Treatment Of Thoracoabdominal Aortic Aneurysms Research Articles

Invited commentary

Invited commentary

Endovascular Treatment of Thoracoabdominal Aortic Aneurysms Using Branched and Fenestrated Grafts: Single-Center Experience

Endovascular Treatment of Thoracoabdominal Aortic Aneurysms Using Branched and Fenestrated Grafts: Single-Center Experience

Advanced Technical Considerations for Implanting the t-Branch Off-the-Shelf Multibranched Stent-Graft to Treat Thoracoabdominal Aneurysms

Purpose: To demonstrate different techniques and device modifications that can expand the anatomic suitability of the off-the-shelf multibranched t-Branch for treatment of thoracoabdominal aortic aneurysm. Technique: The t-Branch device is not customized for specific patient anatomy, and the most frequent limitations to its use are an inadequate sealing zone and renal artery anatomy. Experience with this device has prompted the development of several techniques that can be employed to maximize the suitability of this stent-graft. Advice is offered on modification of the device to minimize the risk of paraplegia or better match patient anatomy. Maneuvers are explained to ease delivery through tortuous anatomy or existing stent-grafts, catheterize visceral target vessels, select a bridging stent, reduce ischemia time in the limbs, and alter the configuration of the branches. Conclusion: Employing adjunctive maneuvers can increase the anatomic suitability of the t-Branch; in our experience, these techniques have increased the applicability to more than 80% of all elective and urgent thoracoabdominal aortic aneurysm cases.

Endovascular treatment of thoracoabdominal aortic aneurysm in Loeys-Dietz syndrome

Endovascular treatment of thoracoabdominal aortic aneurysm in Loeys-Dietz syndrome

A 30-Minute Supraceliac Aortic Clamping in the Rat Causes Death Due to an Inflammatory Response and Pulmonary Lesions

The treatment of thoracoabdominal aortic aneurysms through an open approach has general and pulmonary consequences of multiple etiologies. Our assumption was that the supraceliac aortic clamping needed for this operation causes a systemic inflammatory response associated with a pulmonary attack. We developed a model of 30-min supraceliac aortic clamping in Wistar rats weighing 300g. After 90min of reperfusion, the rats were sacrificed. The effects on the digestive tract wall were analyzed by measurement of the mucosal thickness/total thickness ratio. The effects on the mesenteric endothelial function were determined byan ex situ measurement of the arterial pressure/volume curves (third branch). Thesystemic consequences of the procedure were analyzed by dosing tumor necrosis factor alpha (TNFα), interleukin (IL)1β, and IL10 in the blood. The pulmonary consequences were analyzed by the measurement of macrophages, polymorphonuclear neutrophils (PNs), T lymphocyte infiltration, pulmonary apoptosis (TUNEL) and active caspase 3. The experimental scheme included 20 rats with ischemia-reperfusion (IR) and 20 control rats. An analysis of survival was carried out on 20 other rats (10 IR and 10 controls). The results were expressed as average±standard error of the mean. The statisticaltests were Student's t-test and Mann-Whitney test. This visceral IR model decreased the ratio of the thickness of the intestinal mucosa compared with that of the control rats (0.77±0.008 vs. 0.82±0.009 [P<0.001]). This local effect was not accompanied by any mesenteric endothelial dysfunction (P=0.91). On a systemic level, IR increased TNFα (37.9±1.5 vs. 28.2±0.6 pg/mL; P<0.0001), IL1β (67.1±9.8 vs. 22.5±5.6 pg/mL; P<0.001), and IL10 (753.3±96 vs. 3.7±1.7 pg/mL; P<0.0001). As regards the lungs, IR increased the parenchymal cellular infiltration by macrophages (6.8±0.8 vs. 4.5±0.4cells per field; P<0.05) and PNs (7.4±0.5 vs. 6.2±03cells per field; P<0.05). There was no increase in the pulmonary cellular apoptosis measured by TUNEL (P=0.77) or in the caspase 3 activity (P=0.59). The mortality of the visceral IR rats was 100% at 36hr vs. 0% in the animals without IR. This work showed that the inflammatory response to visceral IR had systemic and pulmonary effects which always results in the death in the rat.

The Chimney or Snorkel Technique for Rescuing Visceral Aortic Branch during Endovascular Treatment of Thoracoabdominal Aortic Aneurysm

The Chimney or Snorkel Technique for Rescuing Visceral Aortic Branch during Endovascular Treatment of Thoracoabdominal Aortic Aneurysm

Percutaneous axillary artery access for fenestrated and branched thoracoabdominal endovascular repair

ObjectiveThe aim of this study was to assess the safety and effectiveness of upper extremity access (UEA) with percutaneous closure of the axillary artery (AxA) during endovascular treatment of thoracoabdominal aortic aneurysms with fenestrated and branched endografts. MethodsBetween January 2014 and 2017, 34 out of 37 patients (92%) required UEA during a staged branched and fenestrated endovascular approach. A percutaneous AxA (pAxA) approach was used in 14 consecutive patients (41%) with the off-label use of two Perclose ProGlide (Abbott Vascular, Santa Clara, Calif) devices. The results of patients who had received a pAxA access were analyzed; technical success was defined as successful arterial closure with no evidence of persistent bleeding or arterial occlusion requiring secondary interventions. Early (30 days) and short-term (6 months) success rates were recorded. The anatomic characteristics of the AxA of the entire cohort (34 cases) were studied. ResultsPrimary technical success of pAxA was 100%; in one case, an adjunctive Perclose ProGlide device was used to achieve complete closure. No secondary open or endovascular procedures were required. At predischarge computed tomography, no intimal defects, pseudoaneurysms, or signs of bleeding were observed, and all patients were discharged without neurologic deficits related to the AxA puncture site. All 14 patients are alive at follow-up, and 9 of 14 patients completed a 6-month clinical follow-up with computed tomography examination; no late complications were observed at the site of UEA percutaneous repair. With regard to the anatomic characteristics of the AxA, the vessel diameters in the first and third segments were statistically different (P < .001) with a median difference of 1.5 mm (1.0-2.0 mm), with no differences between the right and left sides. The distance between the end of the first segment of the AxA and the origin from the aortic arch was statistically different between the right and left sides, with a median difference of 36 mm (17-50 mm). A positive linear correlation was found between the diameter of the AxA and the height of the patients. ConclusionsAxA is adequate in terms of both caliber and lack of calcifications as an access vessel for large-sheath catheterizations, and it might be considered an alternative UEA for complex aortic endovascular procedures thanks to its proximity to visceral target vessels. In this preliminary experience, percutaneous closure of AxA access with the Perclose ProGlide device is clinically safe and technically feasible with high rates of success.

Ten-year experience of the thoraco-abdominal aortic aneurysm treatment using a hybrid thoracic endovascular aortic repair.

The treatment of thoraco-abdominal aortic aneurysm continues to have a high mortality and paraplegia rate. In superaging societies, the methods of performing less invasive operations remain a major issue. We reviewed our 10-year experience in the treatment of thoraco-abdominal aortic aneurysm using a hybrid procedure of combined visceral reconstruction and thoracic endovascular aortic repair. Sixty patients underwent a hybrid repair for the treatment of the thoraco-abdominal aortic aneurysm between 2007 and 2016. The mean age was 72.7 years. A true aneurysm was found in 43 (72%) patients and a chronic dissection in 17 (28%) patients. The standard operative procedure involved replacing the abdominal aorta with an artificial graft, and the visceral arteries were reconstructed using a quadrifurcated graft. Renovisceral debranching and stent grafting were performed as a 2-stage procedure. The hospital mortality rate was 5%. Two (3%) patients died due to an aneurysmal rupture in the hospital just after renovisceral debranching. The other 2 patients died due to an aneurysmal rupture in the long-term period after preventive renovisceral debranching. Two (3%) patients experienced spinal cord ischaemia after the stenting procedure. Four (7%) patients required additional treatment during the follow-up period. The overall survival was 75.9% at 2 years, 65.2% at 5 years and 43.5% at 8 years. The rates of freedom from aorta-related events were 92.9% at 2 years, 80.5% at 5 years and 72.5% at 8 years. The hybrid repair is considered to be a good option for elderly and high-risk patients. Further long-term follow-up is necessary to extend the indication in younger patients.

Staged approach for hybrid thoracoabdominal aortic replacement

To generalize our experience of step-by-step hybrid thoracoabdominal aortic replacement. Twenty-three patients were enrolled who underwent staged hybrid treatment of thoracoabdominal aortic aneurysm. There were 5 (21.7%) women and 18 (78.3%) men aged 61.4±8.3 years (37-74 years). The first stage was proximal debranching, the second - distal (abdominal) procedure and the third - stenting of the thoracoabdominal aorta. There were no any complications after proximal debranching and aortic stenting. Abdominal debranching was followed by lethal outcome in 3 (13.0%) patients and early postoperative occlusion of the prosthesis brunch in 3 out of 87 cases. Staged approach for hybrid surgical treatment is optimal solution, especially in high risk patients. In our opinion no necessity for cardiopulmonary bypass is the main advantage of this technique.

Surgical treatment of DeBakey type 1 aortic dissection

The article is devoted to the founder of Russian Research Center for Surgery, academician B.V. Petrovsky, who created a multi-field surgical institution of the highest world standards. Treatment of thoracoabdominal aortic aneurysms and dissections being the most difficult and laborious has been solved at the Russian Research Center for Surgery from initial procedures to the most difficult hybrid interventions and total aortic repair.

Early Outcomes of the t-Branch Off-the-Shelf Multibranched Stent-Graft in Urgent Thoracoabdominal Aortic Aneurysm Repair

Purpose: To assess the short-term outcomes of the multibranched off-the-shelf t-Branch stent-graft for urgent thoracoabdominal aortic aneurysm (TAAA) repair and to evaluate the impact on outcomes of the learning curve and adherence to the instruction for use (IFU). Methods: Between 2014 and 2017, 42 patients (mean age 73.3±7 years; 26 men) underwent urgent TAAA treatment using the t-Branch stent-graft [18 in the early (2014–2015) period and 24 in the late (2016–2017) period]. Nearly half the patients were symptomatic (n=18) and 12 had contained rupture. Aneurysm diameter >80 mm was present in 12 (mean diameter 77.7±13.2 mm). Nineteen patients did not meet the IFU for the t-Branch due to target vessel anatomy. The primary endpoints were spinal cord ischemia (SCI), renal function impairment, and 30-day mortality. Target vessel patency and endoleak incidence were assessed at 30 days. Multivariate analyses examined associations between perioperative variables and outcomes; the results are presented as the odds ratio (OR) and 95% confidence interval (CI). Results: The technical success rate was 93% (39/42). Successful catheterization was achieved in 150/155 target vessels (97%). The postoperative SCI rate was 21% (5 paraplegia/4 transient paraparesis) and was correlated with age (OR 1.26, 95% CI 1.01 to 1.56, p=0.04). The renal function impairment rate was 23% (10/42; 2 temporary, 2 permanent dialysis) and was correlated with early experience (OR 7.74, 95% CI 1.3 to 43.9, p=0.019). The 30-day mortality was 14% (no intraoperative deaths); no factor was associated with mortality. During the first month, the incidences of type I, II, and III endoleaks were 0%, 43%, and 0%, respectively; branch patency was 99% (150/151). Procedure time decreased in the later experience (479±333 vs 407±25 minutes, p=0.09), though it was increased in cases outside the IFU (497±135 vs 389±118 minutes, p=0.009), along with fluoroscopy time (121±48 vs 92±33 minutes, p=0.036). Conclusion: Endovascular repair of urgent TAAA using the t-Branch is a feasible treatment option with acceptable 30-day mortality and morbidity in terms of SCI and renal function impairment. Adherence to the IFU prolonged procedure time but had no effect on outcomes. Increased experience of such cases over time may improve outcomes.

Late patency of reconstructed visceral arteries after open repair of thoracoabdominal aortic aneurysm

BackgroundIn the era of rising endovascular treatment of thoracoabdominal aortic aneurysms (TAAAs), the analysis of visceral vessel (VV) patency after open surgical repair is crucial to provide a future benchmark between these different approaches. This study reports the late outcomes of a single-center experience with open TAAA repair, focusing on the results of different techniques adopted for renal and splanchnic revascularization. MethodsData were analyzed for 382 consecutive open TAAA repairs performed between January 2009 and July 2015 (284 men; mean age, 66 ± 10 years). Follow-up of surviving patients was carried out by computed tomography angiography and office checkups at 3 and 12 months and yearly afterward. Kaplan-Meier analysis was performed for overall survival, patency of reconstructed VVs (celiac trunk, superior mesenteric artery, right renal artery, left renal artery), and reinterventions on visceral arteries. Furthermore, VV long-term patency was analyzed in subgroups of patients according to the revascularization strategy (patch inclusion of all vessels, group 1; one-vessel separate reattachment and patch inclusion of the remaining vessels, group 2; separate reattachment of all VVs, group 3). ResultsIn-hospital mortality and paraparesis/paraplegia occurred in 7.6% and 8.1% of patients, respectively. Among the 353 survivors, 338 complied with the follow-up protocol, and adequate computed tomography angiography images were available in 247 patients (952 VVs were analyzed). Overall follow-up survival was 94%, 91%, and 70% at 1 year, 2 years, and 5 years, respectively. At the same time points, VV patency was 99%, 98%, and 98% for celiac trunk; 100%, 100%, and 100% for superior mesenteric artery; 100%, 96%, and 96% for right renal artery; and 91%, 87%, and 82% for left renal artery (log-rank test, P < .0001). Estimates for reinterventions on VVs were 1.2%, 6.3%, and 17% at the same time points. Freedom from occlusion of any VV at 1 year and 3 years was 95% and 87% for group 1, 89% and 79% for group 2, and 92% and 92% for group 3, respectively (log-rank test, P = .13). ConclusionsLong-term patency of VVs after open TAAA repair performed in high-volume centers is high, regardless of the technique employed for revascularization. The left renal artery appears to be most prone to occlusion over time.

Emergency treatment of thoraco-abdominal aortic aneurysms with multibranched stentgrafts: Feasibility study

Emergency treatment of thoraco-abdominal aortic aneurysms with multibranched stentgrafts: Feasibility study

Adjunct Perfusion Branch for Reduction of Spinal Cord Ischemia in the Endovascular Repair of Thoracoabdominal Aortic Aneurysms.

To analyze utilization of a perfusion branch for temporary sac perfusion to reduce the spinal cord ischemia (SCI) in the endovascular repair of thoracoabdominal aortic aneurysms (TAAAs). Between January 2012 and August 2016, 30 patients (18, men; median age 72 years) were treated for TAAAs with total endovascular repair using customized branched/fenestrated endografts in our institution. The median aneurysm size was 6.6 cm. Types of TAAA were: type I, 9 (30%), type II, 5 (16.6%), type III, 4 (13.3%), type IV, 6 (20%), and type V, 6 (20%). Ten patients received a perfusion branch to create an intentional endoleak, which was occluded with vascular plugs in mean interval time of 8.2 weeks (range: 6-10). Staged procedure and automated cerebrospinal fluid drainage were used in 23 (77%) and 24 (80%) patients, respectively. The technical success was 97%; 107 renovisceral target vessels were revascularized (32 fenestrations, 75 branches). At the time of the planned reinterventions, the mean arterial pressure (MAP) gradients were measured between the temporarily perfused aneurysm sac and the aortic endografts, and they were significantly higher (mean gradients 42.5 ± 10 mm Hg; range: 30-60) within the aortic grafts. The in-hospital and 30-day mortality was 3.3%. The incidence of postoperative SCI was 3/20 (15%) in the standard group and 0% in the group of the perfusion branch (p = 0.28). The mean follow-up was 12 months (range: 2-51). We experience that the use of a dedicated perfusion branch is feasible and may serve as protective adjunct to reduce the risk of SCI in endovascular treatment of TAAA. The risk of rupture in interval appears to be low. Larger series and multicenter studies are warranted to corroborate these results.

Utility and safety of axillary conduits during endovascular repair of thoracoabdominal aneurysms

ObjectiveEndovascular treatment of thoracoabdominal aortic aneurysms (TAAAs) with branched and fenestrated stent grafts often requires upper extremity arterial access for antegrade delivery of bridging covered stents into the visceral arteries. Axillary, brachial, and radial artery approaches have been described, but data on the safety and utility of the different approaches remain limited. We have preferentially used axillary artery conduits for upper extremity arterial access during endovascular repair of TAAA and describe our technique and report our experience herein. MethodsThirty-two patients were treated within an investigator-sponsored investigational device exemption clinical trial of endovascular repair of TAAAs using custom-manufactured stent grafts. In 29 of these cases, the axillary artery was exposed through an infraclavicular incision, and an axillary conduit was used for antegrade delivery of bridging visceral artery stent components. In all cases, a 12F sheath was placed through the conduit for delivery of stent graft components. The left axillary artery was used in 27 of these 29 cases, and the right axillary artery was used in 2 patients. Proximal brachial artery access was used in two patients, and one patient did not require upper extremity access. Aneurysms treated included pararenal (n = 3) and Crawford TAAA extent I (n = 1), extent II (n = 3), extent III (n = 10), and extent IV (n = 15). Patients have been followed up to 2 years after the procedure, with a mean follow-up of 226 days. ResultsAxillary conduits were used to deliver a total of 170 stent components placed into 81 branches and 27 fenestrations with 99.1% technical success (one accessory renal branch could not be cannulated). There were no intraoperative complications related to the construction or use of the conduit. There were two postoperative complications (6.9%) potentially attributable to the conduit; one patient experienced ipsilateral hand weakness and one patient had postoperative minor stroke, which resolved by the first postoperative visit. There were no cases of arm ischemia, wound hematoma, or reoperation related to the conduit. ConclusionsThe use of an axillary conduit during endovascular repair of complex aortic aneurysms provides safe and effective upper extremity access for delivery of visceral branches. Moreover, axillary conduits facilitate delivery of 12F sheaths without interrupting upper extremity perfusion and provide a shorter working distance compared with brachial artery approaches.

Этапное хирургическое лечение торакоабдоминальной аневризмы аорты IV типа при мультифокальном атеросклерозе

Этапное хирургическое лечение торакоабдоминальной аневризмы аорты IV типа при мультифокальном атеросклерозе

Hybrid treatment of thoracoabdominal aortic aneurysms with Marfan syndrome

Hybrid treatment of thoracoabdominal aortic aneurysms with Marfan syndrome

Passive Temporary Visceral Shunt from the Axillar Artery as an Adjunct Method during the Open Treatment of Thoracoabdominal Aortic Aneurysm

Distal aortic retrograde perfusion systems like the left heart bypass or femoro-femoral extracorporeal circulation are the methods of reference for organ protection during direct approaches to thoracoabdominal aortic aneurysms. The aim of this work was to evaluate the use of a passive arterial shunt to reduce visceral ischemia during aortic operations when occlusive diseases of the iliac arteries make distal aortic retrograde perfusion inappropriate. Ten patients affected by a Crawford type III thoracoabdominal aneurysm (TAA) were operated on between January 2013 and January 2015 with the use of a temporary shunt inserted onto the left axillar artery that allows visceral perfusion immediately after the aorta is opened. The operation was performed after a single dose of heparin (50 UI/kg). The sera lactate levels were measured 2hr after the last aortic clamp was removed and compared with those obtained from a group of 19 patients operated on for a Crawford type IV TAA during the same period without any arterial shunt. Neither mortality nor paraplegia occurred. The sera lactate levels were lower in the group of patients operated on for a type III TAA (2.57±1) than for a type IV TAA (3.68±1) (P<0.01, Student's t-test). This method was effective for low mesenteric ischemia, easy to perform, and did not require high doses of anticoagulants.

Multibranched Stent-Grafts for the Treatment of Thoracoabdominal Aortic Aneurysms

Purpose: To evaluate the available literature on endovascular repair of thoracoabdominal (TAAA) and pararenal aortic aneurysms (PRAA) using multibranched stent-grafts. Methods: MEDLINE, EMBASE, and Cochrane databases were searched between January 2001 and June 2015 to identify articles related to the use of multibranched stent-grafts for the treatment of TAAA and PRAA. Articles with <4 cases and those on juxtarenal aortic aneurysms were excluded. Meta-analyses were conducted to evaluate 30-day mortality, all-cause mortality, spinal cord ischemia, renal insufficiency, endoleak, target vessel patency, and reintervention. Of 370 articles screened, only 4 articles encompassing 185 patients (mean age 71.1 years; 137 men) were aligned with the inclusion criteria. There were 23 PRAAs; the mean aneurysm diameter was 64.5 mm. The Crawford TAAA classification was 10 type I, 47 type II, 37 type III, 58 type IV, and 9 type V; there was 1 Stanford type B dissection in association with a large TAAA. Results of the meta-analyses are reported as proportions and 95% confidence interval (CI). Results: Pooled analysis indicated a technical success rate of 98.9%. As study heterogeneity was significant, random effects models were used for meta-analysis. The rate for 30-day mortality was 9% (95% CI 3% to 19%), for all-cause mortality 27% (95% CI 17% to 38%), endoleaks 10% (95% CI 1% to 25%), target vessel patency 98% (95% CI 95% to 99%), SCI 17% (95% CI 1% to 26%), irreversible SCI 6% (95% CI 3% to 10%), renal insufficiency 15% (95% CI 0.8% to 41%), and reinterventions 21% (95% CI 4% to 47%). Conclusion: Use of multibranched stent-grafts in the treatment of TAAAs and PRAAs appears to be feasible and safe based on satisfactory early outcomes in the limited literature available to date. Long-term surveillance and further studies are essential to determine the durability of this technique.

A computational simulation of the effect of hybrid treatment for thoracoabdominal aortic aneurysm on the hemodynamics of abdominal aorta.

Hybrid visceral-renal debranching procedures with endovascular repair have been proposed as an appealing technique to treat conventional thoracoabdominal aortic aneurysm (TAAA). This approach, however, still remained controversial because of the non-physiological blood flow direction of its retrograde visceral revascularization (RVR) which is generally constructed from the aortic bifurcation or common iliac artery. The current study carried out the numerical simulation to investigate the effect of RVR on the hemodynamics of abdominal aorta. The results indicated that the inflow sites for the RVR have great impact on the hemodynamic performance. When RVR was from the distal aorta, the perfusion to visceral organs were adequate but the flow flux to the iliac artery significantly decreased and a complex disturbed flow field developed at the distal aorta, which endangered the aorta at high risk of aneurysm development. When RVR was from the right iliac artery, the abdominal aorta was not troubled with low WSS or disturbed flow, but the inadequate perfusion to the visceral organs reached up to 40% and low WSS and flow velocity predominated appeared at the right iliac artery and the grafts, which may result in the stenosis in grafts and aneurysm growth on the host iliac artery.