Thoracoabdominal Aneurysm Research Articles

Physician-modified Endograft for the Urgent Treatment of High-risk Chronic Dissecting Thoracoabdominal Aneurysms

Physician-modified Endograft for the Urgent Treatment of High-risk Chronic Dissecting Thoracoabdominal Aneurysms

Surgical strategies in the management of chronic dissection of the thoracoabdominal aorta.

Most operations for dissection of the thoracoabdominal aorta take place in the chronic phase of the disease, because the acutely dissected distal aorta is almost always initially treated non-surgically with aggressive pharmacological anti-impulse therapy. Identifying patients who are no longer responding to medical treatment is the first step in preventing further disease progression and rupture. Symptomatic aneurysms should be promptly repaired. Asymptomatic patients are followed until significant aortic dilation occurs and reaches a threshold of intervention: current guidelines endorse repair once a diameter of 5.5 cm is reached. In patients with heritable thoracic aortic disease (such as Marfan Syndrome), the threshold of intervention is often lowered. Aortic replacement typically centers on the dilatated segment. For all extents of repair, we use passive mild hypothermia, sequential aortic cross-clamping, aggressive reimplantation of intercostal and lumbar arteries, and cold renal perfusion whenever possible. For Crawford extents I and II thoracoabdominal aneurysm repair, we routinely use cerebrospinal fluid drainage, left heart bypass, and selective visceral perfusion. A four-branched graft approach to thoracoabdominal aortic aneurysm repair is frequently used in patients with chronic aortic dissection; this approach facilitates visceral artery perfusion during repair, expedites the distal anastomosis, and prevents subsequent visceral patch aneurysms. Lifelong imaging surveillance is necessary, because the distal aorta often continues to expand; residual aortic dissection commonly remains after repair and may necessitate further repair.

Lateral Axillary Exposure for Antegrade Access during Endovascular Repair of Complex Abdominal Aortic and Thoracoabdominal Aneurysms

During endovascular treatment of pararenal aortic aneurysms (PAA) and thoracoabdominal aortic aneurysms (TAAA), our antegrade vascular access of choice is a lateral axillary exposure (LAE). We directly access the axillary artery with multiple sheaths followed by primary closure of the axillary artery at case completion. The aim of this study is to describe our technique and to report our results with this approach. This study is a single-institution, retrospective review of 53 patients who were treated with parallel grafts for endovascular repair of PAA and TAAA from 2006 to 2018. The aortic repairs requiring LAE included: 9 cases of endo-leaks from prior endovascular repair, 20 TAAAs, and 24 PAAs. The axillary artery was exposed with a vertical axillary skin incision followed by retraction of the lateral border of the pectoralis major to expose the axillary artery distal to the pectoralis minor. A 5-French (F) through 12F sheaths were used to directly access the axillary artery for delivery of endovascular devices. Two hundred and sixty reno-visceral stents were delivered through 125 axillary sheaths in an antegrade fashion to 114 arteries without intraoperative complications or technical failures. Two postoperative complications included an access-site hematoma managed conservatively (1.9%) and a left brachial vein thrombosis treated with anticoagulation (1.9%). There were no cases of cerebrovascular or peripheral neurologic events, upper extremity ischemia, or reoperation related to LAE. LAE is a valid approach for upper extremity access during the endovascular repair of complex aortic aneurysms requiring simultaneous delivery of multiple reno-visceral devices. It does not require the use of a prosthetic conduit. There were no neurologic events or upper extremity ischemia in our series.

Respiratory-induced changes in renovisceral branch vessel morphology after fenestrated thoracoabdominal aneurysm repair with the BeGraft balloon-expandable covered stent

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

Fenestrated-branched endovascular aortic repair is a safe and effective option for octogenarians in treating complex aortic aneurysm compared with nonoctogenarians

ObjectiveOpen repair of complex aortic aneurysms is frequently not an option for octogenarians because of prohibitive surgical risks. This study aimed to analyze the outcomes of fenestrated-branched endovascular aortic repair (F-BEVAR) in octogenarians (≥80 years old) compared with nonoctogenarians (<80 years old). MethodsWe reviewed 893 patients with pararenal or extent I to V thoracoabdominal aneurysms, enrolled in six prospective physician-sponsored investigational device exemption studies from 2012 to 2018. All patients were treated with either company-manufactured off-the-shelf or patient-specific F-BEVAR stent grafts. Data analyzed included demographics, cardiovascular risk factors, history of active cancer, American Society of Anesthesiologists classification, aortic anatomy characteristics, and procedural data. End points included mortality, major adverse events (all-cause mortality, stroke, paralysis, acute kidney injury [RIFLE criteria], dialysis, myocardial infarction, respiratory failure, and bowel ischemia), technical success, hospital length of stay, target artery instability (occlusion/stenosis, endoleak, rupture or death), and secondary interventions. ResultsDuring the study period, 195 octogenarian patients (22%) and 698 (78%) nonoctogenarian patients were treated with F-BEVAR. Octogenarians presented more frequently with a history of cancer (17% vs 11%; P = .01), whereas nonoctogenarians more frequently had hyperlipidemia (76% vs 65%; P = .003), chronic obstructive pulmonary disease (42% vs 33%; P = .04) and American Society of Anesthesiologists class III to V (78% vs 70%; P = .02). Male sex was similar between groups (68% [octogenarians] vs 70% [nonoctogenarians]; P = .62). Octogenarians had a larger mean aneurysm diameter (67 ± 1 mm vs 65 ± 1 mm; P = .002). The thoracoabdominal classification and the use of upper extremity access were similar between groups. Estimated blood loss was also similar (484 ± 454 mL [octogenarian] vs 416 ± 457 mL [nonoctogenarian]; P = .07). Octogenarians had an increased mean number of vessels incorporated into the repair (3.1 ± 1.4 vs 2.7 ± 1.7; P < .001). The technical success rate was 99% for octogenarians and 97% for nonoctogenarians (P = .19). The 30-day mortality rate was 0.5% for octogenarians and 1.3% for the nonoctogenarians (P = .70). Major adverse events (9.2% vs 9.7%), types I/III endoleak (4.6% vs 2.4%) access complication (3.1% vs 3.3%), and length of stay (8.2 ± 27 days vs 5.7 ± 6.3 days) were all similar between the groups. Freedom from target artery instability and freedom from secondary interventions at 3 years were similar between the groups. Octogenarian survival was lower at 3 years compared with nonoctogenarians on univariate analysis (log-rank P < .01) and on multivariable analysis after adjusting for history of active cancer, hyperlipidemia, and chronic obstructive pulmonary disease. ConclusionsDespite small differences in demographics, anatomic factors, and procedural data, F-BEVAR was safe and effective with nearly identical early outcomes in octogenarians in these experienced aortic centers. More extensive clinical experience and longer follow-up are needed to better delineate factors impacting longer term mortality.

Managing Vascular Surgery Emergencies and Referrals During the COVID-19 Pandemic at a Tertiary Centre in Oman.

ObjectivesThis study aimed to discuss the different challenges faced while managing emergency vascular surgery cases during the COVID-19 pandemic and how these challenges were overcome.MethodsThis study details 14 emergency cases that were managed during a period of one month from mid-March to mid-April at Sultan Qaboos University Hospital, Muscat, Oman. The cases included acute limb ischaemia, critical limb ischaemia, type B dissection of the thoracic aorta, thoraco-abdominal aneurysm, critical internal carotid artery stenosis, trauma, infected arteriovenous forearm loop graft and thrombosed arteriovenous fistulas.ResultsOnly one patient was confirmed to have COVID-19. Five were negative for COVID-19 while the remaining eight were not tested. Various strategies on how the vascular surgical team accommodated changes in hospital protocols and nationwide lockdown are discussed in detail.ConclusionsWith the judicious use of personal protective equipment and consumable surgical and endovascular devices, communication with support services and other hospitals and implementation of triage protocols, it was possible to manage vascular surgery emergencies effectively.

Commentary: Success lies in attention to details when performing open repair of thoracoabdominal aneurysms

Chronic thoracoabdominal aortic aneurysm (TAAA) with dissection presents an interesting and complex challenge for surgeons owing to the high degree of variability in the anatomy of the dissected aorta and its branch vessels. Although some success has been made with endovascular interventions in a subset of highly selected patients, the applicability of endovascular solutions remains limited by anatomy. The locations of branch vessels, the primary tear, downstream fenestrations, and landing zones all need to be considered carefully.

Mortality is High Following Elective Open Repair of Complex Abdominal Aortic Aneurysms

Objective To evaluate the 30 day mortality of elective open complex abdominal aortic aneurysm (cAAA) repair and identify factors associated with death. Methods This was a retrospective cohort study using a Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). All patients undergoing elective repair for juxta- and suprarenal abdominal aortic aneurysm (AAA), or type IV thoraco-abdominal aneurysms (TAAA) from 2011 to 2017 were identified. Thirty day mortality and complication rates for open repair were established. A comparison endovascular aneurysm repair (EVAR) group was extracted from the same time period, and inverse probability weighting was applied for comparison. Logistic regression was used to identify factors independently associated with open repair mortality. Results Of the 957 patients who underwent an elective open cAAA repair over the study period, 65 (6.8%) died. The mean age of the patient was 71.3 ± 8.0 years. The distribution by aneurysm type was 605 juxtarenal AAA (28 deaths, 4.6%); 284 suprarenal AAA (16 deaths, 9.5%), and 68 type IV TAAA (10 deaths, 14.7%). During the same time period, there were 1149 endovascular repairs for cAAA, with 43 deaths (3.7%). After inverse probability weighting and weighted logistic regression, open repair 30 day mortality yielded an OR 1.9, 95% CI 1.2-3.1, p = .01 compared with EVAR. Factors independently associated with death included more proximal extent aneurysm (referent [ref]: juxtarenal: OR 2.0 per extent increase, 95% CI 1.4-3.0, p Conclusion The 30 day mortality was 4.6% for juxtarenal AAA, 9.5% for suprarenal AAA, and 14.7% for type IV TAAA. The open repair odds of 30 day mortality was nearly twice that of endovascular repair for cAAA. Independent associations with death included BMI

Proximal Aortic Coverage and Clinical Results of the Endovascular Repair of Juxta-/Para-renal and Type IV Thoracoabdominal Aneurysm with Custom-made Fenestrated Endografts

Juxta-renal (JAAA)/para-renal (PAAA) and type IV-thoracoabdominal (TAAA) aneurysms can be repaired by custom-made fenestrated endografts (CM-FEVAR). Differently from open repair, a relatively long segment of healthy proximal aorta needs to be covered to achieve a durable sealing, and this may be considered a disadvantage of the endovascular approach. We aimed to quantify the additional proximal aortic coverage in JAAAs, PAAAs, and type-IV TAAAs treated with CM-FEVAR and to evaluate its impact on early/follow-up clinical outcomes. Between 2006 and 2018, preoperative, intraoperative, and postoperative data of JAAAs, PAAAs, and type-IV TAAAs submitted to CM-FEVAR were collected. The length of proximal healthy aortic coverage was evaluated on the preoperative endograft planning as the distance between the top of the CM-FEVAR endograft and the hypothetical level of aortic cross-clamping in case of open repair (type-IV TAAA-above the celiac trunk; PAAA-above the superior mesenteric artery; JAAA-above the lowest renal artery). Spinal cord ischemia (SCI), bowel ischemia (BI), renal function worsening (RFW) (estimated glomerular filtration rate reduction>25% of the baseline level - RFW), and mortality were assessed at 30-day. Survival, target visceral vessel (TVV) patency, and freedom from reinterventions (FFRs) were assessed during follow-up by Kaplan-Meier analysis R2. One hundred forty-seven cases were submitted to CM-FEVAR, for 72 (49%) JAAAs, 46 (31%) PAAAs, and 29 (20%) type IV-TAAAs, with 1(4-3%), 2 (28-19%), 3 (48-33%), and 4 (67-45%) fenestrations. JAAAs required a fenestration+bridging stent graft for the superior mesenteric artery and celiac trunk, in 46(64%) and 24(33%) cases, respectively. Nineteen (41%) PAAAs required a fenestration+bridging stent graft for the celiac trunk. The mean proximal additional aortic coverage was 48 ± 2mm with no differences among JAAAs (52 ± 1mm), PAAAs (42 ± 2mm), and type IV-TAAAs (50 ± 2mm) (P.09). Technical success, defined as correct endograft deployment, with TVV patency, absence of type I-III endoleaks, iliac leg stenosis/occlusions, open surgical conversion, and 24-hour mortality, was achieved in 98% of cases. Failures occurred for 1 type-III endoleak (type-IV TAAA) and 2 renal artery losses (PAAA and type IV-TAAA). The only case of SCI (0.7%) occurred in a type-IV TAAA where the proximal healthy aortic coverage was 80mm. One BI was caused by acute thrombosis of the bridging stent graft for the superior mesenteric artery at 24hours in 1 type IV-TAAA (0.7%). Thirty-five patients (24%) suffered postoperative RFW and required hemodialysis in 1 (0.7%) JAAA with severe preoperative chronic renal failure. There was no difference of proximal additional aortic coverage between patients with (49±29mm) and without (48±23mm) RFW (P.2). The 30-day mortality was 1.4%. The mean follow-up was 37 ± 2months with no cases of aneurysm-related late mortality. Survival was 94%, 89%, and 75% at 1, 2, and 5years, respectively. TVV patency was 97%, 97%, and 93% at 1, 2, and 5years, respectively. FFR was 98%, 95%, and 87% at 1, 2, and 5years, respectively. Custom-made FEVAR requires a mean proximal additional aortic coverage of 48 ± 2mm above the level of hypothetical aortic cross-clamping in case of open repair. This aspect should be considered for CM-FEVAR indication in JAAAs, PAAAs, and type-IV TAAAs; nevertheless, it does not appear to be associated with negative early and follow-up clinical sequelae.

Multilayer stents affect the final diameter of aortic aneurysms and maintain renal artery patency for a short time in a swine experimental model

OBJECTIVES:We sought to analyze the hemodynamic effects of the multilayer flow-modulated stent (MFMS) in Thoracoabdominal aortic aneurysms (TAAAs).METHODS:The hemodynamic effects of MFMS were analyzed in aortic thoracoabdominal aneurysms in experimental swine models. We randomly assigned 18 pigs to the stent or control groups and underwent the creation of an artificial bovine pericardium transrenal aneurysm. In the stent group, an MFMS (Cardiatis, Isnes, Belgium) was immediately implanted. After 4 weeks, we evaluated aneurysm sac thrombosis and renal branch patency by angiography, duplex scan, and morphological analysis.RESULTS:All the renal arteries remained patent after re-evaluation in both groups. Aneurysmal sac thrombosis was absent in the control group, whereas in the stent group it was present in 66.7% of aneurysmal sacs (p=0.061).The mean final aneurysm sac diameter was significantly lower in the stent group (mean estimated reduction, 6.90 mm; p=0.021). The proximal neck diameter decreased significantly in the stent group (mean difference, 2.51 mm; p=0.022) and grew significantly in the control group (mean difference, 3.02 mm; p=0.007). The distal neck diameter increased significantly in the control group (mean difference, 3.24 mm; p=0.017). There were no significant findings regarding distal neck measurements in the stent group.CONCLUSION:The MFMSs remained patent and did not obstruct the renal arteries within 4 weeks. In the stent group, the device was also associated with a significant decrease in aneurysmal sac diameter and a large proportion (albeit non-significant) of aneurysmal sac thrombosis.

Twenty-year experience in off-pump surgery for thoracic and thoracoabdominal aorta aneurysms and dissections

Twenty-year experience in off-pump surgery for thoracic and thoracoabdominal aorta aneurysms and dissections

The Neuroprotective Mechanism of Spinal Cord Stimulation in Spinal Cord Ischemia/Reperfusion Injury

Spinal cord ischemia/reperfusion (I/R) injury following thoracoabdominal aneurysm surgery can lead to severe lower limb neurologic defect. The preliminary result of our study suggested that spinal cord stimulation (SCS) postconditioning effectively protected spinal cord from I/R injury on rabbits. But the mechanism is unknown. In this study, we further investigated the mechanism of SCS postconditioning. New Zealand white rabbits were randomly divided into sham, I/R, I/R + 2 Hz SCS, and I/R + 50 Hz SCS group (n = 24/group). Transient spinal cord ischemia was induced by infrarenal aortic balloon occlusion and performed on all rabbits except rabbits of sham group. Rabbits of I/R group received no further intervention. Rabbits of I/R + 2 Hz SCS and I/R + 50 Hz SCS group received 2 Hz or 50 Hz SCS for 30 min at the onset of reperfusion and then daily. The expression of Akt (serine-threonine kinase)/p-Akt, STAT3 (signal transducer and activator of transcription 3)/p-STAT3 and GSK-3β (glycogen synthase kinase)/p-GSK-3β of spinal cord were measured by Western blot analysis at 8 h, 1 day, 3 day, and 7 day of reperfusion. The Akt expressions of sham, I/R, I/R + 2 Hz SCS, and I/R + 50 Hz SCS group were not significantly different at all prescribed time points, while the p-Akt expression of I/R + 2 Hz SCS group was significantly higher than that of I/R group and sham group at all prescribed time points; The STAT3 and p-STAT3 expression of I/R, I/R + 2 Hz SCS, and I/R + 50 Hz SCS group were not significantly different at all prescribed time points except that at 1day of reperfusion the p-STAT3 expression of I/R + 50 Hz SCS group was significantly lower than I/R group. The GSK-3β and p-GSK-3β expressions of I/R, I/R + 2 Hz SCS and I/R + 50 Hz SCS group were not significantly different at all prescribed time points. The neuroprotective effect of 2 Hz SCS postconditioning in spinal cord I/R injury is related to Akt activation but not regulation of STAT3 and GSK-3β phosphorylation.

Dissection Flap Fenestration with a Transjugular Intrahepatic Portosystemic Shunt Needle: An Adjuvant Technique in Endovascular Treatment of Post-Dissection Thoraco-Abdominal Aortic Aneurysms

IntroductionIn chronic aortic dissection complicated by aneurysmal degeneration, the absence of spontaneous tears between the true and false lumen at visceral artery level may limit treatment by fenestrated/branched endovascular aneurysm repair (F/BEVAR). The creation of new fenestrations may be required to allow access to the visceral vessels.TechniqueIn this video, the endovascular treatment of a 70 year old white man with chronic type B aortic dissection complicated by Crawford type II thoraco-abdominal aortic aneurysmal degeneration is presented. The right renal artery had a false lumen origin without nearby visible re-entry tears. He underwent dissection flap fenestration at visceral vessel level using a transjugular intrahepatic portosystemic shunt (TIPS) needle and subsequent dilation with a high pressure balloon. A Zenith TX2 dissection endovascular graft was deployed proximally and extended distally with a Zenith dissection endovascular stent until the fenestration level was reached. In a second stage, a F/BEVAR was performed, with fenestration to the left renal artery and branches to right renal artery, superior mesenteric artery, and coeliac trunk. One year follow up computed tomography angiography showed visceral branch patency and a reduction of the aneurysm sac.DiscussionThe chronic dissection flap may be thick and fibrotic, creating a technical challenge for endovascular fenestration. The off label use of a TIPS needle in this procedure created a new fenestration at the desired level and allowed definitive post-dissection treatment of the thoraco-abdominal aneurysm.

Aortic endograft and bridging stent-graft remodeling after branched endovascular aortic repair.

The results of branched endovascular repair of thoracoabdominal aneurysms are mainly dependent on durability of the graft used. The purpose of this study was to evaluate postoperative aortic main body and bridging stent-graft remodeling, and their impact on bridging stent-graft instability at one year. Computed tomoangiographies of 43 patients (43 aortic main body mated with 171 bridging stent-grafts) were analyzed before and after branched endovascular repair as well as after a follow-up of 12 months. Primary endpoint was aortic main body remodeling (migration >5 mm, shortening >5 mm, scoliosis >5° or lordosis >5°). Shortening was defined as a reduced length in the long axis, scoliosis as left-right curvature, and lordosis as antero-posterior curvature. Aortic main body remodeling, aneurysm sac changes, and bridging stent-graft tortuosity were evaluated to study their correlations and the impact on the bridging stent-graft instability. At 12 months, aortic main body remodeling was observed in 72% of the cases, migration in 39.5% (mean 5.21 mm), shortening in 41.9% (mean 5.79 mm), scoliosis in 58.1%, (mean 10.10°), lordosis in 44.2% (mean 5.78°). Migration, shortening, and scoliosis were more frequent in patients with larger aneurysms (p = .005), while scoliosis was significantly more frequent in type II thoracoabdominal aneurysm (p = .019). Aortic main body remodeling was significantly associated to bridging stent-graft remodeling (r: 0.3-0.48). The bridging stent-graft instability rate was 9.3%. Despite a trend toward significance (p = .07), none of the evaluated aortic main body and bridging stent-graft changes were associated with bridging stent-graft instability at 12 months. Aortic main body remodeling is frequent especially in large and extended thoracoabdominal aneurysm aneurysms. Aortic main body and bridging stent-graft remodeling was significantly correlated. While these geometric changes had no significant impact on bridging stent-graft instability at one year, a close long-term follow-up after branched endovascular repair could predict bridging stent-graft failures.

Effect of branch length and tortuosity on the outcomes of branched endovascular repair of thoracoabdominal aneurysms using self-expandable bridging stent graft

ObjectiveWe investigated the effect of the length and tortuosity of directional branches on the mid-term outcomes of branched endovascular aneurysm repair (BEVAR) for thoracoabdominal aortic aneurysms (TAAA). MethodsWe retrospectively reviewed single-center data of consecutive patients who had undergone BEVAR for TAAA from 2015 to 2019. Three-dimensional computed tomography angiogram reconstructions (Aquarius iNtuition software; TeraRecon, Durham, NC) of the first postoperative imaging studies were used to measure the branch total length (TL), branch vertical length (VL), and branch tortuosity index (TI). The branch TL was measured as the centerline distance between the branch proximal radiopaque marker and the distal edge of the bridging stent. The VL was measured as the centerline distance between the branch distal radiopaque marker and the origin of the target artery. The TI was measured in accordance with the Society for Vascular Surgery reporting standard. The primary end point was freedom from branch instability, defined as any branch-related death, occlusion, or rupture and any reintervention for stenosis, endoleak, or disconnection. Cox proportional hazards were used to identify predictors of branch instability. A penalized spline function was used to identify the relationship between branch instability and the branch TL and VL. ResultsPostimplantation analysis was conducted on 32 TAAAs (extent I-III, n = 18 [56%]; extent IV, n = 14 [44%]), with 123 arteries included through a directional branch. A covered self-expanding bridging stent was used in all cases. Intraoperative reinforcement with an additional bare metal stent was performed in 85 cases (69%). The overall freedom from branch instability at 3 years was 88% (95% confidence interval [CI], 81%-94%). Five cases of occlusion and eight cases of branch-related endoleak occurred. A concomitant endoleak and severe stenosis requiring intervention developed in three cases. The Cox model with splines showed that the minimal risk of branch instability was achieved with a branch TL of 60 to 100 mm (P = .002) and a branch VL of 25 to 50 mm (P = .038). A TI of >1.15 was a predictor of branch complications (hazard ratio [HR], 8.6; 95% CI, 2.4-31.4; P < .001). After multivariate analysis, aneurysm diameter (HR, 1.08; 95% CI, 0.03-1.15; P = .003), TI >1.15 (HR, 6.81; 95% CI, 2.17-27.33; P < .001), and TL <60 or >100 mm (P = .002) were significantly associated with branch instability. ConclusionsThe branch length and TI seemed to play an important role in BEVAR outcomes. The lowest branch instability rates were obtained with a branch TL of 60 to 100 mm, and this should be considered during planning and implantation. A branch TI >1.15 might require a more strict monitoring to prevent mid- and long-term complications.

Collective Consciousness on Complex Aortic Repair: Time to Focus on Data Capture

In this issue of EJVES, Antoniou et al. synthesise the current literature comparing open treatment of juxta/para/suprarenal and thoraco-abdominal aneurysms (TAAs) with endovascular treatment using branched and fenestrated techniques.1Antoniou G.A. Juszczak M. Antoniou S.A. Katsagyris A. Haulon S. Fenestrated or branched endovascular versus open repair for complex aortic aneurysms: meta-analysis of time-to-event propensity score-matched data.Eur J Vasc Endovasc Surg. 2021; 61: 228-237Abstract Full Text Full Text PDF Scopus (4) Google Scholar Their meta-analysis of >7 000 patients should be commended, particularly given the fact that they only include comparative studies that utilise propensity or regression analyses, thereby limiting bias. They also capture follow up data. The take home messages are clear. Firstly, their analysis does not show a statistically significant difference in early or late survival between patients treated with either technique. Secondly, re-intervention is twice as likely in patients who have had endovascular vs. open repair, but there is a lack of granular data relating to the impact of these re-interventions, including any adverse effect on survival or quality of life. The third, and perhaps most important, message is that the quality of evidence found to inform both of the aforementioned conclusions is poor. The work by Antoniou et al. is a stark reminder of the need to improve the evidence base that guides treatment of complex aortic aneurysms. However, it is important that we do not obsess with the prospective randomised trial as the only acceptable standard of evidence and recognise the value of other study designs. The European Society for Vascular Surgery guidelines recommended fenestrated endografting as the preferred treatment for juxtarenal aneurysms (Class IIa, Level C), despite the lack of randomised trial data.2Wanhainen A. Verzini F. Van Herzeele I. Allaire E. Bown M. Cohnert T. et al.European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.Eur J Vasc Endovasc Surg. 2019; 57: 8-93Abstract Full Text Full Text PDF PubMed Scopus (757) Google Scholar Antoniou et al. consider a prospective trial randomising open and endovascular juxtarenal aneurysm repair as feasible but, rightly, suggest that TAA are a different proposition without equipoise for randomisation.1Antoniou G.A. Juszczak M. Antoniou S.A. Katsagyris A. Haulon S. Fenestrated or branched endovascular versus open repair for complex aortic aneurysms: meta-analysis of time-to-event propensity score-matched data.Eur J Vasc Endovasc Surg. 2021; 61: 228-237Abstract Full Text Full Text PDF Scopus (4) Google Scholar Branched/fenestrated techniques allow treatment of significant numbers of patients with TAAs who would otherwise be turned down for open repair. However, detractors point to a risk of overenthusiasm for endovascular techniques and undue influence by manufacturers driving the operators' decisions to offer repair. To address this there is a need to instigate large scale, structured, prospective data collation from centres performing both endovascular and open repair to the same standard and to analyse these using the latest data science tools.3Dey D. Slomka P.J. Leeson P. Comaniciu D. Shrestha S. Sengupta P.P. et al.Artificial intelligence in cardiovascular imaging.J Am Coll Cardiol. 2019; 73: 1317-1335Crossref PubMed Scopus (151) Google Scholar In addition to post-operative survival and durability of repair, data on this scale may inform (1) objective assessment of anatomical characteristics that affect choice of repair modality; (2) the projected life expectancy of the patient, identifying those best served by conservative management; and (3) the relative effect on quality of life and likelihood of functional decline with each type of repair. For now, we must recognise that our life changing treatment decisions are best made in multidisciplinary teams consisting of a critical mass of experts. At a minimum, these teams should offer equal expertise in both open and endovascular repair so as not to limit the choice offered to the patient. They should also include medical colleagues able to give an objective opinion on the patient's physiology to aid decision making. The recent furore over the drafting of the National Institute for Health and Care Excellence aneurysm guidelines should be a wakeup call.4National Institute for Health and Care Excellence. Abdominal Aortic Aneurysm: Diagnosis and Management. NICE guideline NG156. Available at: https://www.nice.org.uk/guidance/ng156 [Accessed 25 November 2020].Google Scholar The time to gather better evidence that informs treatment of juxta/para/suprarenal and thoraco-abdominal aneurysms is now. Editor's Choice – Fenestrated or Branched Endovascular versus Open Repair for Complex Aortic Aneurysms: Meta-Analysis of Time to Event Propensity Score Matched DataEuropean Journal of Vascular and Endovascular SurgeryVol. 61Issue 2PreviewThe aim of this review was to investigate comparative outcomes of fenestrated or branched endovascular aneurysm repair (F/BEVAR) with open repair for juxta/para/suprarenal or thoraco-abdominal aortic aneurysms. Full-Text PDF

Increased Soluble Interleukin-1 Type II Receptor Concentrations in Postoperative Patients and in Patients With Sepsis Syndrome

Plasma interleukin-1 (IL-1) activity is modulated in part through the simultaneous appearance of several inhibitors of IL-1 action, including interleukin-1 receptor antagonist (IL-1ra) and the soluble IL-1 type II receptor (IL-1RII). However, little is known concerning the plasma appearance of these inhibitors in patients following operative trauma or those with sepsis syndrome. In the present report, plasma IL-1beta, IL-1ra, and soluble IL-1RI and IL-1RII concentrations were evaluated in 118 patients with sepsis syndrome or after elective operative trauma. Plasma concentrations of IL-1ra increased significantly following elective operative repair of thoraco-abdominal and abdominal aortic aneurysms, and after bowel resection for inflammatory bowel disease, but did not increase after laparoscopic cholecystectomy. Plasma IL-1ra levels were also elevated in patients with sepsis syndrome. In contrast, soluble IL-1RII levels were only increased in patients after operative repair of thoraco-abdominal aortic aneurysms and in sepsis syndrome, whereas concentrations were unaffected by the other more modest surgical procedures. Plasma IL-1RI concentrations decreased in all postoperative patients in the first 24 hours after surgery. We conclude that both plasma IL-1ra and soluble IL-1RII concentrations often increase in sepsis and following some operative trauma. Less severe operative trauma increases the plasma concentration of only IL-1ra, whereas both IL-1ra and soluble IL-1RII are increased in patients with sepsis syndrome or following thoraco-abdominal aneurysm repair.

Staged hybrid repair of type II thoracoabdominal aneurysms

BackgroundOpen repair of type II thoracoabdominal aortic aneurysms (TAAAs) remains a challenging procedure. Staged procedures could decrease the incidence and severity of complications after complex aortic repair. In the present report, we have described a strategy using thoracic endovascular aortic repair (TEVAR) for proximal repair, followed by distal open repair. MethodsFrom 2014 to 2018, 14 patients had undergone TEVAR, followed by distal open repair, for type II TAAAs. All patients should have a suitable proximal landing zone according to the current guidelines. In cases of chronic dissection, false lumen embolization was performed to achieve total exclusion. ResultsThe mean patient age was 48 ± 15 years. Of the 14 patients, 5 had had Marfan syndrome (36%) and 6 had undergone previous aortic arch repair (43%). Ten patients had had a chronic dissection. The maximal aortic diameter was 73 ± 12 mm. The TEVAR technical success rate was 100%. The aortic length coverage was 211 ± 63 mm. The number of covered segmental arteries was 6 (range, 4-13). Two endoleaks were observed, one type Ib and one type II. The delay between TEVAR and open repair was 12 ± 8 weeks. Cerebrospinal fluid drainage was used in 13 patients. Six patients had undergone segmental artery reattachment during surgery. No spinal cord ischemic event was observed. One patient had died 5 weeks after open repair of multiple organ failure. During the 32 months of follow-up, no aortic-related deaths had occurred. No new aortic procedure was needed. The type Ib endoleak had resolved during open repair, and the type II TAAA had resolved spontaneously. The mean maximal thoracic aortic diameter had significantly decreased to 49 ± 8 mm (P < .0001). Aneurysmal shrinkage of ≥5 mm was observed in 13 patients (93%). ConclusionsStaged hybrid repair of type II TAAAs appears to be efficient, with low morbidity and mortality rates. This technique could improve postoperative outcomes after open repair, and TEVAR might have a role in ischemic preconditioning to protect against spinal cord ischemia.

Measuring CMAPs in addition to MEPs can distinguish peripheral ischemia from spinal cord ischemia during endovascular aortic repair

ObjectiveSpinal cord injury is a devastating complication after endovascular thoracic and thoracoabdominal aneurysm repair (EVAR). Motor evoked potentials (MEPs) can be monitored to detect spinal cord injury, but may also be affected by peripheral ischemia caused by femoral artery sheaths. We aimed to determine the incidence of peripheral ischemia during EVAR, and whether central and peripheral ischemia can be distinguished using compound muscle action potentials (CMAPs). MethodsWe retrospectively analyzed all EVAR procedures between March 1st 2015 and January 1st 2020 during which MEPs were monitored. Peripheral ischemia was defined as both a reduction in MEP amplitudes reversed by removing the femoral sheaths and no clinical signs of immediate post-procedural paraparesis. All other MEP decreases were defined as central ischemia. ResultsA significant MEP decrease occurred in 14/27 (52%) of all procedures. Simultaneous CMAP amplitude reduction was observed in 7/8 (88%) of procedures where peripheral ischemia occurred, and never in procedures with central ischemia. ConclusionsMEP reductions due to peripheral ischemia are common during EVAR. A MEP-reduction without a CMAP decrease indicates central ischemia. SignificanceCMAP measurements can help to distinguish central from peripheral ischemia, potentially reducing the chance of misinterpreting of MEP amplitude declines as centrally mediated, without affecting sensitivity.

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

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