Visceral Aortic Patch Research Articles

Endovascular repair of intercostal and visceral aortic patch aneurysms following open thoracoabdominal aortic aneurysm repair

PurposeReoperative open surgical repair (OSR) of thoracoabdominal aortic aneurysms (TAAAs) is associated with high morbidity and mortality. The aim of this study was to analyze outcomes of fenestrated–branched endovascular aneurysm repair (F-BEVAR) for the treatment of intercostal or visceral aortic patch aneurysms after OSR of TAAAs. MethodsWe reviewed the clinical data and outcomes of consecutive patients treated at 8 academic centers by F-BEVAR for visceral and intercostal aortic patch aneurysms after OSR of TAAAs (2011-2019). All patients had involvement of at least one target vessel requiring incorporation by a fenestration or directional branch. End points were technical success, 30-day and/in-hospital mortality, major adverse events, patient survival, target vessel patency/instability, and freedom from reintervention. ResultsThere were 29 patients with a median age of 70 (interquartile range, 63-74) years. Seven patients (24%) had connective tissue disorders. Technical success was 100%. There were no 30-day/in-hospital mortalities. Major adverse events occurred in 5 patients (17%), including estimated blood loss >1 L in 3 patients (10%), acute kidney injury and respiratory failure in 2 patients (7%) each, and transient paraparesis in 1 patient (3%). Median follow-up was 14 (interquartile range, 7-37) months. At 2 years, primary and secondary patency, freedom from target artery instability, freedom from reintervention, and patient survival were 95%, 100%, 83%, 61%, and 96%, respectively. ConclusionsF-BEVAR could be considered as an alternative to reoperative OSR in patients with visceral or intercostal aortic patch aneurysms. This series showed no mortality and a low rate of major adverse events, but a significant need for reintervention.

Hybrid Aortic Repair for Visceral Aortic Patch Aneurysm after Thoracoabdominal Aortic Aneurysm Repair

Hybrid Aortic Repair for Visceral Aortic Patch Aneurysm after Thoracoabdominal Aortic Aneurysm Repair

FT10. Open Repair of Type IV Thoracoabdominal Aortic Aneurysm: Results of Passive Visceral Shunt and Two-Graft Technique

Open repair of type IV thoracoabdominal aneurysms (TAAs) remains a surgical challenge because of the hazardous but necessary intraoperative visceral and renal ischemia. We report a novel approach with passive arterial shunt and two-graft technique to reduce these ischemic complications. A first bifurcated graft is anastomosed laterally to the distal descending thoracic aorta, before left renal artery bypass and intraoperative perfusion of both superior mesenteric and right renal arteries. A second graft is used for in-line aneurysm reconstruction. We herein present our experience of type IV TAA open repair using this technique. Twenty-four patients (mean age, 68 years) underwent elective open repair for type IV TAA with this technique between January 2011 and December 2017. The intervention was achieved through a left thoracophrenic lumbotomy, with retroperitoneal and retrorenal approach. A bifurcated graft was anastomosed laterally to the distal descending thoracic aorta to bypass the left renal artery before aortic cross-clamping. The second limb of this bifurcated graft was connected to a Y-shaped cannula to simultaneously perfuse both superior mesenteric and right renal arteries during supraceliac aortic cross-clamping (Fig 1). An additional tube or bifurcated graft was then used for in-line aneurysm reconstruction. The visceral aortic patch was anastomosed to the aortic graft with the Crawford inclusion technique. The prosthetic limb graft used as a temporary arterial shunt was ligated at the end of the intervention; the left renal artery bypass was preserved as part of the definitive arterial reconstruction (Fig 2). Patients’ records were analyzed for demographics, comorbidities, arterial lesions, operative variables, complications, and 30-day mortality. Mean left renal ischemia time was 10.5 minutes. Mean aortic cross-clamping was 31 minutes. The creatinine level at discharge was not significantly different from the preoperative level (15 vs 13; P = .01). Three patients (12.5%) had transient renal failure (Acute Kidney Injury Network stage 1) postoperatively. Prolonged ventilatory support (>2 days) was necessary in two patients (8%). No cardiac event, no dialysis, and no multivisceral organ failure have been recorded. The postoperative mortality rate was 4% (one patient). Type IV TAA repair with our passive shunt and two-graft technique provides short visceral and renal ischemia times and leads to low rates of end-organ ischemic damages. This technique could be an option to consider for visceral protection in type IV TAA open repair and spurs us on to maintain it for our future cases.Fig 2Arterial reconstruction.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Management of visceral aortic patch aneurysms after thoracoabdominal repair with open, hybrid, or endovascular approach

ObjectiveThe objective of this study was to investigate the outcomes of patients with visceral aortic patch (VAP) aneurysms after open repair of thoracoabdominal aortic aneurysm (TAAA) treated with three different approaches: open, hybrid, and endovascular repair. MethodsBetween 1993 and 2016, there were 29 cases treated for VAP aneurysm after initial TAAA open repair (median time interval, 6.2 years; interquartile range, 4-8 years). Three different treatment modalities were employed: redo open repair (O group) in 14 cases (48.3%), hybrid repair (H group) in 10 cases (34.5%), and endovascular custom-made fenestrated endograft repair (E group) in 5 cases (17.2%). Early (30-day) and midterm results were recorded. The primary end point was a composite major adverse event score: any 30-day death plus any grade ≥2 postoperative complications plus any surgical revision classified according to the Society for Vascular Surgery/American Association for Vascular Surgery reporting standards. Patients were evaluated with computed tomography scans in the outpatient clinic at 3, 6, and 12 months and annually thereafter. ResultsThe composite major adverse event score significantly differed among groups (O group, 79%; H group, 60%; E group, 0%; P = .009). Two cases (6.9%) of temporary delayed spinal cord ischemia (grade 1) were observed in both the E and H groups. The treatment modality employed was differently associated with blood loss ≥1000 mL (O group, 79%; H group, 40%; E group, 0%; P = .007), number of packed red blood cells transfused ≥3 units (O group, 100%; H group, 90%; E group, 40%; P = .003), intensive care unit stay >1 day (O group, 71%; H group, 70%; E group, 0%; P = .014), and length of hospital stay ≥7 days (O group, 79%; H group, 80%, E group, 20%; P = .034). At short term (6 months), we observed one endovascular reintervention in the E group and one fatal visceral graft thrombosis in the H group. At a median follow-up of 30 months (interquartile range, 15-75 months), we observed another aneurysm-related death in the H group due to graft infection and four unrelated deaths (one case in the H group and two cases in the O group). ConclusionsThis retrospective study confirms that repair of VAP aneurysms that develop after open repair of TAAAs can be performed with open, hybrid, and endovascular techniques. Current practice favors endovascular repair if possible, but a conclusion that it is superior to any other technique requires validation in a larger sample or a randomized trial.

Fenestrated and Branched Endovascular Treatment of Recurrent Visceral Aortic Patch Aneurysm after Open Thoracoabdominal Repair

The most common visceral revascularization technique during open repair of thoracoabdominal aortic aneurysms (TAAA) is the “inclusion technique,” but its main long-term drawback is that the retained portion of the diseased aorta might be prone to further dilatation, thus giving rise to a recurrent visceral aortic patch aneurysm. This brief report presents 4 consecutive cases of visceral aortic patch aneurysms treated by means of fenestrated and branched endovascular approach with custom-made endografts. The procedures were technically successful in all 4 patients and no major complications were recorded at 11.9 months of follow-up.

IF16. Management of Recurrent Visceral Aortic Patch Aneurysm After Thoracoabdominal Repair: Open, Hybrid, and Endovascular Approach

IF16. Management of Recurrent Visceral Aortic Patch Aneurysm After Thoracoabdominal Repair: Open, Hybrid, and Endovascular Approach

Visceral aortic patch aneurysm after thoracoabdominal aortic repair: Conventional vs hybrid treatment

Visceral aortic patch aneurysm after thoracoabdominal aortic repair: Conventional vs hybrid treatment

Visceral aortic patch aneurysm after thoracoabdominal aortic repair: Conventional vs hybrid treatment

Visceral aortic patch (VAP) aneurysm repair following thoracoabdominal aortic aneurysm (TAAA) open treatment carries high morbidity and mortality rates. The aim of this study is to compare the outcomes of our series of patients who underwent redo VAP aneurysm open surgery (conventional group) with a selected group of high-risk patients who underwent, in the same time period from 2001-2007, an alternative hybrid surgical and endovascular approach (hybrid group). Conventional group: Twelve patients (11 males, median age 71.5 years, range, 65 to 77 years) underwent VAP aneurysm (median maximum diameter 62 mm, range, 52 to 75 mm) repair with re-inclusion technique via redo thoracophrenolaparotomy or bilateral subcostal laparotomy. Reimplantation of a single undersized VAP or separate revascularization of one or more visceral arteries was performed. Hybrid group: Seven patients (5 males, median age 70 years, range, 63 to 78 years) defined as at high risk for conventional surgery having American Society of Anesthesiology (ASA) class 3 or 4 associated with a preoperative forced expiratory volume in 1 second (FEV1) <50% or an ejection fraction <40%, underwent VAP aneurysm (median maximum diameter 73 mm, range, 62 to 84 mm) repair via median laparotomy, visceral arteries rerouting, and VAP aneurysm exclusion using commercially available thoracic aortic endografts. Conventional group: Perioperative mortality was 16.7% and major morbidity 33.3%. One perioperative anuria was successfully treated with bilateral renal artery stenting. No paraplegia or paraparesis were observed. At a median follow-up of 2.3 years (range, 1.6-7 years), we observed one case of peri-graft fluid collection with sepsis at postoperative day 46 requiring surgical drainage and prolonged antibiotic therapy and one case of renal failure at day 68 requiring permanent hemodialysis. Hybrid group: perioperative mortality was 14.3% and major morbidity 28.6% with one case of transient delayed paraplegia. At a median follow-up of 1.9 years (range, 0.3-6.8 years), we observed one case of late pancreatitis (46 days postoperatively) resolved with pharmacologic treatment and one death due to an acute visceral grafts thrombosis (78 days postoperatively). We did not observe other procedure-related deaths or complications, VAP aneurysm growth, endoleak, and endograft migration. Hybrid repair is clearly a feasible alternative to simple observation for patients unfit for redo VAP aneurysm open surgery. However, despite our promising early results, new mid-term specific procedure-related complications have been observed and a widespread use of this technique should be currently limited until longer-term follow-up is available.

Hybrid approach to thoracoabdominal aortic aneurysms in patients with prior aortic surgery

The hybrid approach to the repair of thoracoabdominal aortic aneurysm (TAAA), consisting of visceral aortic debranching with retrograde revascularization of the splanchnic and renal arteries and aneurysm exclusion using stent grafts, has been previously described and may be considered particularly appealing in high-risk patients, especially those who have undergone prior aortic surgery. This study analyzed prospectively recorded data of a series of high-risk patients with prior aortic surgery who underwent hybrid TAAA repair at our institute and contrasted the outcomes with those of a similar group of patients who underwent conventional open TAAA repair. Between 2001 and 2006, 13 patients (12 men) with a median age of 69.6 years (range, 35 to 82 years) underwent one-stage hybrid repair of TAAA (7 type I, 2 type II, 2 type IV, and 2 aneurysms of the visceral aortic patch). These patients, the hybrid group, had a history of aortic surgery (30.7% ascending, 30.7% descending, 46.1% abdominal aortic repair, and 15.4% redo TAAA) and were at high risk for open repair. The criteria used to define these patients as high risk and to indicate the need for hybrid treatment were American Society of Anesthesiologists (ASA) class 3 or 4 associated with a preoperative forced expiratory volume in 1 second (FEV1)<50%. In all cases, we accomplished partial or total visceral aortic debranching through (1) a previous visceral artery retrograde revascularization with synthetic grafts (single bypass, customized Y or bifurcated grafts), and (2) aortic endovascular repair with one of three different commercially produced stent grafts (Cook, W.L. Gore & Assoc, and Medtronic). We analyzed the results and compared the outcomes of the hybrid group with those of a similar group of 29 patients (25 men) with a median age 65.3 years (range, 58 to 79) selected from our overall series of 246 TAAA repairs between 1988 and 2005. These 29 patients, the conventionally treated group, were selected for having had aortic surgery (22% ascending, 38% descending, 42% abdominal aortic repair, and 10.3% redo TAAA), an ASA 3 or 4, a preoperative FEV1<50%, and a conventional open repair of TAAA (10 type I, 5 type II, 4 type III, 7 type IV, and 3 aneurysms of the visceral aortic patch). In the hybrid group, 32 visceral bypasses were completed and endovascular TAAA repair was successful in all cases. No intraoperative deaths occurred. Perioperative mortality was 23%, and morbidity was 30.8% (renal failure in 2, respiratory failure in 1, and delayed transient paraplegia in 1). At a median follow-up of 14.9 months (range, 11 days to 59.4 months), all grafts were patent at postoperative computed tomography angiography and no aneurysm-related deaths, endoleak, stent graft migration, or morbidity related to visceral revascularization had occurred. No conventionally treated patients died intraoperatively. Perioperative mortality was 17.2% and morbidity was 44.8% (respiratory failure in 7, coagulopathy in 1, renal failure in 2, and paraplegia in 3). At a median follow-up of 5.4 years (range, 1.7 to 7.9 years), no significant complications related to aortic repair occurred, except for three patients (10.3%) with asymptomatic dilatation of the visceral aortic patch<5 cm undergoing radiologic surveillance. Hybrid TAAA repair is technically feasible in selected cases. Perioperative morbidity and mortality were considerable in our subset of high-risk patients with prior aortic surgery, but no aneurysm-related or procedure-related complications were reported at mid-term follow-up. Hybrid TAAA repair did not lead to a significant improvement in outcomes compared with open TAAA repair in a similar group of patients. Larger series are required for valid statistical comparisons and longer follow-ups are necessary to evaluate the durability of hybrid repairs.

Repair of recurrent visceral aortic patch aneurysm after thoracoabdominal aortic aneurysm repair with a branched endovascular stent graft

Aneurysmal degeneration of the visceral aortic patch is an uncommon late complication of surgical replacement of the thoracoabdominal aorta. We report on a 70-year-old woman who had undergone previous open thoracoabdominal aortic aneurysm repair and subsequent revision surgery for a visceral aortic patch aneurysm. The patient presented with a recurrent asymptomatic 60-mm-diameter visceral aortic patch aneurysm involving the celiac axis and superior mesenteric artery. The lesion was successfully treated with a custom-designed Zenith branched endovascular stent graft. The patient remains well at 12 months.

Fate of the Visceral Aortic Patch After Thoracoabdominal Aortic Repair

Fate of the Visceral Aortic Patch After Thoracoabdominal Aortic Repair

Fate of the Visceral Aortic Patch After Thoracoabdominal Aortic Repair

ObjectiveTo analyse the fate of a visceral aortic patch (VAP) in patients that underwent thoracoabdominal aortic aneurysm (TAAA) repair. MethodsWe reviewed 204 consecutive patients (158 M, 46 F) treated for TAAA between 1988 and 2004. We performed VAP in 182 cases. Among the 149 survivors at 6 months, we followed 138 cases, mean follow-up 7 years (range 0.6–16 years). The mean graft diameter we used was 29mm (range 24–34mm) from 1988 to 1999 (83 patients), and 21.7mm (range 16–24mm) from 2000 to 2003 (55 patients). In 23% of cases we performed a separate bypass to the left renal artery. ResultsWe observed 16 (12%) VAP dilatations (<5cm), 6 (4%) VAP aneurysms (>5cm) and one VAP pseudoaneurysm, at a mean time of 6 years after atherosclerotic TAAA was atherosclerotic repair. There were no VAP dilatations/aneurysms in the group of patients with separate left renal revascularization. Five VAP aneurysms were treated electively. In four cases the operation was performed with thoracophrenolaparotomy, in one case with a bilateral subcostal laparotomy. In all cases the visceral aorta was re-grafted. Reimplantation of a single undersized VAP was performed in one case, separate revascularization of visceral arteries was performed in the other four cases. Selective intraoperative hypothermic perfusion of visceral and renal arteries was used in all the patients. There was 1 perioperative death; 2 patients with preoperative renal failure required dialysis. The last VAP aneurysm has remained asymptomatic and stable at annual CT surveillance. The VAP pseudoaneurysm was successfully treated with an emergency thoracophrenolaparotomy and refashioning the left side suture line. ConclusionsAneurysm of VAP is not uncommon in the patients operated on using larger grafts with a single VAP that includes the LRA (7.4%, 5/67 cases). Its treatment carries significant morbidity and mortality.

F1.3 A new technique for grafting to severely calcined aortia

The hybrid approach to the repair of thoracoabdominal aortic aneurysm (TAAA), consisting of visceral aortic debranching with retrograde revascularization of the splanchnic and renal arteries and aneurysm exclusion using stent grafts, has been previously described and may be considered particularly appealing in high-risk patients, especially those who have undergone prior aortic surgery. This study analyzed prospectively recorded data of a series of high-risk patients with prior aortic surgery who underwent hybrid TAAA repair at our institute and contrasted the outcomes with those of a similar group of patients who underwent conventional open TAAA repair.Between 2001 and 2006, 13 patients (12 men) with a median age of 69.6 years (range, 35 to 82 years) underwent one-stage hybrid repair of TAAA (7 type I, 2 type II, 2 type IV, and 2 aneurysms of the visceral aortic patch). These patients, the hybrid group, had a history of aortic surgery (30.7% ascending, 30.7% descending, 46.1% abdominal aortic repair, and 15.4% redo TAAA) and were at high risk for open repair. The criteria used to define these patients as high risk and to indicate the need for hybrid treatment were American Society of Anesthesiologists (ASA) class 3 or 4 associated with a preoperative forced expiratory volume in 1 second (FEV1) <50%. In all cases, we accomplished partial or total visceral aortic debranching through (1) a previous visceral artery retrograde revascularization with synthetic grafts (single bypass, customized Y or bifurcated grafts), and (2) aortic endovascular repair with one of three different commercially produced stent grafts (Cook, W.L. Gore & Assoc, and Medtronic). We analyzed the results and compared the outcomes of the hybrid group with those of a similar group of 29 patients (25 men) with a median age 65.3 years (range, 58 to 79) selected from our overall series of 246 TAAA repairs between 1988 and 2005. These 29 patients, the conventionally treated group, were selected for having had aortic surgery (22% ascending, 38% descending, 42% abdominal aortic repair, and 10.3% redo TAAA), an ASA 3 or 4, a preoperative FEV1 <50%, and a conventional open repair of TAAA (10 type I, 5 type II, 4 type III, 7 type IV, and 3 aneurysms of the visceral aortic patch).In the hybrid group, 32 visceral bypasses were completed and endovascular TAAA repair was successful in all cases. No intraoperative deaths occurred. Perioperative mortality was 23%, and morbidity was 30.8% (renal failure in 2, respiratory failure in 1, and delayed transient paraplegia in 1). At a median follow-up of 14.9 months (range, 11 days to 59.4 months), all grafts were patent at postoperative computed tomography angiography and no aneurysm-related deaths, endoleak, stent graft migration, or morbidity related to visceral revascularization had occurred. No conventionally treated patients died intraoperatively. Perioperative mortality was 17.2% and morbidity was 44.8% (respiratory failure in 7, coagulopathy in 1, renal failure in 2, and paraplegia in 3). At a median follow-up of 5.4 years (range, 1.7 to 7.9 years), no significant complications related to aortic repair occurred, except for three patients (10.3%) with asymptomatic dilatation of the visceral aortic patch <5 cm undergoing radiologic surveillance.Hybrid TAAA repair is technically feasible in selected cases. Perioperative morbidity and mortality were considerable in our subset of high-risk patients with prior aortic surgery, but no aneurysm-related or procedure-related complications were reported at mid-term follow-up. Hybrid TAAA repair did not lead to a significant improvement in outcomes compared with open TAAA repair in a similar group of patients. Larger series are required for valid statistical comparisons and longer follow-ups are necessary to evaluate the durability of hybrid repairs.