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.
- SourceAvailable from: Maximilian Luehr[show abstract] [hide abstract]
ABSTRACT: Aortic endovascular stent-graft implantation is associated with low morbidity and mortality rates. Overstenting of the left subclavian artery may be necessary to create a satisfactory proximal 'landing zone' for the stent-graft. Few cases have been published reporting adverse neurological events after overstenting of the left subclavian artery. We thus evaluated whether this procedure is associated with a higher rate of neurological complications by focusing on the management of the supra-aortic vessels. Twenty patients suffering from aortic arch aneurysms (n=3), descending aortic aneurysms (n=7), acute (n=6) and chronic (n=4) type-B aortic dissections underwent stent-graft repair with complete (n=14) or partial (n=6) overstenting of the left subclavian artery. Three patients underwent overstenting of the entire aortic arch with ascending aortic-bi-carotid bypass grafting. One patient with right carotid and vertebral artery occlusion underwent initial carotid-to-subclavian bypass. All patients subsequently underwent neurological examination and Doppler ultrasound for detection of neurological and peripheral vascular complications. Aortic stent-graft repair was successful in all patients without acute neurologic complications. Two patients developed late central adverse neurological events: right-sided vertebral artery occlusion with brainstem infarction (n=1) and impaired binocular vision combined with dizziness (n=1), necessitating secondary subclavian transposition in one patient. Peripheral symptoms related to occlusion of the left subclavian artery were observed in five patients as sensory and motoric deficits of the left hand and arm. Overstenting of the left subclavian artery as treatment of aortic pathologies in high-risk patients is feasible but associated with the risk of neurological complications and peripheral symptoms. Side effects were mild or transient in most of our patients. Detailed preoperative exploration of vascular anatomy and pathology via Doppler ultrasound, CT- or MRI scan is mandatory to avoid adverse neurological events. Prior surgical revascularization of the left subclavian artery is essential in patients with high-grade stenoses, occlusions, or anatomic variants of the supra-aortic branches. Delayed surgical revascularization is necessary only in patients with relevant subclavian steal syndrome or severe peripheral vascular symptoms.European Journal of Cardio-Thoracic Surgery 05/2007; 31(4):628-36. · 2.67 Impact Factor
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ABSTRACT: Spinal cord injury can occur not only during extensive thoracoabdominal aneurysm repair but also postoperatively, causing delayed-onset paraplegia. A series of 858 thoracoabdominal aneurysm repairs (June 1990-June 2006) with an overall paraplegia rate of 2.7% was analyzed retrospectively. Serial segmental artery sacrifice was monitored by using somatosensory evoked potentials; segmental arteries were not reimplanted. Of a total of 20 cases of paraplegia, 3 occurred intraoperatively and 7 occurred late postoperatively: these will not be analyzed further. In 10 cases (the paraplegia group) spinal cord injury occurred within 48 hours after thoracoabdominal aneurysm repair, despite intact somatosensory evoked potentials at the end of the procedure. These patients with early postoperative delayed paraplegia were compared with 10 matched control subjects who recovered without spinal cord injury. In the paraplegia group a median of 9 segmental arteries (range, 5-12 segmental arteries) were sacrificed. There were 9 male subjects: median age was 63 years (range, 40-79 years), and 4 of 10 had cerebrospinal fluid drainage. A median of 9 segmental arteries (range, 2-12 segmental arteries) were also sacrificed in the matched recovery group. There were 4 male subjects; median age was 66 years (range, 40-78 years), and 8 of 10 had cerebrospinal fluid drainage. During the first 48 hours postoperatively, there were no significant differences in arterial and mixed venous oxygen saturation, partial arterial O2 and CO2 pressures, body temperature, glucose, hematocrit, or pH. The mean central venous pressures, however, were significantly higher in the paraplegic patients from 1 to 5 hours postoperatively (P = .03). In addition, although absolute mean aortic pressures did not differ between matched pairs postoperatively, when pressures were considered as a percentage of individual antecedent preoperative mean aortic pressure, paraplegic patients had significantly lower values during the first 5 hours postoperatively (P = .03). This study suggests that paraplegia can result from inadequate postoperative spinal cord perfusion caused by relatively minor differences from control subjects in perfusion parameters. Delayed paraplegia can perhaps be prevented with better hemodynamic and fluid management.The Journal of thoracic and cardiovascular surgery 03/2008; 135(2):324-30. · 3.41 Impact Factor
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ABSTRACT: To examine the efficacy of a staged approach for the treatment of thoracoabdominal aneurysms, with open visceral revascularization followed by aortic endografting, in selected patients not considered candidates for conventional surgical repair. A retrospective review was conducted of 13 consecutive patients (8 women; mean age 64 years, range 33-77) who underwent visceral bypass followed by endovascular thoracoabdominal stent-graft implantation since 1999. Three patients presented with symptomatic aneurysms and 2 with rupture. Two patients had connective tissue disorders. All patients were deemed unfit for conventional thoracoabdominal repair due to comorbid conditions. The procedures were tailored to the pathology and specific patient anatomical situation: 5 aortic dissections with aneurysmal degeneration and 8 aneurysms (5 Crawford type II, 2 type III, and 1 type IV). The patients underwent retrograde visceral bypass (11 iliovisceral and 2 infrarenal aortic to visceral artery) followed by endovascular aortic relining with Zenith TX2 devices (n=7), homemade endografts (n=5), or a Talent thoracic endograft (n=1). Six patients required either a proximal or distal direct aortic repair (2 infrarenal reconstructions, 3 arch elephant trunk grafts, and 1 ascending aortic repair), while 3 patients also underwent left carotid-subclavian bypass grafting. Two patients developed paraplegia (1 following a ruptured aneurysm), and 2 patients had transient paraparetic events. Two patients had acute renal failure requiring short-term dialysis. Three patients died within 30 days; 2 late aneurysm-related deaths were noted. Three patients developed endoleaks during follow-up. Mean lengths of stay were 13 days (7-30) for the visceral bypass and 12 (3-25) for the endovascular stent-graft. In addition, remaining procedures in 8 patients required a mean of 7 days (0-14) in hospital. Staged endovascular and open procedures are feasible for thoracoabdominal aneurysms in patients at prohibitive risk for open thoracoabdominal reconstruction. However, this approach still carries a significant risk of perioperative mortality and morbidity. The potential for less invasive alternatives should be investigated.Journal of Endovascular Therapy 09/2006; 13(4):481-9. · 2.70 Impact Factor