Thoracoabdominal Aortic Aneurysm Repair Research Articles

Invivo evaluation of a new hybrid graft using retrograde visceral perfusion for thoracoabdominal aortic repair in an animal model.

ObjectivesThe SPIDER technique for hybrid thoracoabdominal aortic aneurysm repair can avoid thoracotomy and extracorporeal circulation. To improve technical feasibility and safety, the new Thoracoflo graft, consisting of a proximal stent graft connected to a 7-branched abdominal prosthesis, was evaluated in a pig model for technical feasibility testing, before implantation in humans.MethodsRetroperitoneal exposure of the infradiaphragmatic aorta, including visceral and renal arteries, was performed in 7 pigs (75-85 kg). One iliac branch was temporarily attached to the distal aorta to maintain retrograde visceral and antegrade iliac perfusion after deployment of the thoracic stent graft segment (SPIDER technique). The proximal stent-grafted segment was deployed in the thoracic aorta via direct aortic puncture over the wire without fluoroscopy. The graft was deaired before flow via the iliac side branch to the visceral and iliac arteries was established. Visceral, renal, and lumbar arteries were subsequently sutured to the corresponding side branches of the graft. Technical feasibility, operating and clamping time, blood flow, and tissue perfusion in the related organs were evaluated before implantation and after 3 and 6 hours using transit-time flow measurement and fluorescent microspheres. Final angiography or postprocedural computed tomography angiography were performed.ResultsOver-the-wire graft deployment was successful in 6 animals without hemodynamic alteration (P = n.s.). In 1 pig, the proximal stent graft section migrated as the guidewire was not removed, as recommended, before release of the proximal fixation wire. Angiography and computed tomography scan confirmed successful graft implantation and transit-time flow measurement confirmed good visceral and iliac blood flow. Fluorescent microspheres confirmed good spinal cord perfusion.ConclusionsOver-the-wire implantation of the Thoracoflo graft using the SPIDER technique is feasible in a pig model. No fluoroscopy was required. For safe implantation, it is mandatory to follow the single steps of implantation.

“Octafen”: A Noninvestigational Alternative Endograft Configuration for the Treatment of Thoracoabdominal Aortic Aneurysms

Purpose: To demonstrate the feasibility of Octafen technique, a novel endovascular configuration for the treatment of thoracoabdominal aortic aneurysms (TAAA). Technique: Two patients with complex TAAA and high surgical risk were treated with Octafen endograft configuration in a hybrid operating room with computed tomography (CT)-fluoroscopy image fusion guidance, using 3D-3D fusion techniques to facilitate procedural success. The procedure is a modification of the previously-described Octopus technique for endovascular repair of TAAA. The main advantage of this technique is the ability to use devices to repair a TAAA with the combination of off-the-shelf and noninvestigational custom-made devices. The devices used are readily available to most practicing vascular surgeons, which provides an alternative treatment in case of limited access to investigational devices, in time-sensitive cases, and in patients with limited functional capacity who cannot undergo open repair. In the modification described herein, we use a combination of standard bifurcated endovascular aneurysm repair (EVAR) devices (Excluder; W.L. Gore & Associates, Flagstaff, Arizona) in combination with a 2-vessel renal fenestrated device (Z-Fen; Cook Medical, Bloomington, Indiana). The article describes a step-by-step approach to this technique to elucidate pitfalls, benefits, and advantages. Conclusion: The Octafen technique might offer an alternative option for thoracoabdominal aneurysm treatment circumventing the need for access to custom-made, investigational devices. Clinical Impact In this manuscript, we describe a technique for endovascular repair of thoraco-abdominal aortic aneurysms that involves the combination of off-the-shelf and non-investigational, custom-made devices. The ‘Octafen’ technique provides a treatment alternative in case of limited access to investigational devices and can be adjusted according to patient anatomy.

TEVAR in TBAD with high-risk features? Not so quickly!!!

For decades, the vascular community has debated the concept of vulnerable plaque to predict the risk of a devastating stroke in patients with asymptomatic carotid disease. It was, at times, rigorous and generated high-quality publications and led, in part, to randomized trials and nested registries. The term high-risk features (HRFs) has gained more credibility after the publication of the reporting standards from the Society for Vascular Surgery (SVS)-Society of Thoracic Surgeons (STS).1Lombardi J.V. Hughes G.C. Appoo J.J. Bavaria J.E. Beck A.W. Cambria R.P. et al.Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) reporting standards for type B aortic dissections.J Vasc Surg. 2020; 71: 723-747Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar It would make sense to offer a preemptive thoracic endovascular aneurysm repair (TEVAR) in patients with HRFs in the hope of avoiding an open thoracoabdominal aortic aneurysm repair and its impact on patients and their families. However, somehow, we skipped the rigorous debate. We easily traded evidence for “common sense.” Except for one feature (aortic diameter of >40 mm), none have been validated prospectively or replicated in large case series. The combined SVS-STS committee used a single paper with mixed data and incomplete follow-up to justify adding persistent pain and hypertension to the list of HRFs, which might explain the boom of unnecessary TEVAR for uncomplicated type B aortic dissection.2Trimarchi S. Eagle K.A. Nienaber C.A. Pyeritz R.E. Jonker F.H. Suzuki T. et al.International Registry of Acute Aortic Dissection InvestigatorsImportance of refractory pain and hypertension in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD).Circulation. 2010; 122: 1283-1289Crossref PubMed Scopus (153) Google Scholar Potter et al queried the Vascular Quality Initiative (VQI) for current practice patterns regarding the timing of TEVAR in patients with type B aortic dissection and refractory hypertension and/or pain and/or rapid expansion.3Potter H.S. Ding L. Han S.M. Weaver F.A. Beck A.W. Malas M.B. et al.Impact of high-risk features and timing of repair for 1 acute type B aortic dissections.J Vasc Surg. 2022; 76: 364-371Abstract Full Text Full Text PDF Scopus (2) Google Scholar They excluded ruptures, malperfusion, and uncomplicated designation (the SVS-STS considers HRF as a subset of complicated dissection). There was no comparison to those without HRFs nor to those treated medically (VQI does not record at present). I do credit the authors for being an honest messenger to tell what happens after the SVS puts out a guiding document. I find it alarming that, of 1100 patients who met the inclusion criteria, 309 received a TEVAR within 48 hours from admission just because they had one or more HRFs. This practice led to 11% stroke rate (compared with 2.3% when TEVAR was delayed to 15 days). Their conclusion was to delay intervention for at least 2 weeks from symptom onset to improve survival and lower the rate of acute complications. However, if intervention can be delayed for 2 weeks without penalty to the patient, we all should ask, why repair earlier if at all? We are due for course correction by prospectively validating HRFs, and the VQI would be most suited for such study. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Impact of high-risk features and timing of repair for acute type B aortic dissectionsJournal of Vascular SurgeryVol. 76Issue 2PreviewThe new Society for Vascular Surgery/Society for Thoracic Surgery reporting standards for type B aortic dissection (TBAD) categorize clinical presentations of aortic dissection into uncomplicated, high-risk features (HRF), and complicated groups. Although it is accepted that complicated dissections require immediate repair, the optimal timing of repair for HRF has yet to be established. This study aims to identify the ideal timing of thoracic endovascular aortic repair (TEVAR) for HRF, as well as outcomes associated with specific HRF. Full-Text PDF

Association Between Type of Anaesthesia and Clinical Outcome in Patients Undergoing Endovascular Repair of Thoraco-Abdominal Aortic Aneurysms by Fenestrated and Branched Endografts

Although endovascular repair of thoraco-abdominal aortic aneurysm (TAAA) is the treatment of choice in the high risk population that is ineligible for an open surgical approach, little is known about the association between the type of anaesthesia and complications. This study compared the short term clinical outcomes of patients undergoing the visceral step of TAAA with fenestrated endograft aortic repair (FEVAR) and branched endograft aortic repair (BEVAR) under general anaesthesia (GA) with sedation with monitored care anaesthesia (MAC). This single centre, retrospective, observational study recruited 124 consecutive patients undergoing elective F/BEVAR from 2014 - 2021. The primary endpoint was the short term complication rate according to the type of anaesthesia. Secondary endpoints included: need for inotropes or vasopressors for hypotension, time spent in the operating room, and admission to the intensive care unit. Propensity score matching was generated to account for the between group imbalance in the pre-operative covariables. After propensity score matching, 42 patients under GA were matched with 42 under MAC. The two groups showed no difference in cardiac and non-cardiac complications. Among the secondary outcomes, a higher number of patients in the GA group required inotropes or vasopressors compared with MAC (33% vs. 9%; p= .031). Although GA and MAC showed the same 30 day technical success (81% vs. 83%; p= .078), non-significant lower rates of major adverse events (10% vs. 12%; p= .72), one year re-intervention (14% vs. 21%; p= .39), and one year target vessel instability (10% vs. 21%; p= .39) were observed in the GA group. Overall, the in hospital mortality rate was 4%, with no difference between GA and MAC (2% vs. 5%; p= 1.0). The type of anaesthesia seemed to have no effect on procedure success, peri-operative morbidity, or mortality in patients undergoing F/BEVAR.

Characterization of Secondary Interventions After Fenestrated-branched Endovascular Repair of Complex Aortic Aneurysms and Its Effect on Quality of Life and Patient Survival.

To assess the impact of secondary intervention (SI) on health-related quality of life (HR-QOL) after fenestrated-branched endovascular aortic repair (FB-EVAR) for complex abdominal aortic aneurysms and thoracoabdominal aortic aneurysms. The effect of SI after FB-EVAR on physical and mental HR-QOL has not been described. A cohort of 430 consecutive patients enrolled in a prospective, nonrandomized study to evaluate FB-EVAR (2013-2020) was assessed with 1325 short-form 36 HR-QOL questionnaires preoperatively and during follow-up visits. SIs were classified as major or minor procedures. Endpoints included patient survival, freedom from aortic-related mortality (ARM), freedom from SIs, and changes in HR-QOL physical component score (PCS) and mental component score. There were 302 male with mean age 74±8 years treated by FB-EVAR for 133 complex abdominal aortic aneurysms and 297 thoracoabdominal aortic aneurysms. After a mean follow up of 26±20 months, 97 patients (23%) required 137 SIs. At 5 years, freedom from any SI was 64%±4%, including freedom from minor SIs of 77%±4% and major SIs of 87%±3%. There was no difference in patient survival and freedom from ARM at same interval. On adjusted analysis, minor SIs correlated with improved survival. SIs had a negative correlation with PCS ( r =-0.8). There were no significant changes in mental component score with SIs. Predictors for SIs were fluoroscopy time, graft design, and aneurysm sac change. SIs were needed in nearly 1 out of 4 patients treated by FB-EVAR with no effect on patient survival or ARM. SI resulted in decline in PCS.

Women with thoracoabdominal aortic aneurysms have increased frailty and more complex aortic anatomy compared with men: Presented at the plenary session of the Thirty-sixth Western Vascular Society Annual Meeting, Jackson Hole, WY, October 16-19, 2021.

Objective: Operative repair of thoracoabdominal aortic aneurysms (TAAAs) is high risk, and many patients will be unfit for intervention. Prior studies have noted lower rates of repair for women than for men. The reasons for this disparity have remained unknown but could include a greater burden of co-morbid illness or anatomic barriers. Frailty could also contribute to the lower intervention rates but has rarely been reported in preoperative risk assessments. The aim of the present study was to assess the sex-related differences in clinical comorbidities, anatomic suitability, and frailty among an unselected cohort of patients who had presented with TAAAs.

Successful Open Thoracoabdominal Aortic Repair in a Patient with Severe Aorto-Iliac Occlusive Disease: A Rare Case Report.

Open repair of thoracoabdominal aortic aneurysm (TAAA) in a patient with severe aorto-iliac occlusive disease is considered to cause an extremely high risk for spinal cord injury. A 71-year-old man who had previously undergone axillo-bifemoral bypass for aorto-iliac occlusive disease presented with persistent dilation of a TAAA. Using distal perfusion via partial extracorporeal circulation at mild hypothermia, we performed segmental sequential repair of Crawford type II TAAA. Various efforts were made to avoid spinal cord injury and ischemic visceral organ damage. Consequently, the patient completely recovered without any serious complications.

Peri-Operative Management of Patients Undergoing Fenestrated-Branched Endovascular Repair for Juxtarenal, Pararenal and Thoracoabdominal Aortic Aneurysms: Preventing, Recognizing and Treating Complications to Improve Clinical Outcomes.

The advent and refinement of complex endovascular techniques in the last two decades has revolutionized the field of vascular surgery. This has allowed an effective minimally invasive treatment of extensive disease involving the pararenal and the thoracoabdominal aorta. Fenestrated-branched EVAR (F/BEVAR) now represents a feasible technical solution to address these complex diseases, moving the proximal sealing zone above the renal-visceral vessels take-off and preserving their patency. The aim of this paper was to provide a narrative review on the peri-operative management of patients undergoing F/BEVAR procedures for juxtarenal abdominal aortic aneurysm (JAAA), pararenal abdominal aortic aneurysm (PRAA) or thoracoabdominal aortic aneurism (TAAA). It will focus on how to prevent, diagnose, and manage the complications ensuing from these complex interventions, in order to improve clinical outcomes. Indeed, F/BEVAR remains a technically, physiologically, and mentally demanding procedure. Intraoperative adverse events often require prolonged or additional procedures and complications may significantly impact a patient’s quality of life, health status, and overall cost of care. The presence of standardized preoperative, perioperative, and postoperative pathways of care, together with surgeons and teams with significant experience in aortic surgery, should be considered as crucial points to improve clinical outcomes. Aggressive prevention, prompt diagnosis and timely rescue of any major adverse events following the procedure remain paramount clinical needs.

Comparative early results of in situ fenestrated endovascular aortic repair and other emergent complex endovascular aortic repair techniques for ruptured suprarenal and thoracoabdominal aortic aneurysms at a regional aortic center

IntroductionEmergent endovascular repair of suprarenal (SRAAAs) and thoracoabdominal aortic aneurysms (TAAAs) poses a significant challenge due to the need for branch vessel incorporation, time constraints, and lack of dedicated devices. Techniques to incorporate branch vessels have included parallel grafting, physician-modified endografts, double-barrel/reversed iliac branch device, and in situ fenestration (ISF). This study describes a single-center experience and the associated outcomes when using these techniques for ruptured SRAAAs and TAAAs. MethodsA retrospective review of patients who underwent endovascular repair of ruptured SRAAAs and TAAAs from July 2014 to March 2021 with branch vessel incorporation was performed. Clinical presentation, intraoperative details, and postoperative outcomes of those who underwent ISF were compared with those who underwent repair using non-ISF techniques. The primary outcome of interest was in-hospital mortality. Secondary outcomes were major adverse events including myocardial infarction, respiratory failure, renal dysfunction, new onset dialysis, bowel ischemia, stroke, and spinal cord ischemia. ResultsForty-two patients underwent endovascular repair for ruptured SRAAAs and TAAAs, 18 of whom underwent ISF repair. Seventy-two percent of ISF patients were hypotensive before surgery, compared with 46% of the patients who underwent repair using non-ISF techniques (physician-modified endografts, parallel grafting, or double-barrel/reversed iliac branch device). The total procedural and fluoroscopy times were similar between the two groups despite a greater mean number of branch vessels incorporated with the ISF technique (3.1 vs 2.2 per patient, P = .015). In-hospital mortality was 19% for all ruptures and 25% for ruptures with hypotension. Compared with the non-ISF group, in-hospital mortality trended lower in the ISF group (11% vs 25%, P = .233), reaching statistical significance when comparing patients who presented with hypotension (8% vs 45%, P = .048). The rate of major adverse events was 57% across all techniques and did not significantly differ between the ISF and non-ISF groups, with postoperative renal dysfunction being the most frequent complication (48%). Overall, ISF became the most commonly used technique later in the study period. ConclusionsAlthough emergent endovascular repair of ruptured SRAAAs/TAAAs remains a challenge, a number of techniques are available for expeditious treatment. In this series, ISF was associated improve survival, including a fivefold reduction in mortality in patients presenting with hypotension, and has now become the dominant technique at our center. Despite these advantages, postoperative complications and reinterventions are common. Further experience and longer-term follow-up are needed to validate these initial results and assess durability.

Fenestrated-branched endovascular repair for distal thoracoabdominal aortic pathology after total aortic arch replacement with frozen elephant trunk

ObjectiveTo report the outcomes of fenestrated-branched endovascular repair (FBEVAR) for thoracoabdominal aortic pathology after total aortic arch replacement with frozen elephant trunk (TAR+FET). MethodsInterrogation of prospectively maintained databases from four high-volume aortic centers identified consecutive patients treated with distal FBEVAR after prior TAR+FET between August 2013 and September 2020. The primary end point was 30-day/in-hospital mortality. Secondary end points were technical success, early clinical success, midterm survival, and freedom from reintervention. Data are presented as median (interquartile range). ResultsA total of 39 patients (21 men; median age, 73 years [67-75 years]) with degenerative (n = 22) and postdissection thoracoabdominal aortic aneurysms (n = 17) (median diameter, 71 mm [61-78 mm]) were identified. Distal FBEVAR was intended in 27 patients (median interval, 9.8 months [6.2-16.6 months]), anticipated in 7, and unexpected in 5. A total of 31 patients had a two- (n = 24) or three-stage (n = 7) distal FBEVAR. Renovisceral target vessel preservation was 99.3% (145 of 146). Early primary and secondary technical success was 92% and 97%, respectively. Thirty-day mortality was 2.6% (n = 1; respiratory failure and spinal cord ischemia [SCI]). Six survivors also developed SCI, which was associated with complete (n = 4) or partial recovery (n = 2) at hospital discharge. No patients required renal replacement therapy or suffered a stroke. Early clinical success was 95%. Median follow-up was 30.5 months (23.7-49.7 months). Eleven patients required 16 late reinterventions. Estimated 3-year survival and freedom from reintervention were 84% ± 6% and 63% ± 10%, respectively. ConclusionsDistal FBEVAR after prior TAR+FET is associated with high technical success and low early mortality. The risk of SCI is significant although the majority of patients demonstrate full or partial recovery before hospital discharge. Midterm patient survival is favorable, but there remains a high requirement for late reintervention. FBEVAR represents an acceptable alternative to distal open thoracoabdominal aortic aneurysm repair.

Fenestrated and Branched Stent-Grafts for the Treatment of Thoracoabdominal Aortic Aneurysms: A Systematic Review and Meta-Analysis.

PurposeTo investigate the safety and efficacy of total endovascular repair for thoracoabdominal aortic aneurysms (TAAAs) with fenestrated and branched stent-grafts.MethodsThe MEDLINE, EMBASE, and Cochrane databases were searched between January 2001 and December 2021 to identify literature relevant to the use of fenestrated and branched endografts for the treatment of TAAAs. Studies with <4 cases and those on juxtarenal or pararenal aortic aneurysms were excluded. Meta-analyses were conducted to evaluate spinal cord ischemia (SCI), irreversible SCI, renal insufficiency, dialysis, endoleak, reintervention, target vessel patency, 30-day mortality and overall mortality. Fourteen studies comprising 1,114 patients (mean age 72.42 years, 847 men) were selected. The mean TAAA diameter was 67 mm. The Crawford TAAA classification was type I-III in 759 cases, type IV in 344 cases, and type V in 10 cases. Outcomes of the meta-analysis are reported as proportions and 95% confidence intervals (CIs).ResultsThe pooled rates for 30-day mortality and overall mortality were 6% and 18%, respectively. The pooled rate for technical success was 94% (95% CI, 93–96%), for SCI was 8% (95% CI, 7–10%), for irreversible SCI was 6% (95% CI, 4–7%), for reversible SCI was 5% (95% CI, 4–6%), for reversible SCI was 2% (95% CI, 2–3%), for renal insufficiency was 7% (95% CI, 5–10%), for dialysis was 3% (95% CI, 2–4%), for target vessel patency was 98% (95% CI, 97–99%), and for reintervention was 15% (95% CI, 9–24%).ConclusionFenestrated and branched endografts for the treatment of TAAAs are safe and effective with acceptable early results. Lifelong regular follow-up and additional prospective studies are necessary to substantiate whether this technique is valid.

Abstract No. 241 Safety and efficacy of fluoroscopically guided cerebrospinal fluid drainage for thoracoabdominal aortic aneurysm repair

To review the safety and efficacy of perioperative cerebrospinal fluid (CSF) drainage catheter placement using fluoroscopic guidance in patients undergoing thoracoabdominal aortic aneurysm (TAAA) repair

Preoperative Predictors of Nonhome Discharge After Fenestrated-Branched Endovascular Repair of Complex Abdominal and Thoracoabdominal Aortic Aneurysms

Nonhome discharge (NHD) to skilled nursing facilities or rehabilitation units has significant implications for patient counseling and discharge planning and is frequently required following fenestrated-branched endovascular aneurysm repair (FB-EVAR) of complex abdominal (CAAA) and thoracoabdominal aortic aneurysms (TAAA). We aimed to identify preoperative predictors of NHD after elective FB-EVAR for CAAA and TAAA. A retrospective review of prospectively collected data on all patients undergoing FB-EVAR between January 2010 and December 2020 at a single institution was performed. Patients undergoing elective repair who were residing at home at the time of index operation were included. Univariate and multivariate analysis was performed to identify factors associated with NHD. From the initial cohort of 612 patient having FB-EVAR during the study period, 575 (74% male; mean age, 74.6 ± 7.8 YEARS) patients had elective surgery, including 403 for CAAA (70%) and 172 for TAAA (30%). Early mortality occurred in seven patients (four in CAAA three 3 in TAAA) and mean total length of hospital stay was 7.1 days (5.9 for CAAA and 10.0 for TAAA). There were 482 patients (84%) who were discharged home and 93 (16%) had NHD. NHD was associated with increasing age (mean age 77 years in NHD group vs 74 years), female gender (27% of females vs 12% of males), a history of congestive heart failure (CHF; 28% vs 15%) or peripheral arterial disease (23% vs 14%), and extent I, II, and III TAAA (27%, 24%, and 25%, respectively; all P = .004). Body mass index, race, prior stroke, device type, and number of target vessels were not associated with NHD. On multivariate analysis, older age (odds ratio [OR], 1.08 per year), female gender (OR, 2.51), CHF (OR, 2.59), and extent I (OR, 3.27), II (OR, 3.77), and III (OR, 3.13) TAAAs were associated with NHD (Figure). Older female patients with CHF and more extensive aneurysms are at higher risk of NHD following FB-EVAR. Following further internal validation, these data will be used to develop a predictive calculator of NHD, therefore allowing preoperative counselling of these patients and initiation of referrals with appropriate facilities that may expedite postoperative discharge.

Comparison of Staging Strategies During Fenestrated-Branched Endovascular Aortic Repair of Thoracoabdominal Aortic Aneurysms

Comparison of Staging Strategies During Fenestrated-Branched Endovascular Aortic Repair of Thoracoabdominal Aortic Aneurysms

Readmissions Following Endovascular Thoracoabdominal Aortic Repairs in the Vascular Implant Surveillance and Interventional Outcomes Network

Prior studies have demonstrated short- and long-term mortality associations with an increasing extent of aortic coverage in complex endovascular thoracoabdominal aortic aneurysm (TAAA) repair. We investigated the readmission rates and principal diagnoses associated with 90-day postoperative readmission and mortality overall and stratified by the extent of coverage in elective endovascular TAAA repair.

A Comparison of Thoracoabdominal Aortic Aneurysms Open Repair in Patients With or Without “Shaggy Aorta”

Shaggy aorta (SA) syndrome is an independent risk factor for mortality, spinal cord ischemia, and acute renal failure in patients submitted to open thoracoabdominal aortic aneurysm (TAAA) repair. The aim of this paper is to report the results of a single-center large cohort of patients treated with open surgical repair (OSR) for TAAA with SA, comparing the outcomes with patients affected by TAAA without SA, and analyzing the impact of the actual scores for SA on the outcomes. All consecutive patients receiving OSR for TAAA between 2012 and 2021 were retrospectively analyzed. Clinical data from patients with degenerative TAAA were included and analyzed for preoperative characteristics and postoperative outcomes; patients with ruptured TAAA and patients with aortic dissection were excluded from the analysis. Patients with degenerative aortic aneurysm, thrombus measurement in nonaneurysmal aortic segments (≤40 mm), atheroma thickness ≥5 mm, and finger-like thrombus projection were included in the “SA group,” whereas the others were included in the “non-shaggy aorta group” (NSA group). The SA group and NSA group were compared using a propensity-matched comparison. Preoperative computed tomography scans of patients in the SA group were also classified according to the actual SA grading scores. A total of 58 patients with SA were identified (male 43 [74.1%], mean age 70.1 ± 7.8 years). After propensity matching, there were 48 patients in the SA group and 48 in the NSA group with correction of all differences in baseline characteristics. Patients in the SA group presented significantly higher in-hospital mortality (SA group: 10.4% vs NSA group: 2.1%, P < .001), postoperative acute renal failure (RIFLE 4-5) (SA group: 16.7% vs NSA group: 0%, P < .002), and embolization rate (SA group: 25.0% vs NSA group: 8.3%, P < .02). Spinal cord ischemia and stroke rate were not significantly influenced by the presence of SA. In the SA group, 16 (27.6%) patients with end-organ embolization were compared with 42 (72.4%) patients without a documented embolization considering the grade of aortic “shagginess,” and no significant difference was identified (P = .0546). Despite several intraoperative adjuncts, TAAA patients with SA treated with OSR still have worse postoperative outcomes if compared with “non-shaggy” patients. The presence of SA is a risk factor itself, whereas the grade of “shagginess” seems not to impact on postoperative outcomes.

Role of Intravascular Ultrasound for In Situ Sizing and Technical Assessment of Directional Branches During Branched Endovascular Aortic Repair

To compare intraoperative and early outcomes of branched endovascular aortic repair (BEVAR) of thoracoabdominal aortic aneurysms with or without the use of intravascular ultrasound (IVUS). We conducted a single-center retrospective study of consecutive patients treated for thoracoabdominal aortic aneurysms with branched devices (2019-2021). Two groups were compared. In standard BEVAR (s-BEVAR), sizing was based exclusively on the preoperative computed tomography angiogram, and the technical assessment consisted of intraoperative angiography. From 2020 (iv-BEVAR), IVUS (Philips platform with 0.035-in. Volcano IVUS catheter) was routinely used for in situ sizing of the bridging stent (diameter and length of the distal landing zone, total bridging stent length) and for technical assessment of the bridging stent after deployment (kink, compression, malapposition, or inadequate sealing). s-BEVAR and iv-BEVAR patients were compared in terms of procedural metrics (duration of surgery, radiation dose, radiation time, and contrast volume), technical success (successful introduction and deployment of the device and bridging stents, in the absence of surgical conversion or mortality, type I or III endoleak, branch occlusion, or graft limb obstruction), and 30-day outcomes. There were 59 target vessels (n = 15 patients) in the s-BEVAR group and 56 (n = 15 patients) in the iv-BEVAR group. Aneurysm anatomic classification was similar (extent I-III, 73% vs 67%; extent IV, 27% vs 33%; P = .999). Comparing s-BEVAR vs iv-BEVAR, the total operating time (280 ± 62 minutes vs 293 ± 84 minutes; P = .073) and contrast volume (168 ± 42 mL vs 153 ± 38 mL; P = .312) were similar, although iv-BEVAR had a lower radiation time (119 ± 35 minutes vs 92 ± 42 minutes; P = .042) and dose (745 ± 75 Gy vs 635 ± 85 Gy; P = .010). The use of IVUS identified a significant branch technical defect in 8 of 56 target vessels (14%) not identified by standard angiography; bridging stent compression in five cases and incomplete stent-to-wall apposition in three. These were all intraoperatively corrected with success. Technical success was 100% for both groups, and there were no postoperative deaths and no IVUS-related complications. At 30 days, there were no complications related to the main endograft or directional branches. The use of IVUS for in situ sizing and technical assessment of BEVAR was safe and allowed for reduced radiation time and exposure during BEVAR, maintaining a similar operating time. Compared with sole angiography, the intraoperative use of IVUS led to adjunctive intraoperative maneuvers in a non-negligible portion of target vessels. Further studies are needed to evaluate the clinical role of IVUS in BEVAR.

Off-the-Shelf Branched Endografts for the Treatment of Thoracoabdominal Aortic Aneurysms: Two-Year Target Vessel-related Outcomes

The objective was to assess clinical outcomes and target vessel patency through 2 years after thoracoabdominal aortic aneurysm (TAAA) repair with the off-the-shelf Zenith t-Branch Thoracoabdominal Endovascular Graft (William Cook Europe).

Outcomes Following Urgent Fenestrated-Branched Endovascular Repair for Pararenal and Thoracoabdominal Aortic Aneurysms

To evaluate outcomes following urgent or emergent fenestrated-branched endovascular aortic repair (F-BEVAR) for pararenal (PRA) and thoracoabdominal aortic aneurysms (TAAA) in patients who are considered high-risk for open repair. A retrospective, single institution evaluation of outcomes following F-BEVAR of symptomatic, rapidly enlarging, or ruptured PRA or TAAA treated with physician modified endograft (PMEG) and company manufactured devices (CMD). Outcomes were technical success, 30-day morbidity and mortality, and 1 year aortic related outcomes. Thirty-two patients (23 male, mean age, 74±9years) underwent F-BEVAR using PMEG or CMD over a 12-year period. Fourteen patients underwent emergent repair for contained rupture and 18 patients underwent urgent repair for symptomatic, mycotic, or rapidly growing aneurysms. Aneurysm classification was PRA in 10 patients and TAAA in 22 (9 extent IV and 13 extent I-III). Twenty-three patients (72%) were repaired with PMEG and 8 patients (26%) with CMD. Technical success was 97% with a total of 98 renal-mesenteric arteries incorporated using 67 fenestrations (68%), 29 directional branches (29%), and 2 double-wide scallops (2%). A 30-day mortality was 6%, with 1 patient expiring from unclear causes after hospital discharge and the other from mesenteric ischemia. Mortality and major adverse events MAEs otherwise occurred in 16 patients (50%), including minor stroke in 3 patients, transient paraparesis and heart failure in 1 patient each, and early return to the operating room in 6 patients. Mean follow-up was 24±22months. At 1-year, overall survival, freedom from aortic-related mortality and freedom from secondary intervention were 70%±8%, 94%±3 and 83%±7, respectively. Urgent F-BEVAR of selected patients with PRA and TAAA is a feasible and potentially safe treatment in patients with suitable anatomy, with low rates of early mortality and spinal cord complications. Long-term follow-up is needed to assess the durability of repair and device-related complications.

Subjective assessment underestimates surgical risk: On the potential benefits of cardiopulmonary exercise testing for open thoracoabdominal repair.

BackgroundInitial clinical evaluation (ICE) is traditionally considered a useful screening tool to identify frail patients during the preoperative assessment. However, emerging evidence supports the more objective assessment of cardiorespiratory fitness (CRF) via cardiopulmonary exercise testing (CPET) to improve surgical risk stratification. Herein, we compared both subjective and objective assessment approaches to highlight the interpretive idiosyncrasies.MethodsAs part of routine preoperative patient contact, patients scheduled for major surgery were prospectively “eyeballed” (ICE) by two experienced clinicians before more detailed history taking that also included the American Society of Anesthesiologists score classification. Each patient was subjectively judged to be either “frail” or “not frail” by ICE and “fit” or “unfit” from a thorough review of the medical notes. Subjective data were compared against the more objective validated assessment of postoperative outcomes using established CPET “cut‐off” metrics incorporating peak pulmonary oxygen uptake, V̇O2PEAK at the anaerobic threshold (V̇O2‐AT), and ventilatory equivalent for carbon dioxide that collectively informed risk stratification. These data were retrospectively extracted from a single‐center prospective National Health Service database. Data were analyzed using the Chi‐square automatic interaction detection decision tree method.ResultsA total of 127 patients were examined that comprised 58% male and 42% female patients aged 69 ± 10 years with a body mass index of 29 ± 7 kg/m2. Patients were poorly conditioned with a V̇O2PEAK almost 20% lower than predicted for age, sex‐matched healthy controls with 35% exhibiting a V̇O2‐AT < 11 ml/kg/min. Disagreement existed between the subjective assessments of risk with ∼34% of patients classified as not frail on ICE were considered unfit by notes review (p < .0001). Furthermore, ∼35% of patients considered not frail on ICE and ∼31% of patients considered fit by notes review exhibited a V̇O2‐AT < 11 ml/kg/min, and of these, ∼28% and ∼19% were classified as intermediate to high risk.ConclusionsThese findings highlight the interpretive limitations associated with the subjective assessment of patient frailty with surgical risk classification underestimated in up to a third of patients compared to the validated assessment of CRF. They reinforce the benefits of a more objective and integrated approach offered by CPET that may help us to improve perioperative risk assessment and better direct critical care provision in patients scheduled for “high‐stakes” surgery including open thoracoabdominal aortic aneurysm repair.