Treatment Of Thoracoabdominal Aortic Aneurysms Research Articles

Fenestrated and Branched Aortic Grafts.

Abdominal and thoracic aortic aneurysms are diagnosed in 40 and 10 to 15 out of 100 000 persons per year, respectively. Fenestrated (fEVAR) and branched (bEVAR) stent grafts have been developed for abdominal juxtarenal and thoracoabdominal aneurysms. We discuss the patency and complication rates of fEVAR and bEVAR procedures and compare them with the outcome of open surgery. This review is based on pertinent publications from 2011 to 2014 that were retrieved by a selective literature search. The clinical outcomes of case series involving a total of more than 1500 patients are presented. The discussion takes account of recommendations contained in the literature and the authors' own experience. Open surgery and aortic stent grafting have not been compared in any randomized trial to date. We identified 7 clinical series that included a total of 1270 fEVAR patients and 5 with a total of 408 bEVAR patients. The perioperative mortality after fEVAR procedures was 0-4%. Spinal cord ischemia arose in 1% of cases. The stent patency rate in visceral vessels ranged from 93 to 98%. bEVAR procedures were associated with both higher mortality (4-7%) and more common spinal cord ischemia (4-13%). 5-8% of all patients needed dialysis perioperatively, and the stent patency rate in visceral vessels was 94-97%. Preoperative renal insufficiency was a risk factor for peri-interventional death. Impaired renal function after fEVAR/bEVAR procedures was mainly associated with intermittent lower limb ischemia. The results of fEVAR/bEVAR procedures in the last 5 years are similar to those of open surgery. The high postoperative rate of spinal cord ischemia remains a serious problem in the endovascular treatment of thoracoabdominal aortic aneurysms. The decision to implant a stent graft by an endovascular approach or to treat surgically should be made on a case-to-case basis in an interdisciplinary vascular conference.

Early Results of Physician Modified Fenestrated Stent Grafts for the Treatment of Thoraco-abdominal Aortic Aneurysms

Early Results of Physician Modified Fenestrated Stent Grafts for the Treatment of Thoraco-abdominal Aortic Aneurysms

Endovascular treatment of thoracoabdominal aortic aneurysm using physician-modified endografts

To report an initial experience with physician-modified thoracic endografts for endovascular treatment of thoracoabdominal aortic aneurysm (TAAA). Single-center cohort study of the treatment of TAAA using a physician-modified fenestrated thoracic endograft for patients deemed to be at high risk of open repair. The cohort includes 21 patients in a prospective physician-sponsored U.S. Food and Drug Administration-approved investigational device exemption study and three patients treated outside the investigational device exemption. The procedure involves physician modification of a Cook TX2 thoracic stent graft with reinforced fenestrations. Branch stents were iCast balloon expandable stents. Treatment success was defined as successful aneurysm exclusion with freedom from permanent organ system dysfunction and return to preoperative level of independent functional status. Twenty-four consecutive patients were treated. Twenty-one patients (88%) met the endpoint of treatment success at a mean of 11months follow-up. One patient (4%) died within 30days due to complications of spinal cord injury (SCI). One patient (4%) died 4months postoperatively after a prolonged recovery from surgery. One other patient (4%) is alive 13months after operation with permanent SCI. One renal reintervention has been required. No device failures have occurred. Early-term data suggest that physician-modified fenestrated thoracic endografts can be used to safely and effectively treat TAAA in patients at high risk of open repair. Physician-modified devices perform similarly to commercially manufactured grafts in terms of treatment success, SCI, perioperative death, and clinical outcome at short-term follow-up. Physician modification is immediately available and allows for a high level of customizability. Procedure success is contingent upon careful preoperative planning, patient selection, experienced providers, and a high volume center.

Cirugía abdominal híbrida para el tratamiento de los aneurismas toracoabdominales complejos

Abdominal hybrid procedures have arisen as an alternative to conventional open surgery for thoracoabdominal aortic aneurysms (TAA), although they are surrounded by controversy. Data available in the literature about morbidity and mortality show a great disparity. However, most series include a large number of high risk patients and of extensive TAA. Considering this, renovisceral debranching still has a role in the treatment of TAA.

Visceral Debranching for the Treatment of Thoracoabdominal Aortic Aneurysms: Based on a Presentation at the 2013 VEITH Symposium, November 19-23, 2013 (New York, NY, USA).

Surgical repair of thoracoabdominal aortic aneurysms (TAAA) is associated with significant morbidity and mortality. Hybrid approaches that involve visceral debranching and aortic endografting allow for an alternative approach in certain high-risk patients. In most circumstances the visceral vessels can be bypassed in a retrograde manner from the iliac arteries via a midline laparotomy, and the aortic aneurysm subsequently excluded with standard aortic endografts. These procedures avoid the extensive two-cavity exposure, aortic cross-clamping, and mechanical circulatory support that comprise open TAAA repair, and offer the theoretical advantage of being less invasive. Despite this, outcomes have been mixed with reported perioperative mortality rates of 0% and 34% and permanent paraplegia rates of 0% to 13% in most major series. The reported outcomes, as well as the variation between centers, highlight the importance of patient selection in undertaking hybrid repair. In practice, the best outcomes are achieved in patients who have high-risk anatomy, rather than high-risk comorbidities.

Temporary Perfusion Branches to Decrease Spinal Cord Ischemia in the Endovascular Treatment of Thoraco-Abdominal Aortic Aneurysms: Based on a Presentation at the 2013 VEITH Symposium, November 19-23, 2013 (New York, NY, USA).

Spinal cord ischemia (SCI) is one of the most feared complications following the repair of thoraco- abdominal aortic aneurysms (TAAA). Endovascular repair of TAAA is now possible with branched stent grafts, but spinal cord ischaemia rates are still unacceptably high. A number of techniques have been utilized to reduce these levels, however, SCI remains a challenge to endovascular repair of TAAA. The use of sac perfusion branches aims to reduce the incidence of this catastrophic complication. A retrospective analysis of all patients undergoing branched endovascular aortic repair for all thoraco-abdominal aneurysms (TAAA) using custom made devices during January 2008 to August 2014. We describe a two staged technique in which perfusion of segmental vessels is maintained by a temporary endoleak through an open perfusion branch, incorporated within the branched stent graft, followed by a closure of this branch at a later date to complete exclusion of the aneurysm. Forty-seven patients underwent TAAA repair. Twenty-five (53%) had a two-stage procedure using either a sac perfusion branch or a target vessel to perfuse the sac. Nine patients (19.15%) suffered some form of SCI with eight patients having temporary SCI (lasting less than 72 hours) and one patient having permanent SCI. Of eight patients that had temporary spinal cord ischemia, all had a perfusion strategy. There was one case of permanent SCI (2.13%). Sac perfusion branches provide a safe method for preventing SCI, however this needs to be used in conjunction with controlling MAP and CSF drainage.

Surgical treatment of thoracoabdominal aortic aneurysms

Surgical treatment of patients with thoracoabdominal aneurysm is still actual problem in cardiovsacular surgery. We have retrospectively analyzed 344 treated patients. Thoracoabdominal aneurysms Crawford I-IV and descending aortic aneurysms were diagnosed in 186 (54,1%) and 158 (45,9%) patients respectively. For the follow-up period surgical mortality in case of thoracoabdominal aneurysms has been decreased to 8.9%. According to our opinion major predictors of adverse events are extended reconstruction (р=0.0086), intraoperative blood loss over 4.5 liters (р=0.003) and postoperative renal failure (р=0.0005). 2-fold decrease of blood loss was observed if «bag handle» technique introduced by us was applied (р=0.0042). Organs protection is provided by using of active selective blood perfusion as well as «Custodiol» infusion. Herewith safe period of absolute ischemia ranges from 30 to 50 minutes in normothermia. Development of «hybrid» methods significantly reduced incidence of complications. We consider that patients with thoracoabdominal aneurysm and dissection are candidates for «hybrid treatment».

Invited commentary

The authors present a unique endovascular solution for the treatment of thoracoabdominal aortic aneurysms (TAAA) involving alteration and assembly of commercial endografts by the physician. The manuscript can be added to the growing body of literature describing “creative techniques” to provide endovascular treatment of TAAA, which include the use of off-the-shelf components to construct chimneys, periscopes, and sandwiches as well as other direct physician modification of commercial grafts.1Oderich G.S. Mendes B.C. Correa M.P. Preloaded guidewires to facilitate endovascular repair of thoracoabdominal aortic aneurysm using a physician-modified branched stent graft.J Vasc Surg. 2014; 59: 1168-1173Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 2Starnes B.W. Tatum B. Early report from an investigator-initiated investigational device exemption clinical trial on physician-modified endovascular grafts.J Vasc Surg. 2013; 58: 311-317Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 3Lee J.T. Greenberg J.I. Dalman R.L. Early experience with the snorkel technique for juxtarenal aneurysms.J Vasc Surg. 2012; 55: 935-946Abstract Full Text Full Text PDF PubMed Scopus (145) Google Scholar The evolution of these techniques is sparked by an apparent clinical need. Only one commercial fenestrated endograft is available, and its use is limited by the need for customization, a short infrarenal neck, and dissemination of physician training. Off-the-shelf devices have reached clinical trials, but none has yet obtained commercialization, and many have limited application to treat extensive TAAA. Currently, outside of the creative techniques, endovascular repair of TAAA requires the use of custom-made devices (and some off-the-shelf designs) that are available only at a few centers nationwide as part of physician-sponsored investigational device exemption trials. Treatment in these trials is frequently difficult for patients because of the time and expense of travel and the potential denial of insurance coverage. Whereas creative techniques offer a potential alternative to custom devices, many questions remain unanswered with respect to this approach: Which patients are suitable candidates? Are the repairs durable? Can and should these techniques be readily adapted by everyone? Can health care systems support the costs associated with use of multiple devices? Despite their shortcomings, customized fenestrated/branched endografts have been closely evaluated during long periods and provide a durable repair in patients who are at high risk for surgery with outcomes that rival those of conventional operations.4Greenberg R. Eagleton M. Mastracci T. Branched endografts for thoracoabdominal aneurysms.J Thorac Cardiovasc Surg. 2010; 140: S171-S178Abstract Full Text Full Text PDF PubMed Scopus (207) Google Scholar, 5Mastracci T.M. Greenberg R.K. Eagleton M.J. Hernandez A.V. Durability of branches in branched and fenestrated endografts.J Vasc Surg. 2013; 57: 926-933Abstract Full Text Full Text PDF PubMed Scopus (238) Google Scholar, 6Reilly L.M. Rapp J.H. Grenon S.M. Hiramoto J.S. Sobel J. Chuter T.A. Efficacy and durability of endovascular thoracoabdominal aortic aneurysm repair using the caudally directed cuff technique.J Vasc Surg. 2012; 56: 53-63Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar Outcomes are reported from physician-sponsored investigational device exemption trials with well-defined patient and anatomic enrollment criteria with standard clinical and imaging follow-up protocols. This type of data is lacking for any of the creative techniques. They should, however, be held to the same standard. If creative techniques are to be accepted as durable options, we must evolve from reporting techniques in a few patients with limited outcomes and instead direct efforts toward understanding patient selection, improving graft modification techniques, predicting those at risk for failure, and determining whether these techniques can be readily disseminated. The ramifications of failure with endovascular TAAA repair are great and need to be avoided. Only a well-planned assessment of robust data will allow us to answer these questions, to assess the modes of failure, and to determine whether these approaches are in our patients' best interests. Future endeavors, in an organized fashion, are necessary to achieve these goals. A novel endovascular debranching technique using physician-assembled endografts for repair of thoracoabdominal aneurysmsJournal of Vascular SurgeryVol. 60Issue 5PreviewThe objective of this study was to demonstrate a technique that uses physician-assembled endografts to make use of the benefits of parallel grafts while also providing for circumferential seal and fixation in repair of thoracoabdominal aneurysms in inoperable patients. Full-Text PDF Open Access

When Not to Implant the Multilayer Flow Modulator: Lessons Learned From Application Outside the Indications for Use in Patients With Thoracoabdominal Pathologies

To scrutinize registry data on thoracoabdominal repairs performed using the Multilayer Flow Modulator (MFM) outside the indications for use (IFU) and analyze the adverse outcomes. Of 380 patients from Europe registered in the MFM Global Registry after treatment for thoracoabdominal aortic aneurysm (TAAA) or dissection, 38 (10%) patients (30 men; median age 71 years, range 30-91) treated on a compassionate basis outside the IFU were analyzed. Thirteen patients had chronic Stanford type B dissection with aneurysmal dilatation >6 cm. There were 6 mycotic and 4 saccular aneurysms in addition to 15 primary TAAAs. The mean aneurysm diameter was 7.1 cm. Ten patients presented with rupture, and 23 patients had previous open or thoracic endovascular aortic repair (TEVAR). Although no death, paraplegia, stroke, or renovisceral compromise was documented during the initial hospital stay, technical success was zero. There were 31 (81.6%) cases in which there was failure to land the device in normal aorta. Other violations of the IFU included 12 with inadequate stent overlap and 11 cases involving a small MFM being deployed inside a larger one. Five of the 9 cases in which an undersized device was used resulted in a type I endoleak (failure mode I). During a mean follow-up of 10.0±6.9 months, all-cause mortality was 89.5% (34/38), of which 27 (71.1%) were aneurysm-related deaths. Overall survival, freedom from aneurysm-related death, and rupture-free survival estimates were 17.5%, 25.0%, 31.5%, respectively, at 18 months. There were 8 visceral branch complications; in all, 14 secondary endovascular interventions were required in 11 patients for endoleak (failure modes I and II) or stent foreshortening. No false lumen was completely thrombosed in the dissecting aneurysms. All aneurysms showed a mean sac growth rate of 0.12±0.16 cm/month. Factors having a significance influence on risk of aneurysm-related death included maximum aneurysm diameter (p=0.025, HR 1.37, 95% CI 1.04 to1.82), previous TEVAR (p=0.03, HR 2.44, 95% CI 1.10 to 2.08), and inadequate overlap between MFM devices (p<0.002, HR 4.02, 95% CI 1.70 to 9.49). There are clinical scenarios in which the MFM does not perform well. The MFM is not a solution for patients living on borrowed time and should not be used indiscriminately in patients in whom other modalities of aortic repair are not feasible. Its use must adhere to the IFU, and robust clinical data are required before constructing a randomized controlled trial.

Sandwich technique reserving four abdominal visceral arteries in treatment of thoracoabdominal aortic aneurysm: a case report

Sandwich technique reserving four abdominal visceral arteries in treatment of thoracoabdominal aortic aneurysm: a case report

EComment. A paradigm shift in the emergent management of aortobronchial fistula

In this interesting case report, the authors described the successful management of an acquired aortobronchial fistula (ABF) using endovascular technology [1]. The authors highlighted an extremely important point in the management of this inconsistently fatal disease if left untreated, which we welcome the opportunity to re-emphasize. The treatment of thoracic aortic disease has changed radically with the advances made in endovascular therapy since the concept of thoracic endovascular aortic repair (TEVAR) was first described 15 years ago. Many studies have demonstrated excellent short- and long-term outcomes of TEVAR for the treatment of thoraco-abdominal aortic aneurysm, with reduced reported perioperative morbidity and mortality compared with conventional open repair. A number of case reports [2–3] and small series [4] describing the successful management of ABF using thoracic stent grafts have been published over the last 10 years. Although immediate and short-term outcomes are encouraging, the major concern is the durability of this approach in the setting of a contaminated milieu in the vicinity of foreign material. Recently, Canaud et al. [5] published a very interesting review of the literature about the mid-term results of TEVAR in patients with ABF because to date long-term follow-up studies are lacking. They identified 134 patients with ABF treated with TEVAR. Most reported cases included patients with secondary ABF (55%). Of note, recurrence of ABF occurred in 14 patients (11%) and this scenario was fatal in 50% of the cases. Stent-graft infection was observed in only 3 patients during the 17 month-period of follow-up; however, this complication was associated with substantial morbidity and mortality. They concluded that TEVAR should be considered as a first-line urgent procedure for ABF. The initial management should include at least 4 weeks of intravenous antibiotic therapy and a long-term and strict follow-up is mandatory to identify early complications. Unfortunately, the Achilles heel of TEVAR in ABF remains the lack of long-term clinical results. Further evidence and long-term results are needed to help us in determining what the best strategies in these very complex patients are.

Early Experience With the First Commercially Available Off-the-Shelf Multibranched Endograft (t-Branch) in the Treatment of Thoracoabdominal Aortic Aneurysms

To assess the feasibility and safety of the first commercially available off-the-shelf multibranched endograft for total endovascular repair of thoracoabdominal aortic aneurysms (TAAA). Between November 2012 and May 2013, 15 patients (10 men; mean age 70 years) with TAAA underwent implantation of the Zenith t-Branch device, which received European marketing approval in late 2012. Three patients presented with symptomatic TAAAs, and 2 patients had a chronic Stanford type B dissection with false lumen expansion. In a retrospective review of the prospectively collected data, the primary endpoint was 30-day mortality from any cause; the primary outcome measure was technical success. Secondary endpoints were postoperative complications, including renal failure requiring dialysis, organ ischemia, and spinal cord ischemia. Radiological outcomes, such as any type of endoleak, further aneurysm expansion, and branch occlusion, were also assessed. Technical success was 100%, with all target vessels connected and patent. There was no renal function deterioration or organ ischemia. Paraplegia was observed in one patient despite cerebrospinal fluid drainage and monitoring. Four patients suffered from transient paraparesis, which was completely resolved before discharge. There was no in-hospital or 30-day mortality. After a mean follow-up of 5 months, no patient has died, and there has been no branch occlusion or type I/III endoleaks. Use of the off-the-shelf t-Branch device in the treatment of TAAAs is feasible and safe, with encouraging early clinical and radiological outcomes. Long-term results are necessary to evaluate the applicability and performance of this endograft in the urgent setting.

Endovascular repair of thoracoabdominal aortic aneurysm (TAAA): early experience

Repair of thoracoabdominal aortic aneurysms (TAAA) represents a considerable technical challenge. Since its first description in 1955, open repair of TAAA has been considered the gold standard of repair. Despite improvements in surgical techniques, spinal cord protection and post-operative critical care support, patients who undergo open repair are faced with a mortality rate of 5-35 %. We report the first Irish experience of endovascular management of TAAAs. To date five patients have undergone endovascular repair; four had hybrid repair and one a fenestrated graft. The mean age of the patients was 66.8 ± 3.4 and the mean aneurysm diameter was 6.74 ± 0.6 cm. All patients were ASA III. Two-stage hybrid repair was associated with an increased risk of complications, prolonged intensive care unit and overall hospital stay. One patient died in the perioperative period due to rupture of their aneurysm between the two stages of their hybrid repair. The role of endovascular techniques in the treatment of TAAA continues to evolve. Hybrid and complete endovascular repairs do not replace conventional repair, but provide an alternative for high-risk patients who might otherwise be denied treatment.

Hybrid procedure in the treatment of thoracoabdominal aortic aneurysms: Case report

Treatment of thoracoabdominal aortic aneurysms is a major problem in vascular surgery. Conventional open repair is associated with significant rates of mortality and morbidity and therefore, there is a need for better solutions. One of them is a hybrid procedure that includes visceral debranching. This paper presents the first such case performed in Serbia, with a brief overview on all published procedures worldwide. A 57-year-old woman was admitted to the hospital because of thoracoabdominal aneurysms type V by Crawford-Safi classifications. Because of the significant comorbidities it was concluded that conventional treatment would bear unacceptably high perioperative risk, and that the possible alternative could be the hybrid procedure in two stages. In the first stage aortobiliacal reconstruction with bifurcated Dacron graft (16 x 8 mm) and visceral debranching with hand made tailored branched graft was done. In the second act, the thoracoabdominal aneurysm was excluded with implantation of the endovascular Valiant stent graft, 34 x 150 mm (Medtronic, Santa Rosa, CA). Control MSCT angiography showed a proper visceral branch patency and positioning of the stent graft without endoleaks. Nine months after the procedure the patient was symptom-free, with no aneurysm, diameter change and no graft-related complication. All visceral branches were patent. So far about 500 cases of visceral debranching have been published with the aim of treating thoracoabdominal aneurysms, and still we have no valid guidelines concerning this method. However, in carefully selected high-risk patients this is an excellent alternative to open surgery of thoracoabdominal aneurysms.

Nationwide Trends and Regional/Hospital Variations in Open Versus Endovascular Repair of Thoracoabdominal Aortic Aneurysms

Conclusions: Use of thoracic endovascular aortic repair (TEVAR) for thoracoabdominal aortic aneurysm (TAAA) repair has increased significantly. Rates of open thoracoabdominal repair have, however, remained relatively stable. Patients otherwise not surgical candidates, or who did not otherwise meet traditional surgical indications for open thoracoabdominal repair, are those most commonly treated with TEVAR for thoracoabdominal aneurysm repair. This occurs most commonly in regions or hospitals where open thoracoabdominal repair is less often performed. Summary: TAAA is an infrequent but highly complex disease with high perioperative morbidity and mortality rates. Perioperative mortality rates for TAAA, even in experienced centers, range from 4% to 16%. Given the morbidity and mortality associated with open TAAA repair, potentially less morbid procedures using TEVAR with adjunctive surgical visceral vessel debranching (hybrid approach) or TEVAR with specialized branch endografts have emerged as alternatives to open TAAA repair. The authors sought to determine regional and hospital variation in use of TEVAR for treatment of TAAA using the Nationwide Inpatient Sample Database from 2002 to 2005. They attempted to identify all patients with a diagnosis of TAAA who were treated with a TEVAR-based technique or standard open thoracoabdominal aortic repair. Procedures were compared between years, across regions and between hospitals of various sizes. The rate of open thoracoabdominal aortic repair remained relatively stable (range, 7.5/100 patients in 2005 to 10.1/100 patients in 2008; P = .26), whereas the rate of TEVAR-assisted repairs increased dramatically (range, 1.4/100 patients in 2005 to 6.3/100 patients in 2008; P < .0001). In 2008, 29% of all TEVAR-based procedures and 11% of all open thoracoabdominal aneurysm repairs were performed in western regions of the United States (P = .03). Smaller hospitals performed 13% of all TEVAR-based thoracoabdominal procedures and 3% of all open thoracoabdominal aneurysm repairs (P < .0001). Comment: I am not sure anyone should be surprised by the fact that there may be regional variation in the performance of surgical procedures. The bigger question is not whether regional variation of surgical procedures exists but whether regionalization of complex procedures should eventually be mandated. If regionalization is mandated, how far should patients be required to travel for their care and how much additional expense should their family entail to be with their family member during the course of the procedure? The authors correctly emphasize concerns for patient safety, but personal, logistic, and economic issues also considerably muddy the waters.

Hybridoperation eines thorakoabdominellen Aortenaneurysmas

The treatment of thoracoabdominal aortic aneurysms remains an ongoing challenge in vascular surgery and has been associated with high periprocedural mortality. Since the introduction of endovascular procedures in the treatment of aortic pathologies during the last decade, new therapeutic options have arisen. We report here some technical aspects of a 2-step hybrid-procedure that consists of an initial debranching of all visceral arteries by perfusing them through a special vascular prosthesis, which is anastomosed to the healthy common iliac artery. The second step is performed after recovery of the patient from the debranching procedure and stentgraft prostheses are implanted to fully exclude the aneurysm. Thoracoabdominal aortic aneurysm. Two-step hybrid-procedure for treatment of thoracoabdominal aneurysms. In our opinion, this procedure is, although technically demanding, safely performable with a tolerable periprocedural morbidity and mortality. Major advantages are the restriction to one visceral cavity and a sequential debranching that allows us to avoid use of a temporary bypass. This procedure appears to be a promising alternative to conventional thoracoabdominal aortic repair in centres with expertise in visceral artery revascularisation.

Nationwide trends and regional/hospital variations in open versus endovascular repair of thoracoabdominal aortic aneurysms

Thoracic endovascular aortic repair (TEVAR) has been gaining popularity for the treatment of thoracoabdominal aortic aneurysm (TAAA). We used a nonvoluntary database to examine national trends and regional/hospital variations in the use of TEVAR and open thoracic aortic repair (OTAR) for TAAA. From the 2005-2008 Nationwide Inpatient Sample database, we identified all patients with the diagnosis of TAAA who were treated with TEVAR or OTAR. Rates of these procedures were compared between years, across geographic regions, and between hospitals of various bed sizes. Over the study period, the rate of OTAR remained relatively stable (range, 7.5/100 patients in 2005 to 10.1/100 patients in 2008; P = .26), whereas the rate of TEVAR increased dramatically (range, 1.4/100 patients in 2005 to 6.3/100 patients in 2008; P < .0001). In 2008, 29% (211) of all TEVAR procedures and 11% (130) of all OTAR procedures were performed in western regions of the United States (P = .03). Additionally, 13% (95) of all TEVAR procedures and 3% (35) of all OTAR procedures were performed in smaller hospitals (P < .0001). The use of TEVAR for TAAA repair increased significantly over the study period, whereas OTAR rates remained relatively stable. Our findings suggest that more patients who were otherwise not surgical candidates or did not have traditional surgical indications for OTAR were treated with TEVAR, most commonly in regions or hospitals where OTAR is less often performed. Given the complexity of TAAA cases, these results may have significant implications for patient safety in the current era of heightened health care scrutiny.

Current Role and Future Directions of Hybrid Repair of Thoracoabdominal Aortic Aneurysms

Hybrid procedures were introduced as a less invasive alternative to open conventional repair, avoiding thoracotomy, single-lung ventilation, and in many patients, aortic cross-clamping. Despite these potential advantages over open repair, results of hybrid repair have varied in the literature, with several reports indicating high morbidity and mortality rates. It is likely that once fenestrated and branched endografts receive approval from the Food and Drug Administration for clinical use, indications for hybrid repair of complex aortic aneurysms will further diminish. This article summarizes the current state of the art on patient selection, techniques, and results of hybrid procedures for the treatment of thoracoabdominal aortic aneurysms.

Endovascular treatment of thoracoabdominal aortic aneurysms

Development in endograft design has extended endovascular treatment to include thoracoabdominal aortic aneurysms (TAAA). We report our experience using fenestrated and branched endografts in the management of TAAA. We analyzed a cohort of consecutive patients treated electively for TAAA using endovascular techniques between 2006 and 2011. All data were collected prospectively. The relationships between preoperative risk factors and clinical outcome were examined using univariate and multivariate statistical techniques. We also compared the outcomes between 33 previously published early cases (EC) with the last 56 later cases (LC). Eighty-nine patients (83 men) were treated. Median age was 69 years. All patients were deemed unfit for open surgery. The 30-day and in-hospital mortality rates were 8.9% and 10%, respectively. Multivariate analysis showed in-hospital mortality was associated with preoperative chronic renal failure and advanced age. Higher postoperative mean arterial blood pressure was a protective factor. Technical success rate was 96.6% (94% and 98% in the EC and LC groups, respectively; P = .14). The spinal cord ischemia (SCI) rate was 7.8% (15% and 3% in the EC and LC groups, respectively; P = .063) and was associated with chronic obstructive pulmonary disease and procedure duration. Six patients (6.7%) required temporary filtration, but none required permanent renal support (associated with left ventricular ejection fraction <40% and procedure duration). Median procedure duration decreased from 232 to 203 minutes (P = .01) in the EC and LC groups, respectively. Actuarial survival was 86.8% ± 3.7% at 1 year and 74.7% ± 6% at 2 years. Although we have treated a cohort at high operative risk, our midterm results compare favorably with the published series of conventional surgery. Accurate hemodynamic control represented by high-normal perioperative blood pressure seems to protect against severe postoperative complications.

Fenestrated Endovascular Repair of Type IV Thoracoabdominal Aneurysms: Device Design and Implantation Technique

Treatment of thoracoabdominal aortic aneurysms has traditionally been by means of open surgery, but in recent years endovascular approaches have emerged as a viable and perhaps superior alternative. Some confusion appears to exist in discussions in the literature regarding the exact definition of the various types of thoracoabdominal aneurysm depending on whether open or endovascular repair is undertaken, with some authors comparing the preoperative extent of disease and others comparing the degree of aortic coverage required. Accurate preoperative planning and meticulous implantation technique are critical to successful outcomes with the endovascular approach. This study discusses the anatomical classification of type IV thoracoabdominal aneurysms as applied in open and endovascular surgery and outlines the authors' approach to the critical preoperative planning of endografts used to treat these aneurysms. The authors describe their techniques used to implant these devices, whether they consist of fenestrated or branched components, and some of the mechanisms by which minimization of complications such as spinal cord ischemia is sought.