Treatment Of Thoracic Aortic Pathology Research Articles

ALTERNATIVE STRATEGIES FOR LEFT SUBCLAVIAN ARTERY REVASCULARIZATION DURING ZONE–2 AORTIC ARCH SURGERYEMENT

Abstract Objective Anatomical extension of surgical treatment of thoracic aortic pathologies involving the aortic arch is still controversial. The adoption of distal anastomosis in aortic arch zone–2 (Z2–AAR), in order to facilitate bleeding control, has been widely recommended. In such case the revascularization of left subclavian artery (LSA) may add further concerns. Here we report our different strategy of LSA revascularization in 2 different scenario of Z2–AAR Clinical. Cases Case#1 17 yo male patient affected by Loeys–Dietz Syndrome and a previous David procedure at age of 11yo. He presented complaining chest pain and CT scan revealed a dilatation (5,8 cm) of ascending aorta and an intimal flap with preserved previous distal anastomosis. Surgical strategy #1 (Left subclavian artery in situ): Arch replacement (Zone 2 distal anastomosis) with Siena Graft 24mm and modified Elephant Trunk Tecnique (2cm distal endoluminal graft). Innominate artery and left carotid artery reimplantation. Distal Anastomosis Siena 24 (Z2). Case #2 78 yo male with a previous (6 month before) Biological AVR (Trifecta 25) + ascending aorta replacement (Jotec 30). Presented complaining acute chest pain, CT Scan revealed a residual dilatation of distal ascending aorta, dissection/rupture of distal aortic arch at level of a complicated plaque. Surgical strategy #2 (Left subclavian artery reimplanted): Arch replacement (Zone 2 distal anastomosis) with Siena Graft 30mm and Elephant trunk Teccnique (10cm distal endoluminal graft). Closure of the extended ulcera. Total epiaortic vessels de–branching 10 mm Tube on LSA – Distal Anastomosis Siena 30 (Z2). Conclusion Surgical extension of aortic arch replacement is still matter of discussion. Zone–2 approach for aortic arch replacement seems a safe and effective option. In our mind strategy for left subclavian revascularization should be tailored according patient’s anatomy and potential future scenarios.

Endovascular surgery for thoracic aortic pathologies involving the aortic arch.

BackgroundAortic arch pathologies are serious clinical conditions associated with a very dismal prognosis. Traditional open surgery has a high mortality and is not suitable for critically ill patients. Recently years, endovascular treatment of thoracic aorta has made rapid progress and has been gradually applied to the treatment of aortic arch pathologies. However, maintaining cerebral blood flow during endovascular treatment of aortic arch lesions remains a challenge at this time. This study aims to evaluate the feasibility, efficacy, and safety of endovascular treatment of thoracic aortic pathologies involving the aortic arch, and to present initial experience with this technique.MethodsFrom October 2016 to December 2020, patients who met the inclusion criteria were enrolled. All patients underwent thoracic endovascular aortic repair with the proximal landing zone of the stent-graft in the aortic arch at Ishimaru zones 0–1, in which cerebral flow needs to be maintained during surgery, and the supra-aortic branches were reconstruction with either in situ fenestration or the chimney technique.ResultsA total of 62 cases with lesions involving the arch were treated with endovascular surgery. Total supra-aortic branches reconstruction was successfully performed in 51 cases, the left carotid artery (LCA) and the innominate artery reconstruction were performed in eight cases, the left subclavian artery (LSA) and the LCA were reconstructed in three patients. Among them, the in situ fenestration or chimney repair technique for the LSA was successful performed in 42 and 12 cases. However, in 20 patients, attempts to reconstruction the LSA using the fenestration technique were unsuccessful due to tortuous and angulated vessels. Early mortality was 6.45%. No neurological complications related to surgery occurred. Computer tomography images at post-operative follow-up (mean 3.51 months) confirmed patency of all branch stents without any signs of endoleaks, migration, conversion to retrograde dissection or receive open-heart surgery.ConclusionThe endovascular technique is an effective, feasible, safe and repeatable method to reconstruct the aortic arch, which allows for the reconstruction of the supra-aortic branches.

Long Term Monitoring of Thoracic Endovascular Aortic Aneurysm Repair Using Transcaval Aortic Access.

Thoracic endovascular aortic repair (TEVAR) has reduced the morbidity and mortality associated with the treatment of thoracic aortic pathologies. However, TEVAR's use is often predicated on sufficiently large femoral access for the delivery of the endograft device. Transcaval access, or the delivery of endovascular device via the vena cava before crossing into the aorta, has been used successfully for the deployment of transcatheter aortic valves. Our institution previously reported on a case of TEVAR using transcaval access. We now report on the long-term follow-up outcome of this case. At 6years post-surgery, computed tomography angiography (CTA) indicates stable aortic repair without any concerning findings associated with the site of transcaval access into the aorta. The patient is clinically without signs of lower extremity vascular or cardiopulmonary compromise. Overall, transcaval access for TEVAR is a promising alternative to traditional femoral artery access in highly-select patients with the appropriate anatomical and pathological indications.

Transposition of Isolated Left Vertebral Artery in Hybrid Thoracic Endovascular Aortic Repair.

Objectives: The aim of this study was to present our experience with the management of isolated left vertebral artery (ILVA) during complex thoracic aortic pathology treated with the hybrid thoracic endovascular aortic repair.Methods: This is a single-center, respective cohort study. Between June 2016 and June 2020, 13 patients (12 men; median age 60 years old, range 42–72 years old) who underwent hybrid procedures were identified with ILVA in our center. Demographics, imaging features, operation details, and follow-up in these patients were collected and analyzed.Results: In this study, all patients received the hybrid procedure, and the primary technical success rate was 100%. There were no in-hospital deaths. Complication occurred in two (15.4%) patients. One patient suffered from contrast-induced acute kidney injury (CI-AKI) and recovered before discharge. Another patient required reintervention for acute left-lower-limb ischemia, which was successfully treated using Fogarty catheter embolectomy. Immediate vagus/recurrent laryngeal never palsy, lymphocele, and chylothorax were not observed. The median duration of follow-up was 22 months (range, 13–29 months). No neurologic deficits, bypass occlusion, or ILVA occlusion or stenosis were observed during the follow-up. No aortic rupture, cerebrovascular accident, or spinal cord ischemia was observed during the follow-up period.Conclusions: Our limited experience reveals that hybrid procedures [thoracic endovascular aortic repair (TEVAR), ILVA transposition, and left common carotid artery-left subclavian artery (LCCA-LSA) bypass] are relatively safe, feasible, and durable for the treatment of thoracic aortic pathology with ILVA. However, further technique durability and larger studies with long-term follow-up periods are warranted.

Treatment reality of aortic diseases in Switzerland

HintergrundDurch das föderalistisch organisierte Gesundheitssystem in der Schweiz werden Aorteneingriffe an vielen verschiedenen Krankenhäusern, mutmaßlich mit teils sehr kleiner Fallzahl, durchgeführt. In dieser Arbeit soll anhand der erfassten Aorteneingriffe im schweizerischen Gefäßregister Swissvasc die Versorgungsrealität von Aortenerkrankungen dargestellt werden.MethodeFür diese Übersichtsarbeit wurden sämtliche Eingriffe an der Aorta, welche zwischen Januar 2018 und Dezember 2020 in der Schweiz durchgeführt und in das Swissvasc-Register eingegeben wurden, eingeschlossen. Nicht berücksichtigt wurden Eingriffe zur Behandlung von isolierten Pathologien an den Beckengefäßen sowie Eingriffe an der Aorta ascendens und dem proximalen Aortenbogen.ResultateOffene Aorteneingriffe wurden an 28 und endovaskuläre an 33 Krankenhäusern durchgeführt. Nur knapp die Hälfte dieser Krankenhäuser erreicht dabei die empfohlene Mindestfallzahl für abdominale Aortenaneurysmen von 30 offenen und endovaskulären Eingriffen pro Jahr, die in der Literatur aktuell diskutiert werden. Von den abdominalen Aneurysmen waren im Dreijahreszeitraum der Literatur entsprechend 11 % rupturiert, diese wurden aber entgegen den Richtlinien zu knapp 60 % offen versorgt. Die elektive Behandlung der abdominalen Aneurysmen war den Richtlinien entsprechend zu 67 % endovaskulär. Bei der Versorgung der thorakalen Aortenpathologien zeigt sich eine Zentralisierung. Hier wurden 87 % der Eingriffe an lediglich 5 Krankenhäusern durchgeführt.ZusammenfassungDiese Untersuchung zeigt, dass viele Kliniken in der Schweiz, teils mit sehr kleinen Fallzahlen, Aortenpathologien behandeln. Weitere Untersuchungen zur Versorgungsqualität bei der Behandlung dieser Pathologien sind dringend notwendig.

Early results of a low-profile stent-graft for thoracic endovascular aortic repair.

PurposeTo assess outcomes of a low-profile thoracic stent-graft in the treatment of thoracic aortic pathologies.MethodsA retrospective analysis of all consecutive patients with aortic thoracic pathologies treated with the RelayPro device in two university hospitals between October 2018 and July 2019.Results23 patients (65% men; mean age 63.4 ± 15 years) were treated. Pathologies included aortic dissections (n = 10), 5 residual type A (22%) and 5 type B (22%), 6 degenerative aortic aneurysms (26%), 4 penetrating aortic ulcers (17%), and aortic erosion, intramural hematoma and aortic rupture (n = 1 and 4% in each case). Two cases (9%) were emergent and two urgent. Proximal landing was achieved in zones 0 (4%), 1 (4%), 2 (43%), and 3 (26%). Five grafts were frozen elephant trunk extensions. Technical success was 100% with accurate device deployment in the intended landing zone of the aortic arch in all 23 patients and with no Ia/III endoleaks and three (13%) type II endoleaks. Apposition was adequate in 96%. Two patients had post-implantation syndromes (one fever, one leukocytosis). Mean follow-up was 11.6 ± 3.7 months (range, 2–16) with no other complications, secondary interventions or conversions to open surgery. There was no 30-day mortality and no aortic-related mortality; all-cause mortality was 4% during follow-up.ConclusionA 3–4 French reduced profile in the current generation of stent-grafts facilitates TEVAR particularly in patients with smaller vessels access. Early safety and effectiveness outcomes are favorable, even in endpoints such as deployment accuracy and apposition which may be surrogates for longer-term clinical success and durability.

Endovascular Treatment of Descending Thoracic Aortic Pathology: Results of the Regis-TEVAR Study

Endovascular techniques have become an essential tool for treatment of thoracic aortic pathology. The objective of this study was to analyze indications and results of thoracic endovascular aortic repair (TEVAR) in vascular surgery units, through a retrospective and multicentric national registry called Regis-TEVAR. From 2012 to 2016, a total of 287 patients from 11 vascular surgery units, treated urgently and electively, were recruited consecutively. The primary variables analyzed are mortality, survival, and reintervention rate. The following indications for TEVAR were also analyzed: aortic dissections, thoracic aneurysms, traumatisms, and intramural hematomas or penetrating ulcers, as well as results and postoperative complications in accordance with each indication. Of the 287 TEVAR performed (239 men, mean age 64.1±14.1years), 155 were because of aortic aneurysm (54%), 90 because of type B aortic dissection (31.4%), 36 because of traumatic aortic rupture (12.5%), and 6 because of penetrating ulcers or intramural hematomas (2.1%). Overall mortality at 30days was 11.5% (18.5% in urgent and 5.3% in elective), being higher in dissections (13.3%). The median actuarial survival was 73% at 4years. The stroke rate was 3.1%, and the rate of spinal cord ischemia was 4.9%. Aortic reoperations were necessary in 23 patients (8.1%). This registry provides complete and reliable information on real clinical practice of TEVAR in Spain, with results similar to international series of open surgery. In accordance with these data, TEVAR can be performed with acceptable morbidity and mortality and with low rates of postoperative complications.

One-year Results of a Prospective, Multicenter, Observational Study of Thoracic Aortic Pathologies Treated with a Bare and Non-bare Stent Endograft and Dual-sheath Delivery System

Introduction: To report the results of RelayPlus (Terumo Aortic, Sunrise, FL, USA) which is CE-marked for the endovascular treatment of aneurysms of the descending thoracic aorta (DTA), aortic dissection (AD), aortic transection (AT) and penetrating aortic ulcers (PAU). This study was a postmarket surveillance requirement. The device is available in bare-stent (BS) and non-bare stent (NBS) configurations and a dual-sheath delivery system includes a flexible inner catheter. Methods: A prospective, non-randomized, observational study using a standard treatment and follow-up protocol enrolled consecutive patients treated with the device in 10 sites between January 2015 and December 2018. Standard endpoints (mortality, neurological deficits, endoleaks, all complications, migration, device integrity) are assessed at 30 days and through five years; one-year results are reported here. Results: The study enrolled 170 patients. Data from 148 patients with a mean follow-up of 379 days are reported here; mean age was 67.4 years (25−93), mostly male (n=104, 70%), 78 (52.7%) ASA ≥3. Patients were treated in 59 cases (40%) for DTA, 61 (41%) Type B AD, 16 (11%) AT, and 12 (8%) PAU. Average aneurysm diameter was 57 (28−106) mm. An average of 1.4 units was used per patent. BS or NBS was physician preference: NBS was more typical in AD (n=39, 64%) and AT (n=9, 56%). Landing was in Z0 (6%), Z1 (5%), Z2 (18%), Z3 (43%), and Z4 (28%). Revascularization of the innominate (n=1) and left subclavian (n=16) arteries were associated. There was no surgical conversion. At 30 days, mortality was 2.7%, there were no stroke, 0.6% paraplegia (n=2), no retrograde dissection and 6% type I endoleaks (7 Ia, 4 Ib). At one year, there were 2 non-TEVAR-related deaths (6 in total, all-cause mortality 4%), one type I endoleak, four type II and no conversion to open repair, migration or endograft collapse. There were 15 (10%) secondary interventions for endoleak (n=9, 6%), aneurysm expansion (n=5, 3%), and rupture (n=1, 0.6%). Average aneurysm diameter at one year was 46 (26−74) mm. Conclusion: Real world, standard clinical practice in the treatment of thoracic aortic pathologies with RelayPlus is highly predictable with a low number of units per patients and acceptable rates of mortality and reintervention in a challenging patient population. Disclosure: Nothing to disclose

Left Subclavian Artery Revascularization for Thoracic Aortic Stentgrafting: Single Center Experience in 101 Patients

Introduction - Endovascular treatment of thoracic aortic pathology (TEVAR) requires a landing zone of at least 20mm in length, necessitating coverage of the left subclavian artery (LSA) in approximately 40% of the patients.1 Coverage of the LSA may increase the risk of ischaemic stroke, spinal cord ischaemia (SCI) and/or left arm claudication. Besides some endovascular options to preserve LSA flow, in the majority of cases the LSA is surgically revascularized by either a carotid-to-subclavian bypass graft or subclavian-carotid transposition. A relatively safe option, which has been shown to decrease the risk of stroke compared to LSA coverage without revascularization.2,3 Conflicting data and opinions exist in literature on the (additional) risk of surgical LSA revascularization (requiring temporary occlusion of the left common carotid artery (LCCA) for the anastomosis).4,5,6 In this study, we retrospectively analysed the indications, as well as the operative results of LSA revascularization in 97 patients, in our single centre TEVAR experience. Methods - Between 2000 and 2017, a total of 101 consecutive patients underwent surgical revascularization of the LSA prior to, concomitant, or following TEVAR. Data were retrospective collected. Revascularization was performed through a small supraclavicular incision and consisted of a transposition or bypass graft, using perioperative transcranial Doppler. Data regarding the indication for LSA revascularization, procedural details and early and late postoperative results were analysed. Results - A total of 64 carotid-subclavian bypass grafts and 33 subclavian-carotid transpositions were performed in the context of TEVAR. The majority was performed prior to stentgrafting, indicated to reduce the risk of stroke (n=58, incomplete Willis’ circle, dominant left vertebral artery (LVA) and/or exclusion of an arteria lusoria), to reduce the risk of SCI (n=18, in case of previous aortic repair, and/or stenting the entire descending aorta) or to reduce the risk of left arm malperfusion (n=8, small or absent LVA or LVA originating from the aortic arch). In two patients there was a patent left internal mammary artery to coronary artery bypass graft. In fourteen patients LSA revascularization was performed secondary to the stentgraft procedure, either immediately due to acute left arm malperfusion (n=2) or during follow-up due to invalidating left arm claudication (n=12). There was no in-hospital mortality, two ischaemic strokes (2%) were noted and one patient experienced permanent SCI (1%). Both strokes were considered to be related to the stentgraft procedure rather than the preceding LSA bypass. Additional complications observed were sympathetic chain nerve palsy (Horner’s syndrome) (n=6), phrenic nerve palsy (n=5), recurrent nerve palsy (n=4), chyle leakage requiring diet or re-exploration (n=6). In one patient, the LSA bypass occluded during follow-up requiring a redo surgical bypass. Conclusion - Selective surgical revascularization of the left subclavian artery in case of LSA coverage in TEVAR may be indicated to lower the risk of stroke, spinal cord ischaemia, and left arm malperfusion. The procedure can be performed safely when using perioperative monitoring and result in a low risk of stroke and peripheral nerve injury. References1)Kotelis D, Geisbüsch P, Hinz U, Hyhlik-Dürr A, von Tengg-Kobligk H, Allenberg JR, Böckler D. Short and midterm results after left subclavian artery coverage during endovascular repair of the thoracic aorta. J Vasc Surg. 2009 Dec;50(6):1285-1292.2)Patterson BO, Holt PJ, Nienaber C, Fairman RM, Heijmen RH, Thompson MM. Management of the left subclavian artery and neurologic complications after thoracic endovascular aortic repair. J Vasc Surg 2014;60:1491-1497.3)Saouti N, Hindori V, Morshuis WJ, et al. Left subclavian artery revascularization as part of thoracic stent grafting. Eur J Cardiothorac Surg. 2015 Jan;47(1):120-125; discussion 125.4)Maldonado TS, Dexter D, Rockman CB, Veith FJ, Garg K, Arko F, Bertoni H, Ellozy S, Jordan W, Woo E. Left subclavian artery coverage during thoracic endovascular aortic aneurysm repair does not mandate revascularization. J Vasc Surg. 2013 Jan;57(1):116-124.5)Cooper DG, Walsh SR, Sadat U, Noorani A, Hayes PD, Boyle JR. Neurological complications after left subclavian artery coverage during thoracic endovascular aortic repair: a systematic review and meta-analysis. J Vasc Surg. 2009 Jun;49(6):1594-1601.6)Contrella BN, Sabri SS, Tracci MC, Stone JR, Kern JA, Upchurch GR, Matsumoto AH, Angle JF. Outcomes of Coverage of the Left Subclavian Artery during Endovascular Repair of the Thoracic Aorta. J Vasc Interv Radiol. 2015 Nov;26(11):1609-1614.

A truly non-occlusive stent-graft moulding balloon for thoracic endovascular aortic repair.

Endovascular treatment of thoracic aortic pathologies has recently progressed towards more proximal pathologies, including those of the aortic arch and ascending aorta where there is a higher risk for stent-graft migration during the deployment or the moulding procedure due to the beating and ejecting heart. Typical measures to prevent dislodgement of the balloon or the stent-graft during the procedure are rapid pacing or pharmacologically induced hypotension. We present a circular and fully non-occlusive stent-graft moulding balloon that does not require any reduction of cardiac output or hypotension during inflation, moulding and deflation of the balloon.

Current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic surgery (EACTS) and the European Society for Vascular Surgery (ESVS).

Current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic surgery (EACTS) and the European Society for Vascular Surgery (ESVS).

Editor's Choice – Current Options and Recommendations for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch: An Expert Consensus Document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS)

Editor's Choice – Current Options and Recommendations for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch: An Expert Consensus Document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS)

Spinal ischaemia after thoracic endovascular aortic repair with left subclavian artery sacrifice: is there a critical stent graft length?

Thoracic endovascular aortic repair (TEVAR) is used for treatment of thoracic aortic pathologies, but the covered stent graft can induce spinal ischaemia depending on the length used. The left subclavian artery contributes to spinal cord collateralization and is frequently occluded by the stent graft. Our objective was to investigate the impact of covered stent graft length on the risk of spinal ischaemia in the setting of left subclavian artery sacrifice. Twenty-six pigs (German country race, mean body weight 36 ± 4 kg) underwent simulated descending aortic TEVAR via left lateral thoracotomy, with left subclavian artery and thoracic segmental artery occlusion in normothermia. Animals were assigned to treatment groups according to simulated stent graft length: TEVAR to T8 (n = 4), TEVAR to T9 (n = 4), TEVAR to T10 (n = 4), TEVAR to T11 (n = 7) and TEVAR to T12 (n = 1) and a sham group (n = 6). End points included spinal cord perfusion pressure, cerebrospinal fluid pressure and spinal cord blood flow using fluorescent microspheres. There were no group differences in spinal cord perfusion pressure drop or in spinal cord perfusion pressure regeneration potential at 3 h after the procedure: from a baseline average of 75 mmHg (95% confidence interval 71-83 mmHg) to 73 mmHg (67-75 mmHg) at 3 h in Group T10 versus from a baseline average of 67 mmHg (95% CI 50-81 mmHg) to 65 mmHg (95% confidence interval 48-81 mmHg) in Group T8. There were no differences in the spinal cord blood flow courses over time in the different groups nor was there any difference in cerebrospinal fluid pressure levels and cerebrospinal fluid pressure dynamics between groups. However, we did observe local blood flow distribution to the spinal cord that was inhomogeneous depending on the distance between the simulated stent graft end and the first thoracic anterior radiculomedullary artery. The risk of spinal ischaemia after serial segmental artery occlusion does not depend on the distal extent of the aortic repair alone. Future attempts to allow patient risk stratification for spinal ischaemia need to focus on anterior radiculomedullary artery anatomy together with the extent of planned aortic repair.

Double arterial perfusion strategy for extensive thoracic aortic surgery to avoid lower body hypothermic circulatory arrest

To analyse our results of using a double arterial perfusion strategy to avoid lower body hypothermic circulatory arrest after extensive thoracic aortic surgery. We analysed the intra- and perioperative courses of 10 patients (median age 58 years, median logistic EuroSCORE 14.6) who underwent extensive thoracic aortic surgery with a double arterial perfusion strategy. The main goal of double arterial perfusion is to separate myocardial and supra-aortic from systemic perfusion. Aortic repair starts at the most distal level of the descending aorta, followed by reinsertion of the supra-aortic vessels, and ends with completion of the proximal anastomosis or by any kind of root repair as needed. Seven of 10 patients had prior surgery of the thoracic aorta. Indications for surgery were post-dissection aneurysm in 4 patients, true aneurysm in 3, anastomotic aneurysms in 2 and Type B aortic dissection with pseudo-coarctation in 1. Surgical access was performed through median sternotomy with left hemi-clamshell extension in all cases. There was no in-hospital mortality, but perioperative neurological symptoms occurred in 2 patients. These 2 patients developed delayed stroke (after awaking) after an initial uneventful clinical course, and in 1 of them, neurological symptoms resolved completely during follow-up. The median follow-up was 7 (± 13) months. There was no death and no need for additional redo surgery during this observational period. Extensive surgery of the thoracic aorta using a double arterial perfusion technique in order to avoid lower body hypothermic circulatory arrest is an attractive option. Further refinements of this technique may enable the safe and effective simultaneous multisegmental treatment of thoracic aortic pathology in patients who would otherwise have to undergo a two-step surgical approach.

Torasik Aort Patolojilerinin Endovasküler Tedavisi

Torasik Aort Patolojilerinin Endovasküler Tedavisi

The Hostile Landing Zone in Endograft Repair of the Thoracic Aorta: The Next Frontier

Objective: Thoracic endo-vascular repair of the aorta (TEVAR) is gaining popularity in the treatment of thoracic aortic pathologies. One of the limitations to the use of this treatment modality is unfavorable landing zone (LZ) anatomy proximally and distally involving the aortic arch and visceral branch vessels. We report our experience with extending the LZs using endobranching and an on-table modified device design to offer a treatment option to these high-risk patients.

Superior Nationwide Outcomes of Endovascular versus Open Repair for Isolated Descending Thoracic Aortic Aneurysm in 11,669 Patients

Conclusion: Compared with open aortic repair (OAR) thoracic endovascular aneurysm repair (TEVAR) is associated with shorter hospital stay, similar mortalities, fewer complications, and increased hospital charges. Summary: The first endovascular prosthesis was approved in 2005 for thoracic endovascular aneurysm repair in the United States. The technology has been widely adopted but there is little information available on TEVAR nationwide outcomes for treatment of descending isolated thoracic aortic aneurysm (TAA). The authors therefore compared in hospital outcomes of TEVAR and open descending TAA repairs performed in the United States during the initial 3 years following approval of the GORE TAG device. They used nationwide data to identify patients who had undergone surgery for isolated descending TAA from 2006-2007. Patients treated for aortic dissection or rupture or who underwent simultaneous treatment of other aortic segments were excluded. There were 11,669 patients analyzed and 9,106 had conventional open aneurysm repair (OAR) and 2,563 had TEVAR. Patients were compared for mortality and hospital stay as well as discharge status, morbidity, and hospital charges. Patients undergoing TEVAR were older (69.5 ± 12.7 versus 60.2 ± 14.2 years; P < .001) and had higher preoperative morbidity. Length of stay was shorter for TEVAR patients (7.7 ± 11 versus 8.8 ± 7.9 days). Unadjusted mortality was similar for TEVAR (2.3%) and OAR (2.2%; P = 1.0). There were similar proportions of non elective interventions in the two groups (TEVAR 15.9% versus OAR 15.8%; P = .9). Risk adjusted mortality rates with TEVAR and OAR were similar. TEVAR patients, however, had 60% fewer complications (OR, 0.39; P < .001). TEVAR patients were 4 times more likely to have a routine discharge home than OAR patients. TEVAR hospital charges were greater by $6713 (95% CI, 1869- 11,556; P < .001). Comment: Surgical procedures with good outcomes and that are “easy” to perform are adopted widely. More difficult procedures are generally restricted to high volume centers. Wide spread adoption of TEVAR is appropriate. Even though TEVAR was selectively performed in patients almost a decade older than the OAR patients, outcomes were comparable, if not superior, for TEVAR versus OAR with TEVAR having significantly better risk adjusted morbidity, primarily from lower incidences of neurologic, respiratory and pulmonary complications. Additional data is needed to determine whether TEVAR has volume dependent outcomes, or like endovascular abdominal aortic aneurysm repair, can be performed with relatively low morbidity in low volume hospitals. Such data is needed to determine whether thoracic aortic aneurysm patients should be treated in centers dedicated to treatment of aortic disease or if TEVAR will permit more wide spread treatment of thoracic aortic pathology in community and smaller regional hospitals.

O-49 Neurologic complications after endovascular treatment of thoracic aortic pathology: results from a large Italian single centre registry

Endovascular repair of the thoracic aorta (TEVAR) is becoming the treatment of choice for many vascular aortic diseases. The scope of this study was to evaluate the incidence and related risk factors of severe neurological complications (NC) in our clinical experience.

The value of intravascular phased-array imaging in endovascular treatment of thoracic aortic pathology

Careful pre-, intra- and postoperative diagnostics in endovascular treatment of thoracic aortic pathology is crucial for a favourable outcome. Computer tomography (CT) and digitally subtracted angiography (DSA) do not always provide sufficient diagnostic information. To report our primary experiences of using intraluminal phased-array imaging (IPAI) as an additive tool for diagnostics and endovascular treatment of thoracic aortic pathology. Eleven patients, nine men and two women (mean age 60, range 45) were examined intraoperatively with IPAI in stentgraft procedures of thoracic aortic pathology. IPAI could detect and visualize the entries and re-entries in the intima. Aortic branch vessels could be visualized for patency both during and immediately after stentgraft deployment. It was also possible to detect ceased blood flow in the false lumen or aneurysmal sac after stentgraft deployment. IPAI is a helpful tool for diagnostics and for guiding stentgraft placing in the treatment of thoracic aortic pathology.

Invited commentary

This single-center study is another piece of evidence in a growing wave of reports addressing important clinical outcomes after endovascular treatment of thoracic aortic pathology. In Table III, the authors specifically segregate outcomes in patients who did and did not have left subclavian artery revascularization, and the comparisons are striking, with a 28% risk of combined stroke, paraplegia, or death when the left subclavian artery was not revascularized compared with none when it was revascularized. Their analysis may be confounded by the nonrandomized design in which they more recently have routinely performed the subclavian revascularization, and they have certainly improved other components of their institutional systems. Further confounding may occur with emergency cases, when staged or simultaneous revascularization may not be possible. Taken together with other reports, these institutional experiences from centers of excellence with thoracic endovascular aortic repair are painting an impressive picture. In a recent meta-analysis of 51 eligible studies, sponsored by the Society for Vascular Surgery, the Mayo Clinic Knowledge and Encounter Research Unit found risks increased by odds ratios of 47.7 for arm ischemia, 10.8 for vertebrobasilar ischemia, 2.69 for spinal cord ischemia, and 2.58 for anterior circulation stroke with left subclavian coverage without revascularization compared with revascularization.1Rizvi A.Z. Murad M.H. Fairman R.M. Erwin P.J. Montori V.M. The effect of left subclavian artery coverage on morbidity and mortality in patients undergoing endovascular thoracic aortic interventions: a systematic review and meta-analysis.J Vasc Surg. 2009; 50: 1159-1169Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar The clinical practice guidelines of the Society for Vascular Surgery “suggest” routine preoperative revascularization when the left subclavian artery is covered. They provide a stronger “recommend” routine revascularization in circumstances where collateral perfusion may be compromised.2Matsumura J.S. Lee W.A. Mitchell R.S. Farber M.A. Murad M.H. Lumsden A.B. et al.Management of the left subclavian artery with TEVAR: clinical practice guidelines of the Society for Vascular Surgery.J Vasc Surg. 2009; 50: 1155-1158Abstract Full Text Full Text PDF PubMed Scopus (304) Google Scholar Unfortunately, the evidence supporting these recommendations is very low quality, and there are no randomized data that provide stronger evidence for decisions being made today. It is not surprising there are worse outcomes with occlusion of a major aortic arch vessel compared with strategies that maintain antegrade flow in the left subclavian artery. Vertebral, internal thoracic, and thoracodorsal arteries can be major contributors of brain and spinal cord collateral blood flow. This St. George's Vascular Institute report is another contribution to the evidence favoring revascularization of the left subclavian artery. Outcomes of the endovascular management of aortic arch aneurysm: Implications for management of the left subclavian arteryJournal of Vascular SurgeryVol. 51Issue 6PreviewThis study was conducted to define the outcomes of treating aortic aneurysms involving the arch vessels with a hybrid approach using extra-anatomic reconstruction and endovascular repair with nonfenestrated stents. Full-Text PDF Open Archive