Transapical endovascular aortic repair to treat complex aortic pathologies

Clinical condition, hostile anatomy, and previous heart/aortic surgery may preclude standard open surgery and standard endovascular interventions in patients with complex aortic pathologies. We report our initial experience using the transapical endovascular approach to treat a type IA endoleak after transfemoral endovascular graft repair for a contained rupture of a penetrating descending aortic ulcer; an ascending aortic anastomotic pseudoaneurysm after open surgical repair of an ascending aortic dissection; and a type A aortic dissection after minimally invasive mitral valve repair. There were no neurologic or cardiovascular complications, and the 30-day mortality was 0%.     

Current perspective on aortic valve repair and valve-sparing aortic root replacement

Aortic valve repair and valve-sparing aortic root replacement are attractive concepts because they offer the possibility of valve competence without structural deterioration due to nonviability and they preclude the need for anticoagulation. Enthusiasm for aortic valve repair has waxed and waned over the past 45 years due in part to the inherent technical difficulties and poor mid-term results. Renewed interest in the concept of aortic valve repair has paralleled the development of valve-sparing aortic root replacement over the last 20 years. A current perspective on aortic valve repair and valve-sparing aortic root replacement is presented in the following review. Historical background, indications for repair, technical considerations, and outcomes data are discussed.     

Staged hybrid repair using telescoped stent graft fixation for aortic arch and descending aortic aneurysms

Staged repair of extensive thoracic aortic aneurysms is complicated, with a high incidence of interval rupture between stages. We describe the systematic staged hybrid procedure of a previous endovascular repair of a descending aortic aneurysm and open surgical repair of an aortic arch aneurysm. In the second-stage arch repair, the stent graft was easily retracted and fixed, without dissection, around the aortic arch aneurysm distal side. Extensive thoracic aortic aneurysms were managed without interim rupture or neurologic deficits. This approach avoided the potential for interim rupture because recovery from the first-stage endovascular repair was shorter than that from open repair.     

Outcome of aortic valve repair in children with congenital aortic valve insufficiency

OBJECTIVE: Surgical aortic valvotomy has a long history of providing excellent palliation for aortic stenosis in infancy and childhood. The fate of aortic valve repairs for dominant aortic regurgitation in this same age group is considerably less clear. METHODS: From 1990 to 2000, a total of 21 patients underwent aortic valve repair for aortic regurgitation at our institution. Seventeen patients were younger than 17 years at the time of repair (3-17 years, mean 8.1 +/- 3.7 years). Of these 17 children, 6 (35%) had bicuspid valves and 11 (65%) had tricuspid valves. Type of repair varied with valve type, but repair generally consisted of commissure resuspension, partial commissure closure, triangular resection of redundant leaflets, or some combination. RESULTS: There were no deaths. Follow-up ranged from 1 to 11 years (mean 5.3 +/- 2.4 years). At present 3 of 17 (17.6%) have mild aortic regurgitation according to echocardiography and 6 (35.2%) have moderate aortic regurgitation. In 8 of 17 cases (47.1%) the repair clearly failed, requiring reoperation from 0.5 to 73 months after the original operation (mean 18.9 months). Reoperation consisted of 6 Ross procedures and 2 mechanical aortic valve replacements. There were no deaths at the secondary operation. CONCLUSION: Aortic valve repair in children with a dominant feature of aortic insufficiency tended to fail progressively and at a high rate. Leaflet thickening was associated with higher risk of repair failure in this series. The threshold for aortic valve replacement should remain low.     

Endovascular aortic grafting: current status

Endovascular repair of abdominal aortic aneurysms was first reported in 1991. Since then there has been widespread development of many stent-grafts for abdominal aortic aneurysm repair. Available data support the proposition that stent-grafts are generally safe, although their long-term efficacy remains completely unknown. Importantly, endovascular abdominal aortic aneurysm repair to date does not have fewer complications nor lower mortality rates than open repair; in fact, the opposite appears true. Along with most new techniques come new complications, and endovascular repair of abdominal aortic aneurysm has brought forth the concepts of both `endoleak' and device failure. While uncommon, delayed abdominal aortic aneurysm rupture following seemingly successful endovascular repair of abdominal aortic aneurysm has been reported. In our opinion, these faults, unique to endovascular repair, mandate a cautious approach to the clinical application of stent-grafts. Until ongoing Phase 2 and future Phase 3 studies are completed with a minimum of 2–3 years follow-up, we will not know if endovascular repair of abdominal aortic aneurysm represents a giant step forward or merely an industry-driven overuse of proprietary technology.     

Blunt traumatic aortic transection: endoluminal repair with commercially available aortic cuffs

Blunt traumatic aortic transection remains a lethal condition. Treatment requires a high index of suspicion, prompt diagnosis, and expedient operative repair. Even in the best of circumstances, morbidity and mortality associated with open surgical repair are high, particularly because of frequent occurrence of other severe associated injuries. Endoluminal aortic stent-graft repair is an accepted treatment option in patients with aneurysm degeneration, and may be an alternative means of managing contained aortic transection. We describe three cases of blunt traumatic thoracic aortic transection treated with commercially available aortic endoluminal stent grafts.     

腔内隔绝术联合开窗技术治疗累及主动脉弓部的Stanford B型夹层动脉瘤的临床研究

目的 总结腔内隔绝术联合开窗技术治疗累及主动脉弓部的Stanford B型夹层动脉瘤的可行性和手术效果.方法 采用腔内隔绝术联合开窗技术治疗10例累及主动脉弓部的Stanford B型夹层动脉瘤.腔内隔绝术联合开窗技术封堵夹层破口,保留主动脉弓全部分支8例,保留头臂干及颈总动脉2例.手术均在局部麻醉下完成,覆膜支架开窗在术中进行.结果 患者术中造影无内漏,术后无死亡,2例左锁骨下动脉封堵的患者未出现神经系统并发症.随访中,开窗支架通畅,无移位,保留的主动脉弓分支动脉通畅,降主动脉真腔扩大,假腔血栓化并缩小.结论 对于累及主动脉弓部的Stanford B型夹层动脉瘤,腔内隔绝术联合开窗技术治疗是安全有效的治疗方法.     

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.     

Complications of aortic endografting

Endovascular repair of abdominal aortic aneurysm has been shown to have a significantly lower perioperative mortality rate compared with open repair. It has been a blessing for patients at high risk who were previously denied treatment for their aortic aneurysms. It does, however, have a substantial need for re-intervention for complications. Many of these complications including endoleak, endotension, migration, post implant syndrome and conversion to open repair are unique to endovascular aneurysm repair. Others including injury to the iliac arteries, graft limb thromboses and structural failure of prostheses occur with greater frequency in endovascular repair compared with open repair. It is important, therefore, for vascular surgeons to be aware of these complications including their prevention and appropriate that patients are informed of their incidence. This review discusses the local and vascular complications of endovascular repair of abdominal aortic aneurysm with an emphasis on newer aspects.     

Repair of ascending aortic dissection. Influence of associated aortic valve insufficiency on early and late results

Operative treatment of dissections of the ascending aorta differs from that for the descending aorta, not only because of the need for cardiopulmonary bypass, but also because of the frequent occurrence of aortic valve insufficiency. To determine the early and late results of operative repair, we have reviewed the case histories of 121 consecutive patients who underwent repair of ascending aortic dissections between 1962 and 1985. Ages ranged from 16 to 79 years (mean 56 +/- 14 years); 54 patients had operation within 2 weeks of onset of symptoms (acute), and the remainder had later repair (chronic). Seventy patients (58%) had clinical evidence of aortic insufficiency at the time of admission. During repair of acute dissection, 10 patients (19%) had aortic valve resuspension and 15 patients (28%) had aortic valve replacement. During repair of chronic dissection, eight patients (12%) had resuspension and 43 patients (64%) had replacement. Overall operative mortality was 22%, significantly higher for patients with acute than for those with chronic dissections (39% versus 9%, p less than 0.01). Operative risk was similar for patients who underwent repair of ascending aortic dissections without valve resuspension or replacement (31%) versus those who had repair with aortic valve resuspension (17%) or replacement (17%). During a follow-up period ranging from 1 to 208 months, aortic regurgitation developed in only two patients who did not have aortic insufficiency at the time of repair. Late aortic regurgitation necessitating reoperation developed in one of the 15 survivors who had aortic valve resuspension. Eight patients undergoing aortic valve replacement had complications of their prostheses, including one periprosthetic leak and four mechanical failures. We conclude that resuspension or replacement of the aortic valve does not increase the risk of repair of ascending aortic dissections. Selective management of aortic insufficiency (with valve repair whenever possible) yields satisfactory long-term results.     

Late results of aortic valve repair for isolated severe aortic regurgitation

ObjectivesThe objectives were to analyze the long-term outcomes of tricuspid aortic valve repair for isolated severe aortic regurgitation and the impact of different annuloplasty techniques.MethodsThe study cohort consists of 127 consecutive patients who received aortic valve repair for isolated severe aortic regurgitation in the tricuspid aortic valve between 1996 and 2019 in our institution. Exclusion criteria were aorta dilatation (≥45 mm), connective tissue disease, active endocarditis, type A dissection, and rheumatic disease. Mean age of patients was 55.6 ± 16 years, and 80% were male. Median follow-up was 6.4 years. Time-to-event analysis was performed, as well as risk of death, reoperation, and aortic regurgitation recurrence.ResultsCusp repair was performed in 117 patients (92%), and annuloplasty was performed in 126 patients (99%) with Cabrol stitch (73%), reimplantation technique (19.7%), or ring annuloplasty (6.3%). There was no hospital mortality. At 10 and 14 years, overall survival was 81% ± 5% and 71% ± 6%, respectively, and freedom from reoperation was 80% ± 5% and 73% ± 6%, respectively. Age and left coronary cusp repair were independent predictors of reoperation. Freedom from recurrent severe aortic regurgitation (>2+) was 73% ± 5% and 66% ± 7% at 10 and 12 years, respectively. Age, left ventricular end-diastolic diameter, and patch repair were independent predictors of recurrent aortic regurgitation. Type of annuloplasty had no impact on survival or reoperation.ConclusionsAortic valve repair for isolated severe aortic regurgitation in the tricuspid aortic valve is a safe procedure, and durability at 14 years is acceptable. In this study, the annuloplasty technique did not influence repair durability as was found in bicuspid aortic valve repair or aortic valve–sparing surgery. Severity of cusp pathology seems to be the main determinant of repair durability.     

One-stage repair of an aortic dissection and aortic coarctation

Ascending aortic dissection with aortic coarctation has a high mortality. There are few reports of successful surgical management of the combined condition. We report a case of a successful one-stage repair of type A aortic dissection with aortic coarctation, using an extra-anatomic bypass to connect the ascending to the abdominal aorta.     

Incisional hernia following aortic surgery

Summary Controversy exists in the literature regarding the incidence of incisional hernia formation after aortic reconstruction and the rate of incisional hernia formation in vertical midline and transverse incisions. We reviewed the incidence of incisional hernia after aneurysm (AAA) or occlusive disease (OCC) aortic operations and the incidence of incisional herniorrhaphy for vertical midline versus transverse incisions. Through a retrospective chart review of patients between 1970 and 1998, 618 patients who underwent incisional herniorrhaphy, 265 who underwent AAA repairs, and 331 who underwent OCC repairs were identified. These three groups were cross-referenced to identify patients who underwent incisional herniorrhaphy following aortic reconstruction. Patients were analyzed and compared according to presence of AAA or OCC and the incision and suture material used during the aortic repair. Thirty-six patients underwent incisional herniorrhaphy following aortic reconstruction. Twenty-six patients (9.8%) required incisional herniorrhaphy after AAA repair (22 vertical midline incisions, 4 transverse incisions). All ten patients (3%) who underwent incisional herniorrhaphy after OCC repair had vertical midline incisions. The difference in the incidence of incisional hernia repair (9.8% vs 3.0%) between AAA and OCC was statistically significant (p<0.001). In AAA patients, there was an 11.3% incisional hernia repair rate after vertical midline incisions versus 5.6% after transverse incisions, but the difference was not statistically significant. We have demonstrated a significantly higher incidence of incisional hernia repair following aortic reconstruction for AAA than for OCC repair. Furthermore, we identified a trend towards increased incisional hernia repair after employing vertical midline incisions versus transverse incisions in AAA patients, and a significant risk for incisional hernia after AAA repair when absorbable suture was used.     

Recent advances in thoraco-abdominal aortic aneurysm repair

Thoraco-abdominal aortic aneurysm repair remains a formidable challenge to vascular surgeons. The traditional repair of thoraco-laparotomy with aortic cross-clamping is associated with a high morbidity and mortality despite significant advances in perioperative critical care, anaesthetic and surgical techniques.The advent of the endovascular revolution has shown a marked paradigm in the approach to all aneurysm repairs. As a logical progression from the open repair, the St Mary's visceral hybrid repair combines traditional open techniques (retrograde visceral and renal revascularisation via mid-line laparotomy) with endovascular stent grafting, thereby avoiding the need for thoracotomy and aortic cross-clamping. In specialist centres, the results have been encouraging and easily comparable to the open repair. The technique has been used in several centres around the world and represents a robust, transferrable method of repairing thoraco-abdominal aortic aneurysms.Stent-grafting technologies have reached a point of sophistication that wholly endovascular methods of repairing thoraco-abdominal aortic aneurysms are being performed in several centres around the world. Although these stent grafts have to be customised to the individual patient and are only suitable for certain types of aneurysmal anatomies, they represent the future of thoraco-abdominal aortic aneurysm repair.We review the history of thoraco-abdominal aortic aneurysm repair, the exciting advances in their treatment and discuss our approach to the management of thoraco-abdominal aortic aneurysms in the 21st century.     

A prospective study to assess changes in proximal aortic neck dimensions after endovascular repair of abdominal aortic aneurysms

OBJECTIVE: The purpose of this study was to detect any change in the proximal neck diameter after endovascular repair of abdominal aortic aneurysm. METHODS: The study was performed in a teaching hospital with an endovascular program on 112 patients who had undergone endovascular repair of abdominal aortic aneurysm. The interventions were pre-endovascular and postendovascular repair of abdominal aortic aneurysms with contrast-enhanced, spiral computerized tomography, and the main outcome measures were change in aortic proximal neck diameter, change in maximum aortic diameter, presence of endoleaks, and change in length from lowest renal artery to aortic bifurcation. RESULTS: The median anterior-posterior and transverse diameter decreased from 63.5 mm before surgery to 50.4 and 54.5 mm, respectively, after surgery in a period of 4 years. This trend in reduction in maximum diameter was not seen in the patients with endoleaks. There was no significant change in the proximal neck diameters when measured at 5-mm intervals after endovascular repair. There was also no significant change in the aortic length after endovascular repair. CONCLUSION: We have not demonstrated any evidence for proximal neck dilatation after endovascular repair of abdominal aortic aneurysm.     

Acute aortic dissection into a preexisting abdominal aortic aneurysm

Acute aortic dissection and abdominal aortic aneurysm presenting as coexistent conditions is rare. We report a patient with a history of hypertension and acute severe back pain who had an acute aortic dissection extending into a preexisting 8 cm abdominal aortic aneurysm that was diagnosed by CT scan. There was no evidence of aortic rupture or leakage. The patient was treated with antihypertensive medication for 2 months to allow maturation of the acute dissection prior to elective repair of the abdominal aortic aneurysm. The repair was constructed to allow continued perfusion of both the true and false lumina by fenestration of the aortic septum at the proximal anastomosis. There were no postoperative complications. This case illustrates an unusual combination of aortic diseases. A management plan is described that safely treats both pathologic conditions.Presented at the Fourth Annual Winter Meeting of the Peripheral Vascular Surgical Society, Breckenridge, Colo., January 21– 24, 1994.     

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.     

Total aortic replacement in Loeys-Dietz syndrome

Loeys-Dietz syndrome (LDS) is a recently identified genetic complex characterized in part by rapidly progressive aortic and branch vessel disease. We now describe total aortic replacement using an open Extent II thoracoabdominal repair followed by second-stage redo-sternotomy for a valve-sparing aortic root replacement and hybrid aortic arch repair in a patient with this syndrome.     

Stanford B型主动脉夹层的诊断治疗

Stanford B型夹层是一种严重威胁人类生命健康的主动脉疾病.随着临床分类的细化及诊断方法的改进,Stanford B型主动脉夹层病死率逐渐降低.治疗上,腔内修复因其微创优势逐渐取代传统开放手术成为复杂性Stanford B型主动脉夹层治疗的首选.对于非复杂性夹层,腔内修复也逐渐取代药物治疗,并显示出良好疗效.开放手术仅适用于不适用腔内修复,修复失败或合并结缔组织病患者.     

Surgical treatment of thoracoabdominal aortic aneurysm after repairs of descending thoracic or infrarenal abdominal aortic aneurysm.

OBJECTIVE: The outcome of thoracoabdominal aortic aneurysm repair after operations for descending thoracic or infrarenal abdominal aortic aneurysm was investigated. METHODS: Between May 1982 and July 2000, 102 patients underwent thoracoabdominal aortic aneurysm repair. Of these patients, 36 had previously undergone operations for descending thoracic or abdominal aortic aneurysm. To evaluate the influence of previous descending thoracic or infrarenal abdominal aortic aneurysm repair on the results of TAAA replacement, patients were divided into two groups: one group of patients who had previously undergone descending thoracic or infrarenal abdominal aortic aneurysm repair (group I, n=36) and one group of patients who had not previously undergone descending thoracic or infrarenal abdominal aortic aneurysm repair (group II, n=66). RESULTS: Patients with previous descending thoracic or infrarenal abdominal aortic aneurysm repair had more chronic dissection and extensive thoracoabdominal aortic aneurysm. The distal aortic perfusion time and total aortic clamp time were both longer in group I. The total selective visceral and renal perfusion time and operation time did not differ significantly between the two groups. In 30-day mortality rates were 5.5% in group I and 13% in group II. Major postoperative complications included paraplegia in 14% of patients in group I and 3.1% in group II, renal failure requiring hemodialysis in 22% of patients in group I and 19% of patients in group II, respiratory failure in 36% of patients in group I and 30% of patients in group II, postoperative hemorrhage in 11% of patients in group I and 16% of patients in group II. CONCLUSION: The presence of a previous descending thoracic or infrarenal abdominal aortic aneurysm did not adversely affect the outcome of thoracoabdominal aortic aneurysm repair.