Thoracoabdominal Aneurysm Research Articles

Systematic Multi-Staged Endovascular Repair of Thoracoabdominal Aneurysms with Fenestrated and Branched Endografts (Stear Study)

Systematic Multi-Staged Endovascular Repair of Thoracoabdominal Aneurysms with Fenestrated and Branched Endografts (Stear Study)

Total Endovascular Management of a Symptomatic Post-dissection Thoracoabdominal Aneurysm with the New Physician Modified Fenestrated Thoracic Endograft

Total Endovascular Management of a Symptomatic Post-dissection Thoracoabdominal Aneurysm with the New Physician Modified Fenestrated Thoracic Endograft

Aortic Coverage to Treat Juxta/Para-renal and Type IV Thoracoabdominal Aneurysm with Custom Made Fenestrated Endografts is Greater Compared with Open Repair but Does Not Affect Results

Aortic Coverage to Treat Juxta/Para-renal and Type IV Thoracoabdominal Aneurysm with Custom Made Fenestrated Endografts is Greater Compared with Open Repair but Does Not Affect Results

Impact of left ventricular ejection fraction on the outcomes of open repair of descending thoracic and thoracoabdominal aneurysms

ObjectiveTo discern the impact of depressed left ventricular ejection fraction (LVEF) on the outcomes of open descending thoracic aneurysm (DTA) and thoracoabdominal aneurysms (TAAA) repair. MethodsRestricted cubic spline analysis was used to identify a threshold of LVEF, which corresponded to an increase in operative mortality and major adverse events (MAE: operative death, myocardial infarction, stroke, spinal cord injury, need for tracheostomy or dialysis). Logistic and Cox regression were performed to identify independent predictors of MAE, operative mortality, and survival. ResultsDTA/TAAA repair was performed in 833 patients between 1997 and 2018. Restricted cubic spline analysis showed that patients with LVEF <40% (n = 66) had an increased risk of MAE (odds ratio [OR], 2.17; 95% confidence interval [CI], 1.22-3.87; P < .01) and operative mortality (OR, 2.72; 95% CI, 1.21-6.12; P = .02) compared with the group with LVEF ≥40% (n = 767). The group with LVEF <40% had a worse preoperative profile (eg, coronary revascularization, 48.5% vs 17.3% [P < .01]; valvular disease, 82.8% vs 49.39% [P < .01]; renal insufficiency, 45.5% vs 26.1% [P < .01]; respiratory insufficiency, 36.4% vs 21.2% [P = .01]) and worse long-term survival (35.5% vs 44.7% at 10 years; P = .01). Nonetheless, on multivariate regression, depressed LVEF was not an independent predictor of operative mortality, MAE, or survival. ConclusionsLVEF is not an independent predictor of adverse events in surgery for DTA.

Intermodality feature fusion combining unenhanced computed tomography and ferumoxytol-enhanced magnetic resonance angiography for patient-specific vascular mapping in renal impairment

ObjectiveThe purpose of this study was to establish the feasibility of fusing complementary, high-contrast features from unenhanced computed tomography (CT) and ferumoxytol-enhanced magnetic resonance angiography (FE-MRA) for preprocedural vascular mapping in patients with renal impairment. MethodsIn this Institutional Review Board-approved and Health Insurance Portability and Accountability Act-compliant study, 15 consecutive patients underwent both FE-MRA and unenhanced CT scanning, and the complementary high-contrast features from both modalities were fused to form an integrated, multifeature image. Source images from CT and MRA were segmented and registered. To validate the accuracy, precision, and concordance of fused images to source images, unambiguous landmarks, such as wires from implantable medical devices or indwelling catheters, were marked on three-dimensional (3D) models of the respective modalities, followed by rigid co-registration, interactive fusion, and fine adjustment. We then compared the positional offsets using pacing wires or catheters in the source FE-MRA (defined as points of interest [POIs]) and fused images (n = 5 patients, n = 247 points). Points within 3D image space were referenced to the respective modalities: x (right-left), y (anterior-posterior), and z (cranial-caudal). The respective 3D orthogonal reference axes from both image sets were aligned, such that with perfect registration, a given point would have the same (x, y, z) component values in both sets. The 3D offsets (Δx mm, Δy mm, Δz mm) for each of the corresponding POIs represent nonconcordance between the source FE-MRA and fused images. The offsets were compared using concordance correlation coefficients. Interobserver agreement was assessed using intraclass correlation coefficients and Bland-Altman analyses. ResultsThirteen patients (aged 76 ± 12 years; seven female) with aortic valve stenosis and chronic kidney disease and two patients with thoracoabdominal vascular aneurysms and chronic kidney disease underwent FE-MRA for preprocedural vascular assessment, and unenhanced CT examinations were available in all patients. No ferumoxytol-related adverse events occurred. There were 247 matched POIs evaluated on the source FE-MRA and fused images. In patients with implantable medical devices, the mean offsets in spatial position were 0.31 ± 0.51 mm (ρ = 0.99; Cb = 1; 95% confidence interval [CI], 0.99-0.99) for Δx, 0.27 ± 0.69 mm (ρ = 0.99; Cb = 0.99; 95% CI, 0.99-0.99) for Δy, and 0.20 ± 0.59 mm (ρ = 1; Cb = 1; 95% CI, 0.99-1.00) for Δz. Interobserver agreement was excellent (intraclass correlation coefficient, >0.99). The mean difference in offset between readers was 1.5 mm. ConclusionsAccurate 3D feature fusion is feasible, combining luminal information from FE-MRA with vessel wall information on unenhanced CT. This framework holds promise for combining the complementary strengths of magnetic resonance imaging and CT to generate information-rich, multifeature composite vascular images while avoiding the respective risks and limitations of both modalities.

Two-year evaluation of fenestrated and parallel branch endografts for the treatment of juxtarenal, suprarenal, and thoracoabdominal aneurysms at a single institution

ObjectiveDespite numerous recent pivotal and small-scale trials, real-world endovascular management of juxtarenal aneurysms (JRA), suprarenal aneurysms (SRA), and thoracoabdominal aortic aneurysms (TAAA) remains challenging without consensus best practices. This study evaluated the mortality, graft patency, renal function, complication, and reintervention rates for fenestrated and parallel endografts in complex aortic aneurysms repairs. MethodsThis retrospective review of consecutive included patients with JRA, SRA, or TAAA who underwent complex endovascular repair from August 2014 to March 2017 at one high-volume institution. Treatment modality was a single surgeon decision based on patients anatomy and the urgency of the repair. Patient demographics, hospital course, and follow-up visits inclusive of imaging were analyzed. Ruptured aneurysms were excluded. Survival rates and outcomes were determined using the Kaplan-Meier method with log-rank tests. ResultsSeventy complex endovascular aortic repairs were performed; 38 patients with TAAA were treated with snorkel/sandwich parallel endografts (21 celiac, 28 superior mesenteric arteries, 58 renal arteries) and 32 patients with JRA/SRA were treated by fenestrated endovascular aneurysm repair (FEVAR) with 94 total fenestrations (2 celiac, 30 SMA, 62 renal). The mean patient age was 74.8 ± 10.0 years. Sixty percent were male, and the mean aortic aneurysm diameter was 6.0 ± 1.4 cm. Perioperative mortality was 3.1% (1/32) for FEVAR compared with 2.6% (1/38) for parallel endografts (P = .9). All-cause reintervention rates were 15.6% in FEVAR (5/32) vs 23.6% with parallel endografts (9/38; P = .4). Branch reintervention rates per each branch endograft were 4.3% for FEVAR (4/94; 2 renal stent occlusions, 1 colonic ischemia without technical issue found on reintervention, 1 perinephric hematoma) vs 3.7% for parallel endografts (4/107; 2 renal and 1 celiac stent thromboses, and 1 renal stent kink; P = .41). The endograft branch thrombosis rate was 2.1% in FEVAR (2/94) vs 2.7% in parallel endografts (3/109; P = .77). Reinterventions owing to endoleaks were performed in five patients (2 type I, 2 type III, and 1 gutter endoleak; 13.1%) with parallel grafts vs no endoleak reinterventions in FEVAR. The overall survival and freedom from aneurysm-related mortality at 24 months was 78% and 96.9% in FEVAR vs 73% and 93.4% for parallel endografts (P = .8 and P = .6). The median follow-up was 12 months (range, 1-32 months). ConclusionsParallel and fenestrated endografts have acceptable and comparable mortality and patency rates in endovascular treatment of JRA, SRA, and TAAA. This study reaffirms that parallel endografts are a safe and viable alternative to fenestrated devices for complex aortic aneurysmal disease despite often treating more urgent patients and more complicated anatomy unable to be treated with FEVAR.

Outcome After Fenestrated and Branched Repair of Aortic Aneurysms—Device Failures Predict Reintervention Rates

Previous reports have indicated endovascular repair to be safe and effective in the treatment of complex aortic aneurysms. The endovascular technology evolves rapidly, and continuous evaluation of F/B-EVAR results is critical to detect failing techniques. Our aim was to analyze the outcome after endovascular repair of complex abdominal aortic and thoracoabdominal aneurysms. Single-center, retrospective cohort study, of all F/B-EVAR from August 2009 to December 2018. Primary outcomes were branch instability and freedom from reinterventions at 2years. Secondary outcomes were major adverse events and all-cause mortality at 30 and 90 days. A total of 72 consecutive patients were included, 55 with a complex abdominal aortic aneurysm (AAA) and 17 with a thoracoabdominal aortic aneurysm (TAAA). Two patients were operated on for rupture. A total of 219 vessels were stented through fenestrations (n=163) or branches (n=56). Median follow-up was 24months (IQR 4-24). Fractured bridging stent graft was the most common cause for reintervention, n=6. All fractures were in vessels stented with first generation BeGrafts, (6/41 BeGraft vs 0/61 other stents, P<0.01). Freedom from reinterventions at 2years was 75% and 35%, in the complex AAA and TAAA groups, respectively (P=0.04) and excluding BeGrafts 79% (cAAA) and 66% (TAAA). The most common major adverse event was spinal cord ischemia (SCI), in total 8.3% with either transient (2.8%) or permanent (5.6%) deficit. Elective mortality at 30days was 1.4% (1/70) and at 90days was 2.9% (2/70). The rate of branch instability and reintervention was high, with a clear relation to fractured first-generation BeGrafts. Mortality and major adverse event rates were low. Long-term close surveillance of bridging stent graft performance is crucial, and the endovascular community should strive to find ways to report failing materials at an early stage to avoid potentially serious complications.

Early Experience with the Covera Stent Graft as a Bridging Stent in Branched Thoraco-Abdominal Endovascular Aneurysm Repairs.

To evaluate the Covera Plus (Bard, Tempe, Arizona) covered stent as a bridging stent in branched thoraco-abdominal endovascular aneurysm repair (BEVAR). Retrospective analysis of 112 self-expandable stents was performed at 2 university centers between August 2017 and March 2019. Thirty-one consecutive BEVAR procedures were studied (21 males; mean age, 75 years; 29 American Society of Anesthesiologists grade III/IV) with 119 patent target vessels (7 did not receive the studied device). Primary endpoints were technical success, branch instability, and primary/secondary clinical success. Secondary endpoints included primary/secondary patency and any adverse events. Technical success was 100%. Median follow-up was 12 months (interquartile range, 6-14 months). Branch instability was registered twice (2/112), due to immediate renal occlusion and type Ic endoleak; no additional events occurred during the follow-up. Primary clinical success was 84%. There were 2 immediate deaths, 1 upper limb ischemia, 1 hemorrhage from splenic artery, and 1 type Ic endoleak; these last 3 events were successfully treated, with a secondary clinical success of 100% that was maintained during the follow-up. One late death occurred. Primary patency was 99% (111/112) and 100% (105/105) within 30 days and at the end of the study period,respectively. Adverse events included 4 acute kidney injuries and 2 spinal cord ischemia. No type I/III endoleaks, occlusion, fracture, or dislodging were diagnosed after 30 days. The stent graft seems safe and effective for bridging in BEVAR with low branch instability and high patency rate. Longer follow-up is required to confirm these promising results.

Incidence and Predictors of Neurological Complications Following Thoracic Endovascular Aneurysm Repair in the Global Registry for Endovascular Aortic Treatment

The aim of this study was to investigate the incidence and predictors of early and mid term neurological complications following thoracic endovascular repair (TEVAR) in the Global Registry for Endovascular Aortic Treatment (GREAT). The GREAT is a prospective observational multicentre registry on Gore aortic endografts that was initiated in 2010. Only isolated thoracic aortic pathologies were included (aortic arch and descending thoracic aneurysms, type B dissections, penetrating ulcers, intramural haematomas, pseudoaneurysms, and transections). Thoraco-abdominal aneurysms and concomitant abdominal aneurysms were excluded. Neurological complications were classified as cerebrovascular accidents (CVA) and spinal cord injuries (SCI). Clinical, procedural, and technical data were evaluated for their association with early (30 day) and mid term CVAs and SCIs. In total, 833 patients were included: 28 with arch aneurysms (3.4%), 329 with descending thoracic aneurysms (39.5%), 273 with type B dissections (32.8%), and 203 (24.4%) with other thoracic pathologies. Altogether, 593 (71.2%) were elective procedures and 240 (28.8%) were urgent. Aortic coverage >20 cm was performed in 42.1% (n = 351); proximal landing zone 0-1-2 was adopted in 267 patients (32.1%) and of these 98 (36.7%) underwent left subclavian artery (LSA) revascularisation. There were 13 early CVAs (1.5%) and the four year freedom from CVA rate was 96.3%. On multivariable analysis, aortic arch aneurysm was the only independent predictor of early CVA (odds ratio 16.7, p = .001). LSA coverage (hazard ratio [HR] 3.31, p = .005) and hypercholesterolaemia (HR 2.96, p = .024) were independent predictors of mid term ischaemic CVAs. There were 15 (1.8%) early SCIs, and the four year freedom from SCI rate was 97.8%. No independent predictors of early SCI were identified, but length of coverage was an independent predictor of SCI at four years (HR 1.24; p = .044). In this real world registry, the overall rate of neurological complication after TEVAR for isolated thoracic aortic pathologies was low. Aortic arch aneurysms were associated with increased peri-operative CVA risk. Length of coverage was an independent predictor of mid term SCIs, as LSA coverage was associated with late CVAs.

Fenestrated Endovascular Aneurysm Repair versus Snorkel Endovascular Aneurysm Repair: Competing yet Complementary Strategies.

Juxtarenal/pararenal aortic aneurysms and type IV thoracoabdominal aneurysms pose particular technical challenges for endovascular repair as they involve the visceral segment in addition to insufficient infrarenal neck for the use of standard endovascular aneurysm repair (EVAR) devices. To overcome these challenges, complex EVAR techniques have been developed to extend the proximal landing zone cephalad with maintaining perfusion to vital aortic branches, thereby broadening the applicability of endografting from the infrarenal to the suprarenal aorta. Complex EVAR can be divided into two broad categories: fenestrated endovascular aneurysm repair (FEVAR) and snorkel EVAR. FEVAR is a valid procedure with the standardized procedure, although it remains as a relatively complex procedure with a learning curve. Given time constraints for the custom fenestrated graft, snorkel EVAR may be an alternative for complex repairs in symptomatic or ruptured patients for whom custom-made endografts may not be immediately available. This article discusses these two most commonly used complex EVAR strategies.

Aneurysm anatomy only should guide the choice of the type of reconstruction of the renal arteries during conventional surgery of the suprarenal aneurysms

The aim of this study was to evaluate the mid and long term patency of the elective reconstructions of the renal arteries during the conventional surgical treatment of suprarenal aortic aneurysms (SRAA) and type 4 thoracoabdominal aneurysms (ATA4), as well as the evolution of the pre- and postoperative renal function.

Systematic Review and Meta-Analysis of Preventative Strategies for Acute Kidney Injury in Patients Undergoing Elective Abdominal Aortic Aneurysm Repair

Abstract Objective : To assess the effect of various preventative interventions for reducing the incidence of postoperative acute kidney injury (AKI) in patients undergoing elective abdominal aortic aneurysm (AAA) repair. Methods : We included randomized controlled trials of 10 patients or more which tested a preventative intervention versus standard therapy or placebo in patients undergoing elective AAA repair using the open or endovascular approach. Studies including mixed patient populations such as those with aortic occlusive disease, thoracoabdominal aneurysms or ruptured aneurysms were ineligible for review. We searched Medline (1966 - 2019), EMBASE (1947 – 2019), CINAHL (1961 – 2019), Web of Science (1945 – 2019), Scopus (1966 - 2019), and The Cochrane Library (1996 – 2019) for trials available as published manuscripts in English. Study quality was assessed using the Cochrane Collaboration risk of bias tool. Where possible we pooled the results of similar interventions using random effects meta-analysis. Results : We included 17 trials involving 1443 participants. Most trials were small, single-centre studies, with varying definitions of AKI and a high or moderate risk of bias. The preventative strategies with possible protective effects were mannitol, a composite of antioxidant supplements, an open extraperitoneal approach, and human atrial natriuretic peptide (hANP). Curcumin, methylprednisolone, carbon dioxide contrast medium, haemodynamic monitoring and N-acetylcysteine were found to be ineffective. Six trials with a total of 355 participants reported on remote ischemic preconditioning (RIPC) and our meta-analysis showed no statistically significant difference between RIPC and standard treatment (OR 1.20, 95% CI 0.37, 3.89); although the results should be interpreted with caution due to considerable statistical heterogeneity (I2=70%). None of the interventions studied significantly reduced receipt of renal replacement therapy (RRT). Conclusion : Interventions that have shown some potential to reduce AKI after AAA repair include mannitol, a composite of antioxidant supplements, an open extraperitoneal approach and hANP. These conclusions are limited by the small size, high risk of bias and inconsistency of the included trials. Large, high quality, multi-centre randomized trials will help determine which interventions are effective in reducing the incidence of postoperative AKI among patients undergoing elective AAA repair.

Women undergoing endovascular thoracoabdominal aortic aneurysm repair differ significantly from their male counterparts preoperatively and postoperatively

ObjectiveA rational approach to the management of aortic aneurysm disease relies on weighing the risk of aneurysm rupture against the complications and durability of operative repair. In men, seminal studies of infrarenal aortic aneurysm disease and its endovascular management can provide a reasoned argument for the timing and modality of surgery, which is then extrapolated to the management of thoracoabdominal aortic aneurysms (TAAAs). In contrast, there is less appreciation for the natural history of TAAA disease in women and its response to therapy. MethodsWe used a retrospective cohort design of women, all men, and matched men, fit for complex endovascular thoracoabdominal aneurysm repair at two large aortic centers. We controlled for preoperative anatomic and comorbidity differences, and assessed technical success, postoperative renal dysfunction, spinal ischemia, and early mortality. Women and matched men were reassessed at follow-up for long-term durability and survival. ResultsAssessing women and all men undergoing complex endovascular aortic reconstruction, we demonstrate that these groups are dissimilar before the intervention with respect to comorbidities, aneurysm extent, and aneurysm size; women have a higher proportion of proximal Crawford extent 1, 2, and 3 aneurysms. Matching men and women for demographic and anatomic differences, we find persistent elevated perioperative mortality in women (16%) undergoing endovascular thoracoabdominal aneurysm repair compared with matched men (6%); however, at the 3-year follow-up, both groups have the same survival. Furthermore, women demonstrate more favorable anatomic responses to aneurysm exclusion, with good durability and greater aneurysm sac regression at follow-up, compared with matched men. ConclusionsWomen and unmatched men with TAAA disease differ preoperatively with respect to aneurysm extent and comorbidities. Controlling for these differences, after complex endovascular aneurysm repair, there is increased early mortality in women compared with matched men. These observations argue for a careful risk stratification of women undergoing endovascular thoracoabdominal aneurysm treatment, balanced with women's good long-term survival and durability of endovascular aneurysm repair.

Early Experience with the Octopus Endovascular Strategy in the Management of Thoracoabdominal Aneurysms

The Octopus endovascular strategy involves placement of multiple, stacked bifurcated grafts in the thoracic segment of a thoracoabdominal aneurysm (TAAA) to facilitate deployment of multiple parallel covered stents for visceral perfusion. This study aimed to review early outcomes of the Octopus TAAA repair strategy at a tertiary, high-volume referral center. All patients who underwent this Octopus procedure from 2015 to 2018 were reviewed from a prospectively collected single-institution registry. Demographics, comorbidities, and aneurysm anatomy including side and extent, perioperative data including blood loss, length of procedure length of stay, morbidity, and mortality up to 3years after the procedure were elevated. A total of 21 patients (48% female, age 72.9years) underwent the Octopus procedure over the study period. Mean TAAA diameter was 6.7cm, with 14% dissection related and 86% degenerative TAAA. All patients had been turned down for open repair and 3 (14%) were performed urgently of which 2 were ruptures. TAAA extent was 9% type 2, 62% type 3, and 29% type 4. A mean of 3.04 branches were revascularized per patient, with the superior mesenteric artery (SMA) (90%) perfused through its own limb, and both renals usually reconstructed in parallel graft fashion (left 90%, right 85.7%) with the distal abdominal extension through one of the limbs. Mean operative time was 8hr, fluoroscopy time 164min, contrast 182mL, and blood loss 807mL. We staged the thoracic and juxtavisceral portions of the cases in 24% of patients. 90% of cases were able to be completed with exclusion of the TAAA and all planned visceral branches cannulated. Perioperative complications included paraplegia (19%) (13.3% permanent, 26.6% temporary), acute kidney injury (24%), prolonged ventilation (19%), myocardial infarction (4.9%), and ischemic bowel (4.8%). Median follow-up was 13.5months (range 1-26months). At latest follow-up, type I endoleak rate was 9.5%, with all being treated with proximal cuffs. Other second interventions included restenting of a right renal, angioplasty of an iliac limb kink, and type 2 endoleak coiling. Primary patency of visceral branches was 93.8% at latest follow-up (celiac 100%, SMA 94.7%, right renal 88.9%, left renal 94.8%). In-hospital all-cause mortality rate was 14.2%, with 30-day survival being 90.5%, 6-month survivalwas 88.3%, one-year survival 71.4%, and 3-year survival was 52.1%. The Octopus procedure is a high-risk option for urgent or emergent endovascular TAAA repair with off-the-shelf devices in patients who are not candidates for open repair.

Viabahn Open Revascularization Technique for Renal Artery Revascularization Reduces Renal Ischemia in Thoracoabdominal Aortic Aneurysm Hybrid Open-Endovascular Repair

To improve hybrid open-endovascular repair, the Viabahn Open Revascularization Technique (VORTEC) has emerged as a sutureless method that reduces renal ischemia time. This study aimed to compare the differences between VORTEC and standard hybrid open-endovascular repair of thoracoabdominal aortic aneurysm (TAAA) in renal ischemia. This is a retrospective analysis of 26 TAAA patients who underwent hybrid open-endovascular repair from April 2005 to April 2017. Twenty-one patients underwent standard hybrid open-endovascular repair, and 5 underwent VORTEC hybrid open-endovascular repair. Through April 2018, 26 patients were followed up for 48±43months. Nine patent renal arteries were revascularized by Viabahn in the VORTEC group, while 36 were revascularized with presewn multibranched grafts in the standard treatment group. The renal ischemia time was shorter in the VORTEC group than in the standard treatment group (5±2min vs. 15±6min). The increase in serum creatinine (SCr) on the first postoperative day in the standard treatment group was higher than that in the VORTEC group (1.68±0.79 vs. 1.14±0.05). Acute kidney injury (AKI) occurred in 5 patients in the standard treatment group (5/21, 24%). No patient experienced AKI in the VORTEC group (0/5, 0%). The renal artery (RA) patency rates in the VORTEC group were 100% (7/7) at both 1week and 12months after surgery. In the standard treatment group, the RA patency rates were 97% at 1week (33/34) and 93% at 12months (28/30) after surgery. VORTEC reduces renal ischemia time and decreases postoperative AKI in patients undergoing hybrid repair of thoracoabdominal aneurysms.

First/Preliminary Experience of Gore Viabahn Balloon-Expandable Endoprosthesis as Bridging Stent in Fenestrated and Branched Endovascular Aortic Repair

The aim of this study is to evaluate the preliminary outcomes of the Gore® Viabahn® balloon-expandable endoprosthesis (VBX) as bridging stent for fenestrated/branched aortic endograft. Between April and June 2018, patients undergoing fenestrated and branched-endovascular aortic repair were prospectively collected. Anatomical, procedural, and postoperative data of patients treated with VBX as bridging stents to connect fenestrations/branches to target visceral vessels (TVVs) were analyzed. Technical success and any TVV-related adverse event were assessed before discharge, at 30 days, and after 6months of follow-up. Fifteen patients undergoing fenestrated and branched-endovascular aortic repair for juxta/pararenal aneurysms (11), proximal type I endoleak after endovascular aortic repair (1), and thoracoabdominal aneurysms (3) were included in the study. Overall, 60 TVVs-celiac trunk (n=14), superior mesenteric artery (n=13), renal arteries (n=30), hypogastric artery (n=3)-were accommodated by fenestrations (n=51), branches (n=7), and scallops (n=2). The bridging stent graft was a VBX in 40 (67%) TVVs. A renal artery dissection was successfully managed by a self-expandable bare metal stent. Overall, relining of a bridging stent graft was required in 2 TVVs revascularized by fenestrations (superior mesenteric artery: n=1, renal artery: n=1). One intraoperative type III endoleak from renal fenestration was detected and successfully sealed by an adjunctive flaring maneuver. Technical success was achieved in all cases. At 5-day, 1 VBX (1/40: 2.5%) lost its sealing in a renal artery revascularized by a branch (type II thoracoabdominal aortic aneurysm) and required reintervention and relining with a self-expandable stent graft. No TVV occlusion or reintervention occurred <30 days or after 6months of follow-up. According to these preliminary results, the Gore Viabahn VBX balloon-expandable endoprosthesis can be safely used as bridging stent graft for fenestrated or branched endografts. A longer follow-up with a larger case load is necessary in order to validate this preliminary experience.

Endovascular Abdominal Aortic Aneurysm Repair: Does Anesthesia Type Matter?

Given the various types of anesthesia used for endovascular abdominal aortic aneurysm repair (EVAR), we sought to determine the effect of anesthesia type in the outcomes of elective EVAR in a large multiinstitutional healthcare maintenance organization. A retrospective chart review was conducted on all elective EVAR conducted from August 2010 to August 2017 in 14 regional hospitals of Kaiser Permanente Southern California. Patients undergoing emergent, nonelective abdominal aortic aneurysm repairs, thoracoabdominal aneurysm repair, requiring conversion to open surgery or general anesthesia were excluded from the study. Basic demographic information, medical risk factors, anesthesia type, operative data, and postoperative morbidity and mortality data were obtained for univariate and multivariate statistical analysis. A total of 1,536 patients underwent EVAR, of which 1,206 met inclusion criteria. A total of 788 patients underwent general anesthesia, 164 patients underwent spinal anesthesia, 82 patients underwent epidural anesthesia, and 172 patients underwent local and monitored anesthesia care (AC). There was a significant difference in length of stay and operative time when comparing local/monitored AC to general anesthesia. No significant difference was noted in 30-day morbidity or mortality among the anesthesia groups. Local and regional anesthesia is a safe and effective approach for elective EVAR.

A Comprehensive Update of Current Anesthesia Perspectives on Therapeutic Hypothermia.

Normal thermal regulation is a result of the integration of afferent sensory, central control, and efferent responses to temperature change. Therapeutic hypothermia (TH) is a technique utilized during surgery to protect vital organs from ischemia; however, in doing so leads to other physiological changes. Indications for inducing hypothermia have been described for neuroprotection, coronary artery bypass graft (CABG) surgery, surgical repair of thoracoabdominal and intracranial aneurysms, pulmonary thromboendarterectomy, and arterial switch operations in neonates. Initially it was thought that induced hypothermia worked exclusively by a temperature-dependent reduction in metabolism causing a decreased demand for oxygen and glucose. Induced hypothermia exerts its neuroprotective effects through multiple underlying mechanisms including preservation of the integrity and survival of neurons through a reduction of extracellular levels of excitatory neurotransmitters dopamine and glutamate, therefore reducing central nervous system hyperexcitability. Risks of hypothermia include increased infection risk, altered drug pharmacokinetics, and systemic cardiovascular changes. Indications for TH include ischemia-inducing surgeries and diseases. Two commonly used methods are used to induce TH, surface cooling and endovascular cooling. Core body temperature monitoring is essential during induction of TH and rewarming, with central venous temperature as the gold standard. The aim of this review is to highlight current literature discussing perioperative considerations of TH including risks, benefits, indications, methods, and monitoring.

Visceral stent patency after fenestrated endovascular aneurysm repair using bare-metal stent extensions versus covered stents only

ObjectiveFenestrated endovascular aneurysm repair (FEVAR) is an alternative to treat complex abdominal aortic aneurysms. Patency of visceral vessels remains high when covered stents are used. The use of distal uncovered stents to prevent kinking has been associated with loss of branch patency. The aim of this study was to evaluate branch-related outcomes of FEVAR using covered stents only vs the use of uncovered stents distal to covered stents. MethodsDuring a 4-year period, 142 patients underwent FEVAR. Patients with suprarenal, juxtarenal, and type IV thoracoabdominal aneurysms were included. Patients treated with side branch devices were excluded. Covered iCAST (Maquet, Hudson, NH) stents were used as bridging stents in all cases. The primary end point was primary patency, defined as the absence of stenosis or occlusion that required intervention. Secondary end points included secondary patency, branch-related outcomes (kidney injury and gastrointestinal complications), branch instability, and mortality rates. ResultsA total of 442 target vessels were incorporated (49 scallops and 393 fenestrations). Uncovered stents were used in 38 (9.6%) visceral vessels. Median follow-up time was 11 (interquartile range, 6-13) months. Overall, visceral vessel primary patency was 91% at 12 and 24 months. The overall primary patency rate was 86% in the distal extension group vs 93% when only covered stents were used at 12 and 24 months (P = .8). Similarly, the rate of branch-related reinterventions at 12 months was 9% and 15% for each group, respectively, and 22% vs 32% at 24 months, respectively (P = .5). Overall, freedom from branch instability was 87% at 12 months and 81% at 24 months. Freedom from branch instability in the distal extension group was 82% at 12 and 24 months vs 89% at 12 months and 81% at 24 months when only covered stents were used (P =. 08). Mortality rate at 24 months was 15% for the bare-metal stent extension group vs 14% for the covered stent only group (P = .4). We found no statistical difference in acute kidney injury at any Kidney Disease: Improving Global Outcomes stage (P = 1.0) or gastrointestinal complications (P = 1.0) between the groups. ConclusionsThe use of distal uncovered stents to prevent kinks was not associated with decreased early branch patency. The long-term outcomes of bare-metal stents remain to be determined. For now, the use of uncovered stents distal to covered stents may be considered to prevent kinks in complex anatomy.

Use of the temporal bypass technique in the treatment of thoracic and thoracoabdominal aortic aneurysms

The OBJECTIVE was to analyze the experience of using a vascular prosthesis as a temporary bypass for spinal cord and visceral organs ischemia prevention during the clamping time in surgical reconstruction of thoracic and thoracoabdominal aortic aneurysm.MATERIAL AND METHODS. The study included 60 patients with the pathology of aortic arch, descending and thoracoabdominal aorta (TAAA) from 1997 to 2018. Among them, 42 (11 %) patients were diagnosed with TAAA I–IV types according to E. S. Crawford classification, 18 (32 %) – with the aortic arch aneurysm and the descending thoracic aorta. Planned interventions were performed in 43 (72 %) patients, emergency – in 17 (28 %). A temporary bypass made from vascular prosthesis with a diameter from 15 to 20 mm was used in 29 (48 %) cases as a protection of internal organs and the spinal cord against ischemia, and in 31 (52 %) surgical cases the reconstruction was performed with a cross clamping method.RESULTS. 30 days mortality was 16.6 % (n=10), total hospital mortality was 28.3 % (n=17). The mortality was 23.2 % (n=10) after planned interventions, and 41 % (n=7) – in emergency interventions. When using a temporary bypass during planned operation 9.3 % (n=4) of the patients died within 30 days, while cross clamping method without visceral protection showed 13.9 % death rate (n=6). Acute renal failure developed in 7 (11.6 %) cases and it was observed more often in the group without using of temporary bypass technique. The spinal cord ischemia turning into a spinal stroke occurred in 8 (13.3 %) cases. Five-year survival rate was 61 %.CONCLUSION. The use of a temporary bypass during the thoracic and thoracoabdominal aneurysms repair could be used for prevention of the visceral organs, kidneys and spinal cord ischemic complications during operations with need in cross clamping of the descending thoracic aorta.