Thoracoabdominal Aneurysm Research Articles

Preliminary Results of Gore Viabahn Balloon-Expandable Endoprosthesis in Visceral and Renal Arteries of Patients Treated With Branched or Fenestrated Endografts for Complex Aortic Aneurysmal Disease

The objective was to retrospectively evaluate perioperative and midterm results of Gore Viabahn balloon-expandable endoprosthesis (VBX; W. L. Gore & Associates, Flagstaff, Ariz) as a visceral bridging stent in fenestrated and branched procedures. From January 2007 to December 2019, 127 fenestrated and branched endovascular aneurysm repairs for complex aortic disease were performed and 460 visceral vessels were included in the repair (3.6 vessels per patient). Data concerning such interventions were prospectively recorded in a certified institutional registry. A retrospective analysis of the registry was performed, and 103 visceral vessels treated with Gore VBX in 28 patients between July 2018 and December 2019 were found. Perioperative results were analyzed in terms of technical success, VBX-related adjunctive procedures, 30-day patency, and reinterventions. The follow-up program consisted of a computed tomography angiography scan at 1 month and yearly thereafter and duplex ultrasound examination at 3 months and every 6 months thereafter. Follow-up results were analyzed in terms of bridging stent-related patency, complications, and reinterventions. The indication for intervention was a thoracoabdominal aneurysm in 18 cases, a juxtarenal dilation in 5 patients, a pararenal aneurysm in 3 patients, a proximal para-anastomotic aneurysm after open aortic reconstruction in 1 case, and a short-neck (<5 mm) aneurysm in another patient. All patients underwent an elective intervention. In 19 cases, a fenestrated graft was placed, and in 4, a branched graft; in the remaining 5 cases, a combination of both fenestrations and branches was the configuration of choice. Overall, 55 renal arteries, 25 superior mesenteric arteries, and 23 celiac trunks were treated with Gore VBX. Technical success was 100%. Additional stent placement into a target visceral vessel to extend the distal landing zone was required in five vessels (4.9%). The asymptomatic occlusion (1/103 [0.9%]) of the VBX for a celiac trunk affected by subocclusive stenosis preoperatively was recorded 20 days after the procedure and was left untreated. No perioperative reinterventions were performed. Median duration of follow-up was 4.4 months (range, 1-14 months); no occlusion was documented. Reintervention rate was 0.9% (1/103); a type IC endoleak from a celiac trunk was diagnosed 3 months after the procedure and was treated with distal placement of another VBX stent graft into the celiac trunk, with complete resolution of the endoleak. In our experience of 103 target visceral vessels, the Gore VBX stent graft guaranteed satisfying perioperative results, providing optimal delivery and adaptability into target vessels. Further investigation is needed to evaluate follow-up results, especially in terms of resistance to the continuous aortic remodeling and the pinching load related to vessel pulsatility.

Iliac Artery Endoconduits Should Be the Preferred Adjunctive Access Procedure to Facilitate Endovascular Complex Aortic Aneurysm Repair

Anatomic factors of the iliac arteries, including vessel calcification, luminal diameter, and tortuosity can have a dramatic impact on the success complex endovascular aortic procedures. The aim of this study was to evaluate the outcomes of open and endovascular iliac conduits performed to facilitate complex aortic aneurysm endovascular repair. All patients who underwent complex endovascular aortic aneurysm repair through an iliac conduit to treat thoracoabdominal, juxtarenal or suprarenal aneurysms at the University of Colorado Hospital from September 2013 through June 2019 were included. Primary outcomes were endovascular and open iliac conduits morbidity and mortality. A total of 27 patients with 43 conduits were included in the study. The majority of the patients were female (n = 15, 56%). Hypertension (n = 16, 59%) and diabetes (n = 4, 20%) were the most prevalent risk factors. Twenty-two (51%) endoconduits and 21 (49%) open conduits were performed. Patients undergoing endo conduits had significant less complications than those undergoing open conduits (1, 4% vs 10, 48%; P = .02). The most common complications of open conduits were infection (n = 5, 24%) and postoperative hemorrhage (n = 4, 19%). The only complication noted for endoconduits was one access site hematoma requiring surgical evacuation. Overall mortality rate was similar and not related to type of conduit (endoconduits 1, 4% vs open 0; P = NS). Overall complication rate associated with open iliac artery conduits is not negligible. Endoconduits, however, carry less morbidity than open conduits and are thus preferred as a first line adjunctive access to facilitate complex endovascular aneurysm repair whenever feasible.

Antegrade In Situ Multibranched Endografting for Emergent Thoracoabdominal Aortic Aneurysm Repair

We present a case utilizing antegrade in situ multibranched grafting for emergent endovascular repair of a ruptured thoracoabdominal aneurysm. Through a single femoral approach, the aortic endograft was partially deployed in the descending thoracic aorta, providing an immediate seal of rupture. Using a laser probe through a steerable sheath from the left brachial approach, each visceral and renal arteries were sequentially incorporated, creating a multibranched endograft.

Mid-Term Outcomes of Complex Endografting for Chronic Post-Dissection Thoracoabdominal Aortic Aneurysms.

To report early and mid-term results of post-aortic dissection thoracoabdominal aneurysms (pD-TAAA) treated by complex endografting in three tertiary referral hospitals. A review of all patients with pD-TAAA unfit for open surgery treated with complex endovascular repair from 2012 to 2018 was performed. Simple thoracic endografts (TEVAR) were excluded. Staged procedures in case of extensive aortic coverage were always planned. In total, 21 patients (16 males, mean age 63 ± 10years) with pD-TAAA underwent aortic repair by fenestrated or branched thoracoabdominal endografts for visceral vessels. Mean TAAA diameter was 61 ± 6.2mm. Spinal cord drainage was performed in all patients. A staged approach was used in 12 (57%) cases. Technical success was achieved in 18 (86%) patients. No in-hospital deaths occurred. Two patients experienced transient post-procedural spinal cord ischemia. At 30days, six type II endoleaks (29%), two type Ic endoleak (9.5%) and one type IIIc endoleak (5%) were reported. At a mean follow-up of 23 ± 13months, no late aortic-related deaths occurred. Three patients underwent reintervention for type Ic and IIIc endoleaks. No visceral vessel occlusion was observed. Estimated freedom from reintervention at 12 and 24months was 85.7 ± 0.7%. In 13 cases, TAAA diameter decreased at least 5mm, while increased > 5mm in only one case. Complete false lumen thrombosis was achieved in 18 patients (86%). Complex endografting for pD-TAAA showed favorable mid-term results. Staged and carefully planned endovascular procedures may represent a safe and effective therapeutic option in patients deemed at high risk of open repair.

Kommerell diverticulum – rare complications of a rare disease

Incidence of anomalies of the aortic arch is estimated 1-2 per cent in newborn babies. Lusory artery may arise either from left sided aortic arch in 0.7–2 per cent, or from right sided aortic arch in 0.4 per cent. Leading symptoms develop from compression of the oesophagus or trachea, or both. If lusory artery dilates conically over the time reaching 3 cm or more we call it Kommerell diverticulum. Very rare complications of this are the Type B aortic dissection, which may turn into chronic thoracoabdominal aneurysm, or its shaggy inner surface can be the source of upper extremity embolism. Rupture is extremely rare complication. In our report we focus on five cases of the mentioned complications with their clinical workups and technical solutions. In a female patient with right sided arch transection of the lusory artery was followed by transposition into the right common carotid artery. The central stump 10 years later gradually expanded and the saccular aneurysm indicated intervention. After complete arch debranching thoracic endograft was implanted. In this group of patients with variable surgical and hybrid procedures neither complication nor mortality occurred.

Duplex ultrasound follow-up after fenestrated and branched endovascular aneurysm repair (FEVAR and BEVAR)

Endovascular aneurysm repair (EVAR) is now the predominant method for treatment of infrarenal abdominal aortic aneurysms. Although EVAR has numerous advantages over standard open surgical repair, it also exposes patients to risks such as aneurysm sac enlargement, endoleaks, and graft migration, which make surveillance or follow-up mandatory. Fenestrated (FEVAR) and branched (BEVAR) endografts have extended the application of EVAR to juxtarenal, pararenal/paravisceral, and thoracoabdominal aneurysms, with some complex aneurysms requiring combined approaches (F-BEVAR). Duplex ultrasound has been recommended as an alternative to frequent computed tomography imaging for EVAR follow-up when it can provide the clinically necessary information. The major components of a post-EVAR duplex examination include measurement of aortic aneurysm sac size, assessment for endoleak, and evaluation of the endograft for patency and integrity. The duplex protocol for EVAR follow-up can be extended for follow-up after FEVAR, BEVAR, and F-BEVAR, with additional attention to the device components associated with fenestrations and branches. At the University of Washington, the physician-modified endovascular graft approach has been used for FEVAR. During these procedures, covered stents are placed in the renal arteries through fenestrations and the superior mesenteric artery is perfused through a fenestration, but typically remains unstented. Duplex scanning of the renal and mesenteric arteries has been performed preoperatively and at 30 days, 6 months, 1 year, and annually. In a review of patients having covered stents placed in non-stenotic renal arteries during FEVAR, both peak systolic velocity and the renal to aortic velocity ratio remained below the standard significant stenosis threshold in most patients. The duplex velocity criteria for stenosis in native renal arteries appeared to overestimate the severity of stenosis in renal artery covered stents. The unstented superior mesenteric artery remained widely patent in the presence of fenestrations or crossing struts and was not associated with endoleaks. Duplex ultrasound protocols for follow-up after FEVAR, BEVAR, and F-BEVAR can be based on those that have been established for standard EVAR, along with assessment of fenestrations and branches, as well as patency of the renal and mesenteric arteries.

Fenestrated/Branched Endovascular Repair for Postdissection Thoracoabdominal Aneurysms: A Systematic Review with Pooled Data Analysis.

Patients who have survived an acute aortic dissection remain at risk for postdissection thoracoabdominal aortic aneurysms (PD-TAAAs). Fenestrated/branched endovascular repair for PD-TAAA is increasingly used in some high-volume centers, but outcomes are still limited because of the additional challenges compared to atherosclerotic thoracoabdominal aneurysms. This study was performed to evaluate the literature on fenestrated/branched endovascular repair for PD-TAAAs. PubMed, Embase, and the Cochrane Database were searched for relevant studies published until September 2019. Outcome data were extracted to evaluate the technical success, 30-day mortality, later survival, major complications, endoleaks, target vessel patency, and reintervention. Studies were analyzed in a pooled proportion meta-analysis. In total, 143 patients from 4 studies were identified for the pooled data analysis. The pooled technical success rate was 98% (95% CI: 86%-100%). After the treatment, the overall estimated 30-day mortality rate was 3% (95% CI: 1%-8%), early spinal cord ischemia rate was 10% (95% CI: 4%-21%), early renal injury rate was 5% (95% CI: 1%-19%), endoleak rate was 33% (95% CI: 22%-47%), reintervention rate at a median follow-up of 22.5 months was 34% (95% CI: 27%-42%), and all-cause mortality rate was 12% (95% CI: 6%-24%). The use of fenestrated/branched stent grafts for the treatment of PD-TAAA appears generally feasible based on the limited literature, but endoleaks and reinterventions are frequent.

Upper thoracoabdominal aortic repair through partial posterior incision of the diaphragm via left thoracotomy.

During surgical repair of a thoracoabdominal aortic aneurysm, division of the diaphragm should be minimized to avoid pulmonary complications. We herein describe a modified exposure technique that avoids ordinary circumferential division of the diaphragm. The diaphragm was detached from the aneurysm at the level of the aortic hiatus via a modified anterior lateral thoracotomy incision through the pleural space. The diaphragmatic incision around the aneurysm was extended posteriorly. This partial division of the diaphragm provided sufficient exposure of the distal anastomosis site for thoracoabdominal aneurysms that do not extend below the upper part of the abdomen.

Predictors of 30-day readmission and resource utilization after thoracic endovascular aortic repair.

The introduction and expansion of thoracic endovascular aortic repair (TEVAR) have revolutionized the treatment of a variety of thoracic aortic diseases. We sought to evaluate the incidence, causes, predictors and costs associated with 30-day readmission after TEVAR in a nationally representative cohort. Adult patients undergoing isolated TEVAR were identified in the National Readmissions Database from 2010 to 2014. Hospital costs were estimated by converting individual hospital charge data adjusted to 2014 consumer price indices. Multivariable logistic regression was utilized to determine hospital- and patient-level factors associated with readmissions. A total of 24983 TEVARs were noted during the study period; the average age of the patients was 65 ± 16 years; 40% were women. The most common indication was an intact thoracic aneurysm (43.5%), followed by aortic dissection (30.5%). The average cost of the index admission was $63644 ± $52312; the average hospital stay was 11 ± 14 days; the index mortality rate was 6.7%. Readmissions within 30 days occurred in 17.4% of patients. Indications for readmission were varied; the most common aetiologies were cardiac (17.8%), infectious (16.0%) and pulmonary (12.1%). On multivariable analysis, the strongest predictor of readmission was the diagnosis, with a ruptured thoraco-abdominal aneurysm having the highest readmission burden (adjusted odds ratio 2.23, 1.17-4.24; P = 0.015). Notably, hospital volume did not predict index hospital length of stay, costs or 30-day readmissions (all P > 0.10). Annual TEVAR volume was not associated with any of the outcomes assessed. Rather, indication for TEVAR was the strongest predictor for many outcomes. As TEVAR becomes increasingly utilized, a focus on cardiac and vascular diseases may reduce readmissions and improve quality of care.

Predicting recovery from paraplegia after thoracoabdominal aneurysm repair

Predicting recovery from paraplegia after thoracoabdominal aneurysm repair

Contemporary mortality after emergent open repair of complex abdominal aortic aneurysms

ObjectiveMortality after open repair for emergent complex abdominal aortic aneurysm (AAA) is poorly defined. This study evaluated the 30-day mortality of open complex AAA repair performed for rupture or other emergent indication using a national surgical registry. We subsequently identified factors associated with mortality. MethodsThe targeted vascular module from the American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing open repair for juxtarenal and suprarenal AAAs or type IV thoracoabdominal aneurysms (TAAAs) for rupture or other emergent indication from 2011 to 2017. Univariate analyses were performed using the Fisher's exact test for categorical variables and the Wilcoxon rank sum test for continuous variables. Multivariable logistic regression was performed to identify factors independently associated with mortality. ResultsWe included 374 patients who underwent an emergent complex open AAA repair during the study period. There were 142 (38%) cases performed for rupture with hypotension, 141 (38%) for rupture without hypotension, 40 (11%) for symptomatic AAA, and 51 (14%) for another indication. The distribution by aneurysm type was 224 juxtarenal AAAs, 122 suprarenal AAAs, and 28 type IV TAAAs. Overall, there was a 30-day mortality of 32% (118 deaths). For those with juxtarenal AAA repair, 67 (30%) patients died within 30 days; there were 38 (31%) deaths within 30 days in those with suprarenal AAA, and 13 (46%) deaths within 30 days in those with type IV TAAA. On univariate analysis, preoperative variables associated with death were increasing age, use of a transperitoneal surgical approach, lower preoperative estimated glomerular filtration rate, low baseline albumin concentration (<3.5 g/dL), need for preoperative transfusion, low body mass index (<18.5 kg/m2), and hypotension at presentation. Intraoperative variables associated with mortality were supraceliac clamp location and concurrent renal revascularization. On multivariable analysis, factors independently associated with death included rupture with associated hypotension (reference: other emergent indication; adjusted odds ratio [AOR], 3.28; confidence interval [CI], 1.75-5.41; P < .001), age >60 years (reference: <60 years; AOR, 1.59; CI, 1.18-2.13; P = .002), longitudinal laparotomy incision (reference: retroperitoneal; AOR, 3.28; CI, 1.75-6.16; P < .001), and supraceliac cross-clamp (reference: clamp above one renal artery; AOR, 2.14; CI, 1.31-3.50; P = .003). ConclusionsNearly one-third of patients die within 30 days of emergent open complex AAA repair. Mortality is particularly high for patients with type IV TAAAs, approaching 50%. Predictors of 30-day mortality include rupture with associated hypotension, increasing age, supraceliac clamp location, and longitudinal transperitoneal repair approach. These results will help inform surgical decisions preoperatively and intraoperatively.

Anatomic feasibility of the investigational GORE EXCLUDER Thoracoabdominal Branch Endoprosthesis (TAMBE), off-the-shelf multibranched endograft for the treatment of pararenal and thoracoabdominal aortic aneurysms

ObjectiveThe objective of this study was to evaluate the proportion of pararenal aortic aneurysms and thoracoabdominal aortic aneurysms (TAAAs) that could theoretically be treated with the investigational GORE EXCLUDER Thoracoabdominal Branch Endoprosthesis (TAMBE; W. L. Gore & Associates, Flagstaff, Ariz) off-the-shelf multibranched endograft. MethodsThe preoperative computed tomography scans of patients with pararenal aortic aneurysms and TAAAs treated at a single institution between 2007 and 2017 were reviewed. This cohort included both open and endovascular repairs performed in either elective or urgent/emergent settings. These studies were included in a retrospective feasibility study to verify anatomic feasibility of the TAMBE graft (with four antegrade portals) employed within the manufacturer's investigational instructions for use during the U.S. pivotal trial. The patient cohort was divided into two groups: extended thoracoabdominal aneurysm (E-TAA)—extent I, II, and III TAAA; and limited pararenal and thoracoabdominal aneurysm (L-TAA)—pararenal aortic aneurysm and extent IV TAAA. The anatomic factors determining the overall theoretical feasibility were further divided into three groups: vascular access feasibility, aortic feasibility, and visceral vessel feasibility. ResultsComputed tomography scans of 227 patients with degenerative aneurysms were analyzed, 166 with E-TAA and 61 with L-TAA. In the L-TAA group, 49% of the cases could have been treated with the TAMBE endograft alone; access feasibility was 85%, aortic feasibility 74%, and visceral vessel feasibility 72%. In the E-TAA group, only 23% of the cases could have been treated with a TAMBE combined with a GORE CTAG proximal thoracic stent graft; access feasibility was 79%, aortic feasibility 48%, and visceral vessel feasibility 63%. The different feasibility rate was related to a difference in aortic feasibility between L-TAA and E-TAA (74% vs 48%; P = .0008) because of the lack of a dedicated tapered thoracic component. ConclusionsThe TAMBE multibranched endograft can theoretically be employed in half of an all-comers cohort of patients with degenerative L-TAA. Development of a dedicated tapered thoracic component is warranted to increase the feasibility for E-TAA, and comparative studies are required to investigate differences with other available off-the-shelf stent grafts.

The Combined Use of a Distal Self-Expandable and Proximal Balloon-Expandable Stent Graft in Bridging Hostile Renal Arteries in Thoracoabdominal Branched Endografting

To evaluate early/midterm outcomes of a specific configuration of a bridging stent graft-that is a distal self-expandable (SE) stent graft combined with proximal balloon-expandable (BE) one-in hostile renal artery (RA) anatomy in branched thoracoabdominal aneurysm (TAAA) repair. Between 2010 and 2019, all TAAAs undergoing fenestrated and branched endografting (FB-EVAR) were prospectively collected. Preoperative, procedural, and postoperative data of RAs accommodated by branch design and patent at the completion angiography were retrospectively analyzed. Hostile RA anatomy included upward (type B) and downward+upward (type D) orientations. Type B and D RAs treated by the combination of an SE+BE stent graft as a bridging stent (BE+SE group) were compared with RAs treated by a BE stent graft only (BE group). RA occlusion, reinterventions, and branch instability were assessed. Over a total of 112 TAAAs undergoing FB-EVAR, 189 RAs were treated by fenestrations (113-60%) and branches (76-40%). Among the 66 (86%) RAs accommodated by branch and patent at completion angiography, 55 had a type B/D orientation. BE stent grafts were used in 15/55 (27%) RAs and SE+BE in 40/55 (73%). At a median follow-up of 12 (8) months, 5/55 (9%) RAs occluded: 4/15 (27%) in the BE group and 1/40(2.5%) in the SE+BE group (P: 0.017). RA patency was 83±5% at 24months. The SE+BE group had higher patency than the BE group (90±5% vs. 68±5% at 12months; P: 0.039). Overall freedom from RA-related reinterventions was 87±5% at 24months. Six (9%) RAs required reinterventions: 4/15 (27%) in the BE group and 2/40 (5%) in the BE+SE group (P: 0.041). RAs managed by an SE+BE stent graft had lower reinterventions than RAs treated by a BE stent graft only (93±5% vs. 76±5% at 12months; P: 0.01). Freedom from branch instability was 78±5% at 24months, with 8 overall cases (12%) occurring-5/15 (33.3%) in the BE group versus 3/40 (7.5%) in the SE+BE group (P: 0.02). RAs managed by an SE+BE stent graft had lower branch instability than RAs treated only by a BE stent graft (BE: 68±5% vs. SE+BE: 80±5% at 12months; P: 0.02). In hostile renal anatomy, the combination of a distal SE and proximal BE stent graft as a bridging stent in branched endografting is safe and effective with lower rates of occlusion, reinterventions, and branch instability at midterm follow-up compared with a BE stent graft alone.

Elective Multistaged Endovascular Repair of Thoraco-abdominal Aneurysms with Fenestrated and Branched Endografts to Mitigate Spinal Cord Ischaemia

To evaluate the safety and effectiveness of a multistaged approach for elective thoraco-abdominal aneurysm (TAAAs) repair by means of endovascular fenestrated and/or branched (F/B-EVAR) grafts. Between 2013 and 2018, 80 high risk surgical patients received elective F/B-EVAR for TAAAs with a protocolled multistaged approach (thoracic, visceral, and limb steps) and were enrolled in an ambispective single centre study called STEAR (STaged Endovascular Aortic Repair - NCT03342755). Data regarding all study participants, single step mortality and morbidity (systemic complications) rates were recorded and the overall results were considered for statistical analysis. Previous aortic interventions (61/80 cases, 76.3%) combined with the TAAA extents resulted in different staging strategies: 58 patients (73%) had a thoracic step and 33 (41%) a limb step. The median TAAA treatment time was 77 days (50–107). The overall mortality was six cases (8%) and 30 day clinical success rate 64 cases (80%). The overall rate of grade 2 or 3 (including death) systemic complications was 19 cases (24%) and 20 patients (25%) experienced grade 1 complications. Three patients with type II or III TAAAs (4%) had permanent and fatal spinal cord (SC) impairment. On multivariable analysis, SC ischaemia was associated with an aortic coverage ≥350 mm (OR: 9.15, p = .03, 95% CI: 1.3–66.4) and bovine arch (OR: 10.6, p = .01, 95% CI: 1.6–68.6). The overall short term (six month) clinical success was 72 cases (90%) and none experienced SC ischaemia after late endoleak resolution or treatment. At mid term (mean follow up: 13.3 ± 15.4 months), the overall freedom from conversions, re-interventions, late rupture, or type I and III endoleaks was 57 of 72 survivors (79%). A multistaged approach with a third limb step in case of TAAAs is safe and technically feasible, with an acceptable rate of permanent spinal cord ischaemia. Different staging methods and protocols have been proposed and standardisation is required, especially for type I-II-III aneurysms.

Survival after endovascular therapy in patients with ruptured thoracic aortic diseases: Results from the Global Registry for Endovascular Aortic Treatment Registry

ObjectiveThe Global Registry for Endovascular Aortic Treatment is a prospective observational multicenter cohort registry of all Gore aortic endografts for a variety of aortic pathologies. The purpose of this study was to evaluate the outcome of the Conformable GORE TAG Thoracic Endoprosthesis and GORE TAG Thoracic Endoprosthesis devices for ruptured thoracic aortic syndromes. MethodsBetween December 2010 and October 2016, a total of 5018 patients were enrolled from 114 international sites in this registry. The database was queried for patients with at least one of the following pathologies: descending thoracic aortic aneurysm with rupture, thoracoabdominal aortic aneurysm rupture, descending aortic dissection rupture, and aortic arch aneurysm rupture. Patient demographics, operative details, and clinical outcomes were analyzed. ResultsA total of 40 patients were treated with a ruptured thoracic aortic disease (62.5% male; mean age, 67.5 ± 14.1 years). Nineteen patients were treated for descending thoracic aneurysm rupture, 9 for thoracoabdominal aneurysm rupture, 7 for descending aortic dissection rupture, and 5 for aortic arch aneurysm rupture. Technical success was achieved in 40 of 40 patients (100%). There were no intraoperative mortalities and no conversions to an open procedure. A total of 12 patients (30.0%) required intervention for involvement of at least one aortic branch vessel (4 covered, 5 surgically debranched, 1 stented, and 6 chimney technique). The 30-day mortality was four patients (10.0%). Early reintervention (≤30 days) was required in seven patients (17.5%), five of which were device related. There was a total of five endoleaks and all five required a reintervention. The median follow-up duration was 14.7 months (range, 1-57 months). Freedom from device-related intervention at 1 year was 87.1% (95% confidence interval, [CI], 0.716-0.944), at 2 years was 81.3% (95% CI 0.607-0.917) and at 3 years was 73.1% (95% CI, 0.47-0.878). Freedom from all-cause mortality at 1 year was 65.0% (95% CI, 0.474-0.780), at 2 years was 61.2% (95% CI, 0.431-0.751), and at 3 years was 56.1% (95% CI, 0.369-0.715). ConclusionsThe Conformable GORE TAG Thoracic Endoprosthesis and GORE TAG Thoracic Endoprosthesis thoracic endografts provide an effective treatment for ruptured thoracic aortic diseases. Adjunctive coverage or revascularization of an aortic branch vessel may be necessary. Longer follow-up and larger studies are needed to determine durability of these repairs.

Multicentre Experience with the Chimney Technique for Abdominal Aortic Aneurysms in French University Hospitals

The chimney technique (ChEVAR) allows for proximal landing zone extension for endovascular repair of complex aortic aneurysms. The aim of the present study was to assess ChEVAR national outcomes in French university hospital centres. All centres were contacted and entered data into a computerised online database on a voluntary basis. Clinical and radiological data were collected on all consecutive ChEVAR patients operated on in 14 centres between 2008 and 2016. Patients were deemed unfit for open repair. Factors associated with early (30 day or in hospital) mortality and type 1 endoleak (Type I EL) were calculated using multivariable analysis. In total, 201 patients with 343 target vessels were treated. There were 94 juxtarenal (46.8%), 67 pararenal (33.3%), 10 Crawford type IV thoraco-abdominal (5%) aneurysms, and 30 (15.1%) proximal failures of prior repairs. The pre-operative diameter was 66.8±16.7mm and 28 (13.9%) ChEVAR were performed as an emergency, including six (2.9%) ruptures. There were 23 (11.7%) unplanned intra-operative procedures, mainly related to access issues. The rate of early deaths was 11.4% (n=23). The elective mortality rate was 9.8% (n=17). Nine patients (4.5%) presented with a stroke. The rate of early proximal Type I EL was 11.9%. Survival was 84.6%, 79.4%, 73.9%, 71.1% at 6, 12, 18, and 24 months, respectively. The primary patency of chimney stents was 97.4%, 96.7%, 95.2%, and 93.3% at 6, 12, 18, and 24 months, respectively. Performing unplanned intra-operative procedures (OR 3.7, 95% CI 1.3-10.9) was identified as the only independent predictor of post-operative death. A ChEVAR for juxtarenal aneurysm was independently associated with fewer post-operative Type I ELs (OR 0.17, 95% CI 0.05-0.58). In this large national ChEVAR series, early results were concerning. The reasons may lie in heterogeneous practices between centres and ChEVAR use outside of current recommendations regarding oversizing rates, endograft types, and sealing zones. Future research should focus on improvements in pre-operative planning and intra-operative technical aspects.

Aneurysm Rupture and Mortality During the Waiting Time for a Customised Fenestrated/Branched Stent Graft in Complex Endovascular Aortic Repair

Treatment of complex aortic pathologies with customised fenestrated/branched stent grafts (F/BEVAR) is associated with a longer waiting time to the procedure. This study aimed to investigate the prevalence of aneurysm rupture and mortality during the waiting time for a fenestrated/branched stent graft in a single centre. All patients with a pararenal (PAA), thoraco-abdominal (TAAA), or aortic arch aneurysm planned to be treated with a customised F/BEVAR between January 2010 and December 2018 were included. Patients planned for F/BEVAR who in the end did not undergo the procedure were analysed. 906 patients were planned to undergo F/BEVAR during the study period. Of those, 862 (95.1%)underwent the procedure as planned (FEVAR for PAA; n=494, F/BEVAR for TAAA; n=348, F/BEVAR for arch aneurysm; n=20). In 44 (4.9%) patients, the procedure was cancelled. Thirty-seven (4.1%) patients died before the procedure, four (0.4%) patients turned down the procedure, two (0.2%)werecancelled because of worsened general condition, and one (0.1%) ruptured but underwent emergency open repair in another institution. Causes of death during the waiting time were: aneurysm rupture, n=15 (1.7%); cardiac, n=7 (0.8%); stroke, n=3 (0.3%); gastrointestinal, n=3 (0.3%); death after complete arch debranching, n=2 (0.2%); infection, n=2 (0.2%); death after transcatheter aortic valve implantation, n=1 (0.1%); death after urological surgery, n=1 (0.1%); unknown, n=3 (0.3%).Aneurysm diameter was larger in patients who died of aneurysm rupture compared with patients who died as a result of other causes (79.2±13mm vs. 66.7±12mm, respectively, p=.005). Aneurysm rupture during the waiting time for F/BEVAR can occur but is rare. Patients with a larger aneurysm diameter may be at higher risk of rupture. Measures to reduce the risk of rupture during the waiting time might include the use of off the shelf devices for larger aneurysms, quicker measurement and graft plan order processes, and quicker graft construction and delivery.

Delivering the promise of a minimally invasive thoracoabdominal aneurysm repair: The road less travelled

Rocha et al1 present the most comprehensive—to date—comparative analysis on outcomes after open vs endovascular repair for thoracoabdominal aortic aneurysms (TAAAs). Their analysis is as thorough as it is thoughtful and candid. An important finding of this study relates to the realization that the risk of postoperative complications is high regardless of treatment strategy. Mortality was similar for both treatment modalities, and although one could argue that sicker patients were preferentially treated with endovascular means, clearly the three- to five-fold improvement in early postoperative mortality that is seen when endovascular techniques2-4 are used for infrarenal abdominal aortic aneurysm will be difficult to replicate in the foreseeable future.

Early Results of a Novel Single-Stage Hybrid Aortic Arch Replacement Technique to Reduce Bypass and Circulatory Arrest Duration.

Hybrid repair procedures of the aortic arch have been utilized to reduce surgical risks and apply this therapy to patients who would not traditionally be candidates for open surgical repair. We present a variation on the frozen elephant trunk technique to further reduce cardiopulmonary bypass and circulatory arrest duration. After initiation of cardiopulmonary bypass and during systemic cooling, a wire is advanced from the femoral artery into the aortic arch. In the case of aortic dissection, intravascular ultrasound is used to confirm true lumen placement. Under circulatory arrest, the proximal aortic arch is resected and the wire externalized. Antegrade deployment of a stent graft is performed into the aortic arch and proximal descending aorta. The ascending aortic graft is sewn to the cut end of the aorta, incorporating the stent graft. The graft is cannulated and cardiopulmonary bypass reinitiated. The remainder of the arch replacement is performed during re-warming. Twenty two patients underwent this novel hybrid arch replacement procedure for aortic pseudoaneurysm, aortic dissection, or aneurysm. In comparison to the frozen elephant trunk procedure, where a dacron graft is inserted into the descending aorta, and later fixed with an endograft, this technique allows for immediate distal fixation. In the case of aortic dissection, there is immediate expansion of the true lumen with distal seal, potentially obviating the need for additional procedures. Mean duration of follow up is 12 months (range 1 - 14 months). The mean duration of cardiopulmonary bypass was 109.32 ±3.14 minutes. The mean duration of circulatory arrest was 18.00 ±1.33 minutes at a mean temperature of 23.64 ±0.58 degrees Celsius. There were no mortalities, no permanent disabling strokes, and no renal failure (requiring dialysis). This novel hybrid technique for aortic arch replacement is safe, significantly reduces cardiopulmonary bypass and circulatory arrest times, and is performed readily without need for fluoroscopy. In patients with thoracoabdominal aneurysms, the stent graft can be used as an elephant trunk for further thoracoabdominal aneurysm repair or branched thoracic endovascular aortic repair procedures.

Results of fenestrated and branched endovascular aortic aneurysm repair after failed infrarenal endovascular aortic aneurysm repair

ObjectiveFailure of infrarenal endovascular aneurysm repair (EVAR) due to loss of proximal seal is increasingly common. Open surgical conversion can be challenging and has been associated with significant morbidity and mortality. The aim of this study was to evaluate the use of fenestrated-branched EVAR (F/BEVAR) for the treatment of patients with prior EVAR failure. MethodsConsecutive patients enrolled as part of the Aortic Research Consortium in six prospective, nonrandomized, physician-sponsored investigational device exemption studies evaluating F/BEVAR between 2012 and 2018 were included in this study. The cohort was stratified according to whether the F/BEVAR procedure was performed after EVAR failure. Demographics, operative details, perioperative complications, and length of stay were compared between groups. Postprocedural survival, type I or type III endoleak, target artery patency, target artery instability, and reintervention rates were calculated using Kaplan-Meier method and compared between groups. ResultsA total of 893 patients underwent F/BEVAR; 161 (18%) were treated after failed EVAR and 732 (82%) were treated without prior EVAR. Patients with failed EVAR were more often men (84% vs 66%; P < .01) with larger aneurysms (6.9 cm vs 6.4 cm; P < .01). There were no differences in aneurysm extent (P = .20) between groups; for the entire cohort, there were 19% juxtarenal, 9.2% suprarenal, and 72% thoracoabdominal aneurysms. The average number of targeted arteries per patient was 3.6 in both groups. The procedural technical success (99% vs 97%; P = .15) did not differ between groups, but radiation dose (4750 vs 2920 mGy; P = .02), dose-area product (154,572 vs 82,842 mGy·cm2; P < .01), and operative time (5.2 vs 4.6 hours; P < .01) were significantly higher in the failed EVAR group. Median intensive care unit length of stay (2.9 days) and total length of stay (6.3 days) did not differ between groups. The 30-day mortality rate (failed EVAR, 2.5%; no EVAR, 1.1%; P = .25) and 30-day major adverse event rates did not differ between groups. Kaplan-Meier estimates of freedom from type I or type III endoleak (91.9% vs 92.5%; P = .65), target artery patency (97.3% vs 97.0%; P = .91), freedom from target artery instability (86.3% vs 88.8%; P = .53), and freedom from reintervention at 1 year (84.7% vs 88.7%; P = .10) did not differ between the failed EVAR and no EVAR groups, respectively. One-year survival was decreased in the failed EVAR group (86.3% vs 91.9%; P = .02), but this effect did not persist on multivariable analysis (hazard ratio, 1.52; 95% confidence interval, 0.88-2.62; P = .14). ConclusionsIn this multicenter study, F/BEVAR was safe and effective in patients with prior failed EVAR, with nearly identical outcomes to those of patients without prior EVAR. However, differences in procedural metrics indicate higher level of technical challenge in performing F/BEVAR in patients with prior failed EVAR.