Treatment Of Thoracoabdominal Aortic Aneurysms Research Articles

Comparison of anatomic feasibility of three different multibranched off-the-shelf stent-grafts designed for thoracoabdominal aortic aneurysms

ObjectiveWe compared the theoretical anatomic feasibility of endovascular treatment of thoracoabdominal aortic aneurysms (TAAAs) with three off-the-shelf multibranched stent-grafts: t-Branch (Zenith t-Branch; Cook Medical, Bloomington, Ind), Gore Excluder thoracoabdominal branch endoprosthesis (TAMBE; W. L. Gore & Associates, Flagstaff, Ariz), and E-nside (E-nside multibranch stent graft system; Jotec GmbH, Hechingen, Germany). MethodsComputed tomography scans of patients with degenerative TAAAs treated from 2007 to 2019 were reviewed, and the anatomic feasibility of the multibranched stent-grafts was assessed according to the manufacturer's instructions for use. The anatomic factors determining the overall feasibility were divided into access feasibility, aortic feasibility, and visceral vessel feasibility. ResultsDegenerative TAAAs in 268 patients were analyzed. The overall feasibility did not differ significantly (TAMBE, 33%; t-Branch, 39%; E-nside, 43%; P = .271). Access, aortic, and visceral vessel feasibility alone excluded 18% to 22%, 35% to 49% and 21% to 26% of the patients respectively. The only significant difference between the devices was in aortic feasibility (P = .005), which was more frequently limited by the proximal aortic neck diameter in the TAMBE cohort and the inner visceral aortic diameter in the t-Branch cohort. The overall treatment feasibility using any of the three devices would have been 58%. ConclusionsThe new investigational off-the-shelf multibranched stent-grafts did not significantly improve the theoretical applicability in an extensive cohort of patients with TAAAs. Improvements are warranted to increase their overall feasibility.

Treatment of thoracoabdominal aortic aneurysm by prosthetic vessel replacement under left heart bypass.

Thoracoabdominal aortic aneurysm (TAAA) prosthetic vessel replacement is one of the most complex operations in the field of cardiovascular surgery. The key to success of this operation is to prevent and avoid ischemia of important organs while repairing TAAA. This study aims to summarize and analyze the effect of prosthetic vessel replacement under left heart bypass in the treatment of TAAA. Data of 15 patients with TAAA who underwent prosthetic vessel replacement under left heart bypass in Xiangya Hospital of Central South University were retrospectively analyzed. According to Crawford classification, there were 2 cases of type I, 8 cases of type II, 3 cases of type III, and 2 cases of type V. There were 14 cases of selective operation and 1 case of emergency operation. All operations were performed under left heart bypass, and cerebrospinal fluid drainage was performed before operation. Left heart bypass was established by intubation of left inferior pulmonary vein and distal abdominal aorta or left femoral artery. The thoracoabdominal aorta was replaced segment by segment. After aortic dissection, the kidneys were perfused with cold crystalloid renal protective solution, and the celiac trunk and superior mesenteric artery were perfused with warm blood. One patient with TAAA after aortic dissection of type A died. During the operation, straight blood vessels were used to repair TAAA, and the celiac artery branches were trimmed into island shape and anastomosed with prosthetic vessels. After the operation, massive bleeding occurred at the anastomotic stoma, then anaphylactic reaction occurred during massive blood transfusion, resulting in death. One patient suffered from paraplegia due to ischemic injury of spinal cord. The other patients recovered well and were discharged. The postoperative ventilation time was (16.5±13.8) h and the postoperative hospital stay was (10±4) d. The amount of red blood cell transfusion was (13±9) U. The patients were followed up for 2 months to 2 years, and the recovery was satisfactory. The effect of prosthetic vessel replacement under left heart bypass in the treatment of TAAA is good, which is worthy of clinical promotion.

Successful treatment with transesophageal pacemaker for medically refractory bradycardia during endovascular thoracoabdominal aortic aneurysm surgery: 2 case reports

We present two cases of external pacing using esophageal atrial pacing for the treatment of medically refractory bradycardia during endovascular treatment of thoracoabdominal aortic aneurysms (TAAA) under general anesthesia. TAAA are life-threatening medical emergencies. Prompt management is required to prevent rupture or further dissection. Management focuses on impulse and blood pressure control followed by endovascular repair. Beta-blockers and antihypertensives are considered first line agents. General anesthetics can potentiate the effect of these medications intraoperatively. In our patients, favorable outcome was achieved using transesophageal pacing. Currently, there is limited literature supporting the use of transesophageal pacing in the perioperative setting.

Sex-related outcomes after fenestrated-branched endovascular aneurysm repair for thoracoabdominal aortic aneurysms in the U.S. Fenestrated and Branched Aortic Research Consortium

ObjectiveFenestrated-branched endovascular aneurysm repair (FBEVAR) has expanded the treatment of patients with thoracoabdominal aortic aneurysms (TAAAs). Previous studies have demonstrated that women are less likely to be treated with standard infrarenal endovascular aneurysm repair because of anatomic ineligibility and experience greater mortality after both infrarenal and thoracic aortic aneurysm repair. The purpose of the present study was to describe the sex-related outcomes after FBEVAR for treatment of TAAAs. MethodsThe data from 886 patients with extent I to IV TAAAs (excluding pararenal or juxtarenal aneurysms), enrolled in eight prospective, physician-sponsored, investigational device exemption studies from 2013 to 2019, were analyzed. All data were collected prospectively, audited and adjudicated by clinical events committees and/or data safety monitoring boards, and subject to Food and Drug Administration oversight. All the patients had been treated with Cook-manufactured patient-specific FBEVAR devices or the Cook t-Branch off-the-shelf device (Cook Medical, Brisbane, Australia). ResultsOf the 886 patients who underwent FBEVAR, 288 (33%) were women. The women had more extensive aneurysms and a greater prevalence of diabetes (33% vs 26%; P = .043) but a lower prevalence of coronary artery disease (33% vs 52%; P < .0001) and previous infrarenal endovascular aneurysm repair (7.6% vs 16%; P < .001). The women had required a longer operative time from incision to surgery end (5.0 ± 1.8 hours vs 4.6 ± 1.7 hours; P < .001), experienced lower technical success (93% vs 98%; P = .002), and were less likely to be discharged to home (72% vs 83%; P = .009). Despite the smaller access vessels, the women did not have an increased incidence of access site complications. Also, the 30-day outcomes were broadly similar between the sexes. At 1 year, no differences were found between the women and men in freedom from type I or III endoleak (91.4% vs 92.0%; P = .64), freedom from reintervention (81.7% vs 85.3%; P = .10), target vessel instability (87.5% vs 89.2%; P = .31), and survival (89.6% vs 91.7%; P = .26). The women had a greater incidence of postoperative sac expansion (12% vs 6.5%; P = .006). Multivariable modeling adjusted for age, aneurysm extent, aneurysm size, urgent procedure, and renal function showed that patient sex was not an independent predictor of survival (hazard ratio, 0.83; 95% confidence interval, 0.50-1.37; P = .46). ConclusionsWomen undergoing FBEVAR demonstrated metrics of increased complexity and had a lower level of technical success, especially those with extensive aneurysms. Compared with the men, the women had similar 30-day mortality and 1-year outcomes, with the exception of an increased incidence of sac expansion. These data have demonstrated that FBEVAR is safe and effective for women and men but that further efforts to improve outcome parity are indicated.

Treatment of a Thoracoabdominal Aneurysm With the Cardiatis Multilayer Flow Modulator

Percutaneous treatment of thoracoabdominal aortic aneurysms have been increasingly used recent years. The Cardiatis multilayer flow modulator stents have been used for aneurysms threatment. We report our case and the results of the 2 years follow-up with thoracoabdominal aortic aneurysms treated with the Cardiatis multilayer flow modulator.&#x0D; A 78-year-old female patient was admitted to the hospital with abdominal pain. A computed tomography scan showed an aneurysm of the abdominal aorta with a maximal diameter of 50 mm. The patient refused open surgery, so we decided to treat the patient with a flow-diverting stent. In an angiography, 16x40, 16x80 and 16x80 mm three Cardiatis multilayer stent were successively implanted with an overlap of 1 cm from the distal thoracic aorta. A control angiography showed a good position of the stent and completely close the aneurysmal segment. A CT scan showed regression of the aneurysm with developing partial thrombus after the 6 month and 24 month follow-up process. &#x0D; The use of CMFM for complex aneurysms will remain a matter of debate as long as their efficacy and safety have not been completely elucidated. In conclusion, despite the successful and life-saving treatment of our patient, the use of flow-diverting stents for complex aneurysms should be limited only to those compassionate-use cases without treatment alternatives.

Preliminary results from a multicenter Italian registry on the use of a new branched device for the treatment of thoracoabdominal aortic aneurysms

ObjectiveThe study purpose was to present early outcomes of patients treated for thoracoabdominal aortic aneurysms or complex abdominal aortic diseases using endovascular repair with a new branched endograft. MethodsThis multicenter, retrospective, observational cohort study included all patients treated with a new branched endograft. All elective patients were treated with a staged operative strategy and spinal drainage Primary outcomes of interest were technical success, early (≤30 days) mortality, and late (≥30 days) survival, and freedom from adverse aortic events. ResultsA total of 16 consecutive patients were treated for Crawford's extent type I (n = 1), type II (n = 7), type III (n = 1), and type IV (n = 5) endoleaks, with an additional two complex pararenal abdominal aortic lesions (enlarging type Ia endoleak, n = 1; anastomotic pseudoaneurysm, n = 1). There were 13 male (81%) and 3 female (19%) patients with a median age of 72.5 years (interquartile range [IQR], 69-78 years). The median diameter of the aortic aneurysm was 65 mm (IQR, 58-81 mm) and the median EuroSCORE prediction for mortality was 18% (IQR, 12%-36%). Thoracoabdominal aortic aneurysm was secondary to a previous dissection in four patients. A total of 62 of the 64 visceral vessels (96.9%) were stented. Technical success was achieved in 14 (87.5 %) and the cumulative aorta-related mortality rate was 19%. Spinal cord ischemia did not occur. The mean follow-up was 8 ± 4 months (range, 2-15 months). No type I or type III endoleaks were detected. Primary bridging stent patency was 98% (one asymptomatic thrombotic occlusion of a celiac trunk branch). No aortic reintervention was required. ConclusionsEndovascular repair of complex aortic aneurysms with this new branched endograft can be performed with high technical success and acceptable morbidity. A 19% mortality is quite high; however, it is tolerable in such a high-risk cohort. The survival rate was acceptable, and graft-related outcomes at early follow-up included an absence of threatening endoleaks and a high target visceral vessel patency.

Endovascular Treatment of Thoraco-Abdominal Aortic Aneurysms: Mid Term Results of a Single Centre Experience

Endovascular Treatment of Thoraco-Abdominal Aortic Aneurysms: Mid Term Results of a Single Centre Experience

Sex-Related Anatomical Feasibility Differences in Endovascular Repair of Thoracoabdominal Aortic Aneurysms With a Multibranched Stent-Graft

Purpose: To evaluate the potential anatomical feasibility of using the off-the-shelf multibranched Zenith t-Branch for the treatment of thoracoabdominal aortic aneurysms (TAAAs) in female patients. Materials and Methods: A total of 268 patients (median age 68 years; 69 women) with degenerative TAAA treated at a single institution by means of open or endovascular repair between 2007 and 2019 were retrospectively analyzed to determine the feasibility of using the Zenith t-Branch based on the manufacturer’s instructions for use. The factors determining overall anatomical feasibility were divided into vascular access, aortic anatomy, and visceral vessels. The results were stratified by sex and compared. A logistic regression model was constructed to determine any association between feasibility and clinical factors or potential confounding variables; results are expressed as the odds ratio (OR) with 95% confidence interval (CI). Results: The overall anatomical feasibility was 39% (22% women vs 45% men, p=0.001). The feasibility was negatively influenced by female sex (p<0.001) in multivariable analysis (OR 2.9, 95% CI 1.5 to 5.4, p=0.001). Vascular access feasibility was 82% (61% women vs 89% men, p<0.001). Aorta feasibility was 65% (52% women vs 69% men, p<0.001), and visceral vessel feasibility was 74% (78% women vs 73% men, p=0.260). An access diameter ≤8.5 mm excluded 17% of the patients (39% women vs 9% men, p<0.001). The aortic feasibility was limited by the infrarenal aortic diameter in 16% of patients (45% women vs 6% men, p<0.001) and the aortic lumen at the visceral vessels in 17% patients (19% women vs 17% men, p=0.741). The visceral vessel feasibility was mainly limited by inadequate numbers or diameters of target vessels. Location and orientation of the target vessels were adequate in 96% of patients. Conclusion: A little more than a third of an all-comers cohort of patients with degenerative TAAA could have been treated with on-label use of the Zenith t-Branch. However, only 22% of women could have been treated because of sex-related anatomical limitations. New generations of multibranched devices should address these differences.

Open vs. endovascular thoracoabdominal aortic aneurysm repair: tale of the tape.

Open surgical repair persists as the gold-standard operation for thoracoabdominal aortic aneurysm; however, endovascular repair has become commonplace. Technical considerations in thoracoabdominal aortic aneurysm treatment are particularly complex, insofar as it involves critical branching arteries feeding the visceral organs. Newer, low-profile devices make total endovascular thoracoabdominal aortic aneurysm repair more feasible and, thus, appealing. For younger and low-risk patients, the choice between open and endovascular therapy remains controversial. Despite the advantages of a minimally invasive procedure, data suggest that endovascular aortic repair incurs a greater risk of spinal cord deficit, and the durability of endovascular aortic repair remains unclear. It is difficult to compare outcomes between endovascular and open thoracoabdominal aortic aneurysm repair, primarily because of the current investigational status of endovascular devices, the variety of approaches to endovascular repair, differing patient populations, lack of prospective randomized studies, and minimal medium- and long-tern follow-up data on endovascular repair. When deciding between open and endovascular approaches, one should consider which is more suitable for each patient. Older patients generally benefit from a less invasive approach. Open repair should be considered for young patients and those with heritable thoracic aortic disease. Infection and fistulae are best treated by open repair, although endovascular intervention as a lifesaving bridge to definitive repair has evolved to become a critical component of initial treatment. It is crucial to have technical expertise in both open and endovascular procedures to provide the best aortic repair for the patient. This may require dedicated aortic programs at tertiary institutions.

Aortic Aneurysm: Fenestrated/Branched Endovascular Aortic Repair (EVAR) and Fenestrated/Branched Thoracic Endovascular Aortic Repair (TEVAR). Is Total Endovascular Repair Already Here?

Five years after the first endovascular aortic repair (EVAR), Park et al. reported the first implantation of a fenestrated endoprosthesis. In the meantime, advanced generations of new fenestrated and branched endografts evolved. Endografts for complex pathologies are either so-called "off-the-shelf" grafts with predetermined length, width, diameter and clock position of the branches and fenestrations, predetermined by the manufacturer, "custom-made" grafts which need to be sized and planned individually for patients with specific thoracoabdominal anatomy. Open aortic repair in the treatment of thoracoabdominal aortic aneurysm (TAAA) still remains challenging and is associated with high morbidity and mortality, even in the elective setting. The ongoing development of endovascular treatment modalities, such as fenestrated and branched endovascular aneurysm repair (F-EVAR, B-EVAR), enables less invasive procedures for more challenging aortic pathologies. In recent years, extensive endovascular treatment of the aortic arch to the thoracoabdominal segment has become more and more important, but its outcomes have not been completely evaluated. The aim of this is article is to provide an overview of the currently available endovascular treatment options for complex aortic aneurysms requiring extensive coverage from the aortic arch to the infrarenal aorta.

Thoracic Endovascular Aortic Repair in the Setting of Compromised Distal Landing Zones

The short-term and intermediate-term outcomes of two distinct approaches to thoracic endovascular aortic repair (TEVAR) for descending aortic aneurysms in patients with compromised distal landing zones are reported. Fifty-one patients (38 female, average age 72 ± 9 years) underwent 55 TEVARs (2008 to 2018) for aneurysmal disease. Inclusion criteria consisted of TEVAR in a compromised distal landing zone, defined as follows: diameter 3.5 cm or greater; cross-sectional thrombus 50% or greater; or 25% or greater circumferential mural calcification in the 2 cm supraceliac aorta; or tortuosity index of 1.1 or more over the 10 cm supraceliac aorta. Treatment cohorts were (1) TEVAR alone (n= 29), and (2) TEVAR with adjunct consisting of visceral snorkel graft with distal stent extension (n= 20) or EndoAnchors (Medtronic, Minneapolis, MN [n= 6]). Perioperative complication rate was 20%. Thirty-day mortality was 5% including one access-site related intraoperative death and one postoperative death from embolic mesenteric ischemia. Median clinical follow-up was 2.2 years. Intermediate-term outcomes include type 1B endoleaks, 35%; 0.5 cm or more per year maximal aortic diameter growth, 9%; reintervention, 15%; and all-cause mortality, 25%. The distal landing zone diameter increased by 0.3 cm per year in the TEVAR alone cohort; however, it decreased by 0.1 cm per year in the adjunct cohort ( P= .04). Thoracic endovascular aortic repair is a viable alternative for the treatment of thoracoabdominal aortic aneurysms in patients with compromised distal landing zones, although these patients may benefit significantly from the development of branched thoracoabdominal devices. In the interim, the use of TEVAR adjuncts may limit progressive degeneration of the distal landing zone in this patient population.

Outcome of hybrid visceral debranching endovascular aortic repair

Objective The aim was to study the outcomes of hybrid debranching endovascular aortic repair (H-EVAR) for thoracoabdominal aortic aneurysm. Patients and methods Patients who had H-EVAR for treatment of thoracoabdominal aortic aneurysm between January 2010 and December 2018 were included in this study. Early outcome (30 days) in terms of mortality, morbidity, and target vessel patency were analyzed. Follow-up outcomes in terms of late death, endoleak, and re-intervention rates were evaluated. Results A total of 33 patients (48% males) with a mean age of 68±13 years were included. Eighteen (55%) patients were asymptomatic, whereas eight (24%) patients were symptomatic and seven (21%) patients had a contained rupture. Six (18%) patients died after the visceral debranching operation (stage 1), and 27 (82%) patients completed both stages of H-EVAR. The 30-day mortality in completed H-EVAR was 5 (19%) of 27 patients. Five (15%) patients developed spinal cord ischemia. Four (12%) patients had post-operative dialysis. Two (6%) patients had a stroke. Four (12%) patients experienced respiratory failure. Four (12%) patients had mesenteric ischemia and two (6%) had ischemic colitis. The 30-day overall primary target vessel patency rate was 92±3%. Early endoleak I rate was 3 (11%) of 27 patients, and endoleak III rate was 2 (7%) of 27 patients (completed H-EVAR). The mean follow-up period was 23±11 months for 22 patients who survived the completed H-EVAR. Late death occurred in 4 (18%) of 22 patients. Conclusion Hybrid EVAR had several advantages that included avoiding thoracotomy, aortic cross-clamping, single-lung ventilation, and the need for extensive dissection in multiple aortic segments. However, the controversial outcomes led to criticism, and there is a need to examine the three techniques (open, hybrid, and total endovascular) simultaneously, which would give a unique definition of the selection criteria to achieve the optimum results in each patient.

Anatomic Eligibility for Commercial Branched Endograft Repair of Thoracoabdominal Aortic Aneurysms

First-generation "off-the-shelf" branched endovascular stent grafts are in development for treatment of thoracoabdominal aortic aneurysms (TAAAs). Prior studies have assessed eligibility rates among highly selected cohorts of patients referred for endovascular treatment, and the broader applicability of these devices to all patients with TAAA is unknown. The aims of this study were to assess the overall suitability of the 3 commercial 4-branched devices with or without adjunct procedure(s) in an unselected cohort of patients with TAAA and to identify areas for improvement in the next generation of devices. A retrospective review of three-dimensional centerline reconstructions of contrast-enhanced computed tomography (CT) imaging was performed in consecutive patients with TAAA seen between 2013 and 2017. All patients with contrast-enhanced CT imaging were included, regardless of prior evaluation for suitability for endovascular repair. Eligibility for a device was assessed based on instructions for use (IFU) from the device manufacturer along with prespecified anatomic criteria. Adjunct procedures were defined as carotid-subclavian revascularization, target vessel endovascular intervention, and iliac conduit/revascularization. Of 165 patients with TAAA, 122 had CT scans adequate for study inclusion. Eighteen patients (14.8%) were eligible for at least 1 device by IFU, and 41 (33.6%) could have been made eligible for at least 1 device by an adjunct procedure. Sixty-three (51.6%) were not eligible for any device within IFU even with adjunct procedures, including 31 of 32 patients with TAAA due to dissection. The most common reasons for ineligibility were perivisceral flow channel diameter <20mm (n=43) and an inadequate proximal seal zone (n=29). Women were significantly less likely to be eligible for an off-the-shelf device (P=0.03) and were more likely to require an iliac procedure to become eligible (P=0.006). Almost none of the patients with dissection could receive a device even if adjunct procedures were used. Over half of patients with TAAA could not be made eligible for an off-the-shelf device based on manufacturers' criteria, even with adjunct procedures. Women and patients with TAAA due to dissection had higher rates of ineligibility. These data demonstrate that custom fenestrated devices and low-profile devices are needed to expand eligibility for endovascular repair of TAAA.

Thoracoabdominal aneurysmectomy: Operative steps for Crawford extent II repair.

BackgroundOpen surgical repair remains the gold standard for treatment of thoracoabdominal aortic aneurysm (TAAA). Surgery aims to replace the whole length of the diseased distal aorta while protecting the spinal cord and the visceral organs to limit ischemia-related complications. The substantial associated surgical risks, including death, paraplegia, renal failure requiring permanent dialysis, and respiratory complications leading to prolonged intensive care unit stay, still outweigh the natural history of TAAA with conservative treatment.MethodsWe describe in detail our current approach to open extent II TAAA repair with a step-by-step illustration of the technique and the surgical adjuncts.ResultsWe routinely perform left heart bypass with mild passive hypothermia (34°C), cerebrospinal fluid drainage, sequential aortic cross-clamping, monitoring of motor evoked potentials (MEPs) and cerebral, paraspinal, and lower limb oxygen saturation by near-infrared spectrometry, as well as selective visceral perfusion via the celiac and superior mesenteric arteries and renal protection with intermittent administration of Custodiol HTK (histidine-tryptophan-ketoglutarate) solution via the renal arteries. We advocate for individual branch reimplantation using a branched thoracoabdominal graft when possible, and we selectively reattach 1 or more pairs of the lower thoracic intercostal arteries and/or high lumbar arteries, even in the absence of a significant reduction in the MEPs signal. The distal anastomosis is usually constructed above the aortic bifurcation and occasionally to each iliac separately using a bifurcated graft.ConclusionsFavorable early outcomes and a durable TAAA repair can be achieved at experienced high-volume centers with standardized preoperative selection and multidisciplinary team–based intraoperative and postoperative management of these patients.

Impact of Chronic Kidney Disease and Acute Kidney Injury on Survival After Fenestrated-Branched Endovascular Aneurysm Repair for Thoracoabdominal Aortic Aneurysms

Fenestrated-branched endovascular aneurysm repair (F/B-EVAR) has extended the treatment of thoracoabdominal aortic aneurysms (TAAAs) to “high surgical risk” patients, including patients with chronic kidney disease (CKD). Previous studies have demonstrated that both CKD and acute kidney injury (AKI) are associated with decreased survival after open TAAA repair. The purpose of this study was to assess the impact of CKD and AKI on survival after F/B-EVAR. A total of 105 patients with TAAAs, enrolled in a prospective physician-sponsored investigational device exemption study (G130193) from 2014 to 2019, were analyzed. Data were collected prospectively and audited by an independent external monitor. All patients were treated with Cook manufactured patient-specific F/B-EVAR devices or the Cook t-Branch device (Cook Medical, Bloomington, Ind). CKD was defined as CKD stage 3 to stage 5 without hemodialysis, and a single patient receiving hemodialysis preoperatively was excluded. AKI was determined within 48 hours and at 30 days postoperatively using RIFLE criteria (“risk” or “injury”). Survival was analyzed using Kaplan-Meier analysis, and associated factors were identified using Cox proportional hazards model. Risk factors for AKI were analyzed using logistic regression. Of 105 patients who underwent F/B-EVAR, 46 (43.8%) had CKD. Overall 30-day mortality was 3.81% (4/105). Whereas freedom from 30-day mortality was significantly lower in CKD patients (91.4% vs 100%; P = .02), 2-year survival was not different between CKD and non-CKD patients (78.3% vs 91.5%; P = .12). AKI occurred in 34 patients (32.4%), and there was no difference in survival at 30 days (94.1% vs 97.2%; P = .47) or at 2 years (73.5% vs 91.5%; P = .08) in patients with and without AKI, respectively. CKD patients who developed AKI after F/B-EVAR (CKD + AKI) had significantly lower 2-year survival in comparison to patients without AKI (±CKD; 58.8% vs 90.9%; P = .008; Fig). Multivariable analysis identified CKD + AKI (hazard ratio [HR], 3.2; 95% confidence interval [CI], 1.04-10.07; P = .04) and intraoperative blood loss (HR, 1.001; 95% CI, 1.00-1.001; P = .04) as risk factors for decreased 2-year survival. Increased procedure time was an independent risk factor for AKI (HR, 1.01; 95% CI, 1.00-1.001; P = .04). CKD, sex, renal artery diameter, renal artery stenosis ≥50%, contrast material volume, and intraoperative blood loss showed no significant correlation with AKI. Patients with CKD have increased perioperative mortality after F/B-EVAR but similar 2-year survival compared with patients without CKD. AKI occurs frequently after F/B-EVAR, and patients with pre-existing CKD who develop AKI after F/B-EVAR have markedly worse 2-year survival. Further studies focused on identification of risk factors for AKI and development of strategies to prevent AKI during F/B-EVAR are necessary and may significantly improve patient outcomes.

Sex-related Outcomes After Fenestrated-Branched Endovascular Aneurysm Repair for Thoracoabdominal Aortic Aneurysms in the US Fenestrated and Branched Aortic Research Consortium

Fenestrated-branched endovascular aneurysm repair (F-BEVAR) has expanded the treatment of patients with thoracoabdominal aortic aneurysms (TAAAs). Prior studies have demonstrated that women are less likely to be treated with routine endovascular aneurysm repair due to anatomic ineligibility and experience higher mortality following both infrarenal and thoracic aortic aneurysm repair. The purpose of this study was to describe sex-related outcomes after F-BEVAR for treatment of TAAA. A total of 886 patients with extent I to V TAAAs (excluding pararenal or juxtarenal aneurysms), enrolled in eight prospective physician-sponsored investigational device exemption studies from 2007 to 2019, were analyzed. All data were collected prospectively, audited and adjudicated by clinical events committees and/or data safety monitoring boards, and subject to US Food and Drug Administration oversight. All patients were treated with Cook manufactured patient-specific F-BEVAR devices or the Cook t-Branch off-the-shelf device. Of 886 patients who underwent F-BEVAR, 288 (33%) were women (Table I). Women had more extensive aneurysms, higher prevalence of diabetes, lower prevalence of coronary artery disease, and lower prevalence of prior endovascular aneurysm repair. Women had longer operative times, lower technical success (93 vs 98%; P = .002), and longer length of stay (Table II). Women were more commonly treated with low-profile devices and had smaller target vessels with no difference in access site complications. Thirty-day mortality was 2% in both men and women. Early outcomes were equivalent except women experienced increased risk of permanent paralysis 2.9% versus 0.9% (P < .05). Multivariable model adjusting for age, aneurysm extent, aneurysm size, urgent procedure and renal function demonstrated that patient sex was not an independent predictor of survival (hazard ratio, 0.9; 95% confidence interval, 0.53-1.53; P = .69). At 1 year, freedom from type I or III endoleak (92.5% vs 92.5%; P = .91), reintervention (82.8% vs 85.8%; P = .19), branch vessel instability (86.4% vs 89.7%; P = .54), and survival (89.9% vs 91.6%; P = .37) did not differ between men and women. Women experienced a higher incidence of postoperative sac expansion (13% vs 6.4%; P = .006). F-BEVAR performed on women demonstrate metrics of increased complexity and have a lower level of technical success. Women experienced a higher risk of perioperative spinal cord injury but no increase in 30-day mortality. Female sex is not associated with disadvantaged 1-year outcomes; however, they did experience twice the rate of sac expansion at last follow-up. These data demonstrate that F-BEVAR is safe and effective among women despite being slightly higher risk. Further efforts to improve outcome parity are indicated.Table IPatient demographicsWomen (n = 276)Men (n = 568)P valueAge74 (7.4)74 (7.4).98Medical comorbidities Coronary artery disease33%53%<.0001 Cerebrovascular disease23%19%.18 Hypertension89%91%.41 Hyperlipidemia66%71%.14 Diabetes mellitus33%26%.043 Chronic obstructive pulmonary disease35%35%.85 Renal failure requiring dialysis3%10%.56 Prior aortic surgery44%46%.68 Prior endovascular aneurysm repair7.6%16%<.001 Dissection5.7%7.5%.99 Smoking status87%89%.46TAAA extent<.0001 I9.4%7.2% II36%20% III25%18% IV28%53% V1%0.5%Aneurysm size (cm)6.4 (1.3)6.5 (1.1).20Symptomatic/urgent presentation2.3%1.4%.39TAAA, Thoracoabdominal aortic aneurysm.Data are reported as mean (standard deviation) or as percentage where indicated. Open table in a new tab Table IIDevice and operative detailsWomen (n = 276)Men (n = 568)P valueDevice design Target vessels3.4 (0.9)3.4 (0.9).50 t-Branch14%13%.58 No. of branches1.4 (1.6)1.2 (1.6).08 No. of fenestrations1.7 (1.6)2.0 (1.8).002 Low profile55%46%.034 Preloaded system26%23%.22 Distal landing zone in the infrarenal aorta42%24%<.0001 Distal landing zone in the iliac arteries58%76%<.0001 Celiac stent diameter, mm7.3 (1.9)7.1 (2.6).33 SMA stent diameter, mm7.5 (0.9)8.2 (1.1)<.0001 RRA stent diameter, mm5.9 (0.7)6.3 (0.8)<.0001 LRA stent diameter, mm5.9 (0.9)6.1 (1.1)<.0001Operative details Operative time, hours5.0 (1.8)4.6 (1.7)<.001 Examination dose, mGy1882 (2397)3606 (2418).10 Contrast volume, mL117 (56)111 (59).20 Technical success93%98%.002 ICU Length of stay, days3.8 (3.3)3.0 (3.5).004 Hospital length of stay, days9.5 (25)6.9 (18).14ICU, Intensive care unit; LRA, left renal artery; RRA, right renal artery; SMA, superior mesenteric artery.Data are reported as mean (standard deviation) or as percentage where indicated. Open table in a new tab

A Novel Endosurgical Prosthesis to Treat Thoracoabdominal Aortic Aneurysm in Complex Anatomy or Emergency Settings.

Background Despite improvements in operative techniques, open thoracoabdominal aortic aneurysm (TAAA) repair is complex and characterized by high mortality and morbidity rate. Less invasive techniques have been developed since 2005 for the treatment of TAAA. Unfortunately, many of these devices require custom fabrication, resulting in delay of many weeks until treatment can be delivered but crucial in critical emergency cases. We present a novel hybrid endovascular and surgical prosthesis, which was tested on five pigs, with the aim of reducing the barrier issues of endovascular therapy in such particular cases. Methods The principal characteristic of the proposed hybrid endovascular prosthesis is to combine a proximal and distal stented zones and, in between, a classical surgical blood tied Dacron prosthesis. The device was tested in five pigs where feasibility of implantation and acute postoperative outcomes were evaluated, including bleeding, bowel ischemia, renal function, and peripheral blood perfusion. Results In all cases, following laparotomy, the endoprosthesis was successfully implanted under fluoroscopy and the surgical prosthesis zone could be easily detected by the radio-opaque markers. No major bleeding or cardiac events occurred throughout preparation and implantation. One hour after prosthesis implantation and surgical anastomoses of all vessels were completed, normal urine output was registered, and no acidosis was detected. Conclusions This novel graft has shown ease of endoprosthesis and visceral vessels implantation without the need of thoracotomy or extracorporeal circulation and may be useful in an emergency setting or high risk and complex anatomy TAAA unsuitable for traditional endovascular aneurysm repair, or to avoid an excess waiting time for a “custom made” prosthesis. The great adaptability of this “hybrid” prosthesis in complex anatomy for the majority of TAAA could be important in high-risk patients and in some difficult situations, such as a high risk of imminent rupture.

Geometrical Evaluation of Aortic Sac Remodeling During Two-Step Thoracoabdominal Aortic Aneurysm Endovascular Repair

The present study evaluates aneurysmal sac remodeling and the loss of the intercostal arteries after the first step of staged treatment of thoracoabdominal aortic aneurysms (TAAAs). The purpose of this approach is to keep the aneurysmal sac temporarily perfused to induce progressive thrombosis of the aneurysm while simultaneously allowing the spinal cord to establish adequate perfusion thereby promoting the development of collateral circulation. All patients with type II or type III TAAAs, having undergone 2-step endovascular treatment with at least a 2-branch endoprosthesis at our institution between April 2017 and May 2019, were retrospectively evaluated. Thirty-day mortality and spinal cord ischemia was assessed. The mean number of the intercostal and lumbar arteries, coverage length between the left subclavian artery and the stent graft proximal landing zone, total volume of the aneurysmal sac, lumen volume, and thrombosis volume were measured by preoperative and first-step postoperative computed tomography angiography. Patients were also grouped based on the chosen endoprosthesis (group A: double-branch aneurysmal sac reperfusion; group B: single-branch aneurysmal sac reperfusion). Eleven patients (mean age: 76.5 years; range: 61-86) were considered. No 30-day mortality was observed after the first-step procedure, and 1 patient died after second-step treatment. No permanent paraplegia was observed after either the first or second endovascular steps. The lumen volume significantly decreased (27%; P<0.001) after first-step endovascular treatment although there was a significant increase in aneurysm thrombosis (34% to 54%). The mean number of the intercostal arteries decreased from 19.7 to 9.3 (P<0.001) after first-step endovascular treatment. Volume variations and percentage of intercostal loss did not significantly differ between the 2 groups. Although aneurysm volume continued to increase after first-step treatment, two-step endovascular treatment is a feasible alternative to reduce the risk of severe ischemia in patients with extended TAAAs.

Successful two-step treatment of a ruptured giant thoracoabdominal aortic aneurysm

Treatment of thoracoabdominal aortic aneurysms is one of the most difficult challenges of vascular surgery. Endovascular options for complex aneurysms in urgent situation are limited. Thoracoabdominal giant aortic aneurysms are especially rare phenomena, each of them requires patient-specific treatment. Staged-fashion reconstructions may offer lower rate, especially for spinal cord injury. In our case report, we present a male patient, who had a 19.2 cm maximum diameter modified Crawford type V thoracoabdominal aortic aneurysm with contained rupture. The patient underwent an acute open repair and later a staged endovascular repair successfully. A 64-year-old male patient was admitted to our institution with complaints of chest and lower back pain in stable hemodynamic state. After evaluation, computer tomography angiography revealed a 19.2 cm maximum diameter thoracoabdominal aortic aneurysm, compression signs and hemothorax. Based on the anatomy, the serious compression symptoms and hemothorax associated with the gigantic aneurysm, we decided to perform open aortic repair. To reduce risk of spinal cord ischemia, intraoperatively we chose finishing the full reconstruction in a staged fashion. First, we performed an open repair with a Dacron interpositum distally using an oblique patch involving the visceral orifices. Later we implanted a thoracic endograft. At one-year follow-up, the patient was symptom-free, with no sign of endoleak. Giant aortic aneurysms are rare conditions, especially in the thoracoabdominal region. In the presence of compression symptoms, hemothorax and unsuitable aneurysm anatomy, open repair should be done. Staged repair offers a less invasive approach decreasing the risk of spinal cord ischemia. Orv Hetil. 2020; 161(7): 269-274.

Assessment of Pull-out Forces in TEVAR and ANACONDA FEVAR Combination and Early Clinical Results: Creation of a Proximal Landing Zone for FEVAR in Patients with Extent I and Extent IV TAAAs

Although recent data on the treatment of thoracoabdominal aortic aneurysms (TAAAs) are promising, in some cases, the paravisceral segment of the aorta may not be suitable for a branched endograft due to space restrictions. A combination of a fenestrated aneurysm repair (FEVAR) with a thoracic aneurysm repair (TEVAR) may represent a feasible treatment option. The current investigation was performed to assess the stability of a fenestrated Anaconda device implanted into a set of thoracic endografts from different manufacturers. We then assessed our clinical results with the FEVAR/TEVAR combination. Pull-out forces were measured invitro after docking a fenestrated Anaconda graft within the distal end of different TEVAR devices. Anaconda devices were implanted in 28- or 30-mm thoracic tube grafts (oversizing of at least 2mm: 13.3-21.4; minimum overlap of 15mm). Continuously increasing longitudinal pull forces of up to 100N were applied on an Instron Tensile Tester. Initial break point and damage to the endografts were documented. Clinical results of patients treated with such an FEVAR/TEVAR combination at our institution are presented as a second part of this study. Median pull-out forces ranged from 2.38N to 55.0N. The highest stability was achieved with 34-mm Anaconda devices in 28-mm thoracic tube grafts. Grafts with either thinner Dacron material or those featuring a polytetrafluorethylene membrane seemed especially vulnerable to punctures and tears caused by the downward-looking hooks of the Anaconda device. Between April 1, 2013 and December 31, 2018, in 28 of 172 patients treated with a fenestrated Anaconda device, prior implantation of a thoracic tube graft was necessary to create a sufficient proximal landing zone. In 25 cases (89.3%), the aneurysm was successfully treated. Although the 30-day reintervention rate in this subgroup was relatively high at 28.6%, none of these was due to a failure of the FEVAR/TEVAR combination. Upon an average follow-up of 15months, no failure of the graft connection and no type III endoleak due to membrane damage were observed. The combination of a thoracic tube graft and a fenestrated Anaconda device is a viable option for the treatment of patients with Extent I or IV TAAAs with no adequate landing zone above the celiac trunk. Although pull-out testing has shown good stability with most assessed grafts, the thoracic devices with thicker Dacron membranes seemed to be especially suitable.