选择性覆盖左锁骨下动脉在胸主动脉腔内修复术中的应用

目的:探讨胸主动脉腔内修复术中一期覆盖左锁骨下动脉(LSA)对预后的影响。方法:回顾分析2007年6月—2012年1月76例胸主动脉病变行胸主动脉腔内修复术患者的临床资料,包括主动脉夹层56例,壁间血肿6例,胸主动脉瘤5例,外伤性胸主动脉破裂9例。腔内修复术中一期覆盖LSA 32例,部分覆盖9例,保留35例。观察疗效和并发症发生情况。结果:围手术期死亡1例(1.3%),死于急性脑梗死。32例覆盖LSA的患者中,发生脑血管意外3例(9.4%),左锁骨下动脉窃血1例(3.1%),左上肢乏力4例(12.5%),并发症发生率为25.0%(8/32);9例部分覆盖LSA患者和35例LSA未覆盖患者中,发生脑血管意外各1例。随访3~40个月,死亡1例,I型内漏2例,均再次手术干预获得成功。结论:胸主动脉腔内修复术有选择性地一期覆盖左锁骨下动脉是可行的。     

胸主动脉腔内修复术中封堵左锁骨下动脉的安全性研究

目的：探讨胸主动脉腔内修复术（TEVAR）中封堵左锁骨下动脉（LSA）是否增加术后近期脑梗死、截瘫及远期脑梗死的风险。 方法：回顾性分析2004年1月—2013年3月629例行TEVAR患者资料。其中LSA未封堵399例,部分封堵63例,完全封堵且未重建159例,LSA封堵并重建8例。单因素分析比较LSA封堵与未封堵患者术后近期脑梗死及截瘫的发生率;多因素Logistic回归分析患者发生远期脑梗死的危险因素。 结果：629例患者术后均无左上肢严重缺血; 3例（0.5%）术后发生脑梗死,其中2例（0.5%）LSA未封堵,1例（0.4%）LSA封堵;4例（0.6%）术后发生截瘫,其中3例（0.8%）LSA未封堵,1例（0.4%）LSA封堵;LSA封堵与未封堵患者术后近期脑梗死、截瘫的发生率差异无统计学意义（均P<0.05）。平均随访31.4（1~123）个月,多因素分析显示,LSA封堵不增加远期脑梗死风险（OR=1.03,P=0.088）,但术前有既往脑梗死病史与年龄>70岁的患者远期发生脑梗死风险有所增加（OR=3.41,P=0.023;OR=1.90,P=0.034）。 结论：左上肢可很好耐受LSA封堵,且LSA封堵不增加术后近期脑梗死、截瘫及远期脑梗死风险。     

Outcome after unilateral hypogastric artery occlusion during endovascular aneurysm repair

PURPOSE: The purpose of this study was to determine the long-term functional outcome after unilateral hypogastric artery occlusion during endovascular stent graft repair of aortoiliac aneurysms. METHODS: During a 41-month period, 157 consecutive patients underwent elective endovascular stent graft repair of aortoiliac aneurysms with the Medtronic AneuRx device. Postoperative computed tomography scans were compared with preoperative scans to identify new hypogastric artery occlusions. Twenty-three (15%) patients had unilateral hypogastric occlusion, and there were no cases of bilateral occlusions. Telephone interviews about past and current levels of activity and symptoms were conducted, and pertinent medical records were reviewed. All 23 (100%) patients were available for the telephone interview. A disability score (DS) was quantitatively graded on a discrete scale ranging from 0 to 10 corresponding to "virtually bed-bound" to "greater-than-a-mile" exercise tolerance. Worsening or improvement of symptoms was expressed as a difference in DS between two time points (-, worsening/+, improving). RESULTS: Among the 23 patients, two groups were identified: 10 patients (43%) had planned and 13 patients (57%) had unplanned or inadvertent occlusions. The patients in the two groups did not differ significantly in the mean age (73.4 vs 73.7 years), sex (male:female, 9:1 vs 10:3), and duration of follow-up (15.6 vs 14.4 months). Nine (39%) of the 23 patients, five patients in the planned and four patients in the unplanned group, reported significant symptoms of hip and buttock claudication ipsilateral to their occluded hypogastric arteries. The mean decrement from baseline of these nine patients in their DS postoperatively was -3.3. The symptoms were universally noted on postoperative day 1. Although most patients improved (89%), one (11%) never got better. Among those whose symptoms improved, the mean time to improvement was 15 weeks, but with a plateau thereafter resulting in a net decrement of DS of -2.3 from baseline. Finally, when questioned whether they would undergo the procedure again, all 23 patients unanimously answered, "Yes." CONCLUSIONS: A significant number (39%) of patients who sustain hypogastric artery occlusion after endovascular aneurysm repair have symptoms. Although most patients with symptoms have some improvement, none return to their baseline level of activity. Despite this, all patients in retrospect would again choose endovascular repair over conventional open repair.     

Outcome after hypogastric artery bypass and embolization during endovascular aneurysm repair

BACKGROUND: Multiple strategies have been devised to extend the applicability of endovascular aneurysm repair (EVAR) in patients with common iliac artery (CIA) aneurysms. This study was designed to examine outcome in patients undergoing EVAR with either hypogastric artery embolization or common iliac artery bifurcation advancement by hypogastric bypass. METHODS: A retrospective review of all patients undergoing EVAR since the inception of our program (1997-2006) was performed. Data were prospectively collected in an EVAR registry. Patients with large common iliac artery aneurysms (> or = 20 mm) and patent hypogastric arteries not amenable to a cuff or "bell bottom" technique were treated with coil embolization (EMBO) and/or hypogastric revascularization (BYPASS). The perioperative and mid-term outcomes were compared with the larger group of patients undergoing EVAR that did not require either treatment (CTRL). Bilateral common iliac artery aneurysms were treated with unilateral coil embolization and contralateral bypass. RESULTS: Common iliac artery aneurysms were present in 137 (31%) of the 444 patients undergoing EVAR, but only 57 (42%) of 137 required direct management. This included hypogastric artery embolization alone (EMBO) in 31 or hypogastric artery revascularization (BYPASS) in 26, with and without contralateral embolization (both revascularization/embolization in 46%). The procedure length (CTRL, 159 +/- 72 minutes; EMBO, 153 +/- 39 minutes; BYPASS, 283 +/- 75 minutes) and estimated blood loss (CTRL, 251 +/- 313 mL; EMBO, 233 +/- 158 mL; BYPASS, 400 +/- 287 mL) were significantly greater (P < .05) in the BYPASS group. The incidence of any postoperative complication (CTRL, 26%; EMBO, 68%; BYPASS, 54%), any ischemic complication (CTRL, 6%; EMBO, 55%; BYPASS, 27%), and new-onset buttock claudication (CTRL, 3%; EMBO, 39%; BYPASS, 27%) were all significantly greater in the BYPASS and EMBO group relative to the control (CTRL) group (n = 387). The incidence of new-onset buttock claudication ipsilateral to the hypogastric bypass was 4%; the balance of the new onset claudication in the BYPASS group was due to the contralateral embolization. The primary hypogastric artery bypass patency was 91 +/- 11% (SE) at 36 months by life-table analysis. CONCLUSIONS: Despite its increased complexity, hypogastric artery bypass is an excellent alternative to embolization in terms of patency and freedom from ischemic symptoms for patients with large common iliac artery aneurysms undergoing EVAR.     

Spinal cord injury after thoracic endovascular aortic aneurysm repair

Purpose

Thoracic endovascular aortic aneurysm repair (TEVAR) has become a mainstay of therapy for aneurysms and other disorders of the thoracic aorta. The purpose of this narrative review article is to summarize the current literature on the risk factors for and pathophysiology of spinal cord injury (SCI) following TEVAR, and to discuss various intraoperative monitoring and treatment strategies.

Source

The articles considered in this review were identified through PubMed using the following search terms: thoracic aortic aneurysm, TEVAR, paralysis+TEVAR, risk factors+TEVAR, spinal cord ischemia+TEVAR, neuromonitoring+thoracic aortic aneurysm, spinal drain, cerebrospinal fluid drainage, treatment of spinal cord ischemia.

Principal findings

Spinal cord injury continues to be a challenging complication after TEVAR. Its incidence after TEVAR is not significantly reduced when compared with open thoracoabdominal aortic aneurysm repair. Nevertheless, compared with open procedures, delayed paralysis/paresis is the predominant presentation of SCI after TEVAR. The pathophysiology of SCI is complex and not fully understood, though the evolving concept of the importance of the spinal cord’s collateral blood supply network and its imbalance after TEVAR is emerging as a leading factor in the development of SCI. Cerebrospinal fluid drainage, optimal blood pressure management, and newer surgical techniques are important components of the most up-to-date strategies for spinal cord protection.

Conclusion

Further experimental and clinical research is needed to aid in the discovery of novel neuroprotective strategies for the protection and treatment of SCI following TEVAR.

     

Mid-term results after endovascular repair of the atherosclerotic descending thoracic aortic aneurysm.

INTRODUCTION: Thoracic aortic aneurysms (TAA) are the most common condition of the thoracic aorta requiring surgical treatment. Despite significant improvement in anesthetic, surgical techniques and postoperative care, the mortality and morbidity rate in TAA-repair remains high. The aim of this study was to assess the morbidity and mortality rate after endovascular stent-graft treatment of atherosclerotic (non-dissecting) TAAs. METHODS: Thirty-one patients, ASA-classification III-IV, with symptomatic or expanding atherosclerotic TAAs underwent endovascular stent-graft repair between May 1997 and August 2003. Procedures were performed on an emergency basis in 13 patients and elective in 18 patients. Patients were assessed postoperatively by routine CT-scan within 48 h. Further follow up investigations were performed after 3, 6, 12 months and annually thereafter. RESULTS: Stent-graft placement was successful in all but one patient in whom the stent-graft procedure had to be postponed due severe hemodynamic instability. Perioperative mortality rate was 19% including three haemorrhages, two cardiac events and one respiratory failure (6/31). Technical success rate was 55% (17/31). Completion CT scans performed in 30 patients within 2 days of stent-graft procedure showed type I leaks in seven patients (23%), type II leaks in four patients (13%) and type III leaks in two patients (6%). Further complications included one stroke, one paralysis, one spinalis anterior syndrome and five relevant access related complications. New onset endoleaks, all type I, were observed in seven patients (23%) occurring after 3, 4, 7, 8, 17, 25 and 26 months. Mean follow-up was 15 months (range 2-69 months). CONCLUSION: Thoracic aortic atherosclerotic aneurysm stent-grafting is feasible but not without significant morbidity and mortality.     

Redo thoracic endovascular aortic repair due to endoleak with celiac artery snorkeling

Reintervention due to endoleak of aortic endograft repair is often challenging. Herein, we report endovascular endoleak repair in a patient with previous thoracic and abdominal endovascular grafts with extensive coverage of the aorta. The present technique included snorkeling of the celiac trunk to preserve antegrade flow in the celiac artery and to maintain future options for reintervention.     

Dynamic aortic changes in patients with thoracic aortic aneurysms evaluated with electrocardiography-triggered computed tomographic angiography before and after thoracic endovascular aneurysm repair: preliminary results

The purpose of this study was to utilize dynamic computed tomographic angiography (CTA) on pre- and postoperative thoracic endovascular aneurysm repair (TEVAR) patients to characterize cardiac pulsatility-induced aortic motion on essential TEVAR proximal sealing zones and to study the influence of endograft placement. Six pre- and six postoperative dynamic CTA studies were obtained in six patients with thoracic aortic aneurysms (TAAs) undergoing TEVAR. Data were acquired using a retrospective electrocardiography-triggered dynamic CTA scan, with eight reconstructed phases over the cardiac cycle. Scans were acquired during a single breath hold. Multiplanar reconstructions were made perpendicular to the aorta at five surgically relevant anatomical thoracic landmarks: 1 cm proximal to the innominate trunk, 1 cm proximal and 1 cm distal to the left subclavian artery, and 1 cm proximal and 3 cm distal to the proximal end of the stent. After segmentation of the aortic lumen in the images, diameter change and area change over the cardiac cycle were measured. Diameter change was measured through the center of mass of the aortic lumen, and the average change over 180 axis is presented. We found significant distention of the thoracic aortic arch and descending thoracic aorta during the cardiac cycle before and after TEVAR. Distention ranged 3-12% in diameter and 2-20% in area. This distention was preserved after TEVAR. Patients with TAA experience aortic diameter and area changes during the cardiac cycle. The magnitude, and hence the clinical importance, of this aortic distention varies among patients. After stent-graft placement, aortic distention throughout the cardiac cycle is preserved. This may have major implications for correct sizing of the endograft as well as for stent-graft design and durability as the forces on the stents may be much larger after implantation than initially anticipated by stent manufacturers.     

The risks of celiac artery coverage during endoluminal repair of thoracic and thoracoabdominal aortic aneurysms

The risks of purposeful celiac artery coverage during endovascular thoracic aortic aneurysm repair (TEVAR) to obtain an adequate distal landing zone have received scant scientific attention. Patients undergoing TEVAR at 6 tertiary centers from January 2000 to June 2007 were identified (n = 434); cases requiring celiac artery exclusion (n = 19; 4.4% of the total) were analyzed. The mean follow-up was 8.7 months (range, 0.2-21.2). The mean patients' age was 73.6 years (range, 56-86); 57.9% were men. The mean aneurysm diameter was 6.7 cm (range, 5-8.6). In 2 patients, the celiac artery balloon occlusion test was performed prior to TEVAR. In both, intact collateral foregut circulation was seen. Both underwent TEVAR without celiac artery revascularization; 1 did well, whereas the other developed foregut ischemia. In 16 cases (84.2%), the celiac artery was not revascularized prior to TEVAR. In those patients, 19 complications were reported (3 deaths; 2 paraplegia). No similar events occurred in those who underwent celiac artery revascularization (n = 3). Celiac artery coverage during TEVAR is required in 4.4% of cases. TEVAR correlated with a nonnegligible number of major complications. Complications were more frequent and severe in patients who did not have celiac artery revascularization prior to TEVAR. Specific celiac artery coverage complications are rare and not readily predictable based on preprocedure arteriography.     

Acute retrograde aortic dissection during endovascular repair of a thoracic aortic aneurysm

Endovascular aneurysm exclusion represents a valuable alternative treatment for descending thoracic aortic aneurysms. Although the minimally invasive character of this procedure is obvious, major complications are possible. We report a 77-year-old male who developed acute retrograde dissection of the aortic arch and ascending aorta during endovascular stent-grafting of a descending aortic aneurysm. Emergent open surgical repair provided a successful outcome.