Treatment Of Thoracic Aortic Pathology Research Articles

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

Endovascular treatment of thoracic aortic pathology in renal transplant recipients: early and intermediate-term results

Endovascular correction of aorta thoracic pathology in renal transplant patients is a challenge. The aim of this study is to review early and intermediate-term results of endovascular repair of thoracic aorta pathology in patients with functioning previous renal transplant. The records of 81 patients submitted to a thoracic endograft between 2003 and 2008 were reviewed. Five patients with six previous renal transplants were submitted to six thoracic endografting. Two were women. The mean age was 55.4 years (range, 43-75 years). There were two patients with type B aortic dissection, one penetrating ulcer, one aneurysm of the aortic arch and one descending thoracic aorta aneurysm. Three patients underwent hybrid procedures: two total supra-aortic transpositions and one partial transposition of visceral trunks. Three patients presented postoperative complications. There were two cases of pneumonia, one acute limb ischemia and a stroke, with an early death. The mean follow-up was 16.2 months (range, 1-40 months). In this period all patients sustained renal function without any related complication. Despite the fact that it is a small series, in our clinical experience, endovascular thoracic aortic surgery can be performed as an alternative to open correction, in high-risk patients with a previous working renal transplant.

Emergency Endovascular Treatment of Sac Rupture for Type IIIa Endoleak in Thoracic Aortic Aneurysm Previously Excluded with Endovascular Repair

Elective endovascular treatment of thoracic aortic pathology has been applied in a variety of conditions. The complications of thoracic aortic stenting are also well recognized. Endoleak after endovascular repair of thoracic aortic aneurysms is the most frequent complication; among them, type III is the least frequent. Endovascular treatment of type III endoleak is generally performed under elective conditions; less frequently, in emergency. We report a successful emergency endovascular management of post-thoracic endovascular repair for thoracic aortic aneurysm rupture due to type IIIa endoleak.

Hybrid Procedures for Thoracoabdominal Aortic Aneurysms

Treatment of thoracic aortic pathology has been rapidly changing in the 5 years since US Food and Drug Administration approval of thoracic stent grafts. Although not specifically evaluated in any of the major clinical trials to date, adjunctive techniques are being increasingly used to expand the applicability of stent-graft technology to patients with more extensive thoracoabdominal aortic aneurysms and dissections. Details of procedural techniques have been delineated by several aortic specialists, resulting in a trend toward standardization of effective strategies. Despite this trend, significant variability is evident in the outcomes of reported series. The objective of this article is to analyze published reports of hybrid procedures involving complete visceral debranching of the aorta and endovascular exclusion of the thoracoabdominal aortic aneurysms.

Standard of Practice for the Endovascular Treatment of Thoracic Aortic Aneurysms and Type B Dissections

Thoracic endovascular aortic repair (TEVAR) represents a minimally invasive technique alternative to conventional open surgical reconstruction for the treatment of thoracic aortic pathologies. Rapid advances in endovascular technology and procedural breakthroughs have contributed to a dramatic transformation of the entire field of thoracic aortic surgery. TEVAR procedures can be challenging and, at times, extraordinarily difficult. They require seasoned endovascular experience and refined skills. Of all endovascular procedures, meticulous assessment of anatomy and preoperative procedure planning are absolutely paramount to produce optimal outcomes. These guidelines are intended for use in quality-improvement programs that assess the standard of care expected from all physicians who perform TEVAR procedures.

Guidewires, Catheters, and Sheaths Used for Thoracic Endografting Procedures

Endovascular repair represents an option becoming progressively more integral to the treatment of thoracic aortic pathology. Effective use by practitioners of the most appropriate endovascular equipment is essential to the continued growth of this treatment modality. This article aims to provide an overview of the guidewires, catheters, and sheaths employed in the practice of thoracic endovascular aortic repair (TEVAR). We reviewed our current utilization of guidewires, catheters, and sheaths in TEVAR. Concurrently, we conducted a survey of the present medical literature with regard to the materials and methods used in this procedure by other cardiothoracic surgeons, vascular surgeons, and interventional radiologists. Fundamental principals of the guidewires, catheters, and sheaths used in TEVAR are consistent across the spectrum of specialists performing this procedure. However, considerable variation exists in the specific products used by practitioners. The importance of proper training and experience with the endovascular equipment used in TEVAR cannot be understated. We believe the endovascular tools discussed in this article offer a proper selection for safe and effective performance of these procedures.

Use of the Abdominal Aorta as an Alternative Access Site for Thoracic Aortic Stent Graft Placement

The treatment of thoracic aortic pathology has undergone a paradigm shift in recent years, with a trend toward less invasive endovascular techniques and away from open surgical repair. Reports on the successful use of endografts in the thoracic aorta have demonstrated decreased morbidity and mortality of these procedures compared with traditional open repair. However, some patients are not candidates for an endovascular approach because of a short proximal landing zone, arch angulation, luminal irregularities, or a large diameter of the transverse arch and the proximal descending aorta. Other patients are excluded because of distal pathology or anatomic irregularities. This article presents 2 patients with thoracic aortic pathology, and both had inadequate proximal landing zones and small, calcified iliac arteries prohibiting femoral or iliac access. Successful repair of these patients was achieved by a staged procedure using a brachiocephalic debranching technique, followed by direct infrarenal aortic cannulation through a limited celiotomy.

Thoracic aortic lesions treated with the Zenith TX1 and TX2 thoracic devices: Intermediate- and long-term outcomes

Little data exist to support the durability of thoracic endovascular repair during prolonged periods of follow-up. This study examines the durability and long-term results with the Zenith TX1 and TX2 thoracic devices (Cook Inc, Bloomington, Ind) in high-risk patients. Data were collected prospectively from 2001 to 2007 on high-risk patients who presented with thoracic aneurysms, chronic aortic dissection, or fistulas treated with a Zenith thoracic device. Surgical modifications of proximal or distal landing zones were performed when necessary. Computed tomography follow-up scans were performed before discharge, at 1, 6, and 12 months, and yearly thereafter. Three-dimensional reconstruction software with central line of flow measurements was used to assess aortic morphologic characteristics. Kaplan-Meier analysis was used to assess survival, freedom from reintervention, predictive factors of poor outcome, and morphologic changes, including aneurysm sac behavior. A total of 160 patients (44% women; mean age, 70) were treated for 130 thoracic aneurysms, 25 aortic dissections with aneurysm, 2 fistulas, and 3 symptomatic or aortic ruptures, or both. Mean follow-up was 36 months, and aneurysm size was 67 mm. Seventy-five patients (47%) had undergone prior aortic aneurysm repair. Surgical modifications were required to create adequate landing zones in 33% patients, including 28 elephant trunk/arch reconstruction, 22 carotid-subclavian bypasses, and seven visceral vessel bypasses. Iliac conduits were required in 31 patients. Early mortality (<30 days) occurred in 11 patients (6.9%). Overall mortality at 1 year was 16%. Aneurysm sac increase (>5 mm) requiring intervention was observed only in one patient in the settings of component separation and type III endoleak that was treated; the sac is now stable. Twenty-seven endoleaks were detected in 25 patients: 15 primary endoleaks (9.4%) <30 days and 12 secondary endoleaks (7.5%) >30 days. Secondary interventions were required in 42 patients (26%). Endovascular treatment of thoracic aortic pathologies with the Zenith TX1 and TX2 devices is feasible and durable. The mid- to long-term results are encouraging, with acceptable low reintervention rates and with good survival within high-risk patients.

Endovascular Repair of a Ruptured Descending Thoracic Aortic Aneurysm in a Patient with an Ascending Aortic Aneurysm: Hybrid Open Arch Reconstruction with Simultaneous Thoracic Stent-Graft Deployment within Elephant Trunk

Endovascular repair of the thoracic aorta is now widely practiced. The extension of this technique to emergent settings is in evolution. Pathology of the ascending and transverse aortic arch may preclude thoracic aortic stent grafting due to the lack of a proximal seal zone. Several hybrid open/endovascular approaches have been described. We recently encountered the difficult case of a contained rupture of a 6.8 cm descending thoracic aortic aneurysm in a 60-year-old patient with aneurysmal degeneration of the ascending and transverse aortic arch. This patient was treated with a hybrid approach of open ascending and transverse arch reconstruction along with simultaneous stent-graft repair of the descending thoracic aorta. The open repair established an excellent proximal landing zone by use of the "elephant trunk" technique. This technique also allowed direct suture fixation of the stent graft to the arch graft to prevent stent-graft migration. This hybrid surgical approach was successful and avoided the cumulative morbidity that a left thoracoabdominal approach would have added to the sternotomy. Further creative uses of these hybrid techniques will undoubtedly serve a larger role in the treatment of thoracic aortic pathology.

Endovascular Repair of Thoracic Aortic Disease With the EndoFit Stent-Graft:Short and Midterm Results From a Single Center

To analyze the outcomes of endovascular treatment of thoracic aortic pathologies performed at a single center with the EndoFit thoracic stent-graft system. From January 2002 to January 2007, 41 patients (33 men; mean age 69.3+/-9.7 years, range 48-84) were treated for thoracic aortic disease with the EndoFit stent-graft system. Patient data were retrieved from a retrospective review of hospital records. Indications for treatment were progression of aneurysm size in atherosclerotic aneurysms (n = 24, mean aneurysm diameter 7.19+/-1.48 cm), acute contained aortic rupture (n = 5), aortic dissection (n = 6), penetrating atherosclerotic ulcers (n = 4), post-traumatic pseudoaneurysm (n = 1), and post coarctation repair aneurysm (n = 1). The EndoFit stent-graft was successfully deployed in all 41 patients. The in-hospital and 30-day mortality rate was 7.3% (3 patients). Three (7.3%) postoperative endoleaks were recorded: a proximal type Ia and a distal Ib both resolved spontaneously at 1 and 3 months, respectively. The third patient had a persistent type Ia endoleak; conversion was necessary after 1 year. There was only 1 case of spinal ischemia, with consequent lower extremity weakness; no paraplegia was observed. During a mean 24.8-month follow-up, 2 secondary type Ia endoleaks were treated with additional stent-grafts. There were 7 (17%) deaths during follow-up. At 2 years, overall patient survival by Kaplan-Meier analysis was 70%; aneurysm-related survival was 89%. Endovascular treatment of vascular disease involving the descending thoracic aorta can be safely performed with the EndoFit thoracic stent-graft system.

Endovascular Treatment of Acute Type B Dissection and Kommerell’s Diverticulum

A 59-year-old man presented with severe hypertension and resistant interscapular pain. Transesophageal echocardiography and computed tomographic angiogram demonstrated acute type B dissection associated with aberrant right subclavian artery with 3.5 cm Kommerell's diverticulum. Open repair was deemed to be high risk to elevate perioperative mortality and morbidity of this surgical technique. Therefore the patient was managed with an endovascular procedure after 14 days of medical therapy because of resistant thoracic pain. We did not observe intraoperative or perioperative mortality and right arm ischemia or symptomatic subclavian steal.

ENDOVASCULAR GRAFTING OF THE THORACIC AORTA, AN EVOLVING THERAPY: TEN‐YEAR EXPERIENCE IN A SINGLE CENTRE

Surgical therapy for the thoracic aorta carries a high morbidity and mortality. Endovascular therapy for aneurysms and its adaptation to the thoracic aorta over the past 10 years is an exciting advance. This is a retrospective review of endovascular grafting of the thoracic aorta during the past decade at Royal Prince Alfred Hospital and the outcomes achieved over this period. A retrospective review of all patients at our institution who underwent endovascular grafting of the thoracic aorta between March 1995 and March 2005 was carried out. Data were analysed using Stata version 8.0 (Stata corporation, College Station, TX, USA). Sixty-five patients underwent endovascular stent grafting of the thoracic aorta. The indications were degenerative aneurysm (31), Stanford type B dissection (23) both acute (12) and chronic (11), traumatic transection (9) and penetrating ulcer (2). There were no conversions to open repair. Twenty-two patients required additional procedures, six of which were unplanned. The median age was 65 (range 18-85), 68% of patients were men. The median procedure time was 115 min (range 55-240 min). Mean hospital stay was 9.8+/-7.3 days and high dependency/intensive care unit stay 1.5+/-3.2 days. Thirty-day mortality was 0 in 41 for elective cases (one patient (2.5%) died 37 days post-procedure) and 12% (3 of 25) for emergency cases. Complications occurred in 20 of 41 (49%) elective cases and 14 of 24 (58%) emergency cases within the first 30 days. The most frequent major complications were neurological including paraplegia (transient 2 of 65, permanent (2 of 65)) and stroke (4 of 65). Other complications included endoleak (12 of 65), acute renal failure (1 of 65), and brachial artery false aneurysm (1 of 65). The mean length of follow up was 22.5 months (range, 1-97 months). Six patients required further endovascular procedures for persistent endoleak or ongoing perfusion of chronic dissection. Late deaths (>30 days) related to the endovascular treatment occurred in two patients (3%). Endovascular grafting of the thoracic aorta is an evolution in the treatment of thoracic aortic pathology. The results of elective endovascular grafts were acceptable. Emergency procedures had a higher incidence of complications and death. Improvement in graft technology, design and deployment are required.

Endovascular Treatment of Thoracic Aortic Pathologies in Patients with Aortoiliac Occlusive Disease

Today, with the increasing experience and advances in graft technology, endovascular grafting is applied nearly to all levels of the aorta for the treatment of various aortic pathologies. The major route of the stent graft deployment is from the femoral region through the iliac arteries. Since both aneurysms and arterial occlusive diseases share atherosclerosis as the common ancestor of etiology, some patients may poses both aneurysms and stenosis together. These stenotic changes occurring in the iliac and femoral arteries may complicate the passage of the stent graft system. In this report, we sought to evaluate an alternative novel route of graft system application for endovascular treatment of thoracic aortic aneurysms.

Endovascular Repair of Thoracic Aortic Disease: Overview of Current Devices and Clinical Results

Endovascular repair of thoracic aortic aneurysm has become an important treatment modality in patients who are at increased risk for open surgical repair. Since the US Food and Drug Administration (FDA) approved the clinical application of this technology in the thoracic aorta in 2005, there has been a rapid growth in this treatment modality as numerous endovascular devices have been introduced in the application of thoracic aortic pathology. Although thoracic aortic aneurysm is the only FDA-approved treatment indication for endovascular repair, this technology may lead to a broader clinical applicability in other thoracic pathologies. This article reviews the current endovascular devices designed for the treatment of thoracic aortic pathology. These devices are described, and the current clinical results are discussed.

Device-spezifische Probleme thorakaler Endostents

The outcome of the endovascular repair of abdominal aortic aneurysms seems to be device related. The presented study evaluated the outcome of endovascular procedure in cases of thoracic aortic pathology according to the implanted thoracic stent graft devices. Since November 1999 a variety of thoracic aortic pathologies in 59 patients has been treated endovascularly. The median age of the cohort (53 males, 6 females) was 64 years (rang, 21 to 83). The patients presented the following aortic morphology: aneurysm n = 23, dissections with aneurysm n = 9, dissection without aneurysm n = 9, intramural hematoma n = 2, penetrating ulcers n = 2, transsection n = 8, false aneurysm n = 6. The underlying pathology was: atherosclerotic medial degeneration n = 25, acute dissection (< 14 days) n = 10, chronic dissection (> or = 14 days) n = 10, trauma n = 8, iatrogenic n = 6. Three patients presented the symptoms of aortic pulmonary fistulas; one patient was treated due to traumatic aortic oesophageal fistula. The used stent graft devices included the GORE TAG (n = 35), the Talent device (n = 13), the Cook device (Zenith TX 1: n = 5), and the Endofit device (n = 3). At three cases a home-made device (n = 1) or a combination of different stent grafts was implanted (Talent plus TAG, Talent plus TX1). Totally, 93 stent grafts were primarily implanted. The 30-day mortality was 1 / 59. One patient with acute dissection (Stanford type B) suffered from a per-procedural acute retrograde dissection leading to death in spite of the performed Bentall's procedure. Per-operatively, one patient showed cerebral ischemia, one other patient experienced a transsection of the external iliac artery due to the retraction of the introducer sheath, and another patient showed an extravasation of contrast dye. 24 hours following the endovascular procedure, one patient developed paraplegia without regression in spite of performing a spinal drainage. The passage of the introducer sheath of the primarily chosen device was impossible at three cases, in another three cases type I endoleaks were detectable, a type III endoleak was evident at another patient with formerly implanted multiple stent grafts. The results of the endovascular procedures in treatment of thoracic aortic pathologies demonstrated typically device related problems and unwanted events. Various types of stent grafts, introducer sheaths, and delivery systems may be necessary to satisfy the different requirements for different indications.

Hybrid Interventions for the Treatment of the Complex Aortic Arch

Open surgical replacement of the ascending and arch aorta is a formidable operation that requires extracorporeal circulation and hypothermic circulatory arrest, and may be associated with increased morbidity and mortality. In recent years, endoluminal graft therapy has been increasingly applied to the treatment of thoracic aortic pathologies with decreased morbidity, mortality, and risk of paraplegia. The hybrid approach combines various extra-anatomic debranching procedures with endoluminal graft therapy, providing a less invasive approach for the management of various complex thoracic arch pathologies without the morbidity and mortality associated with hypothermic circulatory arrest. This article reviews the hybrid approach for the management of various complex aortic arch pathologies.

Intimal dehiscence during endovascular treatment of thoracic aortic dissection

Endovascular treatment of thoracic aortic pathology has become a valuable alternative therapeutic option to open surgery, however complications both during implantation and the postoperative period may occur. In this case report we present an intimal dehiscence during endovascular procedure. Diagnosis was made by transoesophageal echocardiography.

Endografts for Thoracic Aortic Pathologies – Uncontested Benefits in Patient Care

Medical and surgical treatment of thoracic aortic pathologies have been associated with considerable morbidity and mortality. Conversely, thoracic aortic endografting is proving to be extremely useful for correcting a variety of lesions with few complications. Endovascular intervention avoids sternotomy or thoracotomy, chest tubes, respirators and general anesthesia, and blood loss is limited. Complications such as paraplegia, renal failure and cardiac and pulmonary difficulties are minimized; hospital and rehabilitation times are also reduced. Selection of patients on the basis of favorable anatomy and pathology for a specific device is critical to procedural success. In addition, hybrid procedures combining endovascular and surgical techniques may extend the uses of available devices. Branched and fenestrated grafts are now being developed and are more accessible in Europe and Australia for use in thorac-abdominal aneurysm exclusion; they may be used in the arch and proximal descending thoracic aorta. However, at present, grafting in these regions has been associated with a significant incidence of stroke.

Early outcomes after elective and emergent endovascular repair of the thoracic aorta

Endovascular treatment of thoracic aortic pathology has emerged as a viable alternative to open surgical repair in both the elective and emergent settings. The aim of this study was to evaluate preoperative work-up, intra-operative strategy, and outcomes of endovascular stent-grafting of the thoracic aorta in patients undergoing elective repair and those undergoing emergent repair. All patient information was obtained by a retrospective review of an established clinical database for all endovascular thoracic stent-graft cases. From October 1999 to August 2005, 70 patients were treated with endovascular stent-grafts for lesions of the thoracic aorta. Thirty-five patients had an elective endovascular procedure, and 35 patients had an emergent procedure. Thirty-five patients in the endovascular (EL) group were treated for aneurysm (n = 34) and type B dissection (n = 1). Thirty-five patients in the emergent (EM) group were treated for aneurysm (n = 10), intramural hematoma (n = 10), type B dissection (n = 7), traumatic rupture (n = 7), and aortoesophageal fistula (n = 1). Preoperative angiography was performed in 94.3% (33/35) of EL patients but in only 45.7% (16/35) EM patients (P < .005). The EM procedures had significantly shorter operative times, used lower contrast volumes, used fewer stent-graft components (mode 2, range 1 to 5 vs mode 1, range 1 to 3; P = .02), and spinal cerebrospinal fluid drains were used significantly less often (82.9% vs 57.1%, P = .04). Both groups had similar 30-day morbidity, mortality (0/35 EL vs 1/35 [2.9%] EM, P = .99), postoperative endoleak (9/35 [25.7%] EL vs 7/35 [20.0%] EM, P = .78), endovascular failure (3/35 [8.6%] EL vs 5/35 [14.3%] EM, P = .71), and patient survival. There are significant differences in the underlying pathology, preoperative evaluation, and operative course between elective and emergency treatment endovascular procedures for lesions of the thoracic aorta. Endovascular repair of thoracic aortic lesions can be accomplished with low perioperative mortality and morbidity rates, as well as acceptable endoleak and endovascular failure rates for both elective and emergency procedures.

Clinical competence statement on thoracic endovascular aortic repair (TEVAR)—multispecialty consensus recommendations: A Report of the SVS/SIR/SCAI/SVMB Writing Committee to Develop a Clinical Competence Standard for TEVAR

Clinical competence statement on thoracic endovascular aortic repair (TEVAR)—multispecialty consensus recommendations: A Report of the SVS/SIR/SCAI/SVMB Writing Committee to Develop a Clinical Competence Standard for TEVAR