Thoracic Stent-graft Placement Research Articles

Optimizing Aortic Endovascular Repair in Patients with Marfan Syndrome

Introduction: The reported experience in endovascular aortic repair for Marfan syndrome (MFS) is limited, and results are heterogeneous. In this population, thoracic stent-graft placement carries a risk of aortic wall aggression, which may result in retrograde aortic dissection, dilatation, or false aneurysms at the landing zone. We hypothesized that these complications may be potentially avoided using modified practices. This study aimed to describe our experience with the use of a specific protocol of endovascular aortic repair in patients with MFS Methods: All MFS patients with FBN-1 gene mutation who were treated with aortic stent-graft placement between February 2015 and August 2018 were included. The following rules were applied: 1) excluding bare stents and barbs in the choice of a stent-graft, 2) proximal landing in a preexisting graft, or 3) minimization of proximal oversizing in the case of proximal landing in the native aorta (< 10%), and 4) distal undersizing Results: Eighteen patients were included (55% men, mean age: 47 ± 17 years). The index procedure was initial endovascular aortic repair in 10 cases, elephant trunk completion in 6, and anastomotic pseudo-aneurysm after thoracic open repair in 2. The technical success rate was 100%. Proximal landing was in the native aorta in 11 patients (61%), with a mean proximal oversizing of 2.4 mm (8% oversized). Distal landing in the native aorta was performed in 16 cases (89%), with a mean distal undersizing of 8.9 mm. No mortality, spinal cord ischemia, stroke, and retrograde aortic dissection occurred during the postoperative course. One type 1b endoleak was observed. The mean follow-up period was 21.4 months. The aortic aneurysm-related mortality was 5.5% (n = 1) and occurred after planned open thoracoabdominal surgery. One patient presented a proximal landing zone complication (5.5%) with aortic enlargement requiring arch repair. The maximal aortic diameter significantly decreased from 59 mm to 45 mm (p < 0.0001) after treatment. Conclusion: The specific protocol described in this study seems to optimize the results of endovascular aortic repair in MFS patients with significant aortic remodeling Disclosure: Nothing to disclose

Salvage Procedure Using a Chimney Endograft for Early Cerebral Ischaemia after Hybrid Aortic Arch Repair of a Primary Aorto-bronchial Fistula.

IntroductionHybrid aortic arch repair for the treatment of aorto-bronchial fistulas has been suggested as a safe alternative to open repair. However, surgical morbidity and mortality are still significant and re-intervention is sometimes inevitable.ReportSuccessful rescue by a hybrid approach is reported in a 76 year old woman who was transferred from another centre with recurrent episodes of left hemiplegia shortly after debranching of the supra-aortic vessels and thoracic aortic stent grafting for an aorto-bronchial fistula associated with a true aneurysm at the level of origin of the left subclavian artery. Investigation revealed partial coverage of the ostium of the brachiocephalic artery and Type Ib and II endoleaks. In the first stage a chimney graft was put into the brachiocephalic trunk, and in the second stage the left subclavian artery was plugged and the thoracic stent graft was extended distally. Completion angiography showed restoration of the supra-aortic blood flow and no residual endoleaks. After 1 year follow up the patient was doing well with no recurrent neurological events and no signs of infection.DiscussionProcedure related problems should be suspected first when early post-operative complications occur after a hybrid aortic arch repair. The chimney graft technique is a valuable option for unintentional covering of a critical supra-aortic branch. Nevertheless, the importance of precise positioning during initial thoracic stent graft placement should be emphasised.

Factors Related to Late False Lumen Enlargement after Thoracic Stent-Graft Placement for Type B Aortic Dissection

PurposeTo evaluate significant factors related to delayed aortic false lumen (FL) enlargement in patients who have undergone thoracic stent-graft placement for type B aortic dissection. Materials and MethodsThe study included 62 patients (45 male, 17 female) aged 26–80 years (mean age, 58.1 y) who underwent thoracic endovascular aortic repair for type B aortic dissection at a single institution between January 2005 and May 2015. Mean age of aortic dissections was 5.3 months (range, 0.1–73.3 mo). Maximum aortic diameter at presentation was 41.7 mm ± 8.3. The follow-up period ranged from 3 to 104 months (mean, 27.1 mo). Computed tomographic (CT) angiography studies were reviewed to identify FL diameter enlargements > 5 mm at different levels along and distal to the stent graft. Imaging findings and clinical variables were investigated to determine their correlation with FL enlargement. ResultsNo significant difference was found between the ages of aortic dissections in patients with and without FL enlargement (P = .26). On follow-up CT angiography, 16 patients had 2 or more communication channels between the FL and the systemic circulation, 7 of whom showed FL enlargement > 5 mm (P = .007). Twenty-seven patients showed complete FL thrombosis, none of whom had FL enlargement (P < .001). ConclusionsTwo or more communication channels between the FL and the systemic circulation represent a risk factor for FL enlargement regardless of the age of the dissection. Patients with thrombosis of the FL are less likely to experience FL enlargement.

Bimodal Delayed Paraplegia after a Thoracic Stent-graft Placement

Bimodal Delayed Paraplegia after a Thoracic Stent-graft Placement

Computational Analysis of Stresses Acting on Intermodular Junctions in Thoracic Aortic Endografts

To evaluate the biomechanical and hemodynamic forces acting on the intermodular junctions of a multi-component thoracic endograft and elucidate their influence on the development of type III endoleak due to disconnection of stent-graft segments. Three-dimensional computer models of the thoracic aorta and a 4-component thoracic endograft were constructed using postoperative (baseline) and follow-up computed tomography (CT) data from a 69-year-old patient who developed type III endoleak 4 years after stent-graft placement. Computational fluid dynamics (CFD) techniques were used to quantitate the displacement forces acting on the device. The contact stresses between the different modules of the graft were then quantified using computational solid mechanics (CSM) techniques. Lastly, the intermodular junction frictional stability was evaluated using a Coulomb model. The CFD analysis revealed that curvature and length are key determinants of the displacement forces experienced by each endograft and that the first 2 modules were exposed to displacement forces acting in opposite directions in both the lateral and longitudinal axes. The CSM analysis revealed that the highest concentration of stresses occurred at the junction between the first and second modules of the device. Furthermore, the frictional analysis demonstrated that most of the surface area (53%) of this junction had unstable contact. The predicted critical zone of intermodular stress concentration and frictional instability matched the location of the type III endoleak observed in the 4-year follow-up CT image. The region of larger intermodular stresses and highest frictional instability correlated with the zone where a type III endoleak developed 4 years after thoracic stent-graft placement. Computational techniques can be helpful in evaluating the risk of endograft migration and potential for modular disconnection and may be useful in improving device placement strategies and endograft design.

Paraplegia prevention branches: A new adjunct for preventing or treating spinal cord injury after endovascular repair of thoracoabdominal aneurysms

In this report, we describe a technique that could potentially be used for both prevention and treatment of spinal cord ischemia (SCI) in endovascular repair of thoracoabdominal aneurysms. This technique involves using a specially designed endograft with side branches (paraplegia prevention branches [PPBs]), which are left patent to perfuse the aneurysmal sac and any associated lumbar or intercostal arteries in the early postoperative period. The use of PPBs with this technique is feasible and allows for a temporary controlled endoleak that may be useful for preventing or reversing spinal cord injury. This technique may be considered as an adjunct to the more standard perioperative physiological manipulations such as permissive hypertension and spinal fluid drainage.

Initial Treatment for Delayed Paraplegia after Thoracic Stent-graft Placement

Initial Treatment for Delayed Paraplegia after Thoracic Stent-graft Placement

Endovascular repair of extent I thoracoabdominal aneurysms with landing zone extension into the aortic arch and mesenteric portion of the abdominal aorta

Thoracic endovascular aortic repair (TEVAR) has emerged as an alternative for patients at prohibitive risk for open thoracic or thoracoabdominal surgery, decreasing perioperative morbidity and mortality. Aneurysms that involve both the left subclavian artery (LSA) proximally and the celiac artery (CA) distally present a unique challenge to the use of TEVAR. We report a series of six high-risk patients presenting with extent I thoracoabdominal aortic aneurysms who were successfully treated with TEVAR including coverage of the LSA and the CA.

Endovascular Repair in the Thoracic and Abdominal Aorta: No Increased Risk of Spinal Cord Ischemia When Both Territories Are Treated

To evaluate the morbidity associated with thoracic and abdominal aortic repair using endovascular exclusion alone or combined endovascular and open repair. Between January 1998 and February 2007, 49 patients (36 men; mean age 70 years) underwent treatment for thoracic and abdominal aorta disease with descending thoracic aortic (DTA) stent-graft and abdominal aortic repair. Thirty-nine patients with coexisting thoracic and abdominal pathologies were classified with multilevel aortic disease (MLAD), whereas 10 patients presented with thoracoabdominal aneurysm. Patients were separated into 3 groups: 1: thoracic stent-grafts and open abdominal repair (n = 18), group 2: thoracic and abdominal stent-grafts (n = 21), and group 3: thoracic stent-grafts with visceral artery debranching (n = 10). Prior carotid-subclavian bypass was performed in 3 (6%) patients with a dominant left vertebral artery. Stent-graft deployment was technically successful in all cases. Eight (16%) patients underwent emergent thoracic stent-graft placement. In 9 (18%) patients, the left subclavian artery was covered. No incidence of spinal cord ischemia was observed. The 30-day mortality was 4%, and overall mortality was 6% over a mean 33-month follow-up. The endoleak rate was 6% (1 type I, 1 type II, and 1 type III). Conventional or endovascular abdominal open repair in combination with DTA stent-grafting is feasible and a safe alternative to traditional open repair. Management of MLAD did not show increased incidence of spinal cord ischemia and was associated with fewer complications and deaths than simultaneous or staged open thoracic and abdominal repairs.

Second-Generation Amplatzer Vascular Plug (AVP) for the Treatment of Subsequent Subclavian Backflow Type II Endoleak After TEVAR

Since its approval as an occlusive device in the peripheral vasculature in 2004, the first-generation Amplatzer Vascular Plug (AVP; AGA Medical, Golden Valley, MN, USA) has already become a therapeutic alternative to coil embolization in dedicated cases. Here, we present for the first time, a case of type II endoleak from the left subclavian artery after thoracic stent-graft placement successfully treated with a second-generation AVP.

胸部大動脈ステントグラフト留置と腹部大動脈人工血管置換の同時手術後に遅発性対麻痺を発症した 1 例

胸部大動脈ステントグラフト留置と腹部大動脈人工血管置換の同時手術後に遅発性対麻痺を発症した 1 例

Strategies to improve spinal cord ischemia in endovascular thoracic aortic repair: Outcomes of a prospective cerebrospinal fluid drainage protocol

Although endovascular repair of thoracic aortic aneurysm has been shown to reduce the morbidity and mortality rates, spinal cord ischemia remains a persistent problem. We evaluated our experience with spinal cord protective measures using a standardized cerebrospinal fluid (CSF) drainage protocol in patients undergoing endovascular thoracic aortic repair. From 2004 to 2006, 121 patients underwent elective (n = 52, 43%) and emergent (n = 69, 57%) endovascular thoracic aortic stent graft placement for thoracic aortic aneurysm (TAA) (n = 94, 78%), symptomatic penetrating ulceration (n = 11, 9%), pseudoaneurysms (n = 5, 4%) and traumatic aortic transactions (n = 11, 9%). In 2005, routine use of a CSF drainage protocol was established to minimize the risks of spinal cord ischemia. The CSF was actively drained to maintain pressures <15 mm Hg and the mean arterial blood pressures were maintained at >/=90 mm Hg. Data was prospectively collected in our vascular registry for elective and emergent endovascular thoracic aortic repair and the patients were divided into 2 groups (+CSF drainage protocol, -CSF drainage protocol). A chi(2) statistical analysis was performed and significance was assumed for P < .05. Of the 121 patients with thoracic stent graft placement, the mean age was 72 years, 62 (51%) were male, and 56 (46%) underwent preoperative placement of a CSF drain, while 65 (54%) did not. Both groups had similar comorbidities of coronary artery disease (24 [43%] vs 27 [41%]), hypertension (44 [79%] vs 50 [77%]), chronic obstructive pulmonary disease (18 [32%] vs 22 [34%]), and chronic renal insufficiency (10 [17%] vs 12 [18%]). None of the patients with CSF drainage developed spinal cord ischemia (SCI), and 5 (8%) of the patients without CSF drainage developed SCI within 24 hours of endovascular repair (P< .05). All patients with clinical symptoms of SCI had CSF drain placement and augmentation of systemic blood pressures to >/=90 mm Hg, and 60% (3 of 5 patients) demonstrated marked clinical improvement. Perioperative CSF drainage with augmentation of systemic blood pressures may have a beneficial role in reducing the risk of paraplegia in patients undergoing endovascular thoracic aortic stent graft placement. However, selective CSF drainage may offer the same benefit as mandatory drainage.

Hybrid Thoracic Stent Graft Repair of a Complex Type B Aortic Dissection in a Patient who Presented Three Weeks after Repair of a Type a Aortic Dissection

Long-term management after repair of a type A aortic dissection includes aggressive medical therapy and routine surveillance with serial imaging to ensure thrombosis of the false lumen. Retained patency of the false lumen can lead to either the development of a false lumen aneurysm with a subsequent rupture or extension of dissection. Typically such events occur late, usually months after repair, and are treated with either a conventional one-stage open thoracoabdominal repair or a two-stage "elephant trunk" procedure. However, most patients who undergo such procedures experience major complications and the procedure-related mortality rate is high. We present a unique case of a 61-year-old woman who presented with a ruptured type B aortic dissection 3 weeks after repair of a type A aortic dissection. She underwent an emergent thoracotomy and primary repair of the ruptured aorta followed by concomitant arch debranching and thoracic stent graft placement. Simultaneous surgical debranching with a median sternotomy and endovascular repair with stent grafts is an attractive hybrid approach in patients who present with an acute rupture of a false lumen aneurysm soon after initial repair of an aortic dissection, a situation in which a conventional repair is not feasible. This report emphasizes that hybrid thoracic stent graft repair should be considered for such high-risk patients in the near future as it offers them relatively lower morbidity and mortality compared with what is seen with conventional repairs.

Rapid Pacing for Better Placing: Comparison of Techniques for Precise Deployment of Endografts in the Thoracic Aorta

To investigate the safety, efficacy, impact on positioning, and neurocognitive outcomes of 3 conceptually different methods of avoiding the "windsock" effect during thoracic stent-graft placement. A retrospective review was conducted of 70 patients (48 men; mean age 63 years) who underwent elective or emergency stent-graft placement in the thoracic aorta for various pathologies. Twenty-seven patients (18 men; mean age 64+/-12 years) had stent-graft positioning during rapid right ventricular (RV) pacing at 180 to 200 beats per minute. Another 27 patients (18 men; mean age 62+/-12 years) had stent-graft placement under controlled hypotension (<or=45 mmHg) achieved with sodium nitroprusside (3 microg/kg/min). Sixteen patients (12 men; mean age 63+/-14 years) had intermittent cardiac arrest induced by a 0.5-mg/kg adenosine bolus prior to launching the stent-graft. Termination of the endovascular procedure, weaning, and recovery were conducted according to the same routines in all patients. Hemodynamics, landing precision (deviation from planned placement site), cerebral blood flow, and neurocognitive function were compared. Rapid RV pacing (median 12 seconds) was conducted without technical difficulty or delayed recovery in any of the 27 patients. Once rapid pacing ceased, blood pressure recovered within 8 seconds from 22+/-8 mmHg to normal prepacing levels. The level of hypotension was most pronounced in the rapid RV pacing group (20+/-4 mmHg, p<0.001), and the duration of hypotension was also the shortest (20+/-10 seconds, p<0.001) at a pacing rate of 190+/-10 beats per minute. The instantaneous mean flow velocity was lowest (10+/-4 cm/s, p<0.001) and recovery to normal pressure was quickest (within 1 minute) with rapid pacing. Instrumentation for rapid pacing did not prolong the procedure, but shortened it approximately 25 minutes. Moreover, precise positioning at a mean 2+/-2 mm from the predetermined launch site was observed with rapid pacing (p<0.05). There were no differences in postprocedural neurological assessment among groups. Rapid RV pacing is safe in selected patients and in experienced hands. It abbreviates hemodynamic compromise, shortens the endovascular procedure, and may eventually emerge as the preferred method to avoid the windsock effect during stent-grafting. The maneuver, however, requires knowledge of right cardiac anatomy and expertise in selecting patients.

Stent-Graft Placement for the Treatment of Thoracic Aortic Diseases

The recent development of aortic stent-grafts has brought the management of thoracic aortic diseases into the realm of interventional radiology. Stent-graft placement is now an alternative to surgery for the treatment of descending thoracic aortic aneurysms, ulcers, and fistulas and is sometimes indicated in cases of mycotic aneurysm, posttraumatic aortic rupture, or thoracic descending aortic dissection. Pretreatment imaging is crucial for evaluating patient eligibility, selecting the appropriate stent-graft, and planning the intervention. Stent-graft treatment of long atherosclerotic aneurysms, lesions close to aortic branch vessels, and aortic dissections is subject to technical pitfalls, and adverse events such as endoleaks, stent migration or misplacement, aortic perforation, and vascular trauma will require specific interventions, although they occur in only a minority of patients. Thoracic stent-graft placement in good surgical candidates remains controversial because long-term results are unknown. However, short-term morbidity and mortality rates from endovascular treatment compare favorably with those from surgery, and stent-graft placement is proving to be a safe, minimally invasive, and effective treatment for thoracic aortic diseases and is already the best option in many affected patients who are poor surgical candidates.

Simultaneous abdominal aortic replacement and thoracic stent-graft placement for multilevel aortic disease.

Patients with aneurysmal disease involving both the descending thoracic and abdominal aorta have historically required simultaneous or sequential conventional operations, but the morbidity rate is high with either approach in these patients, who often exhibit coexisting cardiopulmonary disease. Transluminally placed endovascular grafts have recently been developed for repair of aortic aneurysms, and we have implemented these techniques to eliminate the need for a thoracotomy in patients with multilevel aortic disease. Since January 1994, 18 patients have undergone conventional abdominal aortic replacement with endovascular stent-graft placement into the descending thoracic aorta under fluoroscopic guidance through a 10 mm Dacron side limb off the abdominal graft. Abdominal aortic replacement required a tube graft in eight patients and bifurcated grafts in 10 patients. Thoracic stent-grafts (custom fabricated, woven Dacron covered, self-expandable stents) averaged 12.2 +/- 4.2 cm (mean +/- SD) in length. One patient died, resulting in a hospital mortality rate of 6%. No patients required further surgical intervention to treat their aortic disease. Seventeen patients (94%) are currently well 14 +/- 8 months after surgery (range, 3 to 29 months) with completely excluded thoracic aortic disease, no stent migration, and no change in stent configuration documented by serial radiologic examinations. Simultaneous abdominal aortic replacement and deployment of a thoracic stent-graft can safely exclude multilevel aortic aneurysmal disease and may be a valuable treatment option for these otherwise high-risk patients.