Endovascular treatment for thoracoabdominal aneurysms: outcomes and results.
ABSTRACT Endovascular treatment of thoracoabdominal aortic aneurysms (TAAA) in combination with selective open surgical revascularization may be an alternative to conventional surgical repair. We analyzed our patient outcomes after elective and emergent endovascular TAAA repair.
Mortality and outcome data from 21 consecutive patients treated with endovascular TAAA repair between 2000 and 2006 were reviewed. An integrated neuroprotective approach was used on all patients. Mortality risk estimates for open surgery (OS) were calculated using the published risk assessment models and compared to our outcomes.
Of the 21 patients, 9 had acute presentation: acute pain (9), rupture (6), and malperfusion (1). The celiac axis was overstented in 15. Nine hybrid open surgical procedures were performed: visceral/renal arteries (5), infrarenal aorta (3) and complete arch revascularization (1). Eleven patients had previous aortic surgery. Thirty-day mortality rate was 4.8% (1/21, predicted OS value 8.3%), 1-, 2- and 3-year survival was 80%. One hospital death occurred due to ischemic colitis after inferior mesenteric artery overstenting. No patient with acute presentation died during the initial hospital admission. There was no paraplegia (predicted OS rate 11.46%) and one event of delayed temporary paraparesis 3 weeks after hospital discharge corrected with raising the blood pressure. Other neurologic complications included one minor left pontine stroke with complete resolution, postoperative confusion (1) and saphenous nerve injury (1). No new late endoleaks occurred after initial complete aneurysm exclusion. Five patients underwent early (<30 days) and four patients underwent late endovascular reinterventions for persistent endoleak. An additional reintervention included percutaneous stenting of a superior mesenteric artery stenosis. Actual freedom from late reintervention was 81%, and 76% at 1-, 2 and 3-year follow-up. Late major adverse events included one stent infection leading to multi-organ failure and death.
Endovascular treatment of thoracoabdominal aneurysms with selective visceral and renal revascularization is associated with low mortality and can only be effectively performed by a surgeon. High-risk patients and those with acute presentation appear to benefit most from this therapy. Early results up to three years of this therapy are encouraging, but further follow up to validate long-term results is required.
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ABSTRACT: The present case report details our experience with the hybrid approach for multiple aneurysms in the aortic arch, thoracoabdominal aorta, and around the aortic bifurcation. Total arch replacement for the arch aneurysm under hypothermic cardiopulmonary bypass with antegrade cerebral perfusion was the first stage of aneurysm repair. Five months later, bifurcated graft replacement with debranching of four abdominal branches was undertaken as the second stage of treatment. Finally, stent-graft repair for chronic dissection of the thoracoabdominal aorta was performed utilizing a Gore-Tex Tag endovascular prosthesis. Over 7 months of treatment, all aneurysms were excluded from the aortic blood flow and pressure without abdominal organ dysfunction except a transiently elevated total bilirubin level. Although the patient had an episode of minor gastrointestinal bleeding after discharge, he is currently leading a normal life without limitations at home 5 months after the stent-graft repair.General Thoracic and Cardiovascular Surgery 04/2011; 59(4):288-92.
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ABSTRACT: Recent advances in endovascular surgery have put into question the role of open operative treatment of thoracoabdominal aortic aneurysms. In this context we evaluated our experience with thoracoabdominal aortic aneurysm repair using cardiopulmonary bypass and hypothermic circulatory arrest. From January 1986 to December 2008, 218 patients (mean age, 63 ± 14 years) underwent thoracoabdominal aortic aneurysm repair with cardiopulmonary bypass and hypothermic circulatory arrest. The degree of repair was as follows: Crawford extent I, 57 (26%) patients; Crawford extent II, 91 (41%) patients; and Crawford extent III, 70 (32%) patients. Degenerative aneurysms were present in 160 (73%) patients. Eighteen (8%) patients underwent emergency operations. The mean durations of cardiopulmonary bypass and hypothermic circulatory arrest were 160 ± 44 and 31 ± 12 minutes, respectively. Stroke occurred in 8 (3.7%) patients, and spinal cord ischemic injury occurred in 10 (4.6%) patients (8 with paraplegia and 2 with paraparesis). Temporary dialysis for new-onset renal failure was required in 3.6% of hospital survivors. Thirty-day and 1-year mortality rates were 7.3% and 24.5%, respectively. After emergency operations, the 30-day mortality rate was 33.3% compared with 5.0% after elective operations (P = .001). Five- and 10-year survivals were 55% and 23%, respectively. Twenty-five patients required reoperation on the graft or contiguous aorta at a mean of 5 ± 3 years after the initial procedure. Five- and 10-year rates of freedom from reoperation were 87% and 60%, respectively. Cardiopulmonary bypass with hypothermic circulatory arrest can be safely used for thoracoabdominal aortic aneurysm repair, providing excellent protection against end-organ injury. Early mortality and morbidity rates do not exceed those reported for endovascular repair, with particularly favorable outcomes among patients undergoing elective operations.The Journal of thoracic and cardiovascular surgery 04/2011; 141(4):953-60. · 3.41 Impact Factor
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ABSTRACT: Conventional open surgical repair, endovascular treatment, and the hybrid technique constitute the three treatment options for patients with type IV thoracoabdominal aortic aneurysms (TAAAs). Treatment is advocated to prevent rupture but yields significant risk for spinal cord ischemia, cardiovascular, and renal and respiratory complications, including death. Refinements in open surgical techniques and branched endovascular graft repair together with the development of hybrid techniques have been applied to the treatment of type IV-TAAAs to decrease the risk of these complications. However, much of the evidence of the argument is circumstantial. Large experiences are limited to a few centers worldwide with inherent disparity between patient groups and several limitations to the construction of a prospective randomized trial. This controversial subject is now open to discussion, and our debaters have been given the challenge to clarify the evidence to justify their preferred option for repair of type IV-TAAAs.Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 07/2011; 54(1):258-67. · 3.52 Impact Factor