Thoracoabdominal Aneurysm Research Articles

Primary Tear Distance From Left Subclavian Artery Predicts Growth in Chronic Type B Aortic Dissection

The optimal treatment of acute uncomplicated type B aortic dissection (auTBAD) remains controversial. Currently, thoracic endovascular aortic repair is indicated for the onset of complications. This study investigated whether radiographic characteristics of the primary intimal tear in auTBAD can predict the onset of delayed aneurysm formation. A review of a U.S institutional aortic database from 2000 to 2016 identified 318 auTBADs initially treated with optimal medical therapy. From this cohort, 103 patients with two computed tomography or magnetic resonance imaging scans >6 months apart were available for imaging analysis and were included in this study. These patients were divided into subgroups based on growth of the thoracic aorta ≥1 cm: no growth (n = 46) and growth (n = 57). Twenty-five patients (43.9%) in the growth group underwent open or endovascular intervention. TeraRecon (Foster City, Calif) imaging software was used to analyze characteristics of the primary intimal tear, including the maximum width, maximum length, and distance from the left subclavian artery of the primary tear. Statistical comparisons between groups were performed using χ2, Fisher, Mann-Whitney, and t-tests. The mean age of all patients was 53 ± 11 years, and 70% were male. There were no differences between groups in age, gender, hypertension, diabetes mellitus, tobacco abuse, chronic obstructive pulmonary disease, or renal failure. The mean follow-up was equivalent between the two groups (growth, 33 ± 27 months; no growth, 40 ± 34 months; P = .3). There was no difference in the maximum diameters of the thoracic (growth, 4.4 ± 0.9 cm; no growth, 4.2 ± 0.7 cm; P = .16) or abdominal (growth, 3.7 ± 1.1 cm; no growth, 3.5 ± 0.5 cm; P = .38) aorta at the time of presentation between the two groups. The distance of the primary intimal tear from the left subclavian artery in patients with auTBAD was significantly shorter in the growth group compared with the no growth group (growth, 45 ± 48 mm; no growth, 92 ± 78 mm; P = .001; Fig). There was no difference in the maximum length or width of the primary intimal tear between the two groups (Table). The distance of the primary intimal tear from the left subclavian artery predicts the development of descending thoracic or thoracoabdominal aneurysms in the chronic phase of TBAD. Patients with primary tears located in the distal arch (zone 3) should be monitored more closely and may be considered for early thoracic endovascular aortic repair in the setting of auTBAD.TableRadiographic characteristics of uncomplicated type B aortic dissectionRadiographic characteristicsGrowth (n = 57)No growth (n = 46)P valuePIT distance from left subclavian artery, mm45.4 ± 48.191.5 ± 77.8.001*PIT maximum width, mm11.3 ± 6.610.0 ± 6.9.33PIT maximum length, mm11.7 ± 11.09.5 ± 8.9.28Maximum diameter of thoracic aorta at presentation, cm4.4 ± 0.94.2 ± 0.7.16Maximum diameter of abdominal aorta at presentation, cm3.7 ± 1.13.5 ± 0.5.38PIT, Primary intimal tear. Open table in a new tab

Outcomes of Open Repair of Mycotic Aortic Aneurysms with In Situ Replacement.

BackgroundMycotic aortic aneurysms are rare and life-threatening. Unfortunately, no established guidelines exist for the treatment of patients with mycotic aortic aneurysms. The purpose of this study was to evaluate the midterm outcomes of the open repair of mycotic thoracic and thoracoabdominal aneurysms and suggest a therapeutic strategy.MethodsFrom 2006 to 2016, 19 patients underwent open repair for an aortic aneurysm. All infected tissue was extensively debrided and covered with soft tissue. We recorded the clinical findings, anatomic location of the aneurysm, bacteriology results, antibiotic therapy, morbidity, and mortality for these cases.ResultsThe median age was 62±7.2 years (range, 16 to 78 years), 13 patients (68%) were men, and the mean aneurysm size was 44.5±4.9 mm. The mean time from onset of illness to surgery was 14.5±2.4 days. Aortic continuity was restored in situ with a Dacron prosthesis (79%), homograft (16%), or Gore-Tex graft (5%). Soft-tissue coverage of the prosthesis was performed in 8 patients. The mean follow-up time was 43.2±11.7 months. The early mortality rate was 10.5%, and the 5-year survival rate was 74.9%±11.5%.ConclusionThis study showed acceptable early and midterm outcomes of open repair of mycotic aneurysms. We emphasize that aggressive intraoperative debridement with soft-tissue coverage results in a high rate of success in these high-risk patients.

Complex endovascular repair of postdissection arch and thoracoabdominal aneurysms

ObjectiveWe report our experience of the treatment of postdissection arch aneurysms and thoracoabdominal aortic aneurysms (TAAAs) by endovascular repair using fenestrated and branched endografts. MethodsThis study includes all patients presenting with chronic postdissection aneurysms >55 mm in diameter deemed unfit for open surgery and treated by complex endografting between October 2011 and April 2017. Where appropriate, staged management strategies including left subclavian artery revascularization, thoracic endografting, dissection flap fenestration, and tear enlargement were performed before the complex endovascular repair. Outcome data were collected prospectively, specifically including technical success, endoleaks, target vessel patency, aneurysm diameter, adverse events, reinterventions, and mortality. ResultsWe treated 40 patients with a median age of 63 years (55-71 years). In total, 43 procedures were performed: 19 arch repairs using inner branch endografts (one to three branches) and 24 TAAA repairs using fenestrated or branched endografts. Three patients were treated using both arch and TAAA repair. The median time between initial presentation with acute dissection and the first complex aortic repair was 5 years (3.0-10.0 years). Staged procedures were performed in 33 of 40 patients (82.5%). The technical success rate was 93%, the median procedure length was 240 minutes (170-285 minutes), and the median dose-area product was 80 Gy · cm2 (54.3-138.4 Gy · cm2). The 30-day and in-hospital mortality rates were 2.3% (1/43) and 4.7% (2/43), respectively. The spinal cord ischemia rate was 7% and occurred only after TAAA repair. One stroke with partial recovery and one transient ischemic attack were observed (4.7%) after arch repair. Six early reinterventions (14%) were performed: three for access complications, two to treat acute hemorrhage, and one to treat a type II endoleak. Median follow-up was 25.5 months (11-42.25 months). The 1- and 5-year survival rates were 90% and 76.4%, respectively. Late reinterventions were required in eight patients, two in the arch group (to treat endoleaks at 3 and 33 months) and six in the TAAA group (2 iliac and 1 bifurcated endograft extensions, 2 additional renal stents, 1 inferior mesenteric artery embolization). Aneurysm diameter was stable (72%) or shrank (23%) during follow-up. Enlargement was shown in two patients with endoleaks. ConclusionsComplex endovascular repair of postdissection aneurysms is a safe procedure in patients deemed unfit for open surgery. Our experience suggests that close follow-up is mandatory as secondary procedures are frequently required to completely exclude the false lumen.

Comparable perioperative mortality outcomes in younger patients undergoing elective open and endovascular abdominal aortic aneurysm repair

BackgroundEvidence for benefit of endovascular aneurysm repair (EVAR) over open surgical repair for de novo infrarenal abdominal aortic aneurysms (AAAs) in younger patients remains conflicting because of heterogeneous study populations and small sample sizes. The objective of this study was to compare perioperative and short-term outcomes for EVAR and open surgery in younger patients using a large national disease and procedure-specific data set. MethodsWe identified patients 65 years of age or younger undergoing first-time elective EVAR or open AAA repair from the Vascular Quality Initiative (2003-2014). We excluded patients with pararenal or thoracoabdominal aneurysms, those medically unfit for open repair, and those undergoing EVAR for isolated iliac aneurysms. Clinical and procedural characteristics were balanced using inverse propensity of treatment weighting. A supplemental analysis extended the study to those younger than 70 years. ResultsWe identified 2641 patients, 73% (n = 1928) EVAR and 27% (n = 713) open repair. The median age was 62 years (interquartile range, 59-64 years), and 13% were female. The median follow-up time was 401 days (interquartile range, 357-459 days). Unadjusted perioperative survival was 99.6% overall (open repair, 99.1%; EVAR, 99.8%; P < .001), with 97.4% 1-year survival overall (open repair, 97.3%; EVAR, 97.4%; P = .9). Unadjusted reintervention rates were five (open repair) and seven (EVAR) reinterventions per 100 person-years (P = .8). After propensity weighting, the absolute incidence of perioperative mortality was <1% in both groups (open repair, 0.9%, EVAR, 0.2%; P < .001), and complication rates were low. Propensity-weighted survival (hazard ratio, 0.88; 95% confidence interval, 0.56-1.38; P = .6) and reintervention rates (open repair, 6; EVAR, 8; reinterventions per 100 person-years; P = .8) did not differ between the two interventions. The analysis of those younger than 70 years showed similar results. ConclusionsIn this study of younger patients undergoing repair of infrarenal AAA, 30-day morbidity and mortality for both open surgery and EVAR are low, and the absolute mortality difference is small. The prior published perioperative mortality and 1-year survival benefit of EVAR over open AAA repair is not observed in younger patients. Further studies of long-term durability are needed to guide decision-making for open repair vs EVAR in this population.

Ultra-high-resolution CT angiography of the artery of Adamkiewicz: a feasibility study.

Preoperative identification of the artery of Adamkiewicz can help prevent postoperative spinal cord injury following thoracic and thoracoabdominal aortic repair. Several studies have demonstrated the feasibility of evaluating the artery of Adamkiewicz using multi-detector row computed tomography (CT), but precise visualization remains a challenge. The present study was conducted to evaluate the usefulness of ultra-high-resolution CT for visualizing the artery of Adamkiewicz with a slice thickness of 0.25 versus 0.5mm in patients with aortic aneurysms. Our institutional review board approved this study. Twenty-four patients with thoracic and thoracoabdominal aneurysms were scanned with beam collimation of 0.25mm×128. Images were reconstructed with slice thicknesses of 0.25 and 0.5mm. The signal-to-noise ratio (SNR) of the aorta and contrast-to-noise ratio (CNR) between the anterior spinal artery and spinal cord were measured. Two independent observers evaluated visualization of the artery of Adamkiewicz and its continuity between the anterior spinal artery and the aorta using a four-point scale. No significant differences in the SNR of the aorta or CNR of the anterior spinal artery were observed between 0.25- and 0.5-mm slices. The average visualization score was significantly higher for 0.25-mm slices (3.58±0.78) than for 0.5-mm slices (3.13±0.99) (p=0.01). The percentage of patients with nondiagnostic image quality was significantly lower for 0.25-mm slices (8.3%) than for 0.5-mm slices (33.3%) (p=0.03). In patients with aortic aneurysms, ultra-high-resolution CT with 0.25-mm slices significantly improves visualization of the artery of Adamkiewicz compared to 0.5-mm slices.

Early and late outcomes of open repair for dissecting aneurysms of the descending or thoraco-abdominal aorta.

Although open repair is the standard surgical option for dissecting descending thoracic aneurysms (DTAs) and thoraco-abdominal aorta aneurysms (TAAAs), it remains a significant challenge with considerable perioperative morbidity and mortality. We retrospectively analysed early and late outcomes of open repair for these aortic aneurysms. Early and late outcomes were investigated for 223 consecutive patients who underwent open repair for dissecting DTA or TAAA between January 2003 and December 2014 (mean age 55 ± 16 years). The basic strategy for open surgery comprised liberal use of deep hypothermia and aggressive preservation or reattachment of intercostal arteries, i.e. donor arteries for the artery of Adamkiewicz. Deep hypothermia was used in 150 (67.3%) patients. The overall in-hospital mortality rate was 3.6% and 1.5% for elective cases. The rates of spinal cord ischaemic injury and stroke were 3.1% and 4.5%, respectively. During follow-up (mean 63 ± 40 months), overall 5-year survival rates was 89.2 ± 2.4% and 91.3 ± 2.8% and 86.3 ± 4.1% for DTA and TAAA, respectively. Five- and 10-year rates of freedom from aortic events, defined as surgery for initial operation-related events or for downstream aortic dilation, were 89.1 ± 3.5% and 68.2 ± 7.8% for DTA and 100% and 96.6 ± 3.4% for TAAA, respectively (P < 0.01). Our approach in treating this aortic pathology showed favourable early and long-term outcomes with acceptable neurological complication rates. More careful follow-up is necessary in patients with DTA repair, because downstream aortic enlargement occurs in some patients.

Aortoesophageal Fistulae (AEF): An Imperative Diagnosis

A 58 year old man, with no significant medical history, presented with bright red hematemesis. He denied any abdominal pain, episodes of hematochezia, melena, any medications including NSAIDs, or significant familial history. He admitted to chronic alcohol and tobacco use. In the ED, he had a melanotic bowel movement followed by an episode of large volume hematochezia and 500mLs of hematemesis. The patient became hypotensive and was intubated. In addition to blood product transfusion, he underwent emergent endoscopy which revealed a large amount of blood in the stomach and two darkly pigmented protuberances with adherent clot within the esophagus which could not be removed. Epinephrine and hemostatic clips were applied and the patient was transferred to the MICU. Following additional large volume hematemesis, a second endoscopy revealed active bleeding in the esophagus at 30cm from the incisors. Epinephrine was injected and a hemostatic clip was applied which effectively controlled bleeding until endovascular aortic stenting could be performed. CT scan showed pseudoaneurysm of the proximal descending thoracic aorta with an aortoesophageal fistula (AEF) identified by the adjacent endoscopic clip. AEF are rare and associated with a poor prognosis; 54.2% are associated with primary aortic disease, 19.2% foreign body, 17% esophageal carcinoma, and 4.8% as postoperative events (50% aortic surgery, 50% esophageal). Increased use of endovascular stenting has led to an increase in iatrogenic aortoenteric fistulae, however, the incidence of frank rupture is declining largely due to early detection and treatment of thoracoabdominal aneurysms. Diagnosis is aided by Chiari's triad, aortoesophageal syndrome, (chest pain, sentinel hematemesis, massive exsanguination) with an associated poor prognosis due to an inability to localize hemorrhage. Endoscopy is valuable as CTA may fail to identify fistulous tracts. Additionally, it allows therapeutic advantages (heater probe, clips) and should be considered in combination with other modalities to control bleeding and as temporalizing measures to surgical intervention. Esophageal stents may be an effective alternative to surgery in some cases. AEF is an imperative diagnosis that must be made expeditiously and treatment initiated. Endoscopy is an important tool in diagnosis and a bridge to treatment and repair that should be considered in patients with suspected AEF.Figure: Endoscopic clip identifying the level of aortoesophageal fistula.

Results of the surgical treatment of type 4 thoraco-abdominal aneurysms with debranching of the left renal artery and a passive temporary shunt

Results of the surgical treatment of type 4 thoraco-abdominal aneurysms with debranching of the left renal artery and a passive temporary shunt

Open Distal Fenestration of Chronic Dissection Facilitates Endovascular Elephant Trunk Completion: Late Outcomes

Retrograde false lumen perfusion is a common mode of failure after stent grafting chronic aortic dissection. Open fenestration during the first-stage elephant trunk (ET) creates a landing zone for second-stage endovascular ET completion in patients with a false lumen aneurysm. Our objectives were to assess long-term safety and durability of this technique. From 2007 to 2014, 56 patients with thoracoabdominal dissection and aneurysm underwent stage 1 ET and open fenestration. Fifteen (26.8%) patients had DeBakey type III dissection, and 41 (73%) had type I, 38 (68%) with previous ascending repair. Mean maximum diameter was 5.8 ± 1 cm. Imaging follow-up was complete in all survivors. Endovascular ET completion was performed in 49 patients (87.5%), urgently in 11 (22%). Operative mortality after the first stage was 1.8%. The ET in 8 patients was performed prophylactically. Complications after the first stage included transient ischemic attack in 1 patient (1.8%), subdural hemorrhage in 1 (1.8%), tracheostomy in 1 (1.8%), bleeding in 5 (8.9%), and paraplegia in 1 (1.8%). All 48 patients had false lumen thrombosis in the treated segment without endoleak or retrograde perfusion. The aneurysm sac shrunk in 67%, with a mean overall aortic diameter reduction of 1 ± 0.8 cm. Median follow-up was 33.8 months. Eight patients (16%) underwent 11 late reinterventions, comprising thoracic endovascular aortic repair extension in 4 patients (36%), thoracic endovascular aortic repair and false lumen embolization in 3 (27%), open thoracoabdominal aortic aneurysm completion repair in 2 (18%), and redo proximal repair for infection in 2 (18%). There were 6 late deaths. Open aortic fenestration to create a distal landing zone during stage 1 ET facilitates endovascular completion for chronic dissection with false lumen aneurysm. The technique is safe, effective, and durable. It promotes reverse aortic remodeling and eliminates retrograde false lumen flow.

Remote Ischemic Preconditioning Decreases the Magnitude of Hepatic Ischemia-Reperfusion Injury on a Swine Model of Supraceliac Aortic Cross-Clamping

Temporary hepatic ischemia is inevitable during open aortic surgery when supraceliac clamping is necessary, as in thoracoabdominal or pararenal aneurysms. Remote ischemic preconditioning (RIPC) has been described as a potential protective means against ischemia-reperfusion injury (IRI) in various tissues including the liver. The aim of this experimental study was to detect the effect of RIPC on liver IRI in a model of supraceliac aortic cross-clamping. An animal study was performed. Four groups of 6 swines each were examined: the control (sham) group, the ischemia-reperfusion (IR) group, and 2 remote ischemic preconditioning groups (RIPC I and RIPC II group). In the IR group, the animals underwent a complete cessation of the splanchnic arterial circulation for 30min by a concomitant occlusion of the supraceliac and the infrarenal aorta. In the RIPC groups, a remote preconditioning was applied before the splanchnic ischemia. This consisted of a temporary occlusion of the infrarenal aorta for 15min followed by 15min of reperfusion (RIPC I group), and 3 cycles of 5min similar ischemia, followed by 5min of reperfusion each (RIPC II group). All animals were followed for 24hr after the ischemia (reperfusion period). The liver ischemia-reperfusion injury was assessed by examining specific serum biomarkers indicating the magnitude of metabolic injury from selective blood samples of the hepatic circulation. In particular, the following parameters were examined: C-reactive protein, interleukin 6, tumor necrosis factor a, ferritin, and L-arginine. All parameters were affected in the IR group as compared to the sham group. Both RIPC groups developed a less serious change as compared to the IR group, in all examined parameters. In an animal study of splanchnic ischemia produced in a way to this produced during a supraceliac aortic aneurysm open repair, the remote ischemic preconditioning seemed to attenuate the effect of hepatic ischemia-reperfusion injury. Remote ischemic preconditioning produced with short bouts of ischemia of the lower body by temporary clamping of the infrarenal aorta might be used as a means of decreasing the detrimental effects of hepatic ischemia-reperfusion injury after supraceliac aortic cross-clamping. This was found in a swine model of suprarenal AAA open repair by studying the variance of certain biological biomarkers in selective blood samples retrieved from the hepatic vein.

A clinical review of early outcomes from contemporary flow modulation versus open, fenestrated and branch technologies in the management of thoracoabdominal aortic aneurysm.

Traditional therapeutic options for complex thoracoabdominal aneurysm include open repair, hybrid repair or endovascular repair (involving fenestrated or branched endografts). The Streamliner Multilayer Flow Modulator has been available for treatment of thoracoabdominal aneurysms since 2010. Its design permits blood flow to perfuse through the mesh in a modus that preserves collateral branch patency, while modulating turbulent to laminar flow within the device. The flow then stagnates over time within the surrounding aneurysm sac. Significant complications, including paraplegia, renal failure and cerebrovascular accident, are much lower with Streamliner Multilayer Flow Modulator treatment. Application of the Streamliner Multilayer Flow Modulator to complex aortic pathologies presents a novel solution to an, as of yet, unmet clinical need, and has resulted in promising clinical outcomes when compared to existing solutions. The Streamliner Multilayer Flow Modulator offers potential for treatment of thoracoabdominal aortic pathologies in patients and is not just confined to those with complexity that dictates no other management options. While current literature illustrates that there is a decreased risk of mortality and associated complications when this new disruptive technology is utilised, there is still a need for prospective, long-term clinical trials, as well as comparative trials to accurately assess outcomes of Streamliner Multilayer Flow Modulator treatment that are both precise and reproducible. This article is a review of current clinical literature regarding contemporary flow modulating technology compared with open, branched and fenestrated managements, presenting early outcomes.

EndoAnchors in Thoracic, Thoracoabdominal, and Complex Abdominal Endovascular Aortic Repairs: Safe and Effective

Thoracic endovascular aortic repair (TEVAR) and complex endovascular abdominal aortic repair (CEVAR) are performed despite anatomic constraints and complicated aortic disease. Using Heli-FX EndoAnchors (Medtronic, Santa Rosa, Calif) for endograft fixation in the infrarenal aorta has been described. This study was performed to assess the applicability and outcomes of EndoAnchors in TEVAR and CEVAR. This was a retrospective review of endovascular aortic repairs performed with EndoAnchors between 2012 and 2016. Primary study end points included freedom from migration and type I endoleak requiring reintervention. A total of 101 patients underwent 54 TEVARs and 47 CEVARs with EndoAnchor; 22 patients (21.8%) were treated for thoracic aortic aneurysm, 35 (34.7%) for thoracoabdominal aneurysm, 22 (21.8%) for pararenal aneurysm, and 22 (21.8%) for infrarenal aneurysms with hostile neck anatomy. There were 45 cases (44.6%) performed as index operations, and 56 (55.4%) were redo operations. TEVAR endografts were deployed in zone 0 or 1 in 40.1% of patients, requiring adjunctive procedures (arch debranching, 20; in situ arch fenestration, 9; supra-aortic trunk chimney, 4; visceral debranching, 2). In CEVAR patients, one visceral vessel was treated in 25 patients (24.8%), two in 6 patients (5.9%), three in 24 patients (23.8%), and four in 5 patients (5.0%). EndoAnchors were placed for therapeutic indications in 41.6% of cases and for prophylactic indications in 58.4%. Technical success of deployment was 99.6%. Mean follow-up was 14.3 ± 11.0 months. At 2 years, freedom from type I endoleak requiring reintervention was 93.8% for thoracic aneurysms, 100% for thoracoabdominal aneurysms, and 94.1% for abdominal aneurysms, with no significant difference in freedom from type I endoleak between redo (93.7%) and index (96.7%) operations (P = .752). EndoAnchors can be safely used in TEVAR and CEVAR and can decrease rates of graft migration and type I endoleak. Additional data and long-term follow-up are needed to further define the use of this technology.

Hybrid Visceral and Renal Debranching Followed by Thoracic Endovascular Repair for Thoracoabdominal Aneurysm

Hybrid repair of thoracoabdominal aortic aneurysms (TAAA) may reduce morbidity and mortality in high-risk candidates, but their utility continues to be debated. We report our experience using a hybrid procedure consisting of open visceral debranching followed by endovascular aortic repair.

Fenestrated Repair of a Type III Thoracoabdominal Aortic Aneurysm in a Patient with Marfan Disease and Degenerated Aortic Dissection

Fenestrated repair of thoracoabdominal aneurysms is an acceptable alternative to open repair, especially in patients with high surgical risk. We were referred a patient with Marfan disease who had undergone several open repairs and now had a degenerated chronic aortic dissection. He refused an open operation because of his experience with multiple open repairs and opted for a fenestrated approach. We performed a custom fenestrated repair of a type III thoracoabdominal aortic aneurysm in a patient with Marfan disease and a degenerated thoracic aorta. A video was made depicting the key steps in this complicated repair. A successful repair was performed. Postoperative computed tomography angiography demonstrated no evidence of any endoleaks, and there was thrombosis of the false lumen. Fenestrated repairs are a reasonable operative modality in patients with connective tissue disorders with a complicated surgical history who are at high risk for an open repair.

Two-Year Evaluation of Fenestrated and Parallel Branch Endografts for the Treatment of Juxtrarenal, Suprarenal, and Thoracoabdominal Aneurysms at a Single Institution

Two-Year Evaluation of Fenestrated and Parallel Branch Endografts for the Treatment of Juxtrarenal, Suprarenal, and Thoracoabdominal Aneurysms at a Single Institution

The Durability of Open Surgical Repair of Type IV Thoracoabdominal Aneurysm

The Durability of Open Surgical Repair of Type IV Thoracoabdominal Aneurysm

Thirty-day outcomes after fenestrated endovascular repair are superior to open repair of abdominal aortic aneurysms involving visceral vessels

ObjectiveAlthough few studies have reported outcomes after branched or fenestrated endovascular aortic aneurysm repair (FEVAR) of abdominal aortic aneurysms involving visceral vessels (AAA-Vs), no multi-institutional study has compared FEVAR with open surgery (OS) for AAA-Vs. Our objective was to compare 30-day outcomes after FEVAR vs OS for AAA-Vs. MethodsPatients who underwent FEVAR (n = 535) and OS (n = 1207) for elective AAA-Vs were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) 2008 to 2013 database. Thoracoabdominal aneurysms were excluded. Univariable and multivariable logistic regression analyses were performed. ResultsThere were more men (82% vs 72%; P < .0001), diabetic patients (16% vs 11%; P = .005), patients with dependent functional status (4% vs 2%; P = .002), and nonsmokers (70% vs 56%; P < .0001) in the FEVAR group vs OS. There was no difference in rates of chronic obstructive pulmonary disease, cardiac history, peripheral artery disease, hypertension, and dialysis (P > .05). FEVAR had fewer major postoperative pulmonary complications (3.0% vs 19.0%; P < .0001), less renal failure requiring dialysis (1.9% vs 6.4%; P < .0001), less frequent cardiac arrest or myocardial infarction (2.2% vs 5.8%; P = .001), less bleeding with major transfusion (17.4% vs 50.2%; P < .0001), and decreased incidence of return to the operating room (4.5% vs 9.6%; P < .0001) and death (2.4% vs 4.7%; P = .02). The median length of stay was also significantly shorter for FEVAR (2 days vs 7 days; P < .0001). On multivariable analyses, OS was associated with higher risk than FEVAR for 30-day death (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.3-5.0), pulmonary complications (OR, 8.8; 95% CI, 5.1-15.0), cardiac complications (OR, 3.4; 95% CI, 1.8-6.6), renal failure needing dialysis (OR, 3.8; 95% CI, 1.9-7.7), and return to the operating room (OR 2.5; 95% CI, 1.6-4.0). ConclusionsFEVAR is associated with a lower risk for 30-day mortality and adverse events compared with OS for AAA-Vs.

Outcomes of concomitant renal reconstruction during open paravisceral aortic aneurysm repair

ObjectiveThe objective of this study was to review the outcomes of renal artery revascularizations during open aortic aneurysm repair. MethodsOpen abdominal aneurysm repairs performed from 2010 to 2015 at a single institution were reviewed, including type IV thoracoabdominal, suprarenal, and juxtarenal aneurysms. Direct renal reconstruction techniques included eversion endarterectomy, bypass, and vessel reimplantation based on the patient's anatomy. Renal loss was defined by artery occlusion. ResultsThe study included 125 patients; of these, 57 patients (46%) had 76 renal reconstructions (38 single, 19 bilateral) performed. Interventions included endarterectomy (n = 21), transaortic stenting (n = 2), reimplantation with (n = 25) or without (n = 17) endarterectomy, bypass (n = 4), and ligation (n = 7). Mean aneurysm size was 6.4 cm, with 23% (n = 29) urgent/emergent operations and 20% (n = 25) having had a prior open or endovascular repair. Overall complication rate was 50%, with significant increase among the group requiring renal intervention, primarily accounted for by a 33% early or late dialysis requirement compared with 16% in patients with no renal revascularization (P = .01). Overall 30-day mortality was 9%, with no difference between groups. Urgent/emergent operation (P < .001) was associated with increased 30-day mortality (24% vs 4% elective procedures), but prior open or endovascular repair (P = .4) was not. Mean follow-up was 26 months, with directed imaging out to a mean of 18 months. Renal intervention (P = .01) and urgent/emergent status (P = .04) were predictive of dialysis requirement; however, among those undergoing intervention, renal loss was not associated with an increase in dialysis requirement (P = .2). Of the directed intervention techniques, renal reimplantation with or without endarterectomy was associated with increased risk of dialysis requirement (P = .005) and renal loss (P = .04) relative to endarterectomy alone. Mean creatinine concentration on late follow-up was 1.4 mg/dL (from 1.3 mg/dL preoperatively) and was not statistically significantly different between those undergoing renal intervention (1.5 mg/dL) and those who did not (1.4 mg/dL). ConclusionsRenal artery reconstruction at the time of open repair of paravisceral aneurysms is associated with an increased complication rate, primarily driven by occlusion of reimplanted vessels and increased dialysis requirement. As reported by others, nonelective presentation is the greatest determinant of early death or adverse outcomes.

Endovascular Repair of Thoracoabdominal and Arch Aneurysms in Patients with Connective Tissue Disease Using Branched and Fenestrated Devices

Prophylactic open surgery is the standard practice in patients with connective tissue and thoracoabdominal aortic aneurysm (TAAA) and aortic arch disease. Branched and fenestrated devices offer a less invasive alternative but there are concerns regarding the durability of the repair and the effect of the stent graft on the fragile aortic wall. The aim of this study is to evaluate mid-term outcomes of fenestrated and/or branched endografting in patients with connective tissue disease. All patients with connective tissue disease who underwent TAAA or arch aneurysm repair using a fenestrated and/or branched endograft in a single, high-volume center between 2004 and 2015 were included. Ruptured aneurysms and acute aortic dissections were excluded from this study, but not chronic aortic dissections. In total, 427 (403 pararenal and TAAAs, and 24 arch aneurysms) endovascular interventions were performed during the study period. Of these, 17 patients (4%) (16 TAAAs, 1 arch) had connective tissue disease. All patients were classified as unfit for open repair. The mean age was 51±8years. Thirteen patients with TAAA were treated with a fenestrated, 1 with a branched, and 2 with a combined fenestrated/branch device. A double inner branch device was used to treat the arch aneurysm. The technical success rate was 100% with no incidence of early mortality, spinal cord ischemia, stroke, or further dissection. Postoperative deterioration in renal function was seen in 3 patients (18.8%) and no hemodialysis was required. The mean follow-up was 3.4years (0.3-7.4). Aneurysm sac shrinkage was seen in 35% of patients (6/17) and the sac diameter remained stable in 65% of patients (11/17). No sac or sealing zone enlargement was observed in any of the patients and there were no conversions to open repair. Reintervention was required in 1 patient at 2 years for bilateral renal artery occlusion (successful fibrinolysis). One type II endoleak (lumbar) is under surveillance and 1 type III (left renal stent) sealed spontaneously. One patient died at 2years after the procedure from nonaortic causes (endocarditis). The favorable mid-term outcomes in this series that demonstrate fenestrated and/or branched endografting should be considered in patients with connective tissue and TAAA and aortic arch disease, which are considered unfit for open surgery. All patients require close lifetime surveillance at a center specializing in aortic surgery, with sufficient experience in both open and endovascular aortic surgery, so that if endovascular treatment failure occurs it can be recognized early and further treatment offered.

Transapical aortic perfusion using a deep hypothermic procedure to prevent dissecting lung injury during re-do thoracoabdominal aortic aneurysm surgery

BackgroundAvoiding various complications is a challenge during re-do thoracoabdominal aneurysm surgery.Case presentationA 56-year-old man had undergone surgery for type I aortic dissection four times. The residual thoracoabdominal aortic aneurysm that had severe adhesions to lung parenchyma was resected. Since the proximal anastomotic site was buried in lung parenchyma, deep hypothermia was essential to avoid lung dissection and to protect the spinal cord during the proximal anastomosis. The deep hypothermia was induced with bilateral infusion of cardiopulmonary bypass by femoral artery cannulation for the lower body and by transapical cannulation for the upper body because of easy access. There was no hemorrhagic tendency after deep hypothermic bypass. The patient was discharged uneventfully.ConclusionsFor upper body perfusion, transapical aortic cannulation was a simple and effective procedure during left thoracotomy.