Results of thoracic endovascular grafting in different aortic segments.

PURPOSE: To compare the results of thoracic endovascular grafting of different aortic segments performed with commercially available stent-grafts. METHODS: Between January 1999 and October 2006, 178 patients (150 men; mean age 69.4+/-10.2 years) underwent endovascular grafting of the thoracic aorta (68 hybrid procedures) with commercially produced stent-grafts from 4 manufacturers. Patients were divided into 3 groups according to the aortic segment involved: 64 aortic arch cases (37 hybrids for supra-aortic trunks revascularization), 100 descending thoracic aorta (DTA) cases (17 hybrid: 12 for access and 5 for associated abdominal aortic aneurysm), and 14 thoracoabdominal aorta (TaA) patients excluded from conventional repair (14 hybrids for renal and splanchnic revascularization). RESULTS: The technical success was 93.8% (167/178). Overall 30-day mortality was 5.6% (10/178). There were 10 (5.6%) type I endoleaks. Initial clinical success was 88.2% (157/178). At a mean follow-up of 29.3+/-21.2 months, the midterm clinical success was 89.9% (160/178). In the arch group, the technical success was 85.9% (55/64). Thirty-day mortality was 6.3% (4/64). There were 8 (12.5%) type I endoleaks. Initial and midterm clinical success rates were 79.7% (51/64) and 85.9% (55/64), respectively. In the 100-patient DTA group, the technical success was 98.0%. Thirty-day mortality was 2.0%. The type I endoleak rate was 2.0%. Clinical success was 96.0% initially and 95.0% at midterm. All 14 of the TaA cases were completed successfully, but 30-day mortality was 28.6% (4/14). There were no type I endoleaks. Clinical success rates initially and at midterm were both 71.4% (10/14). CONCLUSION: Over the last 6 years, synergy between endovascular and surgical procedures allowed treatment of all segments of the thoracic aorta. Overall perioperative and medium-term results were reasonably favorable; however, they were more satisfactory when the descending thoracic aorta alone was involved. Hybrid procedures allowed treatment of all aortic segments, but they decreased the success rates significantly. Endovascular grafting is currently our preferred method of treating pathologies involving the DTA and aortic arch, while our data suggest limiting the use of stent-grafts to high-risk patients or compassionate indications when the thoracoabdominal aorta is involved.     

Double tube stent-grafts for infrarenal aortic aneurysm: a new concept.

PURPOSE: To present the concept of double tube stent-grafts and examine the indications for and results achieved with these devices. METHODS: From January 1, 2000, to December 31, 2005, 759 patients who underwent endovascular repair of infrarenal aortic aneurysms at 2 centers. Of these, 45 (5.9%) patients received a double tube stent-graft; complete operative and follow-up data were available for retrospective analysis in 41 patients (33 men; mean age 73.1+/-8.9 years). Diameters measured before stent-graft implantation and at follow-up (12, 24, 36, and 48 months) with clinical examination, 2-phase computed tomographic angiography, duplex sonography, and biplanar abdominal radiography were tested for significant changes using ANOVA with the Bonferroni-Dunn correction. Late outcomes (clinical success and endoleak) were analyzed by the Kaplan-Meier method. RESULTS: The postoperative complication rate was 12.2%, with 2.4% systemic complications (1 patient with angina pectoris); the early mortality rate was 0%. Mean follow-up was 21.9+/-12.8 months (range 12-61) for the 41 patients. Four (9.8%) patients died during follow-up of cardiac causes (n = 2), lung cancer (n = 1), and bowel ischemia (n = 1). Four (9.8%) endoleaks were observed during follow-up: 1 distal type I, 2 type II, and 1 type III. Maximum aneurysm diameters shrank from 52.0+/-9.5 mm preoperatively to 44.0+/-10.9 mm (p<0.0001) postoperatively at the latest available follow-up. CONCLUSION: Our study supports the use of this double tube technique for repair of appropriate saccular infrarenal aortic aneurysms. The double tube stent-graft method appears safe in terms of endoleaks and migration, so we recommend that it be considered an option of endovascular aortic aneurysm therapy.     

Two-Year Single-Center Experience With Thoracic Endovascular Aortic Repair Using the EndoFit Thoracic Stent-Graft

Purpose: To analyze our single-center experience of thoracic endovascular aortic aneurysm repair (TEVAR) using the EndoFit Thoracic Aortic Endograft. Methods: A retrospective review was conducted of 87 consecutive patients (64 men; median age 67.8+/-8.7 years, range 24-88) undergoing TEVAR using the EndoFit thoracic stent-graft from December 2005 to December 2007. Slightly more than half (n = 46) of the patients had thoracic aortic aneurysm, while 41 had thoracic aortic dissection. Seventeen cases were performed emergently. All patients had imaging follow-up before discharge; at 1, 3, and 6 months; and annually thereafter. Results: The technical success rate was 100%. Fifty-five (63.2%) patients had different debranching procedures to extend the proximal or distal landing zone. The in-hospital and 30-day mortality rate was 9.2% (8/87). Neurological complications occurred in 8 (9.3%) patients, including 5 strokes (2 fatal) and 3 cases of paraplegia. One intraoperative massive bleeding from an ascending aortic debranching anastomosis was rescued with the aid of a pump. Five patients had immediate proximal type I endoleak; 3 were remedied with a proximal cuff, 1 was rescued with tri-lobe balloon, and 1 was left untreated. One type II endoleak remains under observation. The average follow-up was 15.2 months (range 5-29), during which 10 (11.5%) patients died of causes unrelated to the aneurysm or stent-graft. All the extra-anatomical bypasses and stent-grafts were patent; no stent-graft kinking, collapse, or dislocation was detected. Two post-TEVAR proximal endoleaks were remedied with a proximal cuff after debranching. There was no post-TEVAR rupture or conversion to open surgery. Conclusion: Our 2-year single-center experience using the EndoFit system for TEVAR showed a high technical success rate and a low incidence of device- or aneurysm-related complications. The flexible, hydrophilic introducer was easy to insert and track through the vasculature. The debranching techniques to extend the landing zones not only broaden the applicability of TEVAR but also reduce post-TEVAR complications.     

Thoracic aortic endografting in patients with connective tissue diseases.

PURPOSE: To present midterm results after thoracic endovascular aortic repair (TEVAR) in patients with connective tissue diseases focusing on secondary endoleak and reintervention due to disease progression. METHODS: Between January 1997 and January 2007, 167 patients received 241 thoracic aortic stent-grafts. Eight patients (6 men; median age 48 years, range 32-67) with connective tissue diseases (6 Marfan and 2 Ehlers-Danlos syndrome) treated with stent-graft repair were retrospectively analyzed at a median follow-up of 31 months (range 3-79). Surveillance included postoperative computed tomographic angiography and/or magnetic resonance imaging exams prior to discharge, at 3, 6, and 12 months, and yearly thereafter. RESULTS: Technical success of endovascular placement was 88% due to 1 primary type I endoleak. There were no perioperative deaths, and there have been no conversions to open surgery so far. Perioperative complications occurred in 2 (25%) of the 8 patients. Endoleaks were observed in 3 patients (primary type I, secondary type I, and type II). The reintervention rate was 38%. Progression of disease resulting in de novo aneurysms or aortic expansion occurred in 4 (50%) patients. Seven (88%) patients are alive. There was no disease- or procedure-related death. CONCLUSION: TEVAR in patients with connective tissue diseases is feasible but still questionable regarding their young age and the rates of endoleaks and reintervention due to disease progression. Close surveillance is mandatory. Low morbidity and mortality rates may justify TEVAR in emergencies as a "bridging" method.     

TEVAR in Patients With Late Complications of Aortic Coarctation Repair

Purpose: To review the use of thoracic endovascular aortic repair (TEVAR) for late pseudoaneurysm formation after surgical repair of aortic coarctation. Methods: From May 2001 to May 2005, 8 patients (5 men; mean age 47.6 years, range 18-73) with a history of aortic coarctation repairs 17 to 40 years prior were referred to our institution for an anastomotic thoracic pseudoaneurysm. TEVAR was performed successfully in 7 patients; 1 died of suspected aneurysm rupture before the scheduled procedure. A carotid-subclavian bypass was performed in 3 patients. Results: All the procedures were immediately successful. No type I endoleaks were seen on the final control angiogram, but 2 of the patients with carotid-subclavian bypasses required additional left subclavian artery embolization due to type II endoleak. One of these patients died before embolotherapy on the 5th postoperative day from presumed aneurysm rupture (14% 30-day mortality rate). Over a follow-up period ranging from 15 to 72 months (mean 37), all the false aneurysms have remained thrombosed and the mean diameter has decreased from 44 to 23 mm. No endograft-related complications have occurred, and no further interventions have so far been necessary. Conclusion: TEVAR is a feasible alternative treatment for patients who have already undergone surgical repair of aortic coarctation. Technical issues regarding the endovascular strategy should be discussed with a multidisciplinary team to define the correct interventional plan.     

Valve preserving surgery in patients with bicuspid aortic valve

Bicuspid aortic valve can be associated with clinically important aortic regurgitation and dilatation of ascending aorta. Aortic valve repair seems to be optimal therapeutic option how to avoid valve-related and anticoagulation-related complications. We have analyzed midterm outcomes of patients after bicuspid aortic valve repair.MethodsBetween January 2008 and December 2015, 91 patients (mean age 40.9 ± 12.2) with bicuspid aortic valve (type 0 or 1) underwent valve-sparing surgery for aortic valve insufficiency or aortic aneurysm. Urgent procedures and patients of age more than 65 were not included. The cohort of patients was retrospectively divided into two groups. Forty-nine patients underwent aortic valve-sparing procedure with root replacement (group 1). Forty-two patients underwent aortic valve repair without root replacement (group 2). The mean length of follow-up was 57.5 months.ResultsThere was no death in connection with aortic valve repair during follow up. Three patients from group 2 required in-hospital reoperation for early repair failure. Another seven patients (4 from group 1 and 3 from group 2) were reoperated for recurrent aortic insufficiency during follow-up period. Freedom from aortic valve reoperation at 5 years was 90% in group 1 and 87% in group 2. Freedom from recurrent aortic insufficiency (>2°) at 5 years was 85% in group 1 and 78% in group 2.ConclusionBicuspid aortic valve repair is a safe procedure, which can be performed with acceptable midterm results. Risk of repair failure depends on preoperative valve morphology and choice of repair technique. Repair technique needs to be tailored to the specific anatomy of the valve.     

Influence of infrarenal neck length on outcome of endovascular abdominal aortic aneurysm repair.

PURPOSE: To evaluate the influence of the infrarenal neck length on clinical outcome after endovascular abdominal aortic aneurysm repair (EVAR). METHODS: Data were analyzed from 3499 patients enrolled in the EUROSTAR registry between January 1999 and April 2005 who underwent EVAR with a Talent or Zenith endograft and had detailed morphological data recorded. The study cohort was divided into 3 groups according to infrarenal neck length: >15 mm (reference group A, n=2822), 11 to 15 mm (group B, n=485), and < or =10 mm (group C, n=192). Uni- and multivariate analyses were performed to evaluate differences in clinical outcomes among the study groups. RESULTS: After correction for confounders, proximal type I endoleak within 30 days occurred in 10.9% of group C compared to 2.6% of group A (OR 4.46, 95% CI 2.61 to 7.61). Within 48 months of follow-up (median 12 months), the incidence of proximal endoleaks was higher in groups B (9.6%; HR 1.98, 95% CI 1.16 to 3.38) and C (11.3%; HR 2.132, 95% CI 1.17 to 4.60) compared to group A (3.4%). CONCLUSION: Our study indicates that endovascular treatment of abdominal aortic aneurysms with infrarenal neck length <15 mm is associated with significantly increased risk of short- and midterm proximal endoleaks after EVAR. The greater risk of proximal endoleaks should be weighed against the risks of alternative treatment modalities.     

Experience with endovascular abdominal aortic aneurysm repair in nonagenarians.

PURPOSE: To report a single-institution experience with endovascular abdominal aortic aneurysm (AAA) repair (EVAR) in nonagenarians. METHODS: A retrospective review was performed of all patients >90 years old undergoing EVAR over an 8-year period at a major academic medical center. The patient population was investigated for the presence of various comorbidities, initial aneurysm size, successful aneurysm exclusion, perioperative complications, disposition, endoleaks, secondary interventions, and overall survival. RESULTS: EVAR was performed in 18 male nonagenarians (mean age 92.4 years, range 90- 95). Mean aneurysm diameter was 7.3 cm (range 5.5-9.8). The cohort had an average of 3.2 comorbid conditions. Sixteen patients were treated electively, while 2 patients underwent emergent repair for contained rupture and bleeding aortoenteric fistula, respectively. Immediate technical success was 100%. Perioperative local/vascular complications occurred in 4 (22%) patients. Perioperative systemic complications occurred in 3 (17%) patients. There were 2 (11%) perioperative (<30 days) deaths. Three (17%) patients required secondary interventions. Mean survival in patients who expired during the follow-up period beyond the first 30 days was 34 months (range 8-78). Mean survival in 8 patients who are still alive is 17.4 months (range 9-39). CONCLUSION: Endovascular AAA repair in nonagenarians is associated with a high rate of technical success and relatively low morbidity rate. Survival times following successful hospital discharge are significant. Suitable patients over 90 years of age may benefit from an endovascular AAA repair.     

Does chronic oral anticoagulation with warfarin affect durability of endovascular aortic aneurysm exclusion in a midterm follow-up?

PURPOSE: To evaluate the effect of oral anticoagulation on durability of endovascular aortic aneurysm repair (EVAR). METHODS: Retrospective review was conducted of 182 consecutive EVAR patients (169 men; mean age 75.3 years, range 53-89) between 1999 and 2003. Patients on warfarin anticoagulation (WA, n=21; International Normalized Ratio of 2 to 3) were compared against a control group (CG) with no postoperative anticoagulation (n=161). Death, aneurysm rupture, and reintervention were considered primary endpoints; endoleaks, endograft migration, and aneurysm remodeling were secondary endpoints. RESULTS: Mean follow-up was 16.3+/-12.6 months. One-year mortality was 6.6% (9.5% WA versus 6.2% CG); overall mortality was 14.3% (p=0.414). No aneurysm rupture occurred. At 1, 2, and 3 years, respectively, cumulative reinterventions (20%/20%/20% WA versus 12%/15%/20% CG; p=0.633) and endoleak rates (25%/25%/25% WA versus 17%/22%/34% CG; p=0.649) were comparable. In both groups, most completion endoleaks resolved (42.9% WA versus 74.4% CG; p=0.474), but few de novo endoleaks did (0% WA versus 12.8% CG; p=0.538). Anticoagulation did not affect mean time to aneurysm sac shrinkage (1.3+/-0.3 WA versus 1.4+/-0.1 years CG; p=0.769). CONCLUSIONS: After EVAR, anticoagulation appears safe and does not significantly alter mortality, risk for rupture, or the incidence of reintervention. Early endoleaks appear more common in anticoagulated patients, but anticoagulation does not preclude spontaneous endoleak resolution nor does it increase late endoleak rates. Irrespective of the anticoagulation status, early but not late endoleaks usually sealed spontaneously. Observing type II endoleaks appears safe in the absence of aneurysm enlargement.     

单中心主动脉腔内隔绝术治疗胸降主动脉扩张性疾病的疗效评价

目的 评价主动脉腔内隔绝术治疗胸降主动脉扩张性疾病的近期和远期疗效及安全性.方法 选择沈阳军区总医院2002年4月至2013年10月行主动脉腔内隔绝术治疗胸降主动脉扩张性疾病的患者449例,其中男349例,女100例,年龄（54.3±11.9）岁.经股动脉切开植入覆膜支架封堵胸降主动脉夹层破口或隔绝胸主动脉瘤,主动脉造影确认疗效;合并严重冠状动脉狭窄的患者,于腔内隔绝术后3-7 d完成经皮冠状动脉介入（percutaneous coronary intervention,PCI）治疗.观察主动脉疾病患者PCI治疗的疗效.结果 主动脉腔内隔绝术操作成功率为100％,共植入416枚主体覆膜支架及56枚短体覆膜支架.43例患者完全封闭左锁骨下动脉开口,仅1例患者出现严重窃血综合征,行血管旁路移植术.34例患者行PCI治疗成功率为100％,对37支靶血管共植入45枚冠状动脉支架,无出血、心肌梗死等并发症.68例患者出现腔内隔绝术后综合征,76例患者术后有残余漏,其中11例因内漏明显同台或再次行手术治疗.住院期间主动脉破裂病死率为1.3％（6/449）.术后随访（68±29）个月,随访率为79.0％（350/443）.随访期间共死亡患者23例（6.6％）：明确主动脉血管破裂死亡4例,急性心肌梗死1例,脑出血4例,肾功衰竭死亡3例,多器官功能衰竭2例,恶性肿瘤4例,猝死5例（原因不明）.25例联合PCI治疗患者临床造影随访主要心血管事件发生率为8.0％（2/25）.结论 主动脉腔内隔绝术治疗胸降主动脉扩张性疾病近期及长期疗效好,并发症发生率低.合并冠状动脉粥样硬化性心脏病患者择期二次行PCI治疗安全可行,主要心血管事件发生率低.     

Anaconda aortic stent-graft: single-center experience of a new commercially available device for abdominal aortic aneurysms

PURPOSE: To report a retrospective evaluation of the efficacy and midterm clinical results of the Anaconda stent-graft in the endovascular repair of infrarenal abdominal aortic aneurysms. METHODS: Fifty-one patients (48 men; mean age 71+/-8 years, range 62-89) were treated with the Anaconda stent-graft from January 2006 to September 2007. Six patients were considered at high risk for open repair (defined as ASA grade 3) and 10 had undergone previous laparotomy. The mean neck diameter and length were 26 mm (range 22-30) and 18.5 mm (range 14-35), respectively. Mean proximal neck angulation was 30 degrees (range 5-60). Severe iliac artery tortuosity (>60 degrees ) was seen in 20 (39%) patients; 3 (6%) had a proximal aneurysm neck angle >45 degrees. RESULTS: The technical success rate was 100%; intraprocedurally, 7 (14%) stent-grafts were repositioned to address renal artery occlusion by the graft (n = 1) or type I endoleak. This maneuver resolved 6 of the 7 situations; a remaining endoleak required a proximal cuff to seal it. The procedural success rate (no major complication at 30 days) was 94%. The mean follow-up was 16 months (range 1-21). Five (10%) endoleaks (1 type I, 4 type II) and 1 (2%) graft migration occurred. The overall reintervention rate was 6%. Two (4%) patients died in late follow-up. CONCLUSION: The Anaconda stent-graft appears both safe and effective in terms of midterm clinical outcome and compares favorably with previously reported EVAR results. The ability to reposition the stent-graft is a particular advantage.     

Le traitement endovasculaire des lésions urgentes de l’aorte thoracique descendante est-il possible dans un centre ne disposant pas de circulation extracorporelle ?

OBJECTIVE: To determine whether access to extra-corporal circulation (ECC) is necessary to treat acute descending thoracic aorta disease. METHOD: From January 2004 to May 2006, 16 patients underwent endovascular stent-graft repair of the descending thoracic aorta, among them 13 (81%) were treated in an emergency setting (nine men, mean age: 75.4 years, range 30-94 years). The indication was traumatic aortic rupture (n=3, 23%), complicated acute type B dissection (n=4; 31%), symptomatic or ruptured thoracic aortic aneurysm (n=4; 31%), aorto-esophageal fistula (n=1; 7,5%) and aortic intramural haematoma (n=1; 7,5%). Computed tomography showed hemomediastin and/or hemothorax in five patients (38%). Transesophageal echocardiography and angiography were performed in two (15%) and one patients respectively. Cerebrospinal fluid drainage was performed for two patients (15%). RESULTS: Endovascular repair was successfully completed in 92.3% of cases. The 30-day mortality was 7.5% (n=1). There was one case (7.5%) of delayed paraplegia. Follow-up ranged between two and 24 months (mean 10.2), no rupture occurred. Three type I endoleaks were detected and only two were treated. Two none related additional mortalities were observed. None of these patients has needed ECC. CONCLUSION: The unavailability of ECC does not seem to be a compromising factor in the management of thoracic aorta disease, however a good experience in endovascular techniques is required.     

Impact of gender on the outcome of endovascular aortic aneurysm repair using the Zenith stent-graft: midterm results.

PURPOSE: To analyze the 2-year outcomes of female patients after endovascular aortic aneurysm repair (EVAR) with the Zenith AAA Endovascular Graft. METHODS: A retrospective analysis was conducted of data from the US Zenith multicenter trial and the Zenith female registry on 40 women (10.9%, study group) and 326 men (89.1%, control group) enrolled. All patients had completed their 2-year follow-up. Primary study endpoints were survival, aneurysm rupture, and conversion rate. Significance was assumed if p<0.05. RESULTS: Overall rates of mortality (12.5% for women versus 13.2% for men, p = 0.94) and aneurysm rupture (2.5% for women versus 0% for men, p = 0.11) were comparable between groups. Conversion to open repair within 2 years was significantly more frequent in women compared to men (7.5% versus 0.6%, p = 0.01). The incidence of endoleaks of any type was equivalent between groups at 2 years (13.3% for women versus 6.9% for men, p = 0.30). No difference was observed in the need for secondary interventions (15% for women versus 13.5% for men, p = 0.81) or aneurysm dilatation >5 mm (10.5% for women versus 2.3% for men, p = 0.10). None of the patients developed device migration >10 mm or required intervention for migration. CONCLUSION: While women underwent conversion to open repair more frequently compared to men at 2 years post EVAR, there was no difference in survival, freedom from aneurysm rupture, or need for secondary interventions between groups. As in men, the Zenith AAA Endovascular Graft provides reliable protection from aneurysm rupture and aneurysm-related death in women in a midterm follow-up.     

Endovascular therapy of aneurysms of the abdominal aorta: report of 4,291 patients of the Eurostar Register

BACKGROUND: The Eurostar project is a multicentred database of the outcome of endovascular repair of infra-renal aortic aneurysms. From 1996 to March, 2002, 113 European centres of vascular surgery have contributed. The purpose of this article is to review the medium term (up to 7 years) results of endovascular aneurysm repair as reported to Eurostar. PATIENTS AND METHODS: Patients intended for endovascular aneurysm repair were notified to the Eurostar Data Registry Centre before treatment in order to eliminate bias due to selective reporting. The following data was collected on all patients: (1) their demographic details and the anatomical characteristics of their aneurysms, (2) details of the endovascular device used, (3) procedural complications and the immediate outcome, (4) results of contrast enhanced CT imaging at 1, 3, 6, 12, 18 and 24 months after operation and at yearly intervals thereafter, (5) all adverse events. Life table analysis was performed to determine the cumulative rates of: (1) death from all causes, (2) secondary intervention. RESULTS: By March 2002, pre- and postoperative data of 4291 patients had been registered. The median duration of follow-up was 12 mo (range 0-96). Successful deployment was achieved in 97.8% of the patients with a perioperative (30 day) mortality of 2.4%. Early conversion to open repair occurred in 1.3%. Late rupture of the aneurysm occurred in 35 patients. The significant factors were endoleaks, graft migration and kinking. Late conversion to open repair occurred at an annual rate of approximately 2%. Risk factors (indications) for late conversion were endoleaks, graft migration and kinking. CONCLUSIONS: Endovascular repair of infra-renal aortic aneurysms using the first and second-generation devices that predominated in this study is associated with a risk of early or late failure of 3% per year, based upon an analysis of observed primary endpoints of rupture and conversion.     

Early and midterm results after open and endovascular repair of ruptured abdominal aortic aneurysms in a comparative analysis.

PURPOSE: To compare early and midterm results of open versus endovascular aortic repair of ruptured abdominal aneurysms (rAAA). METHODS: A retrospective analysis was performed of 58 consecutive patients with rAAA who were treated with open or endovascular aneurysm repair (EVAR) at a single center between January 2000 and December 2005. Patients without definitive signs of rupture (symptomatic patients) were excluded from the study. Twenty-nine patients (21 men; median age 71 years) were treated using endovascular techniques (EVAR group) and 29 (28 men; median age 71 years) with open repair (OR group).The hemodynamic status at the time of admission was evaluated with respect to blood pressure, pulse rate, and hemoglobin level to reduce selection bias. Patients underwent follow-up by clinical examination and computed tomography. RESULTS: The 30-day mortality rate was 31% (9/29) in each group (p = 1.0); the morbidity rates also did not differ between groups [16 (55.2%) EVAR vs. 18 (62.1%) OR; p = 0.9]. There was 1 (3.4%) primary conversion in the EVAR group and 7 (24.1%) endoleaks [3 (10.3%) primary; 4 (13.8%) secondary]. There was no difference between the groups with regard to intensive care unit stay (4 days for EVAR vs. 3 days for OR, p = 0.98) or total hospital stay (9 days for EVAR vs. 12 days for OR, p = 0.69). After a mean follow-up of 40.25 months (range 1-70), the midterm mortality rates did not differ [5 (17.2%) EVAR vs. 3 (10.3%) OR, p = 0.41]. CONCLUSION: EVAR of rAAAs is feasible, with equal early and midterm mortality rates compared to open repair. When a defined patient selection is used for rupture, including hemodynamic status, there is no evidence of a better outcome with EVAR in emergency cases.     

Short term outcome of thoracic endovascular aortic repair in patients with thoracic aortic diseases

Aim and background

Open surgical repair for thoracic aortic diseases is associated with a high perioperative mortality and morbidity. Most of type B aortic dissections are uncomplicated and are medically treated which carries a high mortality rate. Thoracic endovascular aortic repair is the first-line therapy for isolated aneurysms of the descending aorta and complicated type B aortic dissection. The aim of this study is to test the safety of early thoracic endovascular aortic repair in patients with uncomplicated type B aortic dissection and patients with thoracic aortic aneurysms.

Six-year experience with talent stent-graft repair of abdominal aortic aneurysms.

PURPOSE: To report a long-term experience with the Talent Endoprosthesis for the treatment of abdominal aortic aneurysm (AAA). METHODS: In the period between June 1997 and June 2003, 193 patients (171 men; mean age 71.0+/-7.8 years, range 52-89) with AAA were treated with a Talent Endoprosthesis. Patients were clinically and radiologically followed in the postoperative period, at 30 days, and then annually up to 72 months. In addition to computed tomographic scans, a plain abdominal radiogram was also performed annually for structural assessment of the stent-graft. RESULTS: Implantation success was 99.0% (191/193). Delivery system introduction was the cause of 1 failure, and the other patient was converted to surgery for intraprocedural device migration. There were 10 (5.2%) endoleaks (3 type I, 7 type II) at 30 days; all type I and 3/7 type II endoleaks were treated (93.3% secondary clinical success). Seven (3.7%) patients died in the perioperative period, including the conversion. During follow-up, 18 (9.3%) additional deaths occurred, and 4 new endoleaks (1 type I, 2 type II, 1 type III) were encountered. In up to 6 years' follow-up, the Talent Endoprosthesis did not present signs of material fatigue, but 1 component disconnection at 42 months led to death. There was no aneurysm rupture. After an initial increase in the aortic neck (1.2+/-1.1 mm) in the postoperative period, the neck diameters continued to increase until after the third year. An average reduction of 5.6+/-4.1 mm in the aneurysm diameter at 1 year was noted; the reduction gradually reached 14.1+/-10.7 mm after 60 months. CONCLUSIONS: The Talent Endoprosthesis was an efficient alternative for managing AAAs, achieving low morbidity and mortality rates and a good long-term clinical outcome in this study. The Talent Endoprosthesis did not present signs of material fatigue over a 6-year follow-up.     

Outcome of cardiac and thoracic aortic operation in patients over 80 years old

A retrospective analysis was performed to determine the early outcome of cardiac and thoracic aortic surgery in patients over 80 years old. Between 1994 and 2000, 41 octogenarians (mean age, 82.6 +/- 2.5 years) underwent coronary artery bypass grafting (25), valve surgery (8), thoracic aortic aneurysm repair (7), or combined valve and bypass surgery (1). Overall hospital mortality was 9.8%. Mortality rates for specific procedures were 12% for coronary bypass, 0% for valve surgery, and 14% for thoracic aortic aneurysm repair. Major postoperative complications affected 27% of patients and included severe low cardiac output, respiratory failure, and acute renal failure, with a low incidence of perioperative stroke (2.4%). Cardiac and thoracic aortic operations can be performed with acceptable mortality and morbidity when appropriately applied in selected octogenarians.     

Endovascular treatment of thoracic aortic disease: mid-term follow-up.

OBJECTIVE: The aim of this study was to evaluate the mid-term follow-up in a cohort of patients with acute or chronic descending aortic disease treated by stent-graft repair. BACKGROUND: Since 1999, endovascular stent-graft placement has been reported as an alternative treatment to surgical approach for a variety of thoracic aortic diseases; however, results beyond initial short-term follow-up are not widely available for the broad range of applications. METHODS: From March 2001, 43 consecutive patients with traumatic aortic transection (group A = 16) and complicated type B aortic dissection or aneurysm (group B = 27) underwent stent-graft implantation. All patients underwent computed tomography (CT) scan as preoperative assessment and in 26 a transesophageal echo (TEE) exam was performed. RESULTS: Technically successful stent-graft deployment was achieved in all patients. No patient required surgical conversion and no cases of paraplegia occurred. The overall in-hospital mortality was 9.3%. A residual endoleak (type II) was detected in one group B patient who was managed conservatively. The mean follow-up was 29 +/- 8 months (range 10-48 months). No patient died during late follow-up after hospital discharge. At 12 months, one patient (2.5%) who had stent graft repair of an aortic dissection developed an asymptomatic type I endoleak. Three asymptomatic patients with chronic dissection had a persistent retrograde perfusion of the thoracic false lumen via a distal tear(s) in the dissection septum. CONCLUSION: Our results of stent-graft treatment of complicated and uncomplicated diseases of the descending aorta confirms that this alternative to open repair is a safe, less invasive, and relatively low risk approach. Medium-term follow-up results suggest that it is effective and durable therapy with low associated mortality and morbidity rates.     

Endovascular repair for thoracic aortic arch aneurysms.

AIM: The aim of this study was to report our experience with total and subtotal endovascular stent-grafting combined with aortic arch branch surgical revascularization for thoracic aortic arch aneurysms in high-risk patients. METHODS: From December 2000 to June 2005, among 38 patients treated with thoracic stent-grafts in our department, 10 patients (9 men; mean age 71+/-6 years) at high risk for open repair were candidates for endovascular repair and/or aortic arch branch extra-anatomical reconstruction due to inadequate proximal landing zones. The left subclavian artery was over-stented 6 cases for zone 2 aneurysms, and partial or total arch stent-grafting with simultaneous revascularization of the arch branches was performed in 4 cases for zones 0-1 aneurysms. RESULTS: Primary technical success rate was 100%. In-hospital mortality rate was 10%. Neither paraplegia, nor acute renal failure were recorded. Immediate or late surgical conversion was never required. One type 1b was successfully treated with additional stent-graft and 2 type-2 endoleaks were sealed by coil embolization. Mean follow-up was 21-months (range 3-48 months); overall, survival rate at 12, 26, and 36 months was 90%, 60%, and 30%, respectively. CONCLUSIONS: Endovascular repair for thoracic aortic arch aneurysms is feasible. However, our experience suggests stent-grafting is not free of risk, and long-term and larger follow-up is required.