Hybrid-procedures for the treatment of thoracoabdominal aortic aneurysms and dissections.

AIM: The conventional open repair of thoracoabdominal aneurysms and dissections remains complex and demanding and is associated with significant morbidity and mortality. We present our experience of hybrid open and endovascular treatment of thoracoabdominal aneurysms and dissections. METHODS: Within an experience of 226 aortic stent-grafts between 1998 and April 2006, 6 of the patients (median age 60 years, range 35 to 68 years) with thoracoabdominal aneurysms (Crawford type I, II, III, and V) were treated with a combined endovascular and open surgical approach. Five men and one woman, with median aneurysm diameter of 75 mm (range 70-100 mm), received revascularization of the renal arteries, the superior mesenteric artery, and the coeliac trunk accomplished via transperitoneal bypass grafting. Aneurysmal exclusion was then performed by stent-graft deployment. RESULTS: The entire procedure was technically successful in all patients. The patients were discharged a median of 9 days after the operation, while the postoperative studies revealed the patency of the vessels and no evidence of type I endoleak or secondary rupture of the aneurysm. During follow up (1 to 22 months) spiral-CT scanning revealed distinct shrinkage of the aneurysm, no graft migration or endoleak and patency of all revascularised vessels, except one renal artery in two patients. No patient experienced any temporary or permanent neurological deficit, and no dialysis was necessary. CONCLUSION: The combined endovascular and open surgical approach is feasible, without cross clamping of the aorta and with minimized ischemia time for renal and visceral arteries, and seems to be an appropriate strategy for patients with a thoraco-abdominal aortic aneurysm or dissection.     

Endovaskuläre und kombiniert offen-chirurgische Rekonstruktion der thorakoabdominellen Aorta

Purpose

Open surgical grafting of the thoracoabdominal aorta is the method of first choice in this field. However, it is linked to a significant perioperative complication rate (paraplegia, renal failure) and mortality rate. Do risk patients with cardiopulmonary disease and complex aortic pathology particularly benefit from the advantages of minimally invasive exclusion as simultaneous or sequential hybrid procedures by combining endovascular and conventional vascular reconstruction? We report on indication, concept, and preliminary results of combining endovascular therapy with conventional aortic surgery in order to minimize the perioperative stress.

Methods and results

Over a period of 3.5 years (October 1999 to May 2003) 19 patients with complex thoracoabdominal aortic pathology (16 men, 3 women, median age: 68 years) were provided with very long (>30 cm) aortic endografts (2–4 endografts) and an occlusion of the celiac trunk (n=6) or a combination of open surgical revascularization of the visceral arteries and/or the renal arteries (n=11). The indication range covered five patients with Crawford type I thoracoabdominal aneurysms (TAAA) and one patient with chronic expanding type B dissection, three symptomatic plaque ruptures in Crawford type IV TAAA, five combined thoracic aneurysms of the descending aorta and infrarenal aortic aneurysms with an hourglass-shaped exclusion of the visceral segment, three juxtarenal or para-anastomotic aneurysms, and two patients with a simultaneous open aortic arch replacement and rendezvous maneuver of a thoracic endograft with direct suture to the aortic arch replacement. Three different endograft systems were applied (Talent 6, Excluder TAG 12, Lifepath 1). Nine patients underwent elective surgery, five were hemodynamically unstable emergency cases, and five were rated urgent (contained ruptures). In five cases implantation was carried out transprosthetically via a retroperitoneal iliac Dacron conduit. Precise endograft positioning was performed during a temporary drug-induced cardiac arrest in 11 patients. Postoperative follow-ups (median follow-up: 21 months) included clinical examinations, laboratory findings, conventional X-rays (stent integrity), and CT scans or MR angiographies optimized by contrast-enhancing agents (aortic morphology). The technical success rate of all combined interventions amounts to 100%. Complications presented as two retroperitoneal hemorrhages which required revision surgery (anastomosis of the conduit) and one long-term ventilation for a period of 5 days in a patient with preexisting subglottic tracheal stenosis. One patient developed a proximal type I endoleak after chronic expanding type B dissection and thus faces conversion despite endorepair. The 30-day mortality rate of all patients (elective and emergency cases) totals 17%: one patient with an acute type A dissection died as a result of multiple organ failure 3 weeks postoperatively (initial prolonged intestinal ischemia), another one who had presented with a ruptured type A dissection died 3 weeks postoperatively due to a secondary rupture of the conventional aortic arch anastomosis (primarily chronic infection), and one patient who had undergone elective surgery died postoperatively due to a myocardial infarction. We did not observe any perioperative paraplegia or acute renal failure. After a median of 20 months the survival rate amounts to 83%.

Conclusions

Regarding the low morbidity and mortality rates in this high-risk patient population, combined intervention in the thoracoabdominal aorta can be considered a highly promising alternative therapy concept for cardiopulmonary risk patients.

     

Do branched and fenestrated devices have a role in chronic type B aortic dissection?

Morbidity and mortality after conventional open repair of post-dissecting thoracoabdominal aortic aneurysms (TAAA) remain high despite the improvement of results. Recently, "hybrid" open de-branching procedures combined with endovascular stent-grafting of the atherosclerotic thoracic aortic aneurisms have been performed, as an alternative approach. However, patients with significant cardiac, pulmonary or renal comorbidities, may represent an unfit cohort also for such hybrid procedures, and, of consequence, may be resigned to medical treatment. Recent experiences with fenestrated and branched stent-grafts have opened new opportunities in the treatment of extensive aortic aneurysms involving the visceral and renal arteries, particularly in case of atherosclerotic aneurysms. Post-dissection thoracoabdominal aneurysms present with additional challenges such as narrow true lumen at the level of the visceral vessels origin, and the lack of a stable distal landing zone. In this report, we discuss the role of fenestrated and branched stent-grafts as feasible treatment of post-dissecting TAAA.     

Staged hybrid repair of thoracoabdominal aortic aneurysm after chronic type B aortic dissection

The purpose of this study was to evaluate clinical outcomes of combined endovascular and open techniques to eradicate false lumen dilatation in the visceral aortic segment after type B aortic dissection associated with aortic aneurysm. We reviewed eight patients with distal thoracic and abdominal false lumen dilatation treated with a staged procedure. These included arch debranching as needed, proximal thoracic endovascular repair, and open surgical correction with abdominal aortic replacement of the visceral and infrarenal aorta. False lumen eradication was successful in all patients. There were no operative deaths, and paraplegia or paraparesis occurred in two patients. During a mean follow-up of 30 months, no complications or secondary interventions were necessary. The thoracic false lumen remained thrombosed in all patients, with no evidence of aortic dilatation or stent graft complications. Complete thrombosis and eradication of the false lumen can be achieved through a three-stage repair of chronic type B aortic dissection with aneurysmal dilatation. A prospective randomized trial is needed to establish the viability of this approach versus standard open repair of type II thoracoabdominal aortic aneurysms.     

Staged Open and Endovascular Repair of Thoracoabdominal Aneurysms Using the Common Carotid Artery

The purpose of this study was to demonstrate the feasibility of staged open and endoluminal repair of complex thoracoabdominal aneurysms. We report the management of two patients with a staged, open abdominal and endoluminal thoracic repair of Crawford extent II aneurysms, where iliofemoral access was impossible and thoracic repair effected by endograft deployment via a common carotid artery. From this experience we conclude that staged open and endovascular repair for both ruptured and elective Crawford extent II thoracoabdominal aneurysms can be performed using the common carotid artery, when anatomy is favorable.     

Evaluation of spinal cord ischemia in endovascular stent graft repair and surgical operation of descending thoracic or thoracoabdominal aortic aneurysms

Between October 1996 and June 2003, endovascular stent graft repair was performed in 87 patients with descending thoracic aortic aneurysms, graft replacement was performed in 24 patients with thoracoabdominal aortic aneurysms, and endovascular stent graft repair with concomitant surgical bypass of abdominal visceral arteries was performed in 3 patients with thoracoabdominal aortic aneurysms. The retrievable stent graft was inserted and evoked spinal cord potential were monitored in order to predict spinal cord ischemia for stent graft repair. There was no paraplegia or hospital death, although 3 patients had paraparesis in stent graft repair. Two of the 3 patients with paraparesis made a full neurologic recovery. There were no cases of paraplegia or paraparesis in surgical operations with thoracoabdominal aortic aneurysm. The concomitant surgical procedure was a good technique for patients in whom cardiopulmonary bypass could not be used. Our results of stent graft repair and surgical operation for descending thoracic or thoracoabdominal aortic aneurysms were acceptable. The retrievable stent graft was useful for prediction of spinal cord ischemia before endovascular stent graft repair of descending thoracic or thoracoabdominal aortic aneurysm.     

Collective experience with hybrid procedures for suprarenal and thoracoabdominal aneurysms

Not every patient is fit for open thoracoabdominal aortic aneurysm (TAAA) repair, nor is every TAAA or juxtarenal abdominal aortic aneurysm suitable for branched or fenestrated endovascular exclusion. The hybrid procedure consists of debranching of the renal and visceral arteries followed by endovascular exclusion of the aneurysm and might be an alternative in these patients. Between May 2004 and March 2006, 16 patients were treated with a hybrid procedure. The indications were recurrent suprarenal or thoracoabdominal aneurysms after previous abdominal and/or thoracic aortic surgery (n = 8), type I to III TAAAs (n = 3), proximal type I endoleak after endovascular repair (n = 2), penetrating ulcer of the juxtarenal aorta (n = 1), visceral patch aneurysm after type IV open repair (n = 1), and primary suprarenal aneurysm (n = 1). Eight (50%) of 16 patients were judged to be unfit for open TAAA repair. The hospital mortality rate was 31% (5 of 16). Four of five deceased patients were unfit for thoracophrenic laparotomy. Two patients died from cardiac complications and three from visceral ischemia. No spinal cord ischemia was detected, and temporary renal failure occurred in four patients (25%). The mean follow-up was 13 months (range 6-28 months). During follow-up, no additional grafts occluded and no patients died. Hybrid procedures are technically feasible but have substantial mortality (31%), especially in patients unfit for open repair (80%). They might be indicated when urgent TAAA surgery is required or when vascular anatomy is unfavorable for fenestrated endografts in patients with extensive previous open aortic surgery.     

Endovascular stent-graft repair of pararenal and type IV thoracoabdominal aortic aneurysms with adjunctive visceral reconstruction

OBJECTIVE: Pararenal and type IV thoracoabdominal aortic aneurysms (TAAA) are not currently considered as indications for endovascular repair given unfavorable neck anatomy or aneurysm involvement of the visceral vessels. Open repair of these aneurysms is associated with significant morbidity and mortality, particularly postoperative renal dysfunction. In selective high-risk patients, debranching of the visceral aorta to improve the proximal neck region can be used to facilitate endovascular exclusion of the aneurysm. METHODS: Between October 2000 and July 2003, 10 patients were treated with open visceral revascularization and endovascular repair of pararenal and type IV TAAAs at a single institution. Patient demographics and procedural characteristics were obtained from medical records. RESULTS: Overall 13 visceral bypasses were performed in 10 patients: 6 patients with a single iliorenal bypass, 3 with a hepatorenal bypass, and 1 patient with complete visceral revascularization. Juxtarenal aneurysms occurred in 5 patients (50%), suprarenal aneurysms in 3 patients (30%), and type IV TAAAs in 2 patients (20%). All patients had successful endovascular aneurysm exclusion. Mean follow-up was 8.7 months. There were no perioperative deaths, neurologic deficits coagulopathies, or renal dysfunction. Follow-up spiral computed tomography scans demonstrated patency of all bypass grafts with only one patient requiring a secondary intervention for late type I leak which was sealed with placement of a proximal cuff. CONCLUSION: These initial results suggest that are similar to infrarenal AAA endovascular repair. This combined approach to repair of pararenal and type IV TAAAs reduces the morbidity and mortality of open repair, and represents an attractive option in high-risk patients while endoluminal technology continues to evolve.     

Thoracoabdominal aortic aneurysm repair in patients with marfan syndrome.

OBJECTIVE: We assessed the surgical outcome of descending thoracic aortic aneurysm repair (DTAA) and thoracoabdominal aortic aneurym (TAAA) repair in patients with Marfan syndrome. METHODS: During a six year period, 206 patients underwent DTAA and TAAA repair. In 22 patients, Marfan syndrome was confirmed. The median age was 40 years with a range between 18 and 57 years. The extend of the aneurysms included 6 DTAA (1 with total arch, 2 with distal hemi-arch), 11 type II TAAA (2 with total arch, 3 with distal hemi-arch), 4 type III and one type IV TAAA. All patients suffered from previous type A (n=6) or type B (n=16) aortic dissection and 15 already underwent aortic procedures like Bentall (n=7) and ascending aortic replacement (n=8). All patients were operated on according to the standard protocol with cerebrospinal fluid drainage, distal aortic and selective organ perfusion and monitoring motor evoked potentials. In patients undergoing simultaneous arch replacement (via left thoracotomy), transcranial Doppler and EEG assessed cerebral physiology during antegrade brain perfusion. In four patients circulatory arrest under moderate hypothermia was required. RESULTS: In-hospital mortality did not occur. Major postoperative complications like paraplegia, renal failure, stroke and myocardial infarction were not encountered. Mean pre-operative creatinine level was 125mmol/L, which peaked to a mean maximal level of 130 and returned to 92mmol/L at discharge. Median intubation time was 1.5 days (range 0.33-30 days). Other complications included bleeding requiring surgical intervention (n=1), arrhythmia (n=2), pneumonia (n=2) and respiratory distress syndrome (n=1). At a median follow-up of 38 months all patients were alive. Using CT surveillance, new or false aneurysms were not detected, except in one patient who developed a visceral patch aneurysm six years after open type II repair. CONCLUSION: Surgical repair of descending and thoracoabdominal aortic aneurysms provides excellent short- and mid-term results in patients with Marfan syndrome. In this series, a surgical protocol with cerebrospinal fluid drainage, distal aortic and selective organ perfusion and monitoring motor evoked potentials resulted in low morbidity and absent mortality. These outcomes of open surgery should be considered when discussing endovascular aneurysm repair in Marfan patients.     

Graft inclusion technique for thoracoabdominal aortic aneurysms involving visceral branches with the aid of a femoro-femoral bypass

Eleven patients in our institution with thoracoabdominal aortic aneurysms involving the celiac, superior mesenteric and renal arteries underwent surgical treatment with the aid of a partial femoro-femoral bypass during the last three years. Three patients with expanding aneurysms underwent emergency operations. Another three patients with extensive aneurysms had two-stage operations: initial aortic arch or descending thoracic graft replacement followed by thoracoabdominal graft replacement in the second stage. Exposure of the aneurysms was made through a left transthoracic, retroperitoneal abdominal approach in all patients. The surgical technique employed in most cases in this series was graft inclusion with direct reattachment of the visceral vessels by anastomosis to an opening made in the graft. Pairs of intercostal and lumbar arteries between the levels of the ninth thoracic and fourth lumbar regions were reconstructed in a similar fashion on the basis of monitoring somatosensory evoked potentials. The operations were performed with the aid of a partial femoro-femoral bypass with selective celiac and renal arterial perfusion in most cases. All patients but one survived the operation and are leading normal lives late in the postoperative period. Graft inclusion with the aid of a partial bypass is a valid technique for the treatment of thoracoabdominal aortic aneurysms involving visceral branches.     

Paraplegia after endovascular repair of the thoracic and thoracoabdominal aorta

AIM: The aim of this study was to analyse the incidence and aetiology of paraplegia secondary to endovascular repair of the thoracic and thoracoabdominal aorta (TEVAR). METHODS: A retrospective study was conducted in the patients treated at our facility between March 1997 and April 2007. During this interval, 173 patients (163 men; median age: 62 years) underwent endovascular repair of the thoracic aorta. Indications for treatment were thoracic aortic aneurysms in 36 patients, thoracoabdominal aortic aneurysms in 33 patients, type B dissections in 43 patients, type A dissections in 5 patients, penetrating aortic ulcers in 31 patients, traumatic aortic transections in 9 patients, post-traumatic aortic aneurysms in 5 patients, aortobronchial fistulas in 8 patients, aortic patch ruptures in 2 patients, and an anastomotic aortic aneurysm in 1 patient. 101 procedures (58%) were conducted as emergency interventions while 72 were elective. Device design and implant strategy were chosen on the basis of an evaluation of morphology from a computed tomographic scan. Clinical assessment and imaging of the aorta (CT or magnetic resonance imaging) during follow up were performed prior to discharge, at 6 and 12 months, and then annually. RESULTS: A primary technical success was achieved in 170 patients (98%). The overall 30-day mortality rate was 9.2%. Length of follow-up ranged from 1 to 96 months, with a mean of 52 months. Paraplegia or paraparesis developed in 3 patients (1.7%). Two of these patients had a thoracoabdominal aortic aneurysm and the third a chronic expanding type B dissection, being treated with hybrid procedures. CONCLUSIONS: Endovascular repair of the thoracic and thoracoabdominal aorta is associated with a relatively low risk for postoperative paraplegia or paraparesis. Patients requiring long segment aortic coverage, and with prior aortic replacement are especially at risk.     

Hybrid procedures for thoracoabdominal aortic aneurysms and chronic aortic dissections - a single center experience in 28 patients

OBJECTIVE: We report our 6-year experience with the visceral hybrid procedure for high-risk patients with thoracoabdominal aortic aneurysms (TAAA) and chronic expanding aortic dissections (CEAD). METHODS: Hybrid procedure includes debranching of the visceral and renal arteries followed by endovascular exclusion of the aneurysm. A series of 28 patients (20 male, mean age 66 years) were treated between January 2001 and July 2007. Sixteen patients had TAAAs type I-III, one type IV, four thoracoabdominal placque ruptures, and seven patients CEAD. Patients were treated for asymptomatic, symptomatic, and ruptured aortic pathologies in 20, and 4 patients, respectively. Two patients had Marfan's syndrome; 61% had previous infrarenal aortic surgery. The infrarenal aorta was the distal landing zone in 70%. In elective cases, simultaneous approach (n = 9, group I) and staged approach (n = 11, group II) were performed. Mean follow-up is 22 months (range 0.1-78). RESULTS: Primary technical success was achieved in 89%. All stent grafts were implanted in the entire thoracoabdominal aorta. Additionally, three patients had previous complete arch vessel revascularization. Left subclavian artery was intentionally covered in three patients (11%). Thirty-day mortality rate was 14.3% (4/28). One patient had a rupture before the staged endovascular procedure and died. Overall survival rate at 3 years was 70%, in group I 80%, and in group II 60% (P = .234). Type I endoleak rate was 8%. Permanent paraplegia rate was 11%. Three patients required long-term dialysis (11%). Peripheral graft occlusion rate was 11% at 30 days. Gut infarction with consecutive bowel resection occurred in two patients. There was no significant difference between group I and II regarding paraplegia and complications. CONCLUSIONS: Early results of visceral hybrid repair for high-risk patients with complex and extended TAAAs and CEADs are encouraging in a selected group of high risk patients in whom open repair is hazardous and branched endografts are not yet optional.     

When is safe to cover the left subclavian and celiac arteries. Part II: celiac artery

Endovascular repair of thoracic and thoraco-abdominal aortic aneurysms became apparent as an alternative to open repair. When the distal landing zone proximal to celiac artery is inadequate, a traditional open surgical approach with thoracoabdominal aortic replacement concomitant with visceral and renal bypasses is necessary. Alternatively, either an abdominal hybrid procedure with debranching of the visceral vessels with subsequent thoracic stent graft placement or complete endovascular aneurysm exclusion with branched stent grafts is required. Extending the distal landing zone might be possible by covering the celiac artery origin. In this article, the authors review the anatomy of the celiac artery (SA) and the superior mesenteric artery (SMA) and consequences of CA coverage as scenery for a discussion of the ramifications of CA coverage during endovascular thoracic aortic repair (TEVAR). Summarizing the currently available literature, we will demonstrate the feasibility of covering the celiac artery based on a diagnostic algorism.     

Endovascular treatment of aortic aneurysms and dissections in patients with genetically triggered aortic diseases

Connective tissue disease (CTD) syndromes involve the ascending, aortic arch, and thoracoabdominal aorta and are associated with higher risk of aortic aneurysm or dissection. Currently, vascular societies generally recommend open repair as the first option for aortic disease in patients with CTD. However, the implementation of endovascular techniques for patients with CTD with aortic pathologies seems to have increased in recent years, mainly in patients of high surgical risk or in urgent situations. Endovascular treatment of aortic arch pathologies in patients with CTD have been feasible in experienced centers; however, the evidence is scarce. Thoracic endovascular aneurysm repair in patients with CTD is more evident; in 15 studies, 304 patients with CTD were treated with thoracic endovascular aneurysm repair with high technical success rates (88% to 100%) and a low early mortality rate (1.6%). During the median follow-up, 33 patients died and 64 patients underwent a re-intervention. In 6 studies, 26 patients with CTD were treated with fenestrated/branched endovascular aneurysm repair for thoracoabdominal aortic aneurysm, with a technical success rate of 100%, without early mortality and morbidity. The endovascular approach to thoracoabdominal aortic aneurysm, especially in post-dissection patients, mandates adjunctive techniques to achieve false lumen thrombosis with various approaches; in our experience, the Candy-Plug technique has been proven to be technically feasible with good outcomes. Endovascular treatment of aortic pathologies in patients with CTD seems to be feasible and safe in high-risk and urgent patients. Re-intervention remains an issue. The constant development of endovascular techniques and devices may provide improved mortality and morbidity outcomes.     

Tips for successful outcomes for descending thoracic and thoracoabdominal aortic aneurysm procedures

The continuing evolution of endovascular approaches to the repair of descending thoracic and thoracoabdominal aortic aneurysms necessitates careful evaluation of the safety and efficacy of these alternative therapies as they compare to the "gold standard" of open surgical repair. The purpose of this report is to present our approach to conventional open surgical repair of these aneurysms. Routine surgical modalities include use of moderate systemic heparinization, mild permissive hypothermia, and sequential aortic clamping. For extensive thoracoabdominal and select descending aortic procedures, additional modalities are used. The multimodal approach to organ protection during surgical treatment of descending thoracic and thoracoabdominal aneurysms has evolved substantially over the past 20 years. Experienced surgical centers now have much lower mortality and morbidity rates for these operations than previously reported. Current management strategies enable patients to undergo conventional open aneurysm repairs with excellent early survival and acceptable morbidity.     

The history and current status of thoracic endovascular aneurysm repair in Japan

Japan has a long and successful history of performing thoracic endovascular aneurysm repair (TEVAR). While commercial endovascular grafts were being used worldwide, Japan developed and distributed custom and semi-order made triple-branched one-piece grafts and fenestrated devices for the treatment of arch aneurysms. Historically, Japan also innovated and proposed hybrid procedures such as debranching with stent grafting to treat arch aneurysms and thoracoabdominal aneurysms. Since its introduction, Japan has been at the forefront of performing TEVAR for complicated acute aortic dissection and uncomplicated chronic aortic dissection for patients with predicted aortic enlargement. In this review, the authors discuss the many issues surrounding successful TEVAR, focusing on devices, operative methods, and prevention of complications.     

Giant size abdominal aortic aneurysm repair using open proximal anastomosis under hypothermic circulatory arrest: a report of two cases

Hypothermic total circulatory arrest and open proximal anastomosis techniques are not commonly used in abdominal or juxtarenal abdominal aortic aneurysm repair. Proximal aortic clamping is usually adequate for surgical repair of abdominal aortic pathologies. We present two cases of giant-sized abdominal aortic aneurysms, one was juxtarenal and one was a Crawford type IV thoracoabdominal aneurysm, that were repaired by using open proximal anastomosis under hypothermic total circulatory arrest and a transabdominal approach. This technique may be useful for both thoracoabdominal and large abdominal aortic aneurysms because it offers the opportunity to not clamp the aorta and operate in bloodless surgical field.     

Hybrid approach to complex thoracic aortic aneurysms in high-risk patients: surgical challenges and clinical outcomes

BACKGROUND: Endovascular therapy is a less invasive alternative treatment for high-risk patients with thoracic aortic aneurysms. However, this technology alone is often not applicable to complex aneurysmal morphology. The purpose of this study was to evaluate the utility of hybrid strategies in high-risk patients who are otherwise unsuitable for endovascular therapy alone. METHODS: During an 18-month period, 31 high-risk patients (mean age, 69 years; range, 52-89 years) underwent combined open and endovascular approaches for complex aneurysms, including 16 patients with ascending and arch aneurysms and 15 patients with aneurysms involving visceral vessels. Among them, 11 patients had histories of aneurysm repairs. To overcome the anatomic limitations of endovascular repairs, various adjunctive surgical maneuvers were used, including aortic arch reconstruction in 3 patients, supra-aortic trunk debranching in 13 patients (including 8 patients who required aortas as inflow sources), and visceral vessel bypasses in 15 patients (including 10 patients who required bypasses to all 3 visceral branches). Additionally, carotid artery access was obtained in 1 patient, and iliac artery conduits were created in 12 patients. RESULTS: Technical success was achieved in all patients. There was one perioperative death (3.2%) due to postoperative bleeding. Two patients (6.4%) had immediate type II endoleaks, which were resolved by the 1-month follow-up. Other procedure-related complications occurred in three patients (9.6%), including renal bypass thromboses in two patients and retroperitoneal hematoma, which was successfully managed conservatively, in one patient. During a mean follow-up of 16 months, two patients died of unrelated causes, whereas the remainder of patients were asymptomatic, without aneurysm enlargement. CONCLUSIONS: Our study highlights how hybrid strategies incorporating surgical and endovascular approaches can be used successfully in treating patients with complex thoracic aortic aneurysms. This combined approach potentially expands the field of endovascular stent grafting and is an attractive solution for patients with poor cardiopulmonary reserves.     

Endovascular treatment in diseases of the descending thoracic aorta: 6-year results of a single center

OBJECTIVE: The purpose of this study was to evaluate endovascular treatment in diseases of the descending thoracic aorta. Material and methods: This study was designed as a single center's (university hospital) experience. Over a 6-year period (1995 to 2001), thoracic endografts were placed in 74 patients with a diseased descending thoracic aorta who were at high risk for conventional open surgical repair: 34 had atherosclerotic aneurysms, six had posttraumatic aneurysms, 14 had type B dissection with aneurysmal dilatation of the false lumen, 12 had isthmic transections from blunt trauma, five had thoracoabdominal aneurysms (treated with a combined procedure), two had aortic coarctation, and one had an aortobronchial fistula. Twenty-six procedures (35.1%) were conducted as emergencies, and 48 (64.9%) were elective. The feasibility of endovascular treatment and sizing of stent grafts were determined with preoperative spiral computed tomography and intraoperative angiography. RESULTS: Endovascular operations were completed successfully in all 74 patients; postprocedural conversion to open repair was necessary in three cases. The overall 30-day mortality rate was 9.5% (seven deaths). Temporary neurologic deficits developed in two patients; not one patient had permanent paraplegia. The primary endoleak rate was 20.3% (15 patients). The mean follow-up period was 22 months (range, 3 to 72 months). Five deaths occurred in the follow-up period, and three patients needed secondary conversion to open repair 2, 3, and 14 months after initial endografting. CONCLUSION: Endoluminal treatment in diseases of the thoracic descending aorta is feasible and may offer results as good as the open method.     

Hybridverfahren—Ein alternatives Behandlungskonzept beim thorakoabdominalen Aortenaneurysma

Introduction

The conventional approach for the repair of thoracoabdominal aneurysms remains complex and demanding and is associated with substantial morbidity and mortality. Moreover, in cases of reoperation the impact can be dramatic either in survival or in quality of life of the patients, despite the use of adjuncts. A combined endovascular and surgical approach with retrograde perfusion of visceral and renal vessels has been developed to minimize intraoperative and postoperative complications.

Material and methods

Of 137 thoracic aortic stent grafts inserted between 1995 and 2004, 7 of the patients with thoracoabdominal aneurysms were treated with a combined endovascular and surgical approach. Five procedures were electively conducted and two on an emergency basis. The surgical approach was executed in all patients without thoracotomy or redo retroperitoneal exposure. Revascularization of the renal, superior mesenteric artery and celiac trunk was accomplished via transperitoneal bypass grafting. Aneurysmal exclusion was performed by stent graft deployment.

Results

The entire procedure was technically successful in all patients. A 73-year-old man died due to multiorgan failure after having developed ischemia-related pancreatitis, despite the successful combined repair. A second female patient, 76 years old, with ruptured TAAA died due to shock-related multiorgan failure. No patient experienced any temporary or permanent neurological deficit.

Conclusion

The combined endovascular and surgical approach is feasible, without cross-clamping of the aorta and with minimized ischemia time for renal and visceral arteries, and a thoracoabdominal transdiaphragmatic approach seems to be the appropriate strategy for high-risk and previously operated patients.