was admitted to repair a chronic expanding type IIIb dissecting aneurysm. Firstly the patient's abdominal aorta was replaced with a prosthetic graft without any complications, then the thoracicdescending aorta was repaired five months later. Surgery for the thoracic descending aorta was performed with distal perfusion, cerebrospinal fluid drainage, somatosensory evoked potential (SEP) monitoring and reimplantation of three pairs of intercostal arteries. During surgery, SEP showed no significant changes, and the patient awoke without paraplegia three hours after the surgery. However, she developed bilateral complete paraplegia eight hours after the surgery. Reexploration demonstrated thrombo-occlusion of the sidearm graft for reimplantation of the Th10 intercostal artery. After thrombectomy of the sidearm graft, there was gradual neurological recovery and the patient was ambulatory when discharged. Quick treatment to restore the spinal cord blood supply promoted recovery from paraplegia.

Thoracovisceral segment aneurysm repair after previous infrarenal abdominal aortic aneurysm surgery

Objective Repair of thoracovisceral aortic aneurysms (TVAA) after previous open repair of an infrarenal abdominal aortic aneurysm (AAA) poses significant challenges. We sought to better characterize such recurrent aneurysms and to evaluate their operative outcome. Methods We reviewed the records and radiographs of 49 patients who underwent repair of TVAAs between 1988 and 2002 after previous repair of an AAA. Visceral artery reconstructions were completed with combinations of beveled anastomoses, inclusion patches, and side arm grafts. In 14 patients visceral endarterectomy was required to treat associated occlusive disease. Sixteen patients had cerebrospinal fluid drainage, and 10 patients had distal perfusion during cross-clamping. Results Patient mean age was 72 years, and 80% were men. Fifty-one percent of patients had symptomatic disease, and average TVAA diameter was 6.2 cm. Mean time between AAA and TVAA repair was 77 months. Twenty-six percent of aneurysms were restricted to the lower visceral aortic segment, 35% extended to the diaphragm, another 35% extended to the distal or middle thoracic aorta, and 4% involved the entire remaining visceral and thoracic aorta. The 30-day operative mortality rate was 4.1% in patients with nonruptured aneurysms and 50% in patients with ruptured aneurysms, for an overall mortality rate of 8.2%. Fifteen patients (30.6%) had major morbidity, including paresis in two patients and dialysis-dependent renal failure in five patients. At late follow-up, three patients required further aortic operations to treat additional aneurysms, and four patients had fatal aortic ruptures. Two-year and 5-year cumulative survival rates were 61% (±7.5%) and 37% (±7.8%), respectively. At univariate analysis, operative blood loss was the sole significant predictor of major morbidity ( P < .023), and rupture ( P < .030, P < .0001) and aneurysm extent ( P < .0007, P < .0001) correlated with both operative death and long-term survival. Only aneurysm extent ( P < .010, relative risk 37.3) remained a significant predictor of long-term survival at multivariate analysis. Conclusion Elective repair of TVAAs after previous AAA repair can be performed with an acceptable level of operative mortality, though with considerable operative morbidity. Limited long-term survival mandates careful patient selection, and the high mortality associated with ruptured TVAA underscores the need for post-AAA surveillance.

Discussion: Session 4—Descending/Thoracoabdominal Aorta

Discussion: Session 4—Descending/Thoracoabdominal Aorta

“Cobrahead” graft for intercostal artery implantation during descending aortic replacement

A technique for a separate sidearm graft (“cobrahead”) to facilitate reattachment of intercostal arteries in descending aortic replacement is described. The technique allows for very prompt restoration of spinal cord blood flow (via a Y attachment from the arterial perfusion circuit). The technique permits a simple, quick, and fully accessible anastomosis, technically more facile than the traditional side-to-side anastomosis. None of 7 patients treated with this technique had early or late paraplegia. Preliminary computed tomographic follow-up scans confirm patency of the cobrahead graft.