Visceral Debranching Research Articles

Outcome of Open Repair of Thoracoabdominal Aortic Aneurysm in Takayasu Arteritis: A Retrospective Analysis

Takayasu Arteritis (TA) is an immune mediated arteritis causing inflammation of the aorta and its branches, which can result in aortic aneurysms. Our aim is to describe the outcome of surgical management in these patients who presented with Thoracoabdominal aortic aneurysm (TAAA). Between 2003 and 2023, 40TA patients with TAAA underwent operative repair. There were 24 females and 16 males, in the age group of 19-53years, with hypertension in 20 patients. Raised Erythrocyte sedimentation Rate was present in 13 patients. According to Crawford classification, there were 2 patients with type I, 2 with type II, 17 with type III, 12 patients with type IV and 7 with type V aneurysm. Multiple steno-occlusive lesions of aortic branches were present in 21 patients, with majority affecting the renal artery. Femoral Artery Femoral Vein Partial cardiopulmonary bypass was used for types I, II, III and V. Separate bypass to visceral branches was done in eight patients, of whom five had multiple bypasses and three patients only had renal bypass. Twelve patients underwent reimplantation of branches, out of which nine had multiple vessel reimplantation. Four patients underwent staged repair of the aneurysm, which included visceral debranching in the first day, followed by repair of the aneurysm in the next day. In the immediate postoperative period, ten patients developed acute kidney injury and two required dialysis. Other morbidities included acute respiratory distress syndrome (ARDS), spinal cord dysfunction, bleeding, and wound complications. Three patients expired in the immediate postoperative period. Mean duration of intensive care unit stay was 4.1days and hospital stay was 12.7days. Comparison of disease activity with morbidity and mortality was statistically insignificant. Patients were on follow-up for a range of 6months to 14years and median follow-up of 25months. Over this time period four patients expired and four developed anastomotic pseudoaneurysm requiring intervention. On comparing the disease activity at the time of surgery with the long-term arteritis related complications that required intervention, the P value was 0.653 and hence statistically not significant. The 10-year survival rate is 84.4%. Surgical repair has good and satisfactory outcome, with low early and late mortality rates. Progression of disease can occur at any stage of the disease, hence indicating the need for long term follow-up and frequent imaging.

Single stem visceral debranching for complex aortic disease

What this paper adds Treatment of complex aortic diseases including thoracoabdominal aortic aneurysms and aortic dissection is highly challenging. Hybrid repair may be useful in some situations wherein anatomy, the need of emergent repair or patient comorbidities preclude the use of total endovascular or direct open reconstruction. This paper details an original hybrid repair in which a single branch is used to reroute all visceral vessels. Abstract: Objective: Hybrid treatment of complex aortic disease has been described with various techniques of retrograde visceral bypass. The use of a single branch to revascularize all renal and visceral vessels may be less cumbersome than multiple synthetic branches and may seems to be efficient in terms of patency. Methods: We retrospectively included 15 patients between 2013 and 2021. Indication was aortic dissection (AD) (type A, acute or chronic type B), thoracoabdominal aortic aneurysms (TAA), visceral occlusive disease. Surgery consisted in median laparotomy, visceral vessel debranching from native aorta or from an aortic graft. In case of AD, surgical fenestration was performed. Additional TEVAR completed the treatment when indicated, during the same procedure or later on Results: Mean age was 60 years. 9 (60%) patients were treated for AD, 3 (20%) for TAA, 3 (20%) for occlusive disease. A total of 65 target vessels were debranched through the single stem retrograde vascular graft (SSRVG) technique. Aortic surgical fenestrations were performed in 8 cases and TEVAR in 4 cases. In the postoperative course, 3 TAA patients died,7 patients developed renal insufficiency (47%), 4 patients presented pneumonia (27%) and 3 colonic ischemia (20%). After a mean follow up of 21 months, all vessels (but 2 IMAs) were patent and no endoleak was noted. Conclusion: SSRVG technique offers a feasible and safe solution in various complex aortic diseases. The use of a single graft makes the technique straightforward by reducing the volume of multiple branch assembly in the retroperitoneal space with satisfying patency rates. Further studies with larger patient sample size and longer follow up are needed to elucidated the efficacy and durability of the technique.

Results of the North American Complex Abdominal Aortic Debranching (NACAAD) Registry.

Hybrid debranching repair of pararenal and thoracoabdominal aortic aneurysms was initially designed as a better alternative to standard open repair, addressing the limitations of endovascular repair involving the visceral aorta. We reviewed the collective outcomes of hybrid debranching repairs using extra-anatomic, open surgical debranching of the renal-mesenteric arteries, followed by endovascular aortic stenting. Data from patients who underwent hybrid repair in 14 North American institutions during 10 years were retrospectively reviewed. Society of Vascular Surgery scores were used to assess comorbidity risk. Early and late outcomes, including mortality, morbidity, reintervention, and patency were analyzed. A total of 208 patients (118 male; mean age, 71±8 years old) were treated by hybrid repair with extraanatomic reconstruction of 657 renal and mesenteric arteries (mean 3.2 vessels/patient). Mean aneurysm diameter was 6.6±1.3 cm. Thoracoabdominal aortic aneurysms were identified in 163 (78%) patients and pararenal aneurysms in 45 (22%). A single-stage repair was performed in 92 (44%) patients. The iliac arteries were the most common source of inflow (n=132; 63%), and most (n=150; 72%) had 3 or more bypasses. There were 30 (14%) early deaths, ranging widely across sites (0%-21%). A Society of Vascular Surgery comorbidity score >15 was the primary predictor of early mortality (P<0.01), whereas mortality was 3% in a score ≤9. Early complications occurred in 140 (73%) patients and included respiratory complications in 45 patients (22%) and spinal cord ischemia in 22 (11%), of whom 10 (45%) fully recovered. At 5 years, survival was 61±5%, primary graft patency was 90±2%, and secondary patency was 93±2%. The most significant predictor of late mortality was renal insufficiency (P<0.0001). Mortality after hybrid repair and visceral debranching is highly variable by center, but strongly affected by preoperative comorbidities and the centers' experience with the technique. With excellent graft patency at 5 years, the outcomes of hybrid repair done at centers of excellence and in carefully selected patients may be comparable (or better) than traditional open or even totally endovascular approaches. However, in patients already considered as high-risk for surgery, it may not offer better outcomes.

Visceral debranching followed by chemotherapy and resection for locally advanced pancreatic cancer with arterial invasion: case report

The oncological outcome of patients with locally advanced pancreatic cancer continues to be dismal. Abutment or invasion of visceral arteries, which constitutes irresectability according to the consensus of the International Association of Pancreatology and can be found in a considerable proportion of patients upon initial diagnosis, usually precludes complete resection in curative intent. Simultaneous tumor resection and arterial reconstruction are associated with relevant morbidity and mortality. Here, we present a case in which a therapeutic split was done so that isolated arterial reconstruction (visceral debranching with an iliacohepatic bypass graft) preceded neoadjuvant FOLFIRINOX chemotherapy and subsequent multivisceral tumor resection. Despite several perioperative vascular complications, which were addressed by surgical and endovascular techniques, the patient had a favorable outcome of the operations and is tumor-free after 8 months of follow-up. The feasibility and safety of this novel therapeutic strategy of a therapeutic split with isolated visceral debranching as the first treatment step is currently evaluated in a clinical trial (PREVADER, NCT04136769).

Visceral Debranching Followed by Neoadjuvant Chemotherapy and Pancreatic Resection for Locally Advanced Pancreatic Cancer: A Phase II Clinical Trial

Introduction: Advances in multimodal treatment have led to an increasing number of complex operations for pancreatic cancer . For locally advanced tumors with arterial invasion, only resection with arterial reconstruction offers a chance of cure. However, simultaneous arterial reconstruction and tumor resection is associated with high morbidity and mortality. The study aims to assess feasibility of a novel approach of performing visceral debranching, i. e. arterial reconstruction, prior to neoadjuvant chemotherapy and tumour resection in locally advanced pancreatic cancer. All open vascular procedures can be considered. Examples are aorto-visceral or iliaco-visceral bypasses. Method: The trial is designed as a single-arm multi-center study. After confirming eligibility for pancreatic resection with arterial reconstruction in a multidisciplinary tumor board, patients are offered trial enrolment. At first, patients proceed to undergo visceral debranching. Once the patient has sufficiently recovered from the procedure, neoadjuvant chemotherapy starts. Tumor resection is performed four to six weeks after completion of chemotherapy. After treatment, patients are followed up. The primary outcome is feasibility, measured as the proportion of patients who start neoadjuvant therapy within six weeks of visceral debranching. Using an exact single-stage design (H0=0.7, H1=0.9, alpha=0.05 1-beta=0.8), feasibility of the approach under study is assumed if 24 of the enrolled 28 patients proceed to neoadjuvant chemotherapy. Conclusion: This trial evaluates the feasibility of visceral debranching prior to neoadjuvant chemotherapy and tumor resection in order to avoid the relevant morbidity and mortality associated with simultaneous resection and reconstruction.

Follow-up Results of Endovascular Aneurysm Repair Following Abdominal Visceral Debranching.

The aim of this study is to present a series of six cases with thoracoabdominal aneurysm treated with hybrid technique in our center. Between May 2015 and December 2018, the data of six patients with thoracoabdominal aneurysms and various comorbidities who underwent visceral debranching followed by endovascular aortic aneurysm repair were reviewed retrospectively. Patients' mean age was 65.3±19.6 years. All of them were male. Comorbidities were old age, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease, previous surgical interventions, and/or esophageal hemangioma. Except for one patient who underwent coronary artery bypass grafting (inflow was taken from ascending aorta), debranching was performed from the right iliac artery. Debranching of four visceral arteries (superior mesenteric artery, celiac trunk, and bilateral renal right arteries) was performed in three patients, of three visceral arteries (superior mesenteric artery, celiac trunk, right renal artery) was performed in one, and of two visceral arteries (superior mesenteric artery, celiac trunk) was performed in two patients. Great saphenous vein and 6-mm polytetrafluoroethylene grafts were used in one and five patients, respectively, for debranching. Endovascular aneurysm repair was performed following debranching procedures as soon as the patients were stabilized. In total, three patients died at the early, mid, and long-term follow-up due to multiorgan failure, pneumonia, and unknown reasons. Hybrid repair of thoracoabdominal aneurysms may be an alternative to fenestrated or branched endovascular stent grafts in patients with increased risk factors for open surgical thoracoabdominal aneurysm repair; however, the procedure requires experience and care.

Single Stem Visceral Debranching for Complex Aortic Disease

ObjectiveThe treatment of complex aortic disease has been described with various retrograde visceral bypass techniques. An original technique with a single stem retrograde visceral graft (SSRVG) is presented.MethodsThis was a single centre retrospective study including 16 patients between 2015 and 2019. Patients were treated for aortic dissection (AD; type A and acute or chronic type B), thoraco-abdominal aortic aneurysms (TAAAs), and visceral occlusive disease. Surgery consisted of visceral vessel debranching from the native infrarenal aorta or from an aortic graft. In the case of AD, surgical fenestration was performed. Additional thoracic endovascular aneurysm repair (TEVAR) completed the treatment when indicated, during the same procedure or later. Patient outcomes and reconstruction patency were studied.ResultsThe mean patient age was 64 years (median 68 ± 12.6). Ten (62%) patients were treated for AD, three (19%) for TAAA, and three (19%) for occlusive disease. Sixty-nine target vessels were debranched with this SSRVG technique. Aortic surgical fenestration was performed in eight cases and TEVAR in four. During their hospital stay, three (19%) TAAA patients died, seven cases of renal insufficiency (44%), four cases of pneumonia (25%), and three colonic ischaemia cases (19%) were noted. After a mean follow up of 21 months, no other deaths occurred. All vessels (except two inferior mesenteric arteries) were patent and no endoleak was noted.ConclusionThe SSRVG technique can be offered in various complex aortic diseases. The use of a single graft is feasible and reduces the volume of multiple branch assembly in the retroperitoneal space. The observed patency rate is high.

Meta-analysis finds recurrent infection is more common after endovascular than after open repair of infected abdominal aortic aneurysm.

Controversy has continued regarding the use of endovascular aneurysm repair (EVAR) vs open aneurysm repair (OAR) for infected abdominal aortic aneurysms (AAAs). In the present study, we investigated the comparative outcomes of EVAR and OAR for the treatment of infected AAAs. We conducted a systematic review and meta-analysis using the MEDLINE and EMBASE databases through May 2021. We included studies that had described both EVAR and OAR for the treatment of infected AAAs. The primary endpoints were the rates of recurrent infection and related rupture and/or death. Perioperative and 1-year mortality and readmissions and reinterventions were also analyzed. Fourteen observational studies describing a total of 1203 patients (EVAR, 359 [29.8%]; OAR, 844 [70.2%]) were eligible for qualitative analysis. The baseline characteristics included diabetes mellitus (33.2%), fever at presentation (71.6%), rupture at diagnosis (26.1%), and positive blood cultures (52.5%). The mean follow-up period ranged from 12 to 40months. The use of EVAR became more prevalent in recent years (2016-2020, 32.4%) compared with the former period (2010-2015, 13.8%; P< .0001). Fenestrated, branched, or concomitant visceral debranching EVAR was performed in 6.1% of cases. In OAR, surgical debridement was consistently performed, and in situ reconstruction was applied in 82.2% and an omental flap in 51.5%. In nine studies considered for quantitative analysis, the patients' background (EVAR, n= 264; OAR, n= 274) were statistically balanced. The crude rates of recurrent infection and related rupture or death were 13.6% (95% confidence interval [CI], 8.8%-18.5%) and 4.9% (95% CI 1.8%-8.0%), respectively. The pooled analyses depicted significantly higher rates of recurrent infection after EVAR than after OAR (relative risk [RR], 2.42; 95% CI, 1.80-3.27; P< .0001; I2= 0%). Recurrent infection-related rupture or death (RR, 1.51; 95% CI, 0.70-3.23; P= .29; I2= 0%), perioperative death (RR, 0.80; 95% CI, 0.39-1.65; P= .55; I2= 35%), 1-year mortality (hazard ratio, 1.12; 95% CI, 0.97-1.28; P=.13; I2= 0%), and readmission or reintervention (RR, 1.16; 95% CI, 0.74-1.82; P=.52; I2= 0%) were not significantly different statistically between the two groups. Funnel plots showed no evidence of publication bias. Sensitivity analyses of leave-one-out meta-analysis confirmed higher rates of recurrent infection after EVAR. EVAR has become more prevalent as the initial treatment of infected AAAs. Although operative and 1-year survival were similar between OAR and EVAR groups, recurrent infection was more frequent after EVAR. This limitation should be weighed in selecting patients for EVAR in infected AAAs. Postoperative graft and infection surveillance are critical, especially after EVAR.

Late surgical conversion of failed Multilayer Flow Modulator stenting in thoraco-abdominal aneurysms.

The aim of this study was to report the outcomes of open or hybrid repair of failed thoraco-abdominal aortic aneurysm endovascular treatment with Multilayer Flow Modulator (MFM) stents. All patients who underwent open or hybrid repair of a failed MFM aortic treatment were retrospectively analysed. Perioperative and postoperative data, as well as midterm survival, were assessed. Between 2013 and 2020, 39 patients received an open or hybrid conversion after endovascular treatment. Five of them [13%; 4 males; median age 68 years (interquartile range 66-76)] were previously treated with aortic MFM stents (Cardiatis, Isnes, Belgium). Among these, the median interval between index repair and conversion was 84 months (interquartile range 75-84). The median aneurysm diameter was 9.6 cm (interquartile range 8-10). Renovisceral vessels steno-occlusion was highly prevalent: 2 renal arteries were occluded; 3 coeliac trunks, 2 renal arteries and 1 superior mesenteric artery had a >70% ostial stenosis. Open standard thoraco-abdominal aneurysm conversion was performed in 3 fit patients, while a hybrid approach with visceral debranching and tube endografting was performed in 2 high-risk patients. Two patients (2 open repairs) died intraoperatively, and 1 (hybrid repair) postoperatively. The 2 successfully treated patients are alive at 4- and 34-month follow-up, respectively, with patent visceral branches. Open or hybrid thoraco-abdominal aortic aneurysm treatment after failed endovascular aortic repair with MFM stents might be the only surgical option to address sac enlargements and ruptures or branch-related failures. However, both procedures had a poor prognosis due to both the impaired preoperative patient's status and the surgical complexity in the presented series.

Short-term effectiveness and safety of an anatomy-conforming hybrid surgery protocol for thoracoabdominal aortic aneurysms.

Thoracoabdominal aortic aneurysms (TAAAs) are one of the most complex aortic aneurysms to treat. Traditional open surgery for TAAAs is highly invasive and total endovascular treatment still has many limitations. Hybrid surgery offers a viable option for TAAA patients, but currently it often alters the original hemodynamics. Therefore, we have developed and applied a hybrid surgery protocol for anatomically suitable TAAA patients. Here we analyzed the short-term outcomes of these patients and evaluated the effectiveness and safety of this procedure. A new method was used to perform the required artificial revascularization of the abdominal aorta and its branches. A new visceral debranching and reconstruction approach was used to complete an anatomy-conforming open surgery. Finally, a new vascular access was used for the endovascular operation to complete the implantation of stent-grafts. The clinical data of 10 patients with TAAAs treated at our center with the anatomy-conforming hybrid technique during the period from May 2018 to June 2020 was retrospectively analyzed. The intraoperative and 30-day postoperative key indicators, including survival rates and complications, were analyzed. The hybrid surgery was smoothly performed in all 10 patients. One patient died from non-aortic causes (sepsis/infectious toxic shock) 30 days after surgery, yielding a case-fatality rate of 10.0% (1/10). Two patients (2/10) experienced serious complications within 30 days postoperatively, including multi-organ failure due to infection in one patient and lower limb ischemia in another patient who went on to develop permanent paraplegia. No endoleak after stent implantation was noted and the blood supply of each reconstructed visceral artery was good. Based on the short-term outcomes, the anatomy-conforming hybrid surgical protocol is safe and effective in treating TAAA patients.

Pre-operative/Neoadjuvant Therapy and Vascular Debranching Followed by Resection for Locally Advanced Pancreatic Cancer (PREVADER): Clinical Feasibility Trial.

Introduction: Pancreatic cancer continues to have a poor outcome. Many patients are diagnosed with advanced disease, and in a considerable proportion, abutment or invasion of visceral arteries is present. Moreover, some patients have anatomical variations or stenosis of major visceral arteries requiring arterial reconstruction upon pancreatic cancer resection to avoid organ ischemia. Simultaneous arterial reconstruction during resection is associated with relevant morbidity and mortality. This trial evaluates the approach of visceral debranching, that is, arterial reconstruction, prior to neoadjuvant chemotherapy and tumor resection in patients with locally advanced, unresectable pancreatic cancer.Methods and Analysis: The trial includes patients with locally advanced, non-metastatic pancreatic cancer with arterial abutment or invasion (deemed primarily unresectable), variations in vascular anatomy, or stenosis of visceral arteries. The participants undergo visceral debranching, followed by current standard neoadjuvant chemotherapy (mFOLFIRINOX, gemcitabine–nab-paclitaxel, or other) and potential subsequent tumor resection. The primary outcome is feasibility, measured as the proportion of patients who start neoadjuvant therapy within 6 weeks of visceral debranching. The trial has an exact single-stage design. The proportion below which the treatment is considered ineffective is set at 0.7 (H0). The proportion above which the treatment warrants further exploration in a phase III trial is set at 0.9 (H1). With a power (1-beta) of 0.8 and a type 1 mistake (alpha) of 0.05, the required sample size is 28 patients. Feasibility of the approach will be assumed if 24 of the enrolled 28 patients proceed to neoadjuvant chemotherapy within 6 weeks from visceral debranching.Discussion: This trial evaluates a new treatment sequence, that is, visceral debranching followed by chemotherapy and resection, for pancreatic cancer with invasion or abutment of visceral arteries. The primary objective of the trial is to evaluate feasibility. Trial results will allow for estimating treatment effects and calculating the sample size of a randomized controlled trial, in which the approach will be tested if the feasibility endpoint is met.Clinical Trial Registration: clinicaltrials.gov, identifier: NCT04136769.

Visceral debranching in hybrid surgery of thoracoabdominal aortic aneurysms

Presented herein is a review of the literature dedicated to the method of visceral debranching, i. e., switching of the visceral and renal branches of the abdominal aorta to its intact portion, using synthetic vascular prostheses as the first stage of hybrid surgical treatment of thoracoabdominal aortic aneurysms prior to endovascular aortic aneurysm repair. This is accompanied and followed by describing the history of the problem, operative technique, results of studies, as well as the data from registries and meta-analyses. Also discussed are the main complications of the method and measures of their prevention. We conclude that hybrid surgery of the thoracoabdominal portion of the aorta is a promising method in a particular cohort of patients, especially those at high surgical risk of 'open' aortic surgery.

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.

Comparison of Physician-Modified Fenestrated/Branched Stent-Grafts and Hybrid Visceral Debranching Plus Stent-Graft Placement for Complex Thoracoabdominal Aortic Aneurysm Repair

Purpose: To evaluate the immediate postoperative and midterm outcomes of complex thoracoabdominal aortic aneurysm (TAAA) treatment with fenestrated/branched physician-modified endovascular grafts (PMEGs) or open debranching of the visceral aorta with bypass graft revascularization plus endovascular aneurysm exclusion (hybrid repair). Materials and Methods: A retrospective analysis was conducted of 88 patients (mean age 70.0±10.6 years; 73 men) with complex TAAAs who underwent treatment with PMEGs (60, 68%) or a hybrid technique (28, 32%) between 2016 and 2019. The mean aneurysm diameter was 64.5±11.7 mm, and 37 patients (42%) were symptomatic. The Zenith TX2 and Ankura were the main stent-grafts used in the PMEG group. The hybrid technique involved visceral debranching with extra-anatomical bypass graft revascularization and subsequent stent-graft deployment (1- or 2-stage procedure). Results: In the PMEG group, 35 patients received modified stent-grafts with 4 fenestrations, 8 patients had 4 branches per device, and 17 patients had combinations (50 fenestrations and 18 branches) that successfully revascularized 228 of the 240 targets (95%). In the 28 hybrid cases, all 110 target vessels were successfully revascularized with bypass grafts. The overall 30-day mortality was 3.4% (2 PMEG and 1 hybrid), and the early rate of target vessel stenosis/occlusion was 3.3% (5 in PMEG group and 6 in the hybrid repair group). The 30-day morbidity was mainly attributed to pulmonary complications (15%), lower limb ischemia (8%), or spinal cord ischemia with paraplegia (6%). Eleven patients (13%) had deteriorated renal function with a >30% decrease in the glomerular filtration rate. The mean follow-up was 22.3±4.9 months, and mortality was 4.5% (3.3% in the PMEG group vs 7.1% in the hybrid repair group). Conclusion: PMEGs and hybrid techniques seem to be feasible treatment options for aortic aneurysms necessitating visceral vessel revascularization. PMEGs may have a lower morbidity than the hybrid technique, which nonetheless remains an important option available for complex aortic aneurysms.

Ascending Aortobifemoral Bypass and Visceral Debranching is an Effective Treatment for Complex Symptomatic Thoraco-abdominal Disease

Ascending Aortobifemoral Bypass and Visceral Debranching is an Effective Treatment for Complex Symptomatic Thoraco-abdominal Disease

A case report of a hybrid procedure (visceral and partial aortic arch debranching) in the treatment of a challenging aneurysm of the thoracoabdominal aorta in the endovascular era

Introduction. This paper aimed to present a hybrid approach as a less invasive and acceptable treatment. Case outline. Because of respiratory failure, the patient was deemed at high risk for open repair. Standard thoracic endovascular aortic repair (TEVAR) was unfeasible, so the patient underwent the hybrid procedure ? partial aortic arch debranching at the first stage, followed by visceral debranching and endovascular exclusion of thoracic aortic aneurysm as a final procedure. The postoperative course was uneventful and the patient was discharged 10 days after TEVAR and visceral debranching. Conclusion. Staged hybrid procedure with combined debranching of the aortic arch and visceral arteries is feasible and should be considered as an alternative treatment option in patients with high-risk for open repair.

Comparative outcomes of open, hybrid, and fenestrated branched endovascular repair of extent II and III thoracoabdominal aortic aneurysms

ObjectiveOpen repair of extent II and III thoracoabdominal aortic aneurysms (TAAA) is associated with substantial morbidity. Alternative strategies, such as hybrid operations combining proximal thoracic endovascular aortic repair with either staged open distal TAAA repair or visceral debranching (hybrid), as well as fenestrated/branched endografts (FEVAR), have been increasingly reported; however, benefits of these approaches compared with direct open surgery remain unclear. The purpose of this study was to compare outcomes of these three different strategies in the management of extent II/III TAAA. MethodsAll extent II/III TAAA repairs (2002-2018) for nonmycotic, degenerative aneurysm or chronic dissection at a single institution were reviewed. The primary end point was 30-day mortality. Secondary end points included incidence of spinal cord ischemia (SCI), complications, unplanned re-operation, 90-day readmission, and out-of-hospital survival. To mitigate impact of covariate imbalance and selection bias, intergroup comparisons were made using inverse probability weighted-propensity analysis. Cox regression was used to estimate survival while cumulative incidence was used to determine reoperation risk. ResultsOne hundred ninety-eight patients (FEVAR, 92; hybrid, 40; open, 66) underwent repair. In unadjusted analysis, compared with hybrid/open patients, FEVAR patients were significantly older with more cardiovascular risk factors, but less likely to have a connective tissue disorder or dissection-related indication. Unadjusted 30-day mortality and complication rates were: 30-day mortality, FEVAR 4%, hybrid 13%, open 12% (P = .01); and complications, FEVAR 36%, hybrid 33%, open 50% (P = .11). Permanent SCI was not different among groups (FEVAR 3%, hybrid 3%, open 6%; P = .64). In adjusted analysis, 30-day mortality risk was greater for open vs FEVAR (hazard ratio, 3.6; 95% confidence interval, 1.4-9.2; P = .01) with no difference for hybrid vs open/FEVAR. There was significantly lower risk of any SCI for open vs FEVAR (hazard ratio, 0.3; 95% confidence interval, 0.09-0.96; P = .04); however, no difference in risk of permanent SCI was detected among the three groups. There was no difference in complications or unplanned reoperation, but open patients had the greatest risk of unplanned 90-day readmission. There was a time-varying effect on survival probability, with open repair having a significant survival disadvantage in the first 1 to 6 months after the procedure compared with hybrid/FEVAR patients (Cox model P = .03), but no difference in survival at 1 and 5 years (1- and 5-year survival: FEVAR, 86 ± 3%, 55 ± 8%; hybrid, 86 ± 5%, 60 ± 11%; open 69 ± 7%, 59 ± 8%; Cox-model P = .10). ConclusionsExtent II/III TAAA repair, regardless of operative strategy, is associated with significant morbidity risk. FEVAR is associated with the lowest 30-day mortality risk compared with hybrid and open repair when estimates are adjusted for preoperative risk factors. These data support greater adoption of FEVAR as first-line therapy to treat complex TAAA disease in anatomically suitable patients who present electively.

Hybrid treatment of thoracoabdominal aortic aneurysm: Case series and review of the literature

Background/Aim. Open thoracoabdominal aortic aneurysm (ThAAAs) repair is a challenging mission. Total endovascular approach is performed at selected institutions in developing countries, however these are not generalizable. Hybrid procedures offer an alternative approach. The aim of this study was to present our results of the ThAAA hybrid treatment and a literature review. Methods. This is a retrospective study of all patients that underwent the hybrid ThAAA repair at our institution between January 2011 and January 2018. Hybrid ThAAA repair was done as a twostaged procedure ? open visceral debranching followed by stent-graft placement (TEVAR). The following data from eligible studies were extracted and analyzed: first author, publication year, patient sample, 30-day/in-hospital mortality, permanent paraplegia rate, presence of endoleaks and graft patency after the follow-up period, overall survival and mean follow-up period. Results. Seven patients underwent the hybrid ThAAA repair at our institution. Neither intraoperative death nor technical failure due to TEVAR was observed. Mean follow-up rate after discharge was 51.71 months [95% confidence interval (CI): 14.67?88.74 months]. At the time of the follow-up, all bypasses were patent and no prosthesis migration was documented. After one year, a case of type Ib endoleak was identified and treated successfully. Twenty-five studies were eligible for the literature review. Primary technical success was 91.69% (95% CI: 85.34?97.24%). Mean percentage of permanent paraplegia was 5.27% (95% CI: 3.55?7.01%). Visceral graft patency during the mean follow-up of 27.54 months (95% CI: 17.41?37.66 months) was 94.5% (95% CI: 92.5?96.5%). Mean pooled percentage rate of overall endoleaks during the follow-up period was 16.72% (95% CI: 11.15?22.29%). Analysis revealed 15.32% (95% CI: 11.04?19.61%) of 30- day/in-hospital mortality and 65.98% (95% CI: 58.15? 73.81%) of overall survival after the follow-up period. Conclusion. Although thought as less invasive, the hybrid ThAAA repair is still associated with a considerable morbidity and mortality.

Renal Function Salvage After Delayed Endovascular Revascularization of Acute Renal Artery Occlusion in Patients With Fenestrated-Branched Endovascular Aneurysm Repair or Visceral Debranching

Purpose: To analyze the renal function and outcome after delayed (>6 hours) endovascular revascularization of acute renal artery occlusion (RAO) in patients with fenestrated-branched endovascular aneurysm repairs (EVARs) or open visceral debranching. Methods: A single-center retrospective analysis was conducted involving 7 patients (mean age 61 years, range 49–72; 5 women) with 9 RAOs treated with endovascular revascularization between December 2014 and March 2017. Three patients had a solitary kidney with chronic renal insufficiency; 1 patient had bilateral occlusions as the acute event. Initial aortic surgery included 5 branched and 1 fenestrated EVAR as well as 1 open visceral debranching operation. Revascularization of the RAO was performed using aspiration thrombectomy, local lysis therapy, and stent-graft relining. The median time between initial aortic surgery and RAO was 10 months (range 0.5–17). Results: Median renal ischemic time to revascularization was 24 hours (range 7–168). Technical success was 100%, with 1 procedure-related access complication. Temporary dialysis dependency occurred in 4 patients. Mean in-hospital stay was 17 days (range 7–32) with 1 postoperative death at day 10 due to cardiac arrest of unknown cause. Mean follow-up was 10.3 months (range 1.5–27) in 5 of 6 discharged patients. During follow-up, 1 reintervention for recurrent occlusion was performed. At follow-up imaging, all renal arteries were patent. No permanent dialysis dependency occurred. Conclusion: Renal function can be salvaged by delayed revascularization for RAO with prolonged renal ischemia. The endovascular approach with aspiration thrombectomy, local lysis, and stent-graft relining is a feasible technique for revascularization after RAO in patients with fenestrated-branched EVAR or open visceral debranching.

RS01. Planned Exclusion of the Celiac Artery During Complex Thoracic Endovascular Aortic Repair Procedures: Is It Safe?

Achieving adequate proximal and distal fixation and maintaining visceral branch flow make thoracic endovascular aortic repair (TEVAR) procedures for thoracoabdominal aneurysm (TAAA) complex. Whereas superior mesenteric artery (SMA) and renal vessels must be preserved, there may be selected cases in which patent celiac arteries may be intentionally excluded. We sought to define the incidence of ischemic complications of celiac exclusion during complex TEVAR procedures and to define specific conditions in which the celiac can be safely covered. We performed a retrospective 12-year audit in two tertiary care institutions of patients with a suprarenal aneurysm or TAAA treated by standard TEVAR involving the distal thoracic aorta with intentional celiac fabric coverage or bare distal stent across the celiac (preserved), custom or modified aortic endografts (complex TEVAR/fenestrated EVAR [FEVAR]) involving multiple visceral branch endoprostheses with and without planned celiac exclusion, or a transabdominal hybrid approach with visceral debranching bypasses (with or without celiac revascularization) from distal inflow sites and staged or simultaneous long length thoracoabdominal endografting. The decision to exclude celiac arteries was made from preoperative computed tomography findings of a small diameter, stenotic origin, presence of replaced right hepatic artery, or existing large SMA celiac collaterals. Cases with a chronically occluded celiac were excluded. Primary end points were 30-day mortality, spinal cord ischemia, and any foregut ischemia occurring early or during late follow-up (ischemic acalculous cholecystitis or splenic infarction). There were 223 patients who met inclusion criteria (Table I). In the standard/complex TEVAR/FEVAR group, 26 patients (15%) had celiac coverage with 144 cases of celiac preservation. In the hybrid group, 11 cases (21%) had celiac exclusion, whereas 42 patients had a separate celiac bypass. In the standard/complex TEVAR/FEVAR group, celiac coverage did not result in significant increase in foregut ischemic events (3.8% vs 2.1%; P = .6; Table II). However, exclusion of the celiac artery during hybrid cases resulted in an increase in foregut ischemia (two early and one case presenting 1 year later) compared with patients having celiac bypass revascularization (27% vs 7%; P = .06). The incidence of spinal cord ischemia and 30-day all-cause mortality was not different with regard to celiac exclusion or between treatment groups. Selected celiac exclusion appears safe during standard/complex TEVAR/FEVAR procedures as long as SMA patency is ensured. A hybrid approach to complex TAAA requires separate bypass to all patent visceral branches including the celiac to minimize foregut ischemia.Table IDemographicsVariableTEVAR with celiac coverageTEVAR with celiac revascularizationHybrid without celiac revascularizationHybrid with celiac revascularizationNo.261441142M/F69/3174/2655/4568/32Urgent/emergent35131810History of aortic surgery27515536Dissection present12102710TEVAR, Thoracic endovascular aortic repair.Values are reported as percentage. Open table in a new tab Table IIPostoperative outcomesVariableTEVAR with celiac coverageTEVAR with celiac revascularizationTEVAR covered celiac vs TEVAR revascularized celiac, χ2 comparison P valueHybrid without celiac revascularizationHybrid with celiac revascularizationHybrid with and without revascularization, χ2 comparison P valueNo.26144114230-Day mortality7.7 (2)3.5 (5).319.1 (1)11.9 (5).79SCI3.8 (1)15.3 (22).120 (0)11.9 (5).57Foregut ischemia3.8 (1)2.1 (3).5927.2 (3)7.1 (3).06SCI, Spinal cord ischemia; TEVAR, thoracic endovascular aortic repair.Values are reported as % (No.). Open table in a new tab