Endografting of the thoracic aorta:

BACKGROUND: Thoracic aortic dissections, ruptures, fistulae, and aneurysms pose a unique surgical challenge. Traditional repair of thoracic aortic aneurysms involves thoracotomy with graft interposition. Despite advances in perioperative care and both total and partial cardiopulmonary bypass, conventional surgery carries a significant morbidity and mortality. Principal complications include bleeding, paraplegia, stroke, cardiac events, pulmonary insufficiency, and renal failure. Recent enthusiasm for innovative endovascular therapies to treat aortic disease has spurred many centers to investigate endoluminal grafting of the thoracic aorta. Early reports on endovascular repair using custom made "first generation devices" demonstrated the technique to be feasible with a mortality and morbidity comparable to open repair. METHODS AND RESULTS: From February 2000 to February 2001, endovascular stent graft repair of the thoracic aorta was performed in 46 patients (mean age 70; 29 male and 17 female) using the Gore Excluder. Twenty-three patients (50%) had atherosclerotic aneurysms, fourteen patients (30%) had dissections, three patients (7%) had aortobronochial fistulas, three patients (7%) had pseudoaneurysms, two patients (4%) had traumatic ruptures, and one patient (2%) had a ruptured aortic ulcer. Patient characteristics, procedural variables, outcomes, and complications were recorded. All patients were followed with chest CT scans at 1, 3, 6, and 12 months. Mean follow up was 9 months ranging from 1 to 15 months. All procedures were technically successful. There were no conversions. Average duration of the procedure was 120 minutes. Average length of stay was 6 days, but most patients left the hospital within 4 days (64%) after endoluminal grafting. Overall morbidity was 23%. Two patients (4%) had endoleaks that required a second procedure for successful repair. Two patients (4%) died in the immediate postoperative period. There were no cases of paraplegia. At follow-up, one patient had an endoleak found the day after the procedure and another patient had an endoleak 6 moths post procedure. Both were treated successfully with additional stent grafts. There were no cases of migration. One patient died of a myocardial infarction 6 months after graft placement. The Gore Excluder device was voluntarily recalled on February 26, 2001. Therefore, from June 2000 to January 2001, 37 patients underwent endovascular stent graft repair of the thoracic aorta for various disease entities using our customized thoracic graft (Endomed). Twenty-seven patients (73%) had aneurysms, six (16%) had dissections, two (5%) had pseudoaneurysms, one (2%) had a traumatic transection, and one patient (2%) had an embolizing ulcer. Patients were followed with CT scans at 1, 3, 6, and 12 months. All procedures were technically successful. There were no conversions. The average age was 68 years.(17-87). And the male and female ratio was 24/13. One patient died in the operating room from iliac rupture and one died from embolization/stroke in the immediate postoperative period. Two patients died within 30 days from comorbid factors. The total 30-day mortality was 10%. Two patients had endoleaks. One returned to the operating room and needed an additional cuff. The other had a small leak in a proximal dissection that is being followed. There were no cases of paraplegia. CONCLUSION: Thoracic endoluminal grafting is a safe and feasible alternative to open graft repair and can be performed successfully with good results. Early data suggest that an endoluminal approach to these disease entities maybe favorable to open resection and graft replacement. Technical details of Endoluminal stent grafting of the thoracic aorta for different disease entities have been discussed at length.     

Early and mid-term results of endovascular stent grafting for aortic aneurysms]

Early and mid-term clinical results of 28 cases of endovascular stent grafting for descending thoracic aortic aneurysms and 11 cases of abdominal aortic aneurysms are reported. Early clinical results: Among 28 patients (7 true thoracic aortic aneurysms, 3 pseudothoracic aortic aneurysms and 8 acute, 4 subacute, and 6 chronic aortic dissections), two patients (7.1%) with ruptured acute aortic dissection or ruptured infected pseudoaneurysm died in the perioperative period. Two of the remaining 26 patients experienced minor complications. Aneurysmal sacs or false lumens at the descending thoracic aorta were completely thrombosed in the 26 patients. One patient (9.1%) with a ruptured abdominal aneurysm died, and one of the remaining 10 patients had renal and peripheral emboli and peripheral vascular trauma. Inadvertent covering of the renal arteries occurred in another patient. Unless one patient had persistent endoleak, aneurysmal sacs in the 10 surviving patients were thrombosed. Mid-term clinical results: One aortic dissection at a different section of the descending aorta occurred 6 months after stent grafting for aortic dissection, and one patient died of pneumonia 3 months after stent grafting for an abdominal aortic aneurysm. CT scanning 6 months after stent grafting revealed a decrease in maximal aneurysmal size in 3 of 9 patients with true or pseudothoracic aneurysms and in 2 of 5 patients with abdominal aortic aneurysms. Five of 9 patients with stent grafting for acute or subacute dissection showed elimination of the false lumen in the descending thoracic aorta in a CT scan 6 months after grafting. One patient with a true thoracic aneurysm and one patient with an abdominal aortic aneurysm showed an increase in aneurysmal size in a CT scan 2 years and one year after treatment, respectively.     

Great vessels transposition and aortic arch exclusion

AIM: We describe our experience in endovascular repair of Thoracic Aortic Aneurysms and Dissections (TAAD) involving the aortic arch in high risk patients (HRP). METHODS: Twenty-nine patients presented with TAAD involving the aortic arch and were treated by endovascular exclusion. Pathologies were as follows: atherosclerotic aneurysms of the descending thoracic aorta in 15 cases, acute Stanford type A dissections in 6 cases, Stanford type B dissections in 7 cases (1 acute), and 1 false aneurysm of the ascending aorta. Total-arch transpositions of all supra-aortic vessels (aortic debranching) to the ascending aorta were done in 11 cases throught median sternotomy. We performed carotido-carotid bypass (hemi-arch transposition) in 16 patients by cervicotomy. Secondary to surgical transpositions, we placed endovascular stentgrafts in all but 2 patients for final exclusion, the 2 remaining being planned for later exclusion. The Talent, Excluder, TAG and Zenith endografts were used in 12, 3, 1 and 4 cases respectively. Banding technique was associated in some cases. RESULTS: All surgical transpositions were successful although 1 led to a minor stroke (1/29=3.5%), which worsened to major stroke after endovascular exclusion. Endovascular procedures were performed in all but one case (26/27=96.3%). Two patients (2/26=7.7%) died from catheterization related complications after endovascular exclusion (iliac rupture and left ventricle perforation). One patient had a delayed minor stroke (1/26=3.8%). Recirculation was found in 13.3% (2/15) of aneurysms and 27.3% of thoracic false channels. During a mean follow-up of 15.7 months (13 days to 45.5 months), 1 patient (1/26=3.8%) who had preoperative chronic pulmonary failure died at 6 months from respiratory worsening. We observed one case (3.8%) of unilateral limb palsy unrelated to cerebral ischemia, which we successfully treated by cerebrospinal fluid (CSF) drainage. No stent-related complication was seen. One new type 1 endoleak appeared at 12 months on an aneurysm, which resolved after stentgraft extension. Three thoracic dissection false channels remained patent during follow-up, of which one was retrograde originating distally in the descending aorta. CONCLUSIONS: Secondary endovascular exclusion of thoracic aortic diseases involving the arch in HRP is made feasible thanks to the preliminary aortic debranching. Total-arch transposition may be of greater interest in case of proximal neck length uncertainty and potential embolization from the aortic arch. Mid-term results are good although patients must be followed carefully to detect aortic recirculation and enlargement.     

Combined surgical and endovascular treatment of extensive thoracic aortic aneurysm

AIM: Patients with extensive aneurysm involving ascending aorta, aortic arch and descending aorta are usually treated by sequential operations. For these patients we can also use combined surgical and endovascular treatment. The experience with this procedure published in the literature is very limited. We report our experience in the 'elephant trunk' technique followed by an endovascular stent-grafting of the descending thoracic aorta in a small group of three consecutive patients with extensive thoracic aortic aneurysm. METHODS: Three consecutive patients with extensive thoracic aortic aneurysm or chronic dissection underwent combined surgical and endovascular treatment between January and December 2004. The procedure was carried out as a two-stage procedure. During the first stage aortic arch was replaced using the elephant-trunk' method and during the second stage the stentgrafting of the descending aorta was performed. RESULTS: All three patients were treated successfully. There was no death, no endoleak and no permanent neurological deficit. One patient had a transient paraparesis. In all patients the spiral CT demonstrated excellent technical result without endoleak and with thrombosis of the paraprosthetic space. CONCLUSIONS: We can conclude, that the combined surgical and endovascular treatment of extensive thoracic aortic aneurysm is a feasible method which could reduce mortality and morbidity. In our institution the elephant trunk technique followed by an endovascular stent-grafting of the descending aorta is the preferred method of treatment in patients with extensive thoracic aortic aneurysm involving ascending aorta, aortic arch and descending aorta.     

Single Center Experience with a New Commercially Available Thoracic Endovascular Graft

PURPOSE: To evaluate the intra-operative performance and clinical outcome of a new commercially available stent-graft for the treatment of thoracic aortic diseases. METHODS AND PATIENTS: From January 2003 to October 2004, 45 consecutive patients received endovascular treatment with the Zenith TX1 device for diseases of the thoracic aorta at a single center in northern Italy. Indications included disease of the descending thoracic aorta in 26 cases, of the aortic arch in 17 cases and of the thoraco-abdominal aorta in two cases. We treated 38 atherosclerotic aneurysms, two post-traumatic aortic ruptures, two penetrating ulcers, two chronic dissections and one case was treated for aortic bleeding after voluntary acid ingestion for attempted suicide. General anesthesia was used in 20 cases. Combined or hybrid endovascular and open surgical repair was performed in 11 patients. Mean follow-up was 7 months (range 1-22 months). RESULTS: Technical success was obtained in 44 patients (98%). One primary type I endoleak occurred (2%). ICU was used in 12 cases with a mean stay of 1 day. The mean hospital stay was 6 days (range 4-13 days). There were no hospital deaths or strokes but one transient paraplegia (2%). A type II endoleak was observed in one case and resolved spontaneously 1 month later. No aneurysm enlargement, endograft migration or structural failures were observed during follow-up. Two late unrelated-deaths were observed. CONCLUSIONS: This stent-graft does not fulfill all the characteristics of the ideal graft, however, it proved to be safe and allowed satisfactory short term results in this group of patients treated at a single center.     

Thoracic aortic emergencies: impact of endovascular surgery

BACKGROUND: Conventional surgery for thoracic aortic emergencies, such as contained or free rupture of thoracic aortic aneurysms, acute type B dissections, and traumatic rupture of the thoracic aorta, is frequently associated with a high rate of mortality and morbidity. To obviate this risk, endovascular surgery is considered to be a valid alternative procedure. METHODS: From March 2001 to July 2002, 15 of 22 patients with acute thoracic aortic syndromes were submitted to endovascular surgery: 3 patients (20%) for traumatic rupture, 4 patients (26.7%) for contained or free rupture of thoracic aortic aneurysm, and 8 patients (53.3%) for acute type B dissection evolving to rupture. Computed tomographic scan was diagnostic in all patients. The stent grafts were introduced through the femoral artery. RESULTS: In the endovascular group there were no perioperative deaths or open conversions. The intraoperative angiography and computed tomographic scan performed on discharge showed no significant endoleaks and successful sealing of the aortic dissection. Average intensive care unit and hospital stay was 1.7 +/- 0.8 and 5.9 +/- 3.0 days. Follow-up ranged between 4 and 23 months and included clinical examinations and serial computed tomographic scan at 3, 6, and 12 months, and every 6 months thereafter. One 84-year-old patient with thoracic aortic aneurysm died of pneumonia 78 days after endovascular surgery. Only one type 1 endoleak was noted in the first patient with traumatic rupture, 3 months after the procedure. CONCLUSIONS: Endovascular surgery is a safe technique, showing encouraging early and midterm results and allowing for prompt treatment of associated lesions in complex multitrauma patients.     

Endovascular repair of lesions involving the descending thoracic aorta

BACKGROUND: Vascular lesions involving the thoracic aorta are often life-threatening conditions that carry significant morbidity and mortality with traditional open surgical repair. Preliminary results suggest that endovascular therapy is an effective and possibly advantageous treatment for diseases of the descending thoracic aorta. METHODS: Between October 2000 and May 2004, 50 consecutive patients underwent endovascular stent-grafting of lesions involving the descending thoracic aorta. Attempted stent-graft deployment was performed electively in 39 patients and emergently in 11. The pathology of electively treated aortic lesions included degenerative/atherosclerotic aneurysms (n = 24), pseudoaneurysms (n = 11), aortic dissections (n = 2), and penetrating ulcers (n = 2). Emergently treated aortic lesions were for acute rupture due to infectious (mycotic) aneurysms (n = 4), atherosclerotic/degenerative aneurysms (n = 3), acute type B dissections (n = 2), and acute transections (n = 2). Devices used include Talent (n = 45), AneuRx aortic cuffs (n = 2), custom-fabricated Gianturco-Dacron grafts (n = 2), and a modified Cook-Zenith abdominal aortic graft (n = 1). Follow-up was performed at 1-month, 6-months, 1-year, and annually thereafter. RESULTS: Primary technical success, defined as successful deployment and exclusion of the lesion without evidence of type I or type III endoleak, was achieved in 48 (96%) of 50 patients. In one patient, the procedure was terminated due to inability to access the iliac vessels. In another patient, a type III endoleak was observed at the completion of the primary procedure that required deployment of an additional stent-graft component 2 months later. Of the 49 patients who received endografts, seven underwent secondary procedures to correct endoleaks, with five of these seven requiring the deployment of additional endovascular stent-graft components. Major complications included four in-hospital deaths, with three of these occurring in patients treated emergently. Additionally, respiratory failure (n = 6), multisystem organ failure (n = 2), cerebrovascular accident (n = 2), retroperitoneal hematoma (n = 2), acute renal insufficiency (n = 1), and pulmonary embolus (n = 1) were also observed. The overall endoleak rate was 20%, with five primary (< or = 30 days) and five secondary (> 30 days) endoleaks observed. Five of the endoleaks were treated with the deployment of one or more additional endovascular stent-graft components. Two of the endoleaks were treated with endovascular balloon remolding. Mean follow-up was 271 days. There were no aneurysm ruptures or aneurysm-related deaths. CONCLUSIONS: Endovascular treatment of vascular lesions involving the descending thoracic aorta can be safely performed with low morbidity in high-risk patients. Endovascular repair may become an attractive alternative for the treatment of a wide range of pathology along this vascular territory.     

Endoluminal stent grafting of the thoracic aorta: initial experience with the Gore Excluder

PURPOSE: The purpose of this study was to describe our experience with endoluminal graft repair of a variety of thoracic aorta pathologies with a commercially developed device currently under investigation. Our patient population included patients eligible for open surgical repair and those with prohibitive surgical risk. METHODS: From February 2000 to February 2001, endovascular stent-graft repair of the thoracic aorta was performed in 46 patients (mean age, 70 years; 29 male and 17 female patients) with the Gore Excluder. Twenty-three patients (50%) had atherosclerotic aneurysms, 14 patients (30%) had dissections, three patients (7%) had aortobronchial fistulas, three patients (7%) had pseudoaneurysms, two patients (4%) had traumatic ruptures, and one patient (2%) had a ruptured aortic ulcer. Patient characteristics, procedural variables, outcome, and complications were recorded. All patients were followed with chest computed tomographic scans at 1, 3, 6, and 12 months. Follow-up period ranged from 1 month to 15 months, with a mean of 8.5 months. RESULTS: All the procedures were technically successful. There were no conversions. Average duration of the procedure was 120 minutes. Average length of stay was 6 days, but most patients (64%) left the hospital within 4 days after endoluminal grafting. The overall morbidity rate was 23%. Two patients (4%) had endoleaks that necessitated a second procedure for successful repair. Two patients (4%) died in the immediate postoperative period. There were no cases of paraplegia. At follow-up examination, one patient had an endoleak found the day after the procedure and another patient had an endoleak 6 months after the procedure. Both cases were treated successfully with additional stent-grafts. There were no cases of migration. One patient died of a myocardial infarction 6 months after graft placement. In patients treated for aneurysm (n = 23), the aneurysm diameter ranged from 5.0 to 9.5 cm (mean, 6.8 cm). Residual sac measurements were obtained at 1, 6, and 12 months, with mean sac reductions of 0.59 cm, 0.77 cm, and 0.85 cm, respectively. In three cases, the sac remained unchanged, without evidence of endoleak. CONCLUSION: Thoracic endoluminal grafting with the Gore Excluder is a safe and feasible alternative to open graft repair and can be performed successfully with good results. Early data suggest an endoluminal approach to these disease entities may be favorable over classical resection and graft replacement.     

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.     

Endovascular treatment of penetrating aortic ulcers: mid-term results.

OBJECTIVES: The aim of this study was to evaluate mid-term results of endovascular treatment of penetrating aortic ulcers. METHODS: Between February 2000 and November 2006, 18 consecutive patients underwent endovascular treatment of the descending thoracic aorta (N=16) and abdominal infrarenal aorta (N=2) for penetrating aortic ulcer, in a single University Hospital. Data were prospectively collected and retrospectively analyzed. Mean follow-up was 41 months (range 4 to 77 months). RESULTS: Technical success was achieved in all patients. No perioperative deaths occurred. No conversion to open repair or secondary procedures were required. Two patients died in the follow-up period for reasons not related to penetrating aortic ulcers. One type II endoleak was observed. It was still present, unchanged, twelve months after the procedure. CONCLUSION: Endovascular treatment of penetrating aortic ulcers of the descending thoracic and infrarenal aorta were safe and effective in the mid-term in this small series of patients.     

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.     

胸主动脉夹层腔内隔绝术后内漏的分型及意义

目的 探讨胸主动脉夹层腔内隔绝术后内漏的分型及其意义。方法 97例主动脉夹层行腔内隔绝术。移植物释放定位成功后进行主动脉DSA，术后7－10天行螺旋CT，分别评估内漏的来源及量的多少，决定内漏的处理。近端多量内漏时，在近端附加延伸移植物置入，少量内漏暂不处理；移植物针孔内漏暂不处理；远端内漏根据量的多少决定处理方式。结果 12例近端内漏中，10例多量内漏经附加延伸移植物将内漏封闭，2例少量近端内漏未处理。5例远端反流及针孔内漏均在观察中。结论 根据内漏的来源，可将内漏分成4型，正确分型将有利于判断、处理以及规范化统计比较。     

Stent graft repair in the aortic arch and descending thoracic aorta: a 4-year experience

BACKGROUND: Thoracic aortic aneurysms (TAAs) and type B aortic dissections (ADs) are relatively frequent, serious conditions that are often managed nonoperatively because of perceived poor outcome of standard surgical reconstruction. Recently developed stent graft techniques represent a more attractive, less invasive option. We sought to determine the technical feasibility and safety of endovascular repair in the thoracic aorta with a retrospective review of our experience with such an approach. METHODS: Forty-seven patients received thoracic stent graft implants during the 4-year period ending March 31, 2002. All patients signed an Institutional Review Board-approved informed consent. Thirty-one patients had TAAs, and 16 had ADs. Device design and implant strategy were on the basis of evaluation of morphology with angiography and computed tomographic scan. The procedures were done with fluoroscopic guidance, with local anesthesia in five cases, spinal anesthesia in 19 cases, and general anesthesia in 23 cases. Endovascular access was achieved with femoral cutdown in 41 cases and a temporary iliac conduit in six cases. A Talent patient-specific device, with 4-mm to 6-mm oversize, was used in all. Proximal endograft attachment was in the descending thoracic aorta in 16 cases, parasubclavian in 21 cases, and the suprasubclavian aorta in 10 cases. Eight patients had adjunctive cervical reconstruction to transpose or revascularize the left subclavian or left common carotid arteries, enabling more proximal endograft attachment in the aortic arch. RESULTS: Access failure occurred in one patient (2.1%). One patient (2.1%) died within 30 days of access-related iliac artery rupture. Another death occurred at 60 days from a ruptured thoracoabdominal aneurysm with type I endoleak. No instances of paraplegia, stroke, or surgical conversion were seen. Five patients (TAA) were found to have endoleak on 30-day computed tomographic scan. Repair of type I endoleak was undertaken in three cases at 1, 4, and 6 months. Eight patients (17%) had adverse events within the first 30 days. Length of follow-up ranged from 1 to 44 months, with a mean of 18 months. Two patients were lost to follow-up, and one withdrew from the study. Four additional mortalities were observed, none related to the endograft or aortic pathology. CONCLUSION: Stent graft repair of TAA and AD is feasible and can be achieved with technical success and relatively low rates of perioperative morbidity and mortality. The Talent customized design proved versatile in various morphologies. More information is needed on indications, clinical efficacy, and long-term results.     

Repair of Anastomotic Abdominal Aortic Pseudoaneurysm Utilizing Sequential AneuRx Aortic Cuffs in an Overlapping Configuration

Anastomotic aortic pseudoaneurysm is a known late complication following aortic repair and presents a considerable surgical challenge. We herein evaluate the endovascular alternative of using sequential AneuRx aortic cuffs to bridge the degenerative anastomotic pseudoaneurysms as a definitive treatment. Over a 3-year period, six patients with a mean age of 68.7 years (range 58-75) were identified who had proximal anastomotic aortic pseudoaneurysms secondary to previously implanted bifurcated aortic grafts (mean 15, range 12-20 years) following open surgical correction of aortoiliac occlusive disease. Five patients (83%) presented with concomitant palpable femoral anastomotic pseudoaneurysms and one patient (16%) had a pulsatile abdominal mass. All patients had computed tomographic (CT) scans confirming proximal anastomotic pseudoaneuryms without evidence of infection. The mean diameter of the pseudoaneurysms was 5.3 cm (range 4.0-7.0). Five patients were treated with endovascular methods, while one patient was not suitable for endovascular repair due to the diameter of the native aorta as seen on imaging study at the time of the procedure. AneuRx aortic extender cuffs (3.75 cm length) were deployed sequentially in five patients via a femoral approach. Devices were overlapped approximately 1.5 cm in order to achieve total exclusion of the pseudoaneurysms, and all concomitant femoral aneurysms were repaired surgically at the same time. Successful exclusion of the anastomotic pseudoaneurysm was achieved in four patients (80%) using a combination of two or three overlapping aortic cuffs. One patient had a small residual endoleak that had sealed by 1 month, evidenced by follow-up CT. The renal arteries were preserved in all patients. The average estimated blood loss and operative time were 355 ± 25 cc and 84 ± 21 min, respectively. The average length of hospital stay was 2.1 days, and there was no mortality or major morbidity. All patients underwent CT scanning surveillance at 6 and 12 months and yearly afterward. There was no evidence of late endoleak, aneurysmal expansion, or device migration during the mean follow-up of 10 months, ranging 6-27 months. Our study demonstrated that utilizing sequential AneuRx aortic cuffs applied in an overlapping configuration is an effective strategy for degenerative aortic anastomotic pseudoaneurysm from previously placed aortic grafts. Additionally, our study suggests this unique endovascular technique is an ideal alternative for creating a customized tube graft in challenging cases, particularly in high-risk patients.     

Major complications following endovascular surgery of descending thoracic aorta

We evaluated the impact of major complications on clinical outcome in a series of patients undergoing endovascular repair (EVAR) of descending thoracic aorta. From March 2001 to June 2005, 51 patients underwent EVAR for descending aortic diseases. Thirty-five were treated in emergency (60.7%) and 41 (80.4%) were in III-IV ASA class. There were no deaths, surgical conversion or paraplegia. A neurologic complication occurred in one patient (1.9%). Eleven major systemic complications occurred in 5 patients. One patient showed a primary type I endoleak at discharge, resolved spontaneously after 9 months. Three (5.9%) vascular injuries occurred during the endovascular procedure, requiring an emergency rescue iliac-femoral artery bypass. At follow-up (29+/-14 months), there was an overall mortality rate of 5.1% (3/51); 2 deaths (3.9%) were procedure related. Two secondary EVARs (3.9%) were successfully performed, one for a late type I endoleak six months after EVAR in a traumatic patient, and a second for a late rupture distally to the stent-graft implanted 36 months before in an acute type-B dissected patient. EVAR for descending aortic diseases is associated with decreased mortality and complications, however, long-term follow-up and additional studies are mandatory to detect late failure and to confirm clinical safety of this procedure.     

Early and mid-term results of endovascular treatment of thoracic aorta diseases: a single-center experience

We conducted an analysis to assess early and mid-term outcomes of patients after thoracic endovascular aortic repair (TEVAR) for type B thoracic aorta dissection, descending thoracic aneurysm, or traumatic aortic transection. From January 2016 through December 2018, twenty-seven patients (23 male, 4 female, mean age of 57 years) affected by type B dissection (n = 13 [48.2%]), thoracic aneurysm (n = 9 [33.3%]), and post-traumatic aortic isthmus rupture (n = 5 [18.5%]) were treated using TEVAR with and without left subclavian artery revascularization. All procedures were performed in a hybrid operating room using general (n = 12) or regional (n = 15) anesthesia. A combined brachial artery and bilateral femoral artery access was used in all patients. To achieve adequate proximal thoracic aorta landing zone length, coverage of the left subclavian artery with proximal endovascular plug occlusion was performed in 17 patients (62.9%); including 4 patients undergoing carotid–subclavian artery bypass before TEVAR stent-graft deployment. Primary procedural success rate was 96.3%; 1 patient had a Type Ib endoleak that was treated by distal stent graft extension. Four adverse outcomes occurred in the immediate postoperative period, including 2 cases of left upper arm acute ischemia (7.4%), ischemic stroke (3.7%), and asymptomatic iliac artery dissection (3.7%). During a mean follow-up of 18 months, no graft-related deaths or endoleak occurred. One patient developed symptomatic subclavian steal syndrome 1 month after operation and underwent a left carotid–subclavian artery bypass with symptom resolution. One patient died 6 months after TEVAR due to neoplasm. Our experience indicates TEVAR is a safe and less invasive alternative to open surgery for a spectrum of thoracic aorta diseases, especially for urgent conditions and in patients with high-risk surgical comorbidities.     

Serious complications following endovascular thoracic aortic stent-graft repair for type B dissection.

OBJECTIVE: To describe our experience with endovascular stent-graft repairs in type B aortic dissection focusing on serious secondary complications resulting in immediate or late conversion to open repair. METHODS: From November 1997 to May 2007, 28 patients underwent a thoracic endovascular stent-graft procedure for acute symptomatic type B dissection at our institution. Indication for endovascular repair at our department is a complicated course of type B dissection, including thoracic aortic rupture, suspicion of impending rupture, visceral and/or peripheral ischemia, uncontrollable hypertension, and severe therapy-resistant pain. Median follow-up time was 48.3 months (range 2-97 months). RESULTS: Secondary complications with indication for a secondary intervention occurred in 5/28 patients, resulting in additional procedures in 4 patients. One patient declined any further therapy. Conversion to an open procedure was performed in four patients, one due to type I endoleak followed by retrograde type A dissection, and three due to retrograde type A dissection. One of these patients had an additional stent-graft procedure performed due to a type III endoleak 20 months post stent grafting. Retrograde type A dissection occurred 39 months later, finally leading to conversion to an open procedure. Open surgery was performed in four patients after 3, 26, 29, and 1170 days post stent-graft placement and was successful in three patients. The fourth patient died 3 months post-surgically due to multi-organ failure. The procedure-related mortality rate following secondary complications was (1/5) 20%. CONCLUSIONS: Endovascular stent-graft repair of the thoracic aorta is an alternative to surgical repair, however not without significant morbidity and mortality. Potentially lethal complications, acute or delayed, may occur.     

Remodeling of the thoracic aorta after stent grafting of type B dissection: a Swedish multicenter study

AIM: Endovascular repair of complicated type B dissections has evolved as a promising alternative to open repair. Previous studies have indicated that continued false lumen flow is a predictor of continued aortic dilatation and risk of rupture during follow-up. This multicenter study was conducted to analyze the postoperative changes of the false lumen after endografting of complicated type B dissections. METHODS: All patients treated with endovascular stent grafts for thoracic type B dissections at 5 major Vascular Centers in Sweden were identified through local databases. Review of charts and all available pre- and postoperative CT scans were performed to identify demographics, indications for repair as well as postoperative changes of the aorta and false lumen. RESULTS: A total of 129 patients treated for type B dissections between 1994 and December 2005 were identified. Median radiological follow-up was 14 months. Fourteen patients died perioperatively leaving 115 patients available for analysis. Seventy-four of these had CT imaging of sufficient quality for morphological analysis. The vast majority of acute patients were treated for rupture or end-organ ischemia whereas most chronic patients were treated for asymptomatic aneurysms. In 80% of patients, the false lumen thrombosed along the stent graft but it remained perfused distal to the stent graft fixation in 50% of patients. Only 5% of patients presented with aortic enlargement of the stent grafted area when adequate proximal sealing was achieved. The distal, uncovered aorta displayed expansion in 16% of patients. CONCLUSIONS: The stent grafted thoracic aorta after type B dissection appears to be stabilized by covering the primary entry site with a stent graft in the majority of both acute and chronic dissections. The uncovered portion of the aorta distal to the stent graft, however, remains at risk of continuous dilatation. Stent grafting for complicated type B thoracic dissections seems to be a treatment option with reasonable morbidity and mortality even though the incidence of severe complications is still significant.     

Endovascular repair of lesions involving the descending thoracic aorta. Mid-term morphological changes

Thoracic aortic lesions are often life-threatening conditions with significant morbidity and mortality after open surgical repair. If preliminary results suggest that endovascular therapy is an effective and advantageous treatment, long-term effectiveness remains questionable. We analysed 75 consecutive patients who underwent endovascular stent-grafting of lesions involving the descending thoracic aorta (32 emergent, 43 elective). Aortic pathologies were aneurysms (n=31), chronic (n=8) or complicated (n=6) type B dissections, penetrating ulcers (n=4) or aortic ruptures (n=26). Follow-up was performed using magnetic resonance angiography. In three cases, the procedure was stopped due to inappropriate arterial access calibre. The hospital mortality and morbidity were 8% and 12%, respectively. One patient of the chronic group presented a type I endoleak, treated by embolisation. After 1.5 months, the mortality and morbidity rates were 10.6% and 10.6%, respectively. The secondary endoleak rate was 16%. One patient died of aortic rupture 24 months after the procedure. In the aneurysm group, the regression of the aortic calibre was significant in 23 and stable in 28 patients. Thus, and despite encouraging early outcomes, mid-term results suggest a trend toward increased re-intervention and late complication rates in these high surgical risk patients. Therefore, continued surveillance of patients treated with stent-grafts is necessary.     

Endovascular Treatment of Thoracic Aortic Pathology: Lessons Learned

Introduction : Endovascular repair has emerged as a very important treatment modality in the management of thoracic aortic diseases due to its reduced invasiveness especially in patients at increased risk for open surgery. Aim of this study is to analyze the lessons learned in our experience of thoracic aortic endografting.

Material and methods : From June 1999 to January 2006, 145 selected patients (121 men and 24 women with a mean age of 70 ± 9 years) with thoracic aorta disease received endovascular treatment with one of four different commercially produced stent grafts (Cook, Gore, Endomed, Medtronic). Indications for treatment included disease of the descending thoracic aorta in 92 cases, of the aortic arch in 43 cases and of the thoracoabdominal aorta in 10 cases. In 48 patients, an hybrid surgical and endovascular approach was required.

Results : Primary technical success was achieved in 137/145 (94.5%) cases. One patient died intraoperatively and seven patients had a type “I a” endoleak. In-hospital complications included perioperative stroke in three patients, acute renal failure in two patients, acute respiratory failure in one. Initial clinical success was obtained in 128/145 patients (88.3%) with a mortality rate of 9/145 (6.2%). At 38 ± 16 months, mid-term clinical success was obtained in 89.5% of the followed patients. Two patients died from fatal aneurysm rupture. One type I endoleak was successfully treated with a rescue endovascular procedure, four cases of type I endoleak resolved completely without any further intervention, no new onset endoleak was discovered. One patient underwent a successful open conversion. Aneurysm expansion was observed in one patient.

Conclusion : Endovascular surgery is changing the management of complex aortic disease. Synergy between endovascular and surgical procedures may provide a solution for many challenging clinical problems.