Hybrid procedures for the treatment of thoracoabdominal aortic aneurysms and dissections

The search for less invasive therapeutic approaches to thoracoabdominal aortic aneurysms (TAAAs) brought endovascular procedures to establish themselves as alternatives to open surgery in high-risk patients. Aim of this study is to illustrate the hybrid - open and endovascular - treatment of dissecting and non-dissecting TAAAs, and to analyze short and midterm results at our Center. We analyzed 41 high-risk patients who underwent hybrid TAAA repair (dissecting TAAA in 17% of cases) with a variety of visceral rerouting configuration and of commercially available thoracic endografts. Thirty-one simultaneous (76%) and 10 staged procedures (24%) were performed with a four-vessel revascularization in 13 cases (32%), a three-vessel in 9 (22%) and a two-vessel in 19 (46%). No intraoperative deaths were observed in our series, with a technical success in endovascular TAAA repair of 100%. Two patients died in the intersurgical time. A perioperative mortality of 13% and a perioperative morbidity of 32% were recorded, including one case (2.4%) of permanent paraplegia. At a median follow-up of 23.3 months, we observed a visceral graft occlusion rate of 6%, three type II endoleak and one endograft migration. Six patients died for unrelated events. Typical complications of conventional TAAA open surgery have been not eliminated by hybrid repair and still significant mortality and morbidity have been reported. Dissecting etiology did not negatively affect the outcome of hybrid repair in our experience. Fate of visceral bypasses and incidence of endoleak and other endograft-related complications need to be carefully assessed. Hybrid TAAA repair should nowadays be limited as alternative to simple observation in patients unfit for the conventional open repair.     

杂交技术在胸腹主动脉瘤的治疗选择

胸腹主动脉瘤(thoracoabdominal aortic aneurysm,TAAA)修复手术是血管外科最具挑战性的手术,其死亡率和并发症率都高.胸腹主动脉瘤指的是主动脉瘤累及到腹腔干、肠系膜上动脉、肾动脉的动脉瘤.胸腹主动脉瘤的分型与Safi修订的Crawford分类一致.Crawford Ⅰ型胸腹主动脉瘤指动脉瘤从左锁骨下动脉开口远端扩展至肾动脉以上,Ⅱ型指从左锁骨下动脉远端扩展至肾动脉以下,Ⅲ型指从第6肋间隙至肾动脉平面以下,Ⅳ型指从第12肋间隙至肾动脉以下,Ⅴ型指从第6肋间隙至肾动脉以上.     

杂交技术治疗胸腹主动脉瘤

目的 总结联合传统开刀和腔内修复杂交技术治疗胸腹主动脉瘤的诊疗经验及近远期疗效.方法 回顾性分析1998年9月至2008年10月杂交技术治疗15例胸腹主动脉瘤患者的临床资料.男性12例,女性3例,年龄44～72岁,平均年龄58.7岁.Ⅰ型2例,Ⅱ型8例,Ⅲ型2例,Ⅳ型3例.瘤体直径55～82 mm,平均(67.5±7.5)mm.患者术后出院时,3、6、12个月及每年进行随访.结果 2例顺行旁路,13例逆行旁路.手术时间6.8～12.7 h,平均(8.1±1.4)h,术中出血量750～3000 ml,平均(956.7±80.1)ml.围手术期病死率13.3%(2/15).随访3～72个月,1例因急性心肌梗死死亡,其他患者无截瘫发生,无支架移位.结论 杂交技术治疗胸腹主动脉瘤是可行、有效的,早期及中期治疗结果满意,但远期疗效尚待评价.     

Hybrid aortic procedures for endoluminal arch replacement in thoracic aneurysms and type B dissections

The aim of this study was to report our clinical experience with and review current literature on endoluminal aortic hybrid techniques and to evaluate outcome in high-risk patients treated for complex aortic arch lesions combining conventional supra-aortic debranching bypasses with subsequent or staged thoracic endovascular grafting. Of 172 patients treated with thoracic endografts for different thoracic aortic pathologies within the last 8 years, the mid-aortic arch was involved in 25, i.e. at least the left common carotid artery had to be overstented and revascularized to provide a proper proximal landing zone. These debranching bypasses were performed as a simultaneous or a staged procedure. All patients were at high-risk and were excluded by cardiac surgeons as ineligible for conventional arch repair. After partial (n=16) or complete (n=9) supra-aortic transposition, 4 different commercially available endografts (80% TAG, WL Gore) were implanted transfemorally or via iliac conduit. Deployment success was 100% in 25 patients after simultaneous or staged supra-aortic transposition; in 32% an emergency procedure was performed due to contained rupture; in 36% more than 1 endograft system was implanted (2 in 20%, 3 in 8% und 4 in 8%). The overall perioperative thirty-day mortality was 5 of 25 (20%) due to interoperative proximal bare stent perforation (n=1), transfusion related acute lung injury (TRALI n=1), cardiac failure (n=1), embolic stroke (n=1) and pneumonia (n=1). The mean follow-up was 21 months. All endoleaks type I (n=3) were corrected with another endograft; the 2 endoleaks type II sealed spontaneously. The major adverse events were: prolonged ventilation in 5 (20%), temporary renal insufficiency with hemodialysis (n=2), bypass infection (n=1), without any complications (n=9). No cases of paraplegia were recorded. Hybrid aortic arch repair is technically challenging but feasible. This novel approach may be an alternative to standard open procedures in high-risk patients and emergency cases. However, the promising early results need to be confirmed by longer follow-up and larger series.     

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.     

Hybrid approach to thoracoabdominal aortic aneurysms in patients with prior aortic surgery

OBJECTIVE: The hybrid approach to the repair of thoracoabdominal aortic aneurysm (TAAA), consisting of visceral aortic debranching with retrograde revascularization of the splanchnic and renal arteries and aneurysm exclusion using stent grafts, has been previously described and may be considered particularly appealing in high-risk patients, especially those who have undergone prior aortic surgery. This study analyzed prospectively recorded data of a series of high-risk patients with prior aortic surgery who underwent hybrid TAAA repair at our institute and contrasted the outcomes with those of a similar group of patients who underwent conventional open TAAA repair. METHODS: Between 2001 and 2006, 13 patients (12 men) with a median age of 69.6 years (range, 35 to 82 years) underwent one-stage hybrid repair of TAAA (7 type I, 2 type II, 2 type IV, and 2 aneurysms of the visceral aortic patch). These patients, the hybrid group, had a history of aortic surgery (30.7% ascending, 30.7% descending, 46.1% abdominal aortic repair, and 15.4% redo TAAA) and were at high risk for open repair. The criteria used to define these patients as high risk and to indicate the need for hybrid treatment were American Society of Anesthesiologists (ASA) class 3 or 4 associated with a preoperative forced expiratory volume in 1 second (FEV1)<50%. In all cases, we accomplished partial or total visceral aortic debranching through (1) a previous visceral artery retrograde revascularization with synthetic grafts (single bypass, customized Y or bifurcated grafts), and (2) aortic endovascular repair with one of three different commercially produced stent grafts (Cook, W.L. Gore & Assoc, and Medtronic). We analyzed the results and compared the outcomes of the hybrid group with those of a similar group of 29 patients (25 men) with a median age 65.3 years (range, 58 to 79) selected from our overall series of 246 TAAA repairs between 1988 and 2005. These 29 patients, the conventionally treated group, were selected for having had aortic surgery (22% ascending, 38% descending, 42% abdominal aortic repair, and 10.3% redo TAAA), an ASA 3 or 4, a preoperative FEV1<50%, and a conventional open repair of TAAA (10 type I, 5 type II, 4 type III, 7 type IV, and 3 aneurysms of the visceral aortic patch). RESULTS: In the hybrid group, 32 visceral bypasses were completed and endovascular TAAA repair was successful in all cases. No intraoperative deaths occurred. Perioperative mortality was 23%, and morbidity was 30.8% (renal failure in 2, respiratory failure in 1, and delayed transient paraplegia in 1). At a median follow-up of 14.9 months (range, 11 days to 59.4 months), all grafts were patent at postoperative computed tomography angiography and no aneurysm-related deaths, endoleak, stent graft migration, or morbidity related to visceral revascularization had occurred. No conventionally treated patients died intraoperatively. Perioperative mortality was 17.2% and morbidity was 44.8% (respiratory failure in 7, coagulopathy in 1, renal failure in 2, and paraplegia in 3). At a median follow-up of 5.4 years (range, 1.7 to 7.9 years), no significant complications related to aortic repair occurred, except for three patients (10.3%) with asymptomatic dilatation of the visceral aortic patch<5 cm undergoing radiologic surveillance. CONCLUSION: Hybrid TAAA repair is technically feasible in selected cases. Perioperative morbidity and mortality were considerable in our subset of high-risk patients with prior aortic surgery, but no aneurysm-related or procedure-related complications were reported at mid-term follow-up. Hybrid TAAA repair did not lead to a significant improvement in outcomes compared with open TAAA repair in a similar group of patients. Larger series are required for valid statistical comparisons and longer follow-ups are necessary to evaluate the durability of hybrid repairs.     

Mid-term outcome with surgery for type B aortic dissections: a single center experience

BACKGROUND: The approach to acute and chronic type B aortic dissection has changed significantly over the past years. In this aspect, we have reviewed our single-center experience in surgery for type B dissections and compared the current data presented by other centers. METHODS: Twenty-nine patients operated at our center for type B aortic dissection (14 acute, 15 chronic) were reviewed over the years between 1996 and 2004. All patient data in addition to immediate and late outcome following surgery were noted. RESULTS: The mean age in acute and chronic groups was 53 +/- 16 versus 62 +/- 12 years, respectively (p = 0.1). Hospital mortality was 4 patients. The mean period in the intensive care unit was 4.2 +/- 3.1 days. Follow-up time was 36 +/- 11 months. Median interval between the initial symptoms and surgery was 3.8 days for acute cases. No patients underwent reoperation in acute patients; whereas 3 underwent reoperation in the chronic group. False lumen patency rates in acute and chronic dissections were 16.7% versus 46% after 24 months (p< 0.05). Distal anastomoses included both true and false lumens in 83% of the chronic cases with false lumen patency. The mean reoperation-free survival was 79.35 months with standard error of 5.57 months (95% CI, 68.42 to 90.27) in all patients. CONCLUSIONS: Open surgery in acute type B dissections yielded excellent immediate and long-term durability in our series with no false lumen patency or aortic expansion. However, incorporation of both false and true lumina into distal anastomosis in patients with chronic dissection resulted in false lumen patency with aortic expansion.     

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.     

Mycotic aortic aneurysms treated by endovascular repair: initial experience in a single center

Introduction: Mycotic aortic aneurysm (MAA) is an uncommon cause of aneurysmal aortic disease. However, it may have an aggressive presentation and a complicated early outcome. Endovascular aneurysm repair (EVAR) of MAA is emerging as an alternative to open repair (OR) for the treatment of these aneurysms, particularly in high-risk surgical patients. We report a single-center experience with the endovascular management of mycotic aortic aneurysms.

Material and methods: Two mycotic abdominal aortic aneurysms were treated with an endovascular stent graft at Centre Hospitalier Régional du Val de Sambre, Belgium. The mean follow-up was 15 months. Technical success was achieved in all two patients. CT-scan follow up showed shrinkage of the aneurysm sac, with no evidence of infection along the stent graft and no signs of endoleakage in all patients. One patient died during the follow-up period from a cause unrelated to the aneurysm.

Conclusion: EVAR is an effective and safe option and might be a suitable alternative to OR in the absence of predictors of poor prognosis for the treatment of non-complicated forms of MAA.     

Visceral artery aneurysms: a single center experience

BACKGROUND: Splanchnic artery areurysm is a rare but clinically relevant disease, showing a high mortality rate in emergency surgery. Reports on splanchnic aneurysms are rare and often anecdotal. The aim of this study is to discuss data obtained from 16 patients in a single vascular surgery center. MATERIALS AND METHODS: Between January 1987 and December 2000, 16 patients underwent surgery for splanchnic artery aneurysms. In 13 patients the localization was single (in two associated with an infrarenal abdominal aortic aneurysm) and in 3 patients multiple. The arteries involved were: splenic (8), hepatic (4), celiac (3), superior mesenteric (3), ileocolic (2), and pancreatoduodenal (1). 13 patients were asymptomatic and 3 presentec with abdominal pain. All patients underwent CT scan, and abdominal aortic and selective visceral artery angiography. Before surgery, all patients underwent cerebral MR or cerebral CT scan. 13 patients underwent open vascular surgery; 3 patients (2 splenic and 1 hepatic) underwent endovascular procedure (angioembolization). Histological examination of the aneurysmal wall was obtained in 14 patients. Ultrasound examination was performed after 6 months, then yearly. 14 patients underwent abdominal CT scan during the long-term follow-up. RESULTS: Perioperative mortality was absent. 12 cases were classified as displastic, with minor or major secondary atherosclerotic changes, and in many cases severe calcications. 2 cases were classified as atherosclerotic. Cerebral MR did not show any cases of intracerebral displastric aneurismal disease. One patient was lost at follow-up after 9 years. One patient showed a recurrence at 6 years (superior mesenteric artery): the patient underwent a new surgical procedure and died 20 days after surgery for intestinal infarction. All abdominal follow-up CT scans show good results of the vascular reconstruction and escluded other new visceral or aortic aneurysms. CONCLUSIONS: Visceral artery aneurysms are an uncommon form of abdominal vascular disease showing a high postoperative mortality rate in emergencies. Surgery, and in selected cases, endovascular treatment, can successfully manage splanchnic artery aneurysms with few complications and low recurrence.     

Hybrid procedures for the treatment of aortic arch aneurysms

Aortic arch aneurysms present a significant clinical challenge. Historically, open repair has been the mainstay of therapy, but it is associated with significant morbidity and mortality. In particular, the risk of stroke is not insignificant. The development of endovascular therapies has allowed for the less invasive treatment of thoracic aortic aneurysms using endograft therapy. This treatment is limited by the need for "healthy" aorta proximal and distal to the aneurysm in order to get an appropriate seal. This limits use of endografts in the aortic arch as treatment of aneurysms in this location would necessitate coverage of critical brachiocephalic vessels including the innominate and left carotid arteries. To overcome these limitations, hybrid approaches to arch aneurysm repair have been developed. These include partial arch reconstruction through a median sternotomy, or extra-anatomic arch vessel bypass depending on the location of the aneurysm and the patients overall medical condition. These are accompanied by the placement of a thoracic stent-graft at the same setting (either antegrade or retrograde) or at a subsequent procedure. Outcomes evaluating these procedures are just beginning to become available in significant numbers. The outcomes, however, demonstrate these are durable procedures that may provide a viable alternative to conventional aortic arch surgery. As experience with these procedures grows, our understanding of the factors affecting outcomes will be clearer, and the use of these procedures will become associated with even lower morbidities and mortality. The further evolution of aortic endograft technology, however, will ultimately allow for complete endovascular treatment of the entire aortic arch.     

Hybrid procedures as a combined endovascular and open approach for pararenal and thoracoabdominal aortic pathologies

OBJECTIVES: to report our experience with hybrid vascular procedures in patients with pararenal and thoracoabdominal aortic pathologies. METHODS: 68 patients were treated for thoracoabdominal aortic pathologies between October 1999 and February 2004; 19 patients (16 men; mean age 68, range 40-79) with high risk for open thoracoabdominal repair were considered to be candidates for combined endovascular and open repair. Aortic pathologies included five thoracoabdominal Crawford I aneurysms, one postdissection expanding aneurysm, three symptomatic plaque ruptures (Crawford IV), five combined thoracic descending and infrarenal aneurysms with a healthy visceral segment, three juxtarenal or para-anastomotic aneurysms, and two patients with simultaneous open aortic arch replacement and a rendezvous maneuver for thoracic endografting. Commercially available endografts were implanted with standardized endovascular techniques after revascularization of visceral and renal arteries. RESULTS: Technical success was 95%. One patient developed a proximal type I endoleak after chronic expanding type B dissection and currently is waiting conversion. Nine patients underwent elective, five emergency and five urgent (within 24 h) repair. 17 operations were performed simultaneously, and 2 as a staged procedure. Postoperative complications include two retroperitoneal hemorrhages, and one patient required long-term ventilation with preexisting subglottic tracheal stenosis. Thirty-day mortality was 17% (one multiple organ failure, one secondary rupture after open aortic arch repair, one myocardial infarction). Paraplegia or acute renal failure were not observed. Total survival rate was to 83% with a mean follow-up of 30 months. CONCLUSIONS: Midterm results of combined endovascular and open procedures in the thoracoabdominal aorta are encouraging in selected high risk patients. Staged interventions may reduce morbidity.     

Existence of abdominal aortic aneurysms in patients with thoracic aortic dissections

OBJECTIVE: The objective of this study was to determine the coexistence or later development of pararenal and infrarenal abdominal aortic aneurysms (AAAs) in patients with thoracic aortic dissections. METHODS: One hundred forty-five patients (95 men, 50 women) encountered from 1992 to 2001 with thoracic aortic dissections-excluding those associated with trauma, those with Marfan's syndrome, and those with thoracoabdominal aortic aneurysms-were studied. The most common risk factors included hypertension (59%) and a history of tobacco use (52%). Type III dissections affected 86 patients (59%), and type I dissections affected the remaining 59 patients (41%). Aortic computed tomography (CT) scans were obtained annually. Data were assessed by univariate and multivariate analyses. RESULTS: Five patients (3%) had a history of AAA repair prior to their thoracic aortic dissection diagnosis-3 were type III dissections and 2 were type I dissections. Twelve patient's (8%) AAAs were diagnosed with the initial CT study of their thoracic aortic dissection. Type III dissections accounted for all but one of these (11 of 12, 92%). Ten additional AAAs (7%) developed in the 128 patients with no initial evidence of an AAA being recognized from 1 to 48 months (average 16 months) after the thoracic aortic dissection was diagnosed. Type III dissections affected 8 of these 10 patients. Among the total 27 AAAs noted in this series, 74% (20 AAAs) were not continuous with the thoracic aortic dissection. In the univariate analysis, age (P =.0002), male gender (P =.044), history of smoking (P =.01), chronic obstructive pulmonary disease (P <.001), duration of dissection (P =.05), and presence of type III dissection (P =.009) were associated with the presence of an AAA. In the multivariate analysis, both chronic obstructive pulmonary disease (odds ratio 5.4, 95% CI, 1.3 to 22.3; P =.02) and age (OR 1.06, 95% CI, 1.02 to 1.11; P =.004) were significant predictors of the development of AAAs. CONCLUSION: This study documented that patients with thoracic aortic dissections are at risk to harbor or develop a later AAA. This finding supports the tenet that abdominal CTs or ultrasound scanning should be mandatory in the follow-up of patients with known thoracic aortic dissections.     

Hybrid procedures combining conventional and thoracic endovascular aortic repair for thoracic aortic aneurysms

Purpose  

To minimize surgical invasiveness for extensive aortic aneurysms and expand the indications for thoracic endovascular aortic repair (TEVAR), we evaluated outcomes of hybrid procedures combining conventional surgical aortic repair and TEVAR for thoracic aortic aneurysms.     

Hybrid treatment of thoracoabdominal aortic aneurysms with the use of a new prosthesis

We report the case of a 72-year-old woman with thoracoabdominal aortic aneurysm who underwent hybrid surgical and endovascular procedure. First, debranching of the aortic arch and implantation of a new multi-branched prosthesis with transdiaphragmatic celiac artery and superior mesenteric artery revascularization was performed. Two weeks later the procedure was successfully completed with aneurysmal exclusion by deployment of multiple stent grafts. The postoperative course was uneventful. A two-staged surgical and endovascular approach with the use of a new prosthesis reduces the risk of endoluminal graft endoleak and may constitute an attractive alternative to conventional surgery in management of high-risk thoracoabdominal aortic aneurysms.