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Luca Bertoglio Daniele Mascia Tommaso Cambiaghi Andrea Kahlberg Yamume Tshomba Jose Chaves Gomez Germano Melissano Roberto Chiesa 《Journal of vascular surgery》2018,67(5):1360-1371
Objective
The objective of this study was to investigate the outcomes of patients with visceral aortic patch (VAP) aneurysms after open repair of thoracoabdominal aortic aneurysm (TAAA) treated with three different approaches: open, hybrid, and endovascular repair.Methods
Between 1993 and 2016, there were 29 cases treated for VAP aneurysm after initial TAAA open repair (median time interval, 6.2 years; interquartile range, 4-8 years). Three different treatment modalities were employed: redo open repair (O group) in 14 cases (48.3%), hybrid repair (H group) in 10 cases (34.5%), and endovascular custom-made fenestrated endograft repair (E group) in 5 cases (17.2%). Early (30-day) and midterm results were recorded. The primary end point was a composite major adverse event score: any 30-day death plus any grade ≥2 postoperative complications plus any surgical revision classified according to the Society for Vascular Surgery/American Association for Vascular Surgery reporting standards. Patients were evaluated with computed tomography scans in the outpatient clinic at 3, 6, and 12 months and annually thereafter.Results
The composite major adverse event score significantly differed among groups (O group, 79%; H group, 60%; E group, 0%; P = .009). Two cases (6.9%) of temporary delayed spinal cord ischemia (grade 1) were observed in both the E and H groups. The treatment modality employed was differently associated with blood loss ≥1000 mL (O group, 79%; H group, 40%; E group, 0%; P = .007), number of packed red blood cells transfused ≥3 units (O group, 100%; H group, 90%; E group, 40%; P = .003), intensive care unit stay >1 day (O group, 71%; H group, 70%; E group, 0%; P = .014), and length of hospital stay ≥7 days (O group, 79%; H group, 80%, E group, 20%; P = .034). At short term (6 months), we observed one endovascular reintervention in the E group and one fatal visceral graft thrombosis in the H group. At a median follow-up of 30 months (interquartile range, 15-75 months), we observed another aneurysm-related death in the H group due to graft infection and four unrelated deaths (one case in the H group and two cases in the O group).Conclusions
This retrospective study confirms that repair of VAP aneurysms that develop after open repair of TAAAs can be performed with open, hybrid, and endovascular techniques. Current practice favors endovascular repair if possible, but a conclusion that it is superior to any other technique requires validation in a larger sample or a randomized trial. 相似文献8.
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Luca Bertoglio Tommaso Cambiaghi Ciro Ferrer Domenico Baccellieri Fabio Verzini Germano Melissano Roberto Chiesa Yamume Tshomba 《Journal of vascular surgery》2018,67(3):695-702
Background
Off-the-shelf devices for branched endovascular aortic repair of thoracoabdominal aortic aneurysm (TAAA) have been developed to overcome the manufacturing- and logistics-related delays characteristic of device customization. Nonetheless, the structural requirements of branched endovascular aortic repair, together with the need for additional thoracic components to suit different anatomies, might lead to a large sacrifice of healthy aorta.Methods
We enrolled 18 consecutive TAAA patients treated between 2010 and 2016 in two centers employing the off-the-shelf t-Branch (Cook Medical, Bloomington, Ind) device (TB group). We matched these 18 patients one-to-one with another 18 patients of the 464 consecutive TAAAs treated in the same period by means of open repair (O group) in one of the two centers. The patients were matched on the basis of t-Branch feasibility, distance from the left subclavian artery to the beginning of the aneurysm, and diameter of proximal landing zone evaluated at preoperative computed tomography angiography. We compared the overall length of sacrificed healthy native aorta (the sealing zone in the TB group) in the two groups according to postoperative computed tomography angiography, and we investigated the number of intercostal arteries lost from that healthy aortic segment. We calculated also the real unnecessary sacrificed aorta by subtracting the compulsory minimum neck coverage requested to obtain the proximal sealing (25 mm).Results
We matched one-to-one six extent II, seven extent III, and five extent IV TAAAs. Overall, the length of sacrificed healthy aorta was longer (P < .001) in the TB group (median length: TB group, 49 mm [interquartile range (IQR), 31-60 mm]; O group, 14 mm [IQR, 10-20 mm]), and consequently the number of intercostal arteries lost (median number of pairs lost: TB group, four [IQR, three-four]; O group, two [IQR, one-three]) was higher (P = .004). Stratifying the results according to TAAA extent and after having subtracted from the TB group the length of aorta required for proximal sealing (25 mm), the length of sacrificed healthy aorta was longer (P = .008) only in the extent IV TAAA, 125 mm (IQR, 56-155 mm). The number of intercostal artery pairs sacrificed was longer only in extent III TAAA (P = .043) and extent IV TAAA (P = .024). No significant 30-day clinical outcomes difference was observed between the matched groups.Conclusions
The use of the t-Branch device compared with open repair is associated with a greater sacrifice of healthy aorta in extent IV TAAA and with an increased loss of intercostal arteries arising from healthy aortic proximal neck. The theoretical possible increased risk of spinal cord ischemia secondary to the routine use of this off-the-shelf device should thus be analyzed further. 相似文献10.
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Andrea Kahlberg Angela M.R. Ferrante Riccardo Miloro Daniele Mascia Luca Bertoglio Domenico Baccellieri Germano Melissano Roberto Chiesa 《Journal of vascular surgery》2018,67(4):1017-1024
Background
In the era of rising endovascular treatment of thoracoabdominal aortic aneurysms (TAAAs), the analysis of visceral vessel (VV) patency after open surgical repair is crucial to provide a future benchmark between these different approaches. This study reports the late outcomes of a single-center experience with open TAAA repair, focusing on the results of different techniques adopted for renal and splanchnic revascularization.Methods
Data were analyzed for 382 consecutive open TAAA repairs performed between January 2009 and July 2015 (284 men; mean age, 66 ± 10 years). Follow-up of surviving patients was carried out by computed tomography angiography and office checkups at 3 and 12 months and yearly afterward. Kaplan-Meier analysis was performed for overall survival, patency of reconstructed VVs (celiac trunk, superior mesenteric artery, right renal artery, left renal artery), and reinterventions on visceral arteries. Furthermore, VV long-term patency was analyzed in subgroups of patients according to the revascularization strategy (patch inclusion of all vessels, group 1; one-vessel separate reattachment and patch inclusion of the remaining vessels, group 2; separate reattachment of all VVs, group 3).Results
In-hospital mortality and paraparesis/paraplegia occurred in 7.6% and 8.1% of patients, respectively. Among the 353 survivors, 338 complied with the follow-up protocol, and adequate computed tomography angiography images were available in 247 patients (952 VVs were analyzed). Overall follow-up survival was 94%, 91%, and 70% at 1 year, 2 years, and 5 years, respectively. At the same time points, VV patency was 99%, 98%, and 98% for celiac trunk; 100%, 100%, and 100% for superior mesenteric artery; 100%, 96%, and 96% for right renal artery; and 91%, 87%, and 82% for left renal artery (log-rank test, P < .0001). Estimates for reinterventions on VVs were 1.2%, 6.3%, and 17% at the same time points. Freedom from occlusion of any VV at 1 year and 3 years was 95% and 87% for group 1, 89% and 79% for group 2, and 92% and 92% for group 3, respectively (log-rank test, P = .13).Conclusions
Long-term patency of VVs after open TAAA repair performed in high-volume centers is high, regardless of the technique employed for revascularization. The left renal artery appears to be most prone to occlusion over time. 相似文献17.
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