Thoracoabdominal Aneurysm Research Articles

Morphological study of aorta in patients with acute aortic syndromes

Purpose of the study is to investigate the morphology of the aortic wall in patients with acute aortic syndrome.Materials and methods. The results of morphological study of aneurysmatic fragments (n-52), which were collected intraoperatively, each fragment were prepared on the basis of the SI "V.T.Zaycev Institute of General and Urgent Surgery AMSU", which were coloured with hematoxilin eosin, elastic fibers/ were incubated with antibodies to IgG, and with Apo-Alert DNA Fragmentation to determine apoptosis.Results. Post-coarctation aneurysms had the following microscopic picture: a decrease in the medial layer with small fields of disorganization of elastic fibers and smooth muscle cells (SMC). The detection of apoptotic cells in the sections is minimal. In the group of acute aortic dissection aneurysms in 40 % of cases, the elastic fibers were fragmented, the SMC are chaotic with separate parts of the isiocytane medineocrine - a typical pattern for Marfan's syndrome. A microscopic study of thoracoabdominal aneurysms showed a significant decrease in the middle layer with the development of fibrosis. When counting the total number of cells, a decrease in smooth muscle cells was found on average by 54 %. The aneurysms of the abdominal aorta were characterized by major degenerative changes. Reducing the medial layer and fibrous changes were also the most significant. Reduction of the medial layer and fibrous changes were most significant in this groupConclusions. All types of complicated aneurysms are characterized by insufficiency of smooth muscle cells in aortic wall. The study found that a decrease in the number of smooth muscle cells can occur due to apoptosis. There is a clear correlation with inflammatory infiltration by cells that produce apoptosis induction

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 >20cm 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.

Comparison of Perioperative Outcomes of Patients with Iliac Aneurysms Treated by Open Surgery or Endovascular Repair with Iliac Branch Endoprosthesis

Treatment of common and internal iliac aneurysms is usually done by open surgery. A novel iliac branch endoprosthesis (IBE) is commercially available with encouraging initial results. Our objective is to compare perioperative outcomes of patients with iliac aneurysms treated by open surgery (OS) versus endovascular repair with IBE. The study was a retrospective, single-center review of patients who were treated for aortoiliac or isolated common and/or internal iliac artery aneurysms from 2014 to 2017. Patients with connective tissue disorders, infected grafts, or thoracoabdominal aneurysms were excluded. Primary outcomes were perioperative mortality, length of hospital (LOS) and intensive care unit (ICU) stay, estimated blood loss, need for red blood cell transfusion (RBC), and perioperative reinterventions. Sixty-seven patients (96% male) were treated with OS (n=25, mean age 68±8years) or IBE (n=42, mean age 73±8years; P=0.02) with 1 symptomatic patient in each group. Perioperative mortality occurred in 1 patient in the OS group (4%), with no mortality in the IBE group (P=0.37) Total LOS and ICU stay was higher for OS compared to IBE (total stay 7.5±3.4 vs. 1.7±1.4days for IBE, P<0.0001 and ICU LOS 3.3±2.1 vs. 0.1±0.4days, P<0.0001). Estimated blood loss was higher for patients undergoing OS (4,732±2,540mL) compared to patients treated with IBE (263±451mL, P<0.0001), resulting in higher RBC transfusion requirements (1.5±2.4 vs. 0.2±0.8 units, P=0.001). Five patients in the OS group had early procedure-related reinterventions, while 2 patients in the IBE group required reintervention for access site complications (20% vs. 4.7%, P=0.09). Endovascular repair of iliac aneurysms with IBE is feasible and is associated with lower blood loss, LOS and ICU stay, and had lower RBC transfusion requirements. Cost analysis and long-term follow-up will be needed to define the value of this modality for iliac artery aneurysm repair.

Medical image analysis to measure the follow-up geometry of thoraco-abdominal aortic aneurysms treated with multilayer flow modulator stent

ABSTRACTIn the last years, the improvement of minimally techniques for the treatment of aortic aneurysms has proven beneficial both in the reduction of intra-operative mortality and to lower complications rate. However, patients could encounter complications which are most often asymptomatic, and should, therefore, be monitored over the time. Such a follow-up analysis calls a geometric analysis tool able to quantify the aortic aneurysm changes over the time. Motivated by this need, in this work we have proposed a framework for the in-vivo follow-up analysis of the Cardiatis (Isnes, Belgium) Multilayer Flow Modulator (MFM) device in the repair of thoraco-abdominal aneurysms (TAAA) with the aim of reconstructing aneurysms geometry and analysing its changes in time, with and without the MFM stent. Geometrical indices to measure anatomical changes before and after the intervention are introduced. Four patients with two years of follow-up are included. The study is intended to help clinicians understanding the feasibility of the intervention in TAAA using this novel device and interpreting the post-operative outcomes.

PC042. Performance of Gore Viabahn VBX Compared With Atrium iCast as Bridging Stents During Fenestrated Endovascular Aortic Repairs

Fenestrated endovascular aneurysm repair (FEVAR) is a well-established, effective technique for complex abdominal and thoracoabdominal aneurysm repair. Among various bridging stents, Atrium iCast (Maquet, Rastatt, Germany) covered stents have been adopted by many as the device of choice, with excellent outcomes. Recently, Gore Viabahn VBX stents (W. L. Gore & Associates, Flagstaff, Ariz) became commercially available in the United States. The aim of our study was to compare our experience with VBX and iCast as bridging stents during FEVAR. A retrospective review was performed of FEVARs for complex abdominal and thoracoabdominal aneurysms at a single institution from 2015 to 2018. All patients were at high risk for open repairs. Custom-manufactured or physician-modified devices were implanted. Bridging stents across reinforced fenestrations were included in the study. VBX and iCast stents were compared for technical success, branch patency, branch-related endoleak, and reinterventions. There were 75 patients who underwent FEVAR during the study period; 10 patients had juxtarenal, 23 had pararenal, and 41 had thoracoabdominal aortic aneurysms, and 1 had a pseudoaneurysm. Twenty-four patients were symptomatic, and three patients presented with rupture. A total of 197 branch vessels were targeted with fenestrations. Of 197 targeted branch vessels, 193 (34 celiac, 55 superior mesenteric artery [SMA], 104 renals) were bridged successfully (98%). Four target vessels (three renals and one dominant intercostal) could not be bridged because of severe aortic tortuosity causing fenestration misalignment. A total of 87 vessels were incorporated with iCast and 106 vessels with VBX. The mean follow-up was 5.5 months (6.7 months for iCast and 3.8 months for VBX). Secondary relining stents were used in 14 (16.1%) iCast branches (1 celiac, 3 SMA, and 10 renals) and 8 (7.5%) VBX stents (4 SMA, and 4 renals; P = .072). The 6-month branch patency for iCast was 96.2%, with one celiac and one renal in-stent stenosis; the 6-month patency for VBX was 97.4%, with one celiac branch occlusion (P = .661). At 6 months, there were no branch-related endoleaks for iCast, whereas six VBX branch (5.7%) vessels had type IC endoleak due to branch stent undersizing (P = .033). There were no type III endoleaks across the fenestration seal in either group. Overall short-term branch-related reintervention rate was 0% for iCast and 2.8% (3/106) for VBX (P = .253). One celiac and two SMA endoleaks were intervened on in the VBX group. Gore Viabahn VBX and Atrium iCast show high short-term patency and low endoleak rates as bridging stents during fenestrated endovascular repair of complex abdominal and thoracoabdominal aneurysms. Longer follow-up is needed to assess late device-related complications.

IFT16. Long-term Outcomes of Visceral and Renal Arteries in Patients Treated With Branched/Fenestrated Endografts for Complex Abdominal Aortic Aneurysms

To retrospectively analyze perioperative and late Results of branched and fenestrated endografts implanted in patients with complex abdominal aortic aneurysms (AAA), paying particular attention to the long-term outcomes of stented visceral and renal arteries From January 2007 to August 2018, 953 endovascular repairs of AAA were performed. Data concerning these interventions were prospectively recorded in a certified institutional registry. A retrospective analysis of the registry was performed and 100 interventions performed for complex (thoracoabdominal, pararenal and juxtarenal) AAA were found. Perioperative analyzed. Follow-up program consisted of duplex ultrasound examination at 1 month and every 6 months and of angiocomputed tomography scan at 1 month and yearly thereafter. Follow-up Results were analyzed with Kaplan-Meier curves in terms of survival, freedom from AAA-related complications and reinterventions. Primary and secondary patency of the stented visceral and renal arteries were assessed. The indication for the intervention was a proximal para-anastomotic aneurysm following open aortic reconstruction in eight cases. Among the remaining 92 patients, 47 had a thoracoabdominal aneurysm, 34 a pararenal aneurysm and 11 a juxtarenal one. All but three patients had an elective intervention. In 58 cases, a fenestrated graft was placed, whereas in 17 cases a branched graft was used; 25 patients had both fenestrations and branches. Overall, 359 renal and visceral vessels were treated: 193 renal arteries, 94 superior mesenteric arteries and 72 celiac trunks. The technical success rate was 99%. Perioperative mortality was 4%; eight perioperative reinterventions were required. The overall complication rate was 21%, with nine cases of spinal cord ischemia, leading to paraplegia in four cases. Median duration of follow-up was 38 months (range, 1-98 months); all the patients who survived the intervention were followed-up. Estimated 5-year survival was 68.5% (standard error [SE], 0.05); there were neither ruptures nor conversions to open surgery. Freedom from reintervention at 5 years was 84.5% (SE, 0.05). Complications at the visceral and renal arteries occurred in five patients, in three cases requiring a reintervention: one acute thrombosis of both renal and visceral arteries, treated with thrombolysis, one thrombosis and one symptomatic stenosis of a renal artery, both treated with adjunctive stenting. Two patients with asymptomatic renal and mesenteric thrombosis were medically managed. The estimated 5-year primary and secondary patency rates were 85% (SE ,0.05) and 98.8% (SE, 0.06), respectively Late complications of the visceral and renal arteries following endovascular treatment of complex AAA are rare and they can be safely managed with endovascular means.

IFT12. Hemorrhagic Complications of Two Stages Procedure for Prevention of Spinal Cord Ischemia in Fenestrated/Branched Endovascular Repairs for Thoracoabdominal Aneurysm

IFT12. Hemorrhagic Complications of Two Stages Procedure for Prevention of Spinal Cord Ischemia in Fenestrated/Branched Endovascular Repairs for Thoracoabdominal Aneurysm

Neuroprotective mechanism involved in spinal cord stimulation postconditioning

ObjectivesDelayed paraplegia developed postoperatively after thoracoabdominal aneurysm surgery is primarily associated with spinal cord ischemia/reperfusion injury. Our previous study suggested that spinal cord stimulation postconditioning protected the spinal cord from ischemia/reperfusion injury through microglia inhibition. In this study, we further investigated whether α7 nicotinic acetylcholine receptors were involved in the neuroprotective mechanism of spinal cord stimulation. MethodsRabbits were randomly assigned to sham, control, 2 Hz, α-bungarotoxin, and 2 Hz-α-bungarotoxin groups (n = 24/group). Transient spinal cord ischemia was performed on all rabbits except rabbits in the sham group. Rabbits in the control group received no further intervention, rabbits in the 2 Hz group were given 2 Hz spinal cord stimulation, rabbits in the α-bungarotoxin group received prescribed intrathecal α-bungarotoxin (α-bungarotoxin, a specific α7 nicotinic acetylcholine receptor antagonist) injections, and rabbits in the 2 Hz-α-bungarotoxin group received both α-bungarotoxin injections and 2 Hz spinal cord stimulation. Hind-limb neurologic function was assessed, and spinal cord histologic examination, terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling staining, and microglia staining were performed at 8 hours, 1 day, 3 days, and 7 days of reperfusion. ResultsRabbits in the 2 Hz group had significantly better neurologic functions, more α-motor neurons, and lower terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling–positive neuron rates and microglia area/anterior horn area ratios (microglia area ratios) than the control group. The neurologic functions of the α-bungarotoxin group were significantly worse than those of the control group, whereas other results were not significantly different from the control group. The results of the 2 Hz-α-bungarotoxin group were insignificant to the control group except for the terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling–positive neuron rates, which were significantly lower than in the control group. ConclusionsThe neuroprotective effects of spinal cord stimulation postconditioning against spinal cord ischemia/reperfusion injury were partially mediated by activating α7 nicotinic acetylcholine receptors.

Use of the Octopus Technique for Endovascular Treatment of Complex Aortic Lesions

PurposeTo evaluate feasibility and effectiveness using the octopus endograft technique to treat complex aortic aneurysms (CAAs). Materials and MethodsEndovascular repair of CAAs, including thoracoabdominal aneurysms (TAAAs) and dissections involving major side branches, was performed at a single center from June 2014 to June 2017. Patients included 9 men and 2 women (mean age, 60.5 y; range, 40–89 y) were included. The octopus technique was applied using standard aortic grafts with branch stent grafts to preserve the renovisceral arteries. ResultsAortic pathologies comprised 3 mycotic aneurysms, 2 chronic dissections with acute rupture, 1 progressively enlarging chronic type B dissection, 1 acutely ruptured TAAA, and 4 unruptured TAAAs. Mean procedural and fluoroscopic times were 562 min (range, 324–840 min) and 183 min (range, 73–338 min), respectively. Three patients died within 1 month. Mean duration of follow-up was 26.3 months (range, 8–42 months) for remaining patients. Technical success rate of target vessel stent placement was 89.7% (35/39). Major complication rate was 45.5% (5/11), including 3 deaths, 1 permanent paraplegia, and 1 temporary paraplegia that resolved in 2 months. All 3 mycotic aneurysms with mean duration of follow-up of 29 months (range, 8–42 months) were excluded successfully without endoleak. ConclusionsThe octopus technique is feasible for treatment of CAAs requiring urgent management or with difficult anatomy without the use of available custom-made or off-the-shelf branched devices. The procedure carries substantial morbidity and mortality and requires further investigation for its long-term durability.

Geometric changes over time in bridging stents after branched and fenestrated endovascular repair for thoracoabdominal aneurysm

ObjectiveThe objective of this study was to assess long-term durability of bridging stents in branched and combined branched and fenestrated endovascular aneurysm repair (B/F-EVAR) for thoracoabdominal aortic aneurysm (TAAA) and pararenal abdominal aortic aneurysm. MethodsA retrospective database analysis was performed of patients treated by B/F-EVAR for TAAA. Computed tomography angiography images were analyzed to assess patency, bridging stent angulation and migration, aneurysm diameter, and migration of the endograft. ResultsTwenty-eight patients with a median age of 70 years (interquartile range [IQR], 67-77 years) were included. Assisted technical success was 89%. Within 30 days postoperatively, five patients died. In the remaining 23 patients, median follow-up was 5.3 years (IQR, 2.9-7.2 years), and 1-, 3-, and 5-year estimated overall survival was 69%, 65%, and 44%, respectively. During follow-up, 12 of 47 (26%) branches occluded and 5 of 47 (11%) branches developed a 70% to 99% stenosis. The 1-, 3-, and 5-year estimated freedom from adverse events was 78%, 76%, and 59% for branch stents and 100%, 96%, and 90% for fenestration stents, respectively. The median distal bridging stent migration was 0.5 mm (IQR, −1.9 to 1.4; P > .05 mm). In 10 branches, migration >10 mm was seen, ranging from 14.1 mm sliding in to 23.0 mm sliding out. The angulation between branch and stent became 4 degrees more angulated (IQR, −14 to +2 degrees). In 23 branches, the angulation changed 10 degrees or more, leading to an occlusion in 7 branches, a 70% to 99% stenosis in 3 branches, and a 50% to 70% stenosis in 4 branches. In three cases, the endograft migrated >5 mm caudally, with a breach in a fenestration stent in one and a breach in a branch stent in another. ConclusionsThe anatomic configuration of branches in B/F-EVAR of TAAAs and pararenal abdominal aortic aneurysms changes over time. The change in angle of branches and the bridging stent influences the likelihood of stenosis and occlusion. Follow-up of B/F-EVAR should include computed tomography angiography measurements of aortic diameter, endograft migration, target vessel stent length, and angulation to detect disconnection, stenosis, and occlusion.

Handmade stent graft fenestration to preserve left subclavian artery in thoracic endovascular aortic repair†.

This study aimed to evaluate the efficacy and safety of a handmade fenestrated stent graft over an aortic stent graft for preserving the left subclavian artery (LSA) in thoracic endovascular aortic repair (TEVAR). From July 2015 to October 2018, a total of 32 consecutive patients with various thoracic aortic pathologies who underwent TEVAR in which handmade fenestration over a thoracic aortic stent graft was used for LSA were included. Outcomes including technical success, procedure-related complications, perioperative mortality and morbidity and graft patency were analysed. Twenty-four patients (75.00%) presented with aortic dissection, 5 patients (15.63%) with thoracic aortic aneurysm and 2 patients (6.25%) with penetrating aortic ulcer; 1 patient (3.13%) required re-TEVAR due to endoleak and sac expansion from previous TEVAR for thoraco-abdominal aneurysm. TEVAR was performed in a zone 2 landing with single fenestration for LSA (26 patients, 81.25%), zone 1 landing with double fenestration for both LSA and left common carotid artery (5 patients, 15.63%) or zone 1 landing with single fenestration for LSA and a chimney graft for left common carotid artery (1 patient, 3.13%). The technical success rate, defined as the successful alignment of fenestration to LSA, was 93.75%. At a mean follow-up of 17.3 months, 4 cases of endoleak and 2 cases of stent graft-induced new entry were noted, 3 of which were treated endovascularly. Our preliminary results demonstrate the viability of preserving LSA blood flow in TEVAR using a handmade stent graft fenestration to treat various aortic pathologies in various clinical situations and the technical feasibility and short-term results that may justify the use of this method in emergency cases.

Fenestrated or branched endovascular aortic repair for postdissection thoracoabdominal aortic aneurysm

ObjectiveFenestrated or branched endovascular aortic repair (FB-EVAR) usually represents the last stage in endovascular treatment of postdissection aneurysm after thoracic endograft coverage of entry tear and false lumen embolization. MethodsThe study was a retrospective analysis of all patients with postdissection thoracoabdominal aneurysm treated with FB-EVAR in a single center. Short-term outcomes included technical success, operative mortality, and morbidities. Midterm outcomes included secondary intervention, false lumen thrombosis rate, aneurysm size regression, and subsequent survival. ResultsTwenty patients (95% male with a mean age of 64 ± 9 years) were treated between January 2014 and December 2017. The technical success was 100%. There was one death (5%) within 30 days. Postoperative complications included two patients with spinal cord ischemia (10%; one partial and one full). The median follow-up period was 12 months (range, 0-31 months). A secondary intervention was required in six patients, including thoracic stent graft relining for type III endoleak (n = 2), covered stent relining for junctional leak between main body and renal stent (n = 2), and iliac false lumen embolization (n = 2). Twelve patients completed the 1-year follow-up computed tomography angiogram, and their mean aneurysm diameters were 71 ± 18, 66 ± 19, and 62 ± 19 mm preoperatively, immediate postoperatively, and at 1 year, respectively; the corresponding false lumen thrombosis rates were 0% (0/20), 58% (7/12), and 92% (11/12), respectively. One more patient died during follow-up from a non-aneurysm-related cause. The estimated overall survival rates were 95 ± 5%, 88 ± 8%, and 88 ± 8% at 6, 12, and 18 months, respectively. ConclusionsFB-EVAR was feasible for postdissection thoracoabdominal aneurysm. Despite the associated perioperative risk and high probability of planned or unplanned reintervention, the procedure led to favorable aortic remodeling with false lumen thrombosis and aneurysm regression.

Stent graft as a bridge to allograft to treat a septic thoracic aortic pseudoaneurysm after spinal fusion

A 29-year-old woman was admitted to our institution for severe septic syndrome. Her medical history included a T6-T8 posterior spinal fusion 7 years earlier for tuberculous spondylodiscitis. Contrast-enhanced computed tomography (CT) revealed a 70- × 58-mm pseudoaneurysm of the descending thoracic aorta extending from T6 to T8 level, surrounding the left T6 screw (A/Cover). A T6-T8 spondylodiscitis and bilateral paraspinal collections were also observed. Blood and T7 bone biopsy specimens grew Escherichia coli. To prevent an imminent pseudoaneurysm rupture and to allow cryopreserved aortic allograft (CAA) delivery, the patient first underwent conformable TAG 26- × 26- × 100-mm (W. L. Gore & Associates, Flagstaff, Ariz) thoracic aortic stent graft implantation under general anesthesia through a small left femoral incision. The procedure was uncomplicated. Exclusion of the pseudoaneurysm was assessed by final angiography and postoperative CT scan (B). Five days later, T2-T10 spinal fusion was conducted after infected hardware removal through a posterior approach along with drainage of the paraspinal collections. Aortic replacement using a 10-cm-long thoracic CAA was performed through a left posterolateral thoracotomy in the same operative course. A partial cardiopulmonary bypass at normothermia was established through a left femoral incision. An arterial perfusion cannula was positioned in the abdominal aorta and a venous cannula to the right atrium. During aortic replacement, a fistula was observed at the bottom of the aortic pseudoaneurysm communicating with the former location of the left T6 screw. The final step consisted of implantation in the vertebral defect of a titanium mesh cage containing autologous bone graft. Transdiaphragmatic epiploplasty was performed to isolate the CAA (C). The culture specimens of the removed orthopedic hardware and stent graft grew E. coli. Antibiotic treatment initially consisted of intravenous administration of cefotaxime and gentamycin switched postoperatively to intravenous administration of ceftriaxone for 12 weeks. Follow-up included visits at 1 month and 6 months postoperatively, and follow-up should be continued twice a year. Six months postoperatively, the patient was asymptomatic. The CT scan showed satisfactory coverage of the allograft by the omentum and the absence of allograft pseudoaneurysm or residual collection (D). Vascular injury after spinal instrumentation is a rare but life-threatening condition. Treatment of such injuries is not standardized. Previous studies have reported the use of stent grafts with good outcomes.1Zerati A.E. Leiderman D.B. Teixeira W.G. Narazaki D.K. Cristante A.F. Wolosker N. et al.Endovascular treatment of late aortic erosive lesion by pedicle screw without screw removal: case report and literature review.Ann Vasc Surg. 2017; 39: 285.e17-285.e21Abstract Full Text Full Text PDF Scopus (5) Google Scholar In our case, we believed that simple endovascular treatment was not possible because of the high risk of stent graft infection. We believed that CAA represented the best option in a septic field, as is the case with aortic graft infections.2Corvera J.S. Blitzer D. Copeland H. Murphy D. Hess Jr., P.J. Pillai S.T. et al.Repair of thoracic and thoracoabdominal mycotic aneurysms and infected aortic grafts using allograft.Ann Thorac Surg. 2018; 106: 1129-1135Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Potential postoperative CAA pseudoaneurysm formation requires close and lifelong follow-up. The patient consented to the use of related medical history and images for educational purposes.

Mid-Term Results of Fenestrated/Branched Stent Grafting to Treat Post-dissection Thoraco-abdominal Aneurysms

Mid-Term Results of Fenestrated/Branched Stent Grafting to Treat Post-dissection Thoraco-abdominal Aneurysms

An unexpected cause of abdominal pain or maybe more.

A 61-year old Caucasian woman, presented to the Emergency Department due to a four-week history of vomiting, diarrhea and abdominal pain. Physical examination revealed tenderness in the upper abdomen and normal bowel sounds. A CT was performed and the patient was admitted. A CT scan of the chest and the abdomen revealed a chronically dissected Stanford B thoracoabdominal aneurysm with mural thrombus, thrombosis of the celiac, hepatic, splenic and superior mesenteric arteries with collateral circulation, thrombosis of the portal and superior mesenteric veins and a splenic infarct. Dissection of an aneurysm is a catastrophic complication with high mortality and morbidity, thus an invasive treatment is often warranted with either surgery or endovascular repair. On the other hand, portal thrombosis is associated with inherited or acquired procoagulant states (like Factor V Leiden), hematologic diseases (like myeloproliferative diseases), cirrhosis, abdominal surgery or trauma and intra-abdominal inflammatory conditions. Its treatment involves anticoagulation or rarely, thrombolysis or thrombectomy. Both chronic dissection of the abdominal aneurysm and the portal vein thrombosis can cause abdominal pain, nausea, and other gastrointestinal symptoms secondary to bowel hypoperfusion. Diagnosis: chronically dissected Stanford B thoracoabdominal aneurysm and thrombosis of the celiac, hepatic, splenic and superior mesenteric arteries with collateral circulation, thrombosis of the portal and superior mesenteric veins and a splenic infarct.

Outcomes and complications after fenestrated-branched endovascular aortic repair

ObjectiveTo report the outcomes of patients enrolled in a physician-sponsored investigational device exemption trial for endovascular treatment of complex thoracoabdominal aortic aneurysms with fenestrated and/or branched devices. MethodsThis study represents a retrospective analysis of a prospectively maintained database of patients enrolled in a physician-sponsored investigational device exemption trial for endovascular treatment of complex thoracoabdominal aneurysms between July 2012 and July 2017. Subjects included high-risk patients for open repair and patients with unsuitable anatomy for either standard endovascular aneurysm repair or Zenith (Cook Medical, Bloomington, Ind) fenestrated device. Aneurysm classification was based upon Crawford classification. We included the pararenal and paravisceral aneurysms in the type IV aneurysm group, because the repair of these aneurysms usually involved treatment of all four visceral branches. The endografts implanted were custom manufactured devices or off-the-shelf devices based on the Cook Zenith platform. Variables analyzed included preoperative demographics and comorbidities, anatomic aneurysmal characteristics, procedural details, and perioperative complications. ResultsOne -hundred fifty patients with a mean age of 71 ± 7.9 years were treated; 69% were male. Tobacco use (93%) and hypertension (91%) were the most common risk factors. Fifty-seven patients (38%) had a history of previous aortic repair. The mean aneurysm diameter was 62 ± 12 mm and 14 (9%) aneurysms were associated with chronic dissection. A total of 573 visceral vessels were incorporated (celiac artery/superior mesenteric artery [287 vessels], renal arteries [275 vessels], and 11 additional vessels) and 539 were stented. The celiac artery/superior mesenteric artery received a fenestrated design in 76.1% of cases. Branch designs were used in the renal artery in 13.2%, with the remainder treated with fenestrations. Spinal cord drainage was used in 51% of patients (76/150). The mean operative time, fluoroscopy time, and estimated blood loss were 283 ± 89 minutes, 83 ± 38 minutes, and 417 ± 404 mL, respectively. There were five patients (3.3%) with intraoperative complications, resulting in one intraoperative death. The early mortality was 2.7% (4/150). Major complications included respiratory failure in 7% (10/150), stroke and myocardial infarction in 0.7% each (1/150), and paraplegia in 2.7% (4/150). Acute kidney injury occurred in 4.7% of patients (7/150), two of whom required temporary dialysis. Thirty-nine percent of patients experienced at least one complication. Early branch vessel patency was 99.8% (525/526). Survival, primary, and primary-assisted branch patency at 2 years of follow-up were 79%, 97%, and 99%, respectively. ConclusionsEndovascular repair of complex aneurysms is safe and effective when performed in a high-volume center experienced in aortic disease management. Branch vessels patency and the low incidence of paraplegia and mortality support expanded use to treat most complex thoracoabdominal aortic aneurysms.

Intraoperative neurophysiologic monitoring in thoracoabdominal aortic aneurysm repair: A single-center prospective study

Intraoperative neuromonitoring (IOM) allow the assessment of spinal integrity during thoracoabdominal aneurysm (TAAA) surgery, giving the opportunity to predict or help to prevent spinal ischemia (SCI). The reliability of IOM depends on excluding confounding factors and on warning criteria. Our aims were to investigate the sensitivity and specificity of IOM for SCI and to verify if the study of compound motor action potential (CMAP) is reliable in the identification of limb ischemia and improve IOM sensitivity for SCI. One-hundred consecutive patients (mean 64.3 yrs) undergoing TAAAs surgery between February 2016 and March 2018 were studied prospectively. IOM included motor evoked potentials (MEPs), somatosensory evoked potentials (SEPs), popliteal potentials and CMAPs. MEPs and SEPs were recordable in 99% of cases. MEPs showed transient changes in 49.5% and persistent decrease in 16.2% (3% unilateral). All of 4 patients with persistent bilateral MEPs deterioration and without alteration of peripheral potentials or arm MEPs developed paraplegia. Persistent bilateral MEPs changes, especially without concurrent peripheral alterations, are at high risk of SCI and justify prompt interventions for maximize spinal perfusion. The improvement of the accuracy in the identification of peripheral ischemia could help to clarify which MEPs alterations correlate with neurologic deficits.

Comparative Outcomes of Open, Hybrid, and Fenestrated Branched Endovascular Repair of Extent II and III Thoracoabdominal Aortic Aneurysms

Open repair of Crawford extent II and III thoracoabdominal aortic aneurysms (TAAA) is associated with substantial perioperative risk. In an effort to decrease this risk, endovascular technologies are increasingly used and include either a hybrid operation combining proximal thoracic endovascular aortic repair followed by staged open distal TAAA repair (hybrid) or a total endovascular approach using fenestrated/branched endografts (FEVAR). However, the benefits of these alternative approaches compared with open surgery remains unclear. The purpose of this study was to compare outcomes of these three different strategies in the management of extent II/III TAAA. All patients undergoing extent II/III TAAA repair (2002-2018) for nonmycotic, degenerative aneurysm or chronic dissection related indications by the division of vascular surgery at a single institution were identified. The primary end point was 30-day mortality. Secondary end points included incidence of spinal cord ischemia (SCI), complications, unplanned reoperation and/or 90-day readmission, and survival. To mitigate impact of covariate imbalance and selection bias, intergroup comparisons were made using inverse probability weighted propensity analysis. Cox regression was used to estimate survival while cumulative incidence was employed to determine re-operation risk. There were 198 patients (FEVAR, 92; hybrid, 40; open, 66) underwent extent II/III TAAA repair. Seven hybrid patients (18%) were excluded in adjusted analysis because they never underwent the second stage operation (death, 5; lost follow-up, 2). In an unadjusted analysis, compared with hybrid/open repair patients, FEVAR patients were significantly older with more cardiovascular risk factors, but less likely to have a connective tissue disorder or a dissection-related indication. The unadjusted 30-day mortality and complication risks were as follows: 30-day mortality—4% FEVAR, 13% hybrid, 12% open (P = .01); complications—36% FEVAR, 33% hybrid, 50% open (P = .11); and permanent SCI—3% FEVAR, 3% hybrid, 6% open (P = .64). In adjusted analysis, the 30-day mortality risk was significantly greater for open vs FEVAR (hazard ration, 3.6; 95% confidence interval, 1.4-9.2; P = .008) with no difference for hybrid versus open or hybrid versus FEVAR (Table). There was significantly lower risk of any SCI for FEVAR patients compared with open repair (open: FEVAR, 3.4; 95% confidence interval, 1.0-11.3; P = .04); however, there was no difference overall in the risk of permanent SCI. There was no difference in risk of major complications or unplanned reoperation, but hybrid repair patients had a greater risk of unplanned 90-day readmission compared with FEVAR/open repair patients (Table). There was a time-varying effect of procedure type on survival probability between 30 and 90 days with open repair having greater mortality risk. This difference led to a significant 1-year but not 5-year survival disadvantage compared with hybrid/FEVAR patients (1- and 5-year survival: FEVAR, 86 ± 3%, 55 ± 8%; hybrid, 86 ± 5%, 60 ± 11%; open 69 ± 7%, 59 ± 8%; Cox model P = .03; Fig). Extent II/III TAAA repair, regardless of operative strategy, is associated with significant morbidity risk. FEVAR is associated with the lowest 30-day mortality risk compared with hybrid and open repair when patients are matched based on preoperative risk factors. These data support greater adoption of FEVAR as first-line therapy to treat complex TAAA disease in anatomically suitable patients who present electively.TableInverse probability weighted propensity analysis for inter-group comparison of outcomes after Crawford Extent II/III thoracoabdominal aneurysm (TAAA) repairaGroupHazard ratio95% Confidence intervalP value30-day Death Hybrid:FEVAR1.650.57-4.79.36 Open:FEVAR3.61.4-9.2.008 Hybrid:open0.460.18-1.15.10Permanent SCIb Hybrid:FEVAR0.830.07-10.2.89 Open:FEVAR0.720.14-3.65.68 Hybrid:open1.170.09-13.8.9030-Day death and/or SCIb Hybrid:FEVAR0.640.12-3.42.60 Open:FEVAR0.240.07-0.86.03 Hybrid:open2.680.48-14.84.28Any SCI Hybrid:FEVAR2.930.50-17.1.23 Open:FEVAR3.431.05-11.27.04 Hybrid:open0.850.13-5.46.87Any major complication Hybrid:FEVAR1.720.38-7.89.48 Open:FEVAR0.520.21-1.26.15 Hybrid:open3.330.67-16.47.1490-Day readmission Hybrid:FEVAR6.001.25-28.85.03 Open:FEVAR0.750.24-2.38.63 Hybrid:open7.961.59-39.79.01Any unplanned reoperationb Hybrid:FEVAR1.230.42-3.65.71 Open:FEVAR2.070.66-6.46.21 Hybrid:open0.640.23-1.76.38FEVAR, Fenestrated/branched endografts; SCI, spinal cord ischemia.aInverse probability weighted propensity analysis accounted for age, body mass index, gender, procedure urgency, pathologic indication, American Society of Anesthesia score, and all other cardiopulmonary risk factors.bDeath modeled as a competing risk. Open table in a new tab

A new Percutaneous technique for effective vascular Access Site closure in patients undergoing Transfemoral aortic valve implantation and thoraco-abdominal aortic aneurysm rEpair: the PASTE study.

The success of transfemoral transcatheter aortic valve implantation (TAVI) and thoraco-abdominal aneurysm repair (TAAR) depends on haemostatic control of the access site, which is usually obtained with suture-based closure devices (Prostar or two ProGlide). A single ProGlide/Glubran technique, involving a suture placement on the vessel wall followed by tissue glue injection around the vessel wall, has not been previously investigated in this clinical setting. Our aim was to study the feasibility and safety of a single ProGlide/Glubran technique for vascular access-site closure after transfemoral TAVI and TAAR. This technique was used in 250 patients from 2012 to 2017. The primary endpoint was the success of the technique, defined as access-site haemostasis without complications and not requiring any additional intervention within 30 days of the index procedure. Patients had a mean age of 82.4±1.93 years, with a logistic EuroSCORE of 20.2±2.32. A total of 218 TAVI and 32 TAAR procedures were performed with a mean sheath size of 18.09±1.55 Fr. The mean sheath to femoral artery ratio was 1.04±0.16, with mean femoral artery minimal lumen diameter 6.65±0.64 mm. The overall success rate of this technique was 98.4%. Four patients (1.6%) developed critical stenosis of the femoral artery requiring balloon dilatation. No major VARC-2 vascular complications were observed. Thirty-day mortality was 0.4% (non-cardiovascular). The results of this study suggest that the single ProGlide/Glubran technique is a safe and effective method of closing the arterial access site after transfemoral TAVI and TAAR. The results of our study need to be confirmed in a randomised controlled trial before being adopted in routine clinical practice.

Coverage of visible intercostal and lumbar segmental arteries can predict the volume of cerebrospinal fluid drainage in elective endovascular repair of descending thoracic and thoracoabdominal aortic disease: a pilot study.

Our goal was to identify anatomical and physiological factors that could predict the amount of cerebrospinal fluid (CSF) drainage in patients undergoing elective endovascular repair of descending thoracic and thoracoabdominal aortic disease. All consecutive elective endovascular procedures performed for descending thoracic or thoracoabdominal aortic disease between January 2015 and December 2017 were included in the study. Routine use of CSF drainage was established in all patients. The goal of drainage was to reach a spinal fluid pressure of 10-12 mmHg by draining in 5-15-ml aliquots. The number of visible intercostal and lumbar segmental arteries (SAs) was evaluated before and after endovascular repair. The covering ratio of SAs was calculated as covered preoperative SAs/total preoperative SAs. Twenty-four consecutive patients were included in the final analysis. The indication for the intervention was a descending thoracic aneurysm in 13 cases, a thoracoabdominal aneurysm in 4 cases and a chronic type B dissection in 7 cases. The procedure performed was thoracic endovascular aortic repair in 20 cases and fenestrated endovascular aneurysm repair in 4 cases. None of the patients developed spinal cord ischaemia. The mean volume of CSF drained was 46 ml. The mean length of aortic coverage was 231 mm. The mean number of total preoperative SAs and of covered preoperative SAs was, respectively, 22 and 9. The volume of CSF drained was significantly correlated with all these variables (length of aortic coverage, total visible SAs and covered SAs), but the most powerful correlation was individuated with the covering ratio of SAs. Our findings suggest that the percentage of intercostal and lumbar SAs covered by placement of a stent graft can predict the volume of CSF drained in patients undergoing elective endovascular repair of descending thoracic and thoracoabdominal aortic disease.