Wholly endovascular repair of thoracoabdominal aneurysm.
ABSTRACT The aim was to evaluate a wholly endovascular approach to the repair of thoracoabdominal aortic aneurysm (TAAA).
Six patients (median age 71 years) underwent wholly endovascular repair of TAAA (maximum diameter 56-85 mm) employing individually customized endografts. Procedures were performed under general anaesthesia, with spinal drainage in five patients. Patients were followed by serial computed tomography, plain radiography and duplex imaging for a median of 17 (range 8-44) months.
All grafts were deployed as intended, with preservation of all target vessels. There were no postoperative deaths, strokes or paraplegia. One patient suffered a silent myocardial infarction. In two patients a persistent paraostial endoleak was treated by further balloon dilatation of the stent within the endograft fenestration. Imaging before discharge confirmed aneurysm exclusion in all patients. Two patients required late secondary intervention to abolish endoleaks due to side-branch disconnection. One patient suffered late occlusion of the coeliac axis without clinical sequelae, and late occlusion of a solitary renal artery in another resulted in dependence on dialysis. There have been no late deaths and all aneurysms remain excluded.
Wholly endovascular TAAA repair is relatively safe, but long-term follow-up is required to establish its durability.
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ABSTRACT: Aortic aneurysms are classified as complex based on their extent and involvement of side branches. Complex aortic aneurysms include arch, thoracoabdominal, juxtarenal and suprarenal aortic aneurysms. Open surgical repair carries high morbidity and mortality beyond large tertiary care centers. During the last decade, numerous technological advances have allowed incorporation of side branches using hybrid and total endovascular techniques. Fenestrated and branched endografts have been widely applied to treat patients with complex aneurysm anatomy. Newer stent graft designs are currently under clinical investigation offering an off-the-shelf alternative to custom-made stent grafts for patients with complex aortic aneurysms. Alternatively, a number of endovascular techniques have been described including chimney, snorkel, periscope and sandwich stent grafts. This article summarizes the current status of hybrid and total endovascular techniques to repair of thoracoabdominal, juxtarenal and suprarenal aortic aneurysms.Current Surgery Reports. 1(2).
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ABSTRACT: To assess the pullout force (POF) of bridging stent-grafts used in thoracoabdominal stent-grafts and iliac bifurcated grafts. In an experimental setup, the POFs of Viabahn or Fluency with or without a Zilver stent were measured when deployed into the renal and celiac branches of a Zenith thoracoabdominal cuff-bearing branched stent-graft. The POFs of the Atrium i-Cast, Viabahn, Fluency, and Fluency+Zilver were measured when deployed into an iliac bifurcated graft with a short side-branch for the internal iliac artery. At least 10 trials were performed for each stent in air at room temperature. The median POF (IQR; absolute range) required to dislodge each bridging stent-graft from the 6-mm renal branch was 1.89 N (0.47 N; 1.65-2.5) for the 7-mm Viabahn, 1.17 N (0.39 N; 0.68-1.57 N) for the 7-mm Fluency, and 2.08 N (0.49 N; 1.59-2.62 N) for the 7-mm Fluency with a supporting 8-mm Zilver stent (p<0.001). For the 8-mm celiac branch, the POFs were 2.79 N (0.82 N; 2.31-4.16 N), 1.74 N (0.18 N; 1.51-1.91 N), and 2.73 N (0.94 N; 1.9-3.61 N) for the 9-mm Viabahn, 9-mm Fluency, and 9-mm Fluency with a 10-mm Zilver stent, respectively (p<0.001). For the 8-mm internal iliac branch, the POFs were 3.53 N (0.85 N; 2.55-4.72 N) for the 9-mm i-Cast, 3.82 N (0.41 N; 3.29-4.45 N) for the 9-mm Viabahn, 2.32 N (0.23 N; 1.63-2.64 N) for the 9-mm Fluency, and 2.61 N (0.71 N; 1.65-3.63 N) for the 9-mm Fluency with a 10-mm Zilver stent (p<0.001). There is a small but significant difference in pullout forces among various bridging stent-grafts. As pullout forces may be one factor contributing to type III endoleaks in complex endovascular repairs involving fenestrated and branched stent-grafts, further study is warranted to compare these grafts clinically to determine if they perform differently. According to this study, the theoretical advantages associated with the Viabahn stent-graft make it a strong choice for minimizing branch dislocations.Journal of Endovascular Therapy 04/2011; 18(2):161-8. · 2.70 Impact Factor
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ABSTRACT: Open surgery is widely used as a benchmark for the results of fenestrated endovascular repair of complex abdominal aortic aneurysms (AAA). However, the existing evidence stems from single-centre experiences, and may not be reproducible in wider practice. National outcomes provide valuable information regarding the safety of suprarenal aneurysm repair. Demographic and clinical data were extracted from English Hospital Episodes Statistics for patients undergoing elective suprarenal aneurysm repair from 1 April 2000 to 31 March 2010. Thirty-day mortality and five-year survival were analysed by logistic regression and Cox proportional hazards modeling. 793 patients underwent surgery with 14% overall 30-day mortality, which did not improve over the study period. Independent predictors of 30-day mortality included age, renal disease and previous myocardial infarction. 5-year survival was independently reduced by age, renal disease, liver disease, chronic pulmonary disease, and known metastatic solid tumour. There was significant regional variation in both 30-day mortality and 5-year survival after risk-adjustment. Regional differences in outcome were eliminated in a sensitivity analysis for perioperative outcome, conducted by restricting analysis to survivors of the first 30 days after surgery. Elective suprarenal aneurysm repair was associated with considerable mortality and significant regional variation across England. These data provide a benchmark to assess the efficacy of complex endovascular repair of supra-renal aneurysms, though cautious interpretation is required due to the lack of information regarding aneurysm morphology. More detailed study is required, ideally through the mandatory submission of data to a national registry of suprarenal aneurysm repair.PLoS ONE 01/2013; 8(5):e64163. · 3.53 Impact Factor