Thoracoabdominal Aneurysm Research Articles

Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management.

Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management.

Mechanism of pulsus bisferiens in thoracoabdominal thoracic aneurysms: Insights from wave intensity analysis.

Aortic pulsatile hemodynamics are important in various clinical conditions. Whereas the importance of wave reflections of the closed type in pulsatile hemodynamics has been extensively studied, less is known about the impact of reflections of the open type, in which reflected waves changes both direction and type (compression vs suction) compared to the incident wave. In this report, we present careful pulsatile hemodynamic analyses of a case in which prominent reflections of the open type occur in a patient with a thoracoabdominal aortic aneurysm, causing a highly abnormal proximal aortic and peripheral arterial hemodynamic pattern, known as pulsus bisferiens. Wave intensity analysis of central pressure‐flow data demonstrated an early systolic forward‐traveling compression wave followed by a prominent late systolic forward‐traveling expansion wave, along with an abnormal prominent late systolic/early diastolic backward‐traveling compression wave which produced a sharp rise in diastolic pressure, and was responsible for the pulsus bisferiens pattern.

Decision analysis and personalized clinical tool for cerebrospinal fluid drains in thoracoabdominal aortic aneurysms repair.

The routine use of cerebrospinal fluid (CSF) drainage in patients undergoing operative repair of thoracoabdominal aneurysms (TAAA) has been associated with decreased rates of spinal cord ischemia. The use of CSF drains is not without consequence, howeverwith complications including subarachnoid hemorrhage, epidural hematoma, meningitis, and, in 1% of cases, death. To date, a decision analysis tool to help clinicians decide when to use and not to use a CSF drain does not exist. In this analysis, we set out to develop a decision analysis tool for CSF drain placement in patients undergoing operative repair of TAAA. A Markov state-transition cohort model that compared TAAA repair with adjunctive CSF drain insertion to TAAA repair without drain insertion for the outcome of life expectancy was developed in TreeAge 2020. The cycle length was 1 month and the time horizon was 60 months. The use of a CSF drain was associated with improved 5-year life expectancy (3.21 ± 0.10 vs. 3.09 ± 0.11 life-years gained). In the sensitivity analysis that varied the effectiveness of a CSF drain (odds ratio closer to 1 = less effective), the use of a CSF drain resulted in higher life expectancy in almost all scenarios. The routine use of a CSF drain in patients undergoing TAAA repair is safe and effective, with few exceptions. This decision analysis tool can be used by clinicians to develop a personalized approach.

Markov models in cardiac surgery.

Spinal cord ischemia remains a dreadful complication after thoracoabdominal aortic aneurysm repair. The role of cerebrospinal fluid drain in such patients needs further clarifications. Tam and colleagues carried out an interesting decision analysis study that supports the routine use of the cerebrospinal fluid drain after thoracoabdominal aneurysm repair. They also demonstrated that the use of the cerebrospinal drain was safe. Here, we firstly discuss the paper's finding and methodology and, secondly, we try to simply explain what a decision analysis study is and, broadly, and how to construct a Markov model.

Association between thoracoabdominal aneurysm extent and mortality after complex endovascular repair

ObjectiveTraditional open surgical repair of thoracoabdominal aortic aneurysms (TAAAs) has historically resulted in 30-day mortality rates ranging from 6% to 20%, depending on the Crawford anatomic extent. Although short-term survival is important, long-term survival is essential for patients to benefit from these often elective and potentially morbid procedures. The aneurysm extent affects the long-term survival after open repair; however, effect on endovascular repair is unknown and could influence the decision process for repair. We evaluated the association between aneurysm extent and survival and identified patient and perioperative factors associated with mortality after endovascular repair. MethodsA retrospective cohort of patients treated for TAAAs recorded in the Society for Vascular Surgery Vascular Quality Initiative thoracic and complex endovascular aneurysm repair registry were evaluated. All patients treated for asymptomatic degenerative aneurysms from 2010 to 2019 were included. Crawford extent I to V was defined according to the proximal and distal landing zones documented in the registry. Patients without extension into the visceral aorta were used for comparison and categorized as having extent 0a or 0b, depending on the distal landing zone in the thoracic aorta. Kaplan-Meier plots were used to estimate survival, and Cox proportional hazard regression models were created to identify the predictors of mortality. ResultsFrom 2010 to 2019, 15,333 patients were entered into the registry, of whom 2062 met the inclusion criteria. The Crawford extent was 0a for 379, 0b for 848, I for 81, II for 98, III for 130, IV for 454, and V for 72. Three groups were created in accordance with the similar outcomes noted on a preliminary analysis: (1) extent 0a and 0b; (2) extent I, II, and III; and (3) extent IV and V. The mean survival time for the extent 0a and 0b group was 70.7 ± 1.43 months and was 48.6 ± 1.65 months for the extent I, II, and III group and 57.6 ± 1.24 months for the extent IV and V group. The corresponding 1-year mortality was 8.4%, 18.4%, and 7.8%. Cox regression analysis identified the following preoperative factors were associated with mortality: chronic obstructive pulmonary disease (odds ratio [OR], 1.70; P < .001), Crawford extent I to III (OR, 1.64; P = .015), preexisting chronic kidney disease (OR, 1.37; P = .024), and age per year (OR, 1.03; P < .001). A number of postoperative factors were also associated with mortality. ConclusionsSimilar to open TAAA repair, patients with more extensive aortic disease treated with endovascular repair had worse 1-year and long-term survival. The extent of aortic disease and anticipated postoperative survival should factor prominently into the surgical decision-making process for elective endovascular TAAA repair.

Anatomical feasibility of a new off-the-shelf inner branch stent graft (E-nside) for endovascular treatment of thoraco-abdominal aneurysms.

The aim of this study was to evaluate the proportion of thoraco-abdominal aortic aneurysms (TAAAs) that could theoretically be treated with the JOTEC® E-nside® Thoracoabdominal Branch Endoprosthesis off-the-shelf multibranched endograft. Preoperative computed tomography scans of patients with atherosclerotic TAAA treated between 2007 and 2019 were reviewed, and the anatomical feasibility of the E-nside graft was verified by a retrospective study (clinicaltrials.gov: NCT03959670) based on the investigational manufacturer instructions for use. The anatomical factors determining overall feasibility were divided into vascular access (AC) feasibility, aortic (AO) feasibility and visceral vessels (VV) feasibility. Two hundred sixty-eight patients with thoraco-abdominal aneurysms were analysed: the overall treatment feasibility was 43%. AC feasibility was 78%, AO feasibility 60% and VV feasibility 79%. An iliac diameter <8.5 mm excluded 21% of the patients. Aortic feasibility was limited by infrarenal aortic diameter (16%) and size of aortic lumen at the level of visceral vessels (14%). Visceral vessels feasibility was mainly limited by inadequate number (8%) or diameter (12%) of target vessels. Height and orientation of target vessels were adequate in 97% of the cases. Overall feasibility was negatively influenced by female gender (Odds ratio: 3.89; 95% confidence interval 2.03-7.44; P < 0.001): the limiting factors in this subgroup being iliac diameter, infrarenal aortic diameter and visceral vessels diameter. The E-nside off-the-shelf stent graft can be theoretically employed in almost half of the cases from an all-comers cohort of patients with TAAA. Improvement of device profile and creation of a dedicated infrarenal component are warranted to increase overall feasibility. Female gender significantly affects the overall feasibility. NCT03959670.

Editor's Choice – Mortality is High Following Elective Open Repair of Complex Abdominal Aortic Aneurysms

To evaluate the 30 day mortality of elective open complex abdominal aortic aneurysm (cAAA) repair and identify factors associated with death. This was a retrospective cohort study using a Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). All patients undergoing elective repair for juxta- and suprarenal abdominal aortic aneurysm (AAA), or type IV thoraco-abdominal aneurysms (TAAA) from 2011 to 2017 were identified. Thirty day mortality and complication rates for open repair were established. A comparison endovascular aneurysm repair (EVAR) group was extracted from the same time period, and inverse probability weighting was applied for comparison. Logistic regression was used to identify factors independently associated with open repair mortality. Of the 957 patients who underwent an elective open cAAA repair over the study period, 65 (6.8%) died. The mean age of the patient was 71.3±8.0 years. The distribution by aneurysm type was 605 juxtarenal AAA (28 deaths, 4.6%); 284 suprarenal AAA (16 deaths, 9.5%), and 68 type IV TAAA (10 deaths, 14.7%). During the same time period, there were 1149 endovascular repairs for cAAA, with 43 deaths (3.7%). After inverse probability weighting and weighted logistic regression, open repair 30 day mortality yielded an OR 1.9, 95% CI 1.2-3.1, p=.01 compared with EVAR. Factors independently associated with death included more proximal extent aneurysm (referent [ref]: juxtarenal: OR 2.0 per extent increase, 95% CI 1.4-3.0, p<.001), BMI<18.5 (OR 4.0, 95% CI 1.6-10.1, p=.003), history of severe chronic obstructive pulmonary disease (COPD) (OR 2.6, 95% CI 1.5-4.4, p=.001), more severe chronic kidney disease (CKD) (ref: none/mild): OR 1.9, 95% CI 1.2-2.8, p=.004), and age (OR 1.06/year, 95% CI 1.02-1.09, p=.002. The 30 day mortality was 4.6% for juxtarenal AAA, 9.5% for suprarenal AAA, and 14.7% for type IV TAAA. The open repair odds of 30 day mortality was nearly twice that of endovascular repair for cAAA. Independent associations with death included BMI <18.5, more severe CKD level, more proximally extending aneurysm, age, and history of advanced COPD.

Hybrid treatment of a symptomatic coral reef calcification associated with a thoraco-abdominal aneurysm of the supra celiac aorta

Hybrid treatment of a symptomatic coral reef calcification associated with a thoraco-abdominal aneurysm of the supra celiac aorta

Sequential orthotopic hybrid treatment of type 2 thoracoabdominal aneurysms

The conventional surgical treatment of type 2 thoracoabdominal aortic aneurysms (TAA2) remains with a high morbi-mortality, in particular with the risk of spinal cord ischemia. By analogy with the endovascular treatment, a sequential repair could decrease this morbi-mortality. We describe our strategy of orthotopic sequential hybrid repair of ATA2.

The double aorta technique to treat type II and III thoracoabdominal aneurysms without use of extracorporal circulation

Open surgery to treat thoracoabdominal aneurysms requires the use extracorporal circulation (ECC). This is a key issue in the cases with aneurysms extending to the visceral arteries because an extended ECC can lead to complications of this method: large blood losses, hemolysis with its consequences on the renal, hepatic, pulmonary and intestinal functions. To avoid these complications, we propose the technique of “double aorta”. Parallel alternate circulation makes it possible to provide enough blood flow without the use of ECC.

Comparative study of the early results of laser fenestrated stentgrafts and manufactured fenestrated stentgrafts for the treatment of complex aortic aneurysms

The objective of this study was to compare the 6-month results of laser fenestrated stentgrafts (LFS) and manufactured fenestrated stentgrafts (MFS) for the treatment of complex aneurysms of the abdominal aorta (CAA), of thoracoabdominal aneurysms (TAA) and type I endoleaks in high surgical-risk patients.

Aortoesophageal fistula as a complication of thoracic aorta stent graft implantation: two cases and literature review

Thoracic endovascular aortic repair (TEVAR) is a method of choice in the treatment of thoracic aorta aneurysms and dissections. In case of a thoracoabdominal aneurysm, endovascular treatment is also being chosen more often, especially in patients with multimorbidity. Despite better results and less invasiveness in comparison to classic open surgery, endovascular treatment is also associated with complications. One of the rarer and usually fatal complications are aortoesophageal fistula (AEF). We present two cases, in which TEVAR complication was AEF. Case 1 was an 87-year-old woman with a history of TEVAR 5 years earlier, who presented increased inflammation parameters, massive gastrointestinal bleeding, and progressive anemia. Case 2 was a 66-year-old woman with a history of TEVAR 6 months earlier, who on admission presented medium increased inflammatory markers and anemia. None of the patients was qualified for surgical treatment. Both patient 1 and patient 2 died during hospitalization. Diagnostic imaging plays a key role in the diagnosis of AEF. CT angiography performed in patients with AEF can show the presence of gas in the sac of aneurysm as a result of infection, a defect in the aortic wall, or thickened esophagus with fluid level. CT angiography of the aorta combined with esophagogastroduodenoscopy (EGD) and contrast-enhanced X-ray examination of the gastrointestinal tract, enables to confirm or exclude the diagnosis of AEF. Atypical clinical feature and increased parameters of inflammation in patients with the history of TEVAR should always suggest the presence of AEF.

Fenestrated and Branched Thoraco-abdominal Endografting after Previous Open Abdominal Aortic Repair

Proximal para-anastomotic aneurysms, or aneurysmal degeneration of the native aorta above a previous open abdominal aortic repair (Pr-AAAs), are challenging scenarios. The aim of this study was to report the early and mid term outcomes of endovascular repair of Pr-AAAs by fenestrated and branched endovascular aneurysm repair (FB-EVAR). From 2006 to 2017, pre-operative, intra-operative, and post-operative data from patients undergoing FB-EVAR for Pr-AAAs at two European vascular surgery units were prospectively collected and retrospectively analysed. Early results were considered in terms of technical success (target visceral vessel cannulation and stenting, absence of type I - III endoleak, iliac limb occlusion and 24h mortality); spinal cord ischaemia (SCI) and 30 day and in hospital mortality. Survival, target visceral vessel (TVV) patency, and freedom from re-interventions were also considered at the mid term follow up. Five hundred and forty-four patients underwent FB-EVAR to treat juxta/pararenal or thoraco-abdominal aneurysms. Of these patients, 108 (19.8%) cases were Pr-AAAs (94% male; mean±standard deviation [SD] age 71±4 years; American Society of Anesthesiologists' grade 3-4 in 74% and 26%, respectively). The previous open aortic repair (OR) was performed 10±2 years before FB-EVAR. It was a tubular aorto-aortic repair in 63 (58.3%) cases, a bifurcated aortobi-iliac repair in 37 (34.2%) cases, and an aortobifemoral bypass repair in eight (7.4%) cases. A previous thoracic endovascular aneurysm repair (TEVAR) had been performed in seven patients (6.5%). The aortic lesion at the time of FB-EVAR was, according to the Crawford classification, a type I - III in 69 (63.9%) or a type IV 39 (36.1%) thoraco-abdominal aneurysm. The mean±SD aneurysm diameter was 64±6mm. Overall, 390 TVVs (3.6±1 TVV/case) were revascularised by an endograft with fenestrations (n=63 [58.3%]), with branches (n=26 [24.1%]), or with both fenestrations and branches (n=19 [17.6%]). Tubular, trimodular, or aorto-uni-iliac implants were planned in 68 (63.0%), 38 (35.2%), and two (1.8%) patients, respectively. Proximal TEVAR, carotid-subclavian bypass, and iliac branch devices were planned as adjunctive procedures in 41 (38.0%), five (4.6%), and three (2.8%) cases, respectively. Overall technical success was 93%, with technical failures including five TVV losses (coeliac trunk, n=1; renal arteries, n=4) and three deaths within 24h. Post-operative SCI occurred in seven patients (6.5%), four of which (3.7%) were permanent. SCI was more frequent in category I - III TAAAs (p=.042) and in endografts incorporating both fenestrations and branches (p=.023). Cardiac, pulmonary, and renal complications (reduction in glomerular filtration rate of ≥30% compared with baseline) occurred in 9%, 10%, and 20%, respectively. Bowel ischaemia was seen in three (2.8%) patients. Thirty day mortality was 4% and was associated with pre-operative chronic renal failure (p=.034), post-operative cardiac morbidity (p=.041), and bowel ischaemia (p=.003). Overall in hospital mortality was 5.5% (n=6). Mean±SD follow up was 38±18 months. Survival was 82%, 64%, and 54% at one, three, and five years, respectively, and target visceral vessel patency was 93%, 91%, and 91%, respectively. Permanent haemodialysis was needed in four patients (3.7%). There was no late aneurysm related mortality. Survival during follow up was statistically significantly affected by pre-operative chronic renal failure (p=.022), post-operative cardiac morbidity (p=.042), SCI (p=.044), and bowel ischaemia (p=.003). Freedom from re-intervention at one, three, and five years was 89%, 77%, and 74%, respectively. Endovascular treatment of aneurysmal aortic degeneration above a previous open abdominal repair with FB-EVAR is safe and effective. If those promising results are confirmed at later follow up, FB-EVAR should be considered a prominent therapeutic option, especially in high risk patients.

Respiratory-induced Changes in Renovisceral Branch Vessel Morphology After Fenestrated Thoracoabdominal Aneurysm Repair With a Flexible Balloon Expandable Covered Stent

OBJECTIVE We evaluated the respiratory-induced changes in branch vessel geometry after thoracoabdominal fenestrated endovascular aneurysm repair (fEVAR) with the Bentley BeGraft graft (Innomed GmbH, Hechingen, Germany) as the covered bridging stent. METHODS Patients treated with fEVAR for thoracoabdominal aortic aneurysms with a custom-made Zenith fenestrated endograft (Cook Medical Europe Ltd, Limerick, Ireland) and Bentley BeGraft peripheral stents were prospectively recruited. Using SimVascular software (Open-Source Medical Software Corp, San Diego, CA), the pre- and postoperative aortic and branch contours were segmented from computed tomography angiograms performed during inspiratory and expiratory breath-holds. The centerlines were extracted from the lumen contours, from which the branch take-off angles, distal stent angles, and peak branch curvature changes were computed. Paired, two-tailed t tests were performed to compare the pre- and postoperative deformations. RESULTS Renovisceral vessel geometry was evaluated in 12 patients undergoing fEVAR with a total of 46 target vessels (10 celiac arteries, 12 superior mesenteric arteries [SMAs], 24 renal arteries). Implantation of BeGraft bridging stents was associated with a significant reduction in respiration-induced changes in vessel branch angulation (Δ5.3° ± 3.9° vs Δ12.0° ± 8.3° [postoperative vs preoperative]; P = .001) and mean curvature (0.72 ± 0.22 cm-1 vs 0.53 ± 0.18 cm-1) in the renal arteries, without significant changes in the celiac arteries or SMAs. No significant difference was found in end-stent angle motion in the renal arteries (P = .77), celiac arteries (P = .34), or SMAs (P = .55). The maximum local vessel curvature change decreased after fEVAR in the SMAs (Δ0.28 cm-1 vs Δ0.47 cm-1; P = .04) but was unchanged in the celiac (P = .61) and renal (P = .51) arteries. CONCLUSIONS Implantation of the BeGraft as a bridging stent in fEVAR was associated with decreased respiratory-induced deformation in the renal branch take-off angulation and mean renal artery curvature, with reduced maximum curvature bending in the SMA compared with the preoperative anatomy. However, the BeGraft allowed for celiac and renal artery bending similar to that in the native preoperative state. These findings suggest that the use of BeGraft peripheral stents with fEVAR will closely mimic the native arterial branch geometry and vessel conformability caused by relatively aggressive respiratory motion.

Current assessment and management of endoleaks after advanced EVAR: new devices, new endoleaks?

ABSTRACT Introduction In recent years there has been an increasing application of advanced EVAR techniques to tackle complex clinical and anatomical scenarios. In a bid to overcome the limitations of the traditional stent-grafts, newer EVAR endografts and techniques have been developed and introduced into clinical practice, permitting endovascular management of difficult infrarenal, juxta-renal and thoracoabdominal aneurysms for which previously there was no endovascular solution. As a consequence, we are now confronted with unique patterns of endoleak requiring customized clinical-radiological assessment and treatment. Despite the increasing body of evidence regarding new EVAR techniques and related endoleaks, current guidelines do not specifically address these issues. Objectives Our review aims to assess risk factors, development, and management strategies of these endoleaks, in the most recent infrarenal EVAR devices and in more complex fenestrated EVAR (FEVAR) and Chimney EVAR (Ch-EVAR). Expert opinion Most new devices have demonstrated types of endoleaks that need specific imaging and treatment, as in EVAS, FEVAR, and ChEVAR. Knowledge of specific stent-graft characteristics and the nature of endoleaks associated with the various procedures facilitates the application of relevant useful imaging. In addition, it should aid development of a customized and practically relevant approach to patient management during intervention and follow-up.

Early Limb Reperfusion Using Routinely Preloaded Fenestrated Stent-graft Designs for Complex Endovascular Aortic Procedures.

To evaluate the outcomes of the preloaded stent-graft design (PLD) in the routine treatment of pararenal and thoraco-abdominal aneurysms compared to the standard design (SND). Patients treated by fenestrated/branched endovascular aneurysm repair from 2013 were collected. Since 2017, PLD (23F delivery system) was implemented in our standard practice and the outcomes are reported. Primary outcome measurements were: technical success, 30-day adverse events, leg ischemia time, procedural time and radiation exposure. Secondary outcome measurements were: intraoperative urinary output, need of bicarbonate supplementation, postoperative biomarkers elevations and need for blood transfusions. A propensity 1:1 matching for graft design and aneurysm extent was performed with the SND (18F delivery system) cohort to highlight possible PLD advantages. A PLD was employed in 32 non-consecutive patients with a technical and clinical success rate of 100% and 81% respectively: no mortality was recorded. The Society for Vascular Surgery grade ≥ 1 adverse event was observed in 10 cases (31%): five temporary paraparesis were observed. Seventeen PLD patients were matched. The procedural time was shorter in PLD group (266 vs. 390min; p = 0.001) as well as fluoroscopy time (68 vs. 96min; p = 0.019) and contrast media used (180 vs. 382ml; p = 0.045). Contralateral limb ischemic time was significantly higher in SND group (0 vs. 70min; p = 0.042). The need for blood transfusion and the postoperative peak of creatine phosphokinase was lower in PLD group (151 vs. 449 U/l; p < 0.001). Preloaded stent-graft design allows a uni-femoral approach in the majority of the interventions reducing procedural times and the ischemia on the contralateral leg, leading to possible benefits.

Total endovascular aortic repairs using branched devices for arch and thoracoabdominal aneurysms

Endovascular repair can be an alternative to conventional surgery for arch and thoracoabdominal aneurysms; however, it has the limits of available stent-grafts in anatomy. We present the case of an 87-year-old woman who had dual aneurysms in the arch and thoracoabdominal regions. We considered that traditional open surgery was of extremely high risk, because she was an octogenarian and had multiple comorbidities. We successfully treated the aortic arch aneurysm and the thoracoabdominal aortic aneurysm using endovascular stent-grafts in a high-risk patient who was a poor candidate for the conventional open surgery.

Effect of Branch Length and Tortuosity on the Outcomes of Branched Endovascular Repair of Thoracoabdominal Aneurysms

The objective was to investigate the effect of length and tortuosity of directional branches on the midterm outcomes of branched endovascular aneurysm repair (BEVAR) for thoracoabdominal aortic aneurysms (TAAAs).

Splanchnic Occlusive Disease Strongly Predicts Spinal Cord Injury and Mortality After Open Descending Thoracic and Thoracoabdominal Aneurysm Repair

We speculated that there could be a positive correlation of occlusive disease of splanchnic and intercostal arteries because of the atherosclerotic or dissecting process affecting the common aortic segments from which they arise. Therefore, as a surrogate of such relation with clinical relevance, we investigated the impact of splanchnic occlusive disease (SOD: renal, superior mesenteric, and celiac axis arteries) on spinal cord injury (SCI: paraparesis or paraplegia) and major adverse events (MAEs) after descending thoracic aortic (DTA) and thoracoabdominal aortic aneurysm (TAAA) open repair.

Aortic Coverage to Treat Juxtarenal, Pararenal, and Type IV Thoracoabdominal Aneurysms With Custom-made Fenestrated Endografts Is Greater Compared With Open Repair but Does Not Affect Results

Juxtarenal abdominal aortic aneurysms (JAAAs), pararenal abdominal aortic aneurysms (PAAAs), and type IV thoracoabdominal aortic aneurysms (TAAAs) can be repaired by custom-made fenestrated endografts. Different from open repair, a relatively long segment of healthy proximal aorta needs to be covered to achieve a durable seal, and this may be considered a disadvantage of the endovascular approach. We aimed to quantify the additional proximal aortic coverage in JAAAs, PAAAs, and type IV TAAAs treated with custom-made endovascular aneurysm repair (CM-FEVAR) and to evaluate its impact on early and follow-up clinical outcomes.