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

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

Collective experience with hybrid procedures for suprarenal and thoracoabdominal aneurysms

Not every patient is fit for open thoracoabdominal aortic aneurysm (TAAA) repair, nor is every TAAA or juxtarenal abdominal aortic aneurysm suitable for branched or fenestrated endovascular exclusion. The hybrid procedure consists of debranching of the renal and visceral arteries followed by endovascular exclusion of the aneurysm and might be an alternative in these patients. Between May 2004 and March 2006, 16 patients were treated with a hybrid procedure. The indications were recurrent suprarenal or thoracoabdominal aneurysms after previous abdominal and/or thoracic aortic surgery (n = 8), type I to III TAAAs (n = 3), proximal type I endoleak after endovascular repair (n = 2), penetrating ulcer of the juxtarenal aorta (n = 1), visceral patch aneurysm after type IV open repair (n = 1), and primary suprarenal aneurysm (n = 1). Eight (50%) of 16 patients were judged to be unfit for open TAAA repair. The hospital mortality rate was 31% (5 of 16). Four of five deceased patients were unfit for thoracophrenic laparotomy. Two patients died from cardiac complications and three from visceral ischemia. No spinal cord ischemia was detected, and temporary renal failure occurred in four patients (25%). The mean follow-up was 13 months (range 6-28 months). During follow-up, no additional grafts occluded and no patients died. Hybrid procedures are technically feasible but have substantial mortality (31%), especially in patients unfit for open repair (80%). They might be indicated when urgent TAAA surgery is required or when vascular anatomy is unfavorable for fenestrated endografts in patients with extensive previous open aortic surgery.     

Hybrid one-stage approach to extensive atherosclerotic aneurysm of thoracoabdominal aorta

We report a 62-year-old man with an atherosclerotic Crawford type II aneurysm involving both common iliac arteries who underwent surgical revascularization of the visceral vessels and renal arteries from the ascending aorta and subsequent endovascular aneurysmal exclusion. Computed tomography imaging at 2 years showed complete exclusion of the aneurysm throughout the thoracoabdominal aorta, confirming the successful antegrade revascularization of visceral vessels and renal arteries. A hybrid approach to thoracoabdominal aneurysms using antegrade visceral and renal revascularization from the ascending aorta before endovascular repair is technically feasible and might constitute an attractive alternative to conventional surgical treatment.     

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.     

Repair of thoracoabdominal aortic aneurysms with fenestrated and branched endovascular stent grafts

OBJECTIVE: To report the repair of thoracoabdominal aortic aneurysms (TAAAs) with fenestrated and branched endovascular stent grafts (EVSGs). METHODS: Four patients with asymptomatic TAAAs were treated with custom-designed Zenith fenestrated and branched EVSGs. Three patients had undergone previous open aortic aneurysm repair. Thirteen visceral vessels in four patients were targeted for incorporation by graft fenestrations and branches. RESULTS: The fenestration/orifice interface was secured with balloon-expandable Genesis stents or Jostent stent grafts in 9 of 13 target vessels. Completion angiography demonstrated antegrade perfusion in 12 of 13 target vessels. One renal artery occluded because of graft rotation during deployment. There were no endoleaks. Three patients required additional surgical procedures related to access vessels. One patient required reoperation for bleeding from an extra-anatomic bypass graft and subsequently died from multisystem organ failure. Three patients made an uncomplicated recovery. No patient developed spinal cord ischemia. Computed tomography at 12 months in the 3 survivors demonstrated complete aneurysm exclusion with antegrade perfusion in all 10 target vessels. CONCLUSIONS: TAAA repair with fenestrated and branched EVSGs is feasible and provides an acceptable and promising alternative to conventional surgical repair in selected patients.     

Hybrid procedures for the treatment of thoracoabdominal aortic aneurysms and dissections

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

Hybrid procedures for thoracoabdominal aortic aneurysms and chronic aortic dissections - a single center experience in 28 patients

OBJECTIVE: We report our 6-year experience with the visceral hybrid procedure for high-risk patients with thoracoabdominal aortic aneurysms (TAAA) and chronic expanding aortic dissections (CEAD). METHODS: Hybrid procedure includes debranching of the visceral and renal arteries followed by endovascular exclusion of the aneurysm. A series of 28 patients (20 male, mean age 66 years) were treated between January 2001 and July 2007. Sixteen patients had TAAAs type I-III, one type IV, four thoracoabdominal placque ruptures, and seven patients CEAD. Patients were treated for asymptomatic, symptomatic, and ruptured aortic pathologies in 20, and 4 patients, respectively. Two patients had Marfan's syndrome; 61% had previous infrarenal aortic surgery. The infrarenal aorta was the distal landing zone in 70%. In elective cases, simultaneous approach (n = 9, group I) and staged approach (n = 11, group II) were performed. Mean follow-up is 22 months (range 0.1-78). RESULTS: Primary technical success was achieved in 89%. All stent grafts were implanted in the entire thoracoabdominal aorta. Additionally, three patients had previous complete arch vessel revascularization. Left subclavian artery was intentionally covered in three patients (11%). Thirty-day mortality rate was 14.3% (4/28). One patient had a rupture before the staged endovascular procedure and died. Overall survival rate at 3 years was 70%, in group I 80%, and in group II 60% (P = .234). Type I endoleak rate was 8%. Permanent paraplegia rate was 11%. Three patients required long-term dialysis (11%). Peripheral graft occlusion rate was 11% at 30 days. Gut infarction with consecutive bowel resection occurred in two patients. There was no significant difference between group I and II regarding paraplegia and complications. CONCLUSIONS: Early results of visceral hybrid repair for high-risk patients with complex and extended TAAAs and CEADs are encouraging in a selected group of high risk patients in whom open repair is hazardous and branched endografts are not yet optional.     

Hybrid-procedures for the treatment of thoracoabdominal aortic aneurysms and dissections.

AIM: The conventional open repair of thoracoabdominal aneurysms and dissections remains complex and demanding and is associated with significant morbidity and mortality. We present our experience of hybrid open and endovascular treatment of thoracoabdominal aneurysms and dissections. METHODS: Within an experience of 226 aortic stent-grafts between 1998 and April 2006, 6 of the patients (median age 60 years, range 35 to 68 years) with thoracoabdominal aneurysms (Crawford type I, II, III, and V) were treated with a combined endovascular and open surgical approach. Five men and one woman, with median aneurysm diameter of 75 mm (range 70-100 mm), received revascularization of the renal arteries, the superior mesenteric artery, and the coeliac trunk accomplished via transperitoneal bypass grafting. Aneurysmal exclusion was then performed by stent-graft deployment. RESULTS: The entire procedure was technically successful in all patients. The patients were discharged a median of 9 days after the operation, while the postoperative studies revealed the patency of the vessels and no evidence of type I endoleak or secondary rupture of the aneurysm. During follow up (1 to 22 months) spiral-CT scanning revealed distinct shrinkage of the aneurysm, no graft migration or endoleak and patency of all revascularised vessels, except one renal artery in two patients. No patient experienced any temporary or permanent neurological deficit, and no dialysis was necessary. CONCLUSION: The combined endovascular and open surgical approach is feasible, without cross clamping of the aorta and with minimized ischemia time for renal and visceral arteries, and seems to be an appropriate strategy for patients with a thoraco-abdominal aortic aneurysm or dissection.     

Open repair of pararenal aortic aneurysms

Surgical treatment of pararenal aortic aneurysms, if compared to open repair of infrarenal aneurysms, is characterized by more technical difficulties and haemodynamic problems. Since endovascular repair has become feasible in most cases of infrarenal aneurysms, surgical treatment of pararenal aneurysms is a matter of great interest for vascular surgery. Detection of pararenal aneurysms needs a careful preoperative diagnosis, assessment of cardiac, renal and pulmonary status of the patient and planning of the surgical intervention. The surgeon needs to face an extended proximal aorta exposure, to manage the left renal vein and to choose an appropriate clamping site. Then a skilled and quick reconstruction of the visceral arteries is fundamental to minimize organ disfunction. Coupled intraoperative selective perfusion of visceral arteries and systemic administration of nephroprotective drugs optimizes organ protection during ischemia. To better define challenges, risks and results, we reviewed our experience with the treatment of pararenal aortic aneurysms. In the period between January 1993 and May 2003, 98 consecutive patients underwent surgery for pararenal aneurysms at our Institution. We treated 98 pararenal aneurysms, divided in 68 juxtarenal and 30 pararenal ones. In the juxtarenal aneurysms group, the 30 days mortality rate was 5.8% (4/68); 3 of these patients underwent urgent operation for ruptured aneurysm. In the suprarenal aneurysms group, the 30 days mortality rate was 3.3% (1/30). In conclusion pararenal aneurysm repair is a safe procedure, especially if performed electively, and represents an interesting field of research to improve surgical and anesthesiologic techniques.     

Endovascular treatment of pararenal aortic aneurysms

Endovascular procedures have emerged as an attractive alternative technique for the repair of abdominal aortic aneurysms with an increasing popularity and diffusion. Even if technology progresses are developing more and more efficient grafts and devices, at the moment the endovascular treatment is still not applicable to all patients. The most common reason for patient exclusion remains an unsuitable proximal implantation site. Endografts with suprarenal fixation were studied for solving the problem of the proximal neck but results seem to be not so encouraging. At the moment pararenal aortic aneurysms, involving ostia of renal or visceral arteries, are usually excluded from endovascular treatment. The solution could be a custom-made graft for each single patient, with fenestrations or branches for renal and visceral arteries. The first clinical use of a fenestrated graft was by Park in 1996 and some groups are now studying different kinds of grafts, both in experimental and clinical studies, which are opening attractive new possibilities. At present results are only preliminary but this would be the first step towards the potential substitution of the entire aorta through endovascular techniques.     

Fenestrated and branched stent-grafting after previous surgery provides a good alternative to open redo surgery.

OBJECTIVE: To present our experience using fenestrated and branched endoluminal grafts for Para-anastomotic aneurysms (PAA) following prior open aneurysm surgery, and after previous endovascular aneurysm repair (EVAR) complicated by proximal type I endoleak. METHODS: Fenestrated and/or branched EVAR was performed on eleven patients. Indications included proximal type I endoleak after EVAR and short infrarenal neck (n=4), suprarenal aneurysm after open AAA (n=4), distal type I endoleak after endovascular TAA (n=1), proximal anastomotic aneurysm after open AAA (n=1), and an aborted open AAA repair due to bleeding around a short infrarenal neck. RESULTS: The operative target vessel success rate was 100% (28/28) with aneurysm exclusion in all patients. Mean hospital stay was 6.0 days (range 2-12 days, SD 3.5 days). Thirty day mortality was 0%. All cause mortality during 18 months mean follow-up (range 5-44 months, SD 16.7 months) was 18% (2/11) with no deaths from aneurysm rupture. Cumulative visceral branch patency was 96% (27/28) at 42 months. Average renal function remained unchanged during the follow-up period. CONCLUSIONS: Our report highlights the potential of fenestrated and branched technology to improve re-operative aortic surgical outcomes. The unique difficulties of increased graft on graft friction hindering placement, short working distance, and increased patient co-morbidities should be recognized.     

Management of thoracoabdominal aneurysm type IV.

BACKGROUND: Thoracoabdominal aneurysm type IV (TAA IV) represents only a minority of aortic aneurysms, but as it is an entirely abdominally located aneurysm, vascular surgeons are likely to see such aneurysms in their practice. The current surgical management of TAA IV is reviewed. METHODS: A PubMed/Medline-literature search for TAA IV. RESULTS AND CONCLUSIONS: A detailed preoperative evaluation to determine the rupture and operative risk is required. A threshold size of 5.5-6 cm is recommended for elective repair of TAA IV, which then is adjusted for age and other risk factors. Operative simplicity with the clamp and sew approach to obtain a short aortic cross-clamp time seems to have most support in the literature. The necessity of adjunct treatment to prevent visceral and spinal cord ischemia seems to be needed rarely. Uncomplicated repair has a minimal risk of neurological injury and a low risk of renal failure requiring dialysis in patients without preoperative renal dysfunction or renal artery stenosis. The role of endovascular repair of these aneurysms remains to be established.     

Repair of type IV thoracoabdominal aneurysm with a combined endovascular and surgical approach.

We report an unusual case of type IV Thoracoabdominal Aneurysm (TAA) with Superior Mesenteric Artery (SMA), celiac artery, and bilateral renal artery aneurysms in a patient who underwent an earlier repair of two infrarenal Abdominal Aortic Aneurysm (AAA) ruptures. Because of the presence of the visceral artery aneurysms and the earlier operation through the retroperitoneum, standard surgical treatment via a retroperitoneal approach with an inclusion grafting technique was considered difficult. A combined surgical approach achieving retrograde perfusion of all four visceral vessels and endovascular grafting allowing exclusion of the TAA was accomplished. Complete exclusion of the aneurysm and normal perfusion of the patient's viscera was documented by means of follow-up examinations at 3 and 6 months. The repair of a type IV TAA with a Combined Endovascular and Surgical Approach (CESA) allowed us to manage both the aortic and visceral aneurysms without thoracotomy or re-do retroperitoneal exposure and minimized visceral ischemia time. If the durability of this approach is confirmed, it may represent an attractive alternative in patients with aneurysmal involvement of the visceral segment of the aorta.     

Early results after staged hybrid repair of thoracoabdominal aortic aneurysms

BACKGROUND: The morbidity and mortality rates associated with open thoracoabdominal aortic aneurysm (TAAA) repair are substantial. This study was designed to review our early experience with the hybrid endovascular and, or open approach for TAAA repair. STUDY DESIGN: Patients undergoing elective hybrid repair of their TAAAs were retrospectively reviewed. RESULTS: Seventeen patients (mean age 69+/-15 years, male, 76%) underwent visceral and renal revascularization as the first stage of their hybrid repair. The Crawford extent included: II, 2; III, 8; and IV, 7. Perioperative mortality and complication rates after the first stage were 24% and 25%, respectively; the mean intensive care unit stay and total length of stay were 7+/-12 days (range 1 to 45 days) and 22+/-33 days (range 3 to 100 days), respectively. The endovascular aneurysm repair or second stage procedure was performed in 12 of 13 (92%) of the surviving patients, with a mean of 27+/-27 days (range 6 to 99 days) between the procedures. Two patients experienced intraoperative complications during the second stage, but there were no deaths or additional postoperative complications. Patients did not require the intensive care unit, and the overall mean length of stay after the second stage was 2+/-2 days (range 1 to 5 days). The mean postoperative followup among the 11 patients completing both stages was 8+/-12 months (range 1 to 15 months). The primary patency rate for the visceral and renal bypasses was 96% (54 of 56). CONCLUSIONS: The hybrid approach for patients with TAAAs may reduce complications in the average, low-risk patient and may extend the indications for repair to patients considered higher risk based on age, comorbidities, or anatomic considerations.     

Surgical treatment of pararenal aortic aneurysms in the elderly

AIM: Until fenestrated endografts will become the standard treatment of pararenal aortic aneurysms, open surgical repair will currently be employed for the repair of this condition. Suprarenal aortic control and larger surgical dissection represent additional technical requirements for the treatment of pararenal aneurysms compared to those of open infrarenal aortic aneurysms, which may be followed by an increased operative mortality and morbidity rate. As this may be especially true when dealing with pararenal aneurysms in an elderly patients' population, we decided to retrospectively review our results of open pararenal aortic aneurysm repair in elderly patients, in order to compare them with those reported in the literature. METHODS: Twenty-one patients over 75 years of age were operated on for pararenal aortic aneurysms in a ten-year period. Exposure of the aorta was obtained by means of a retroperitoneal access, through a left flank incision on the eleventh rib. When dealing with interrenal aortic aneurysm the left renal artery was revascularized with a retrograde bypass arising from the aortic graft, proximally bevelled on the ostium of the right renal artery. RESULTS: Two patients died of acute intestinal ischemia, yielding a postoperative mortality of 9.5%. Nonfatal complications included 2 pleural effusions, a transitory rise in postoperative serum creatinine levels in 3 cases, and one retroperitoneal hematoma. Mean renal ischemia time was 23 min, whereas mean visceral ischemia time was 19 min. Mean inhospital stay was 11 days. CONCLUSION: Pararenal aortic aneurysms in the elderly can be surgically repaired with results that are similar to those obtained in younger patients.     

Open Repair of Pararenal Aortic Aneurysms: Operative Management, Early Results, and Risk Factor Analysis

Surgical treatment of pararenal aortic aneurysms, if compared to open surgical repair of infrarenal aneurysms, is technically more demanding and characterized by problems related to organ ischemia. To better define challenges, risks, and results, we analyzed our experience with the treatment of pararenal aortic aneurysms. Between January 1993 and March 2005, 119 consecutive patients underwent surgery for pararenal aneurysms at our institution. A prospective analysis of results was performed. According to their localization, we treated 85 juxtarenal aneurysms and 34 suprarenal aneurysms. One hundred and three patients underwent primary repair of an atherosclerotic aneurysm, four patients underwent surgical repair of an anastomotic pseudoaneurysm, and eight patients underwent correction of an aneurysm of the pararenal aorta proximal to a previous infrarenal anastomosis. Four patients underwent emergency operation for a ruptured aneurysm. In the juxtarenal aneurysm group, the 30-day mortality rate was 4.7% (4/85) including three patients with ruptured aneurysm. In the suprarenal aneurysm group, the 30-day mortality rate was 2.9% (1/34). Preoperative renal insufficiency was present in 16 patients, respectively in 7 patients with juxtarenal aneurysms and in 9 patients with suprarenal ones. In 22 patients, we registered a transient increase in creatinine levels with return to baseline levels by discharge. Four patients required long-term dialysis. In three patients, a short period of dialysis was required. Clamping time longer than 30 min was associated with a higher risk of transient postoperative deterioration of renal function (p = 0.0073). Preoperative renal insufficiency was associated with a higher risk of persistent postoperative deterioration of renal function (p < 0.0001). Morbidity and mortality of elective surgery for pararenal aneurysms is acceptable. One of the main risks of this surgery is renal morbidity. Preoperative renal insufficiency and long periods of renal ischemia are associated with a higher risk of postoperative deterioration of renal function that is often, but not always, reversible. Nowadays, pararenal aneurysm repair is a safe procedure, especially if performed electively.     

Long-term durability of multibranched endovascular repair of thoracoabdominal and pararenal aortic aneurysms

Objective

The objective of this study was to assess the durability of multibranched endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms by examining the rates of late-occurring (beyond 30 days) complications.

Experimental development of an endovascular graft for thoraco-abdominal aortic aneurysm repair

AIM: Current treatment of thoraco-abdominal aortic aneurysms is surgical. Despite significant advances in surgical technique and anesthetic management, significant morbidity and mortality remain associated with their repair. In compliance with principles of reducing postoperative morbidity, we developed a thoraco-abdominal endovascular graft in experimental models of type III and type IV thoraco-abdominal aortic aneurysm. This device had to preserve the vascularization of the visceral arteries while ensuring full aneurysmal exclusion. METHODS: Six implantations of the endovascular graft were performed. This graft was a modular system, made of: 1) a custom made main body containing 4 prosthetic visceral branches, 2) 4 self-expandable stent-grafts connecting prosthetic visceral branches with visceral arteries, 3) a custom made tubular endovascular graft connecting the main body with one of the iliac arteries. RESULTS: On angiographic controls, full aneurysmal exclusion was achieved while maintaining visceral artery perfusion. At the end of each procedure, the experimental model was opened. Macroscopic examination showed harmonious thoraco-abdominal endovascular graft deployments, without abnormal component constraint or kinking. There was no discordance between macroscopic and angiographic RESULTS: CONCLUSIONS: Our experimental work led to the development of a thoraco-abdominal endovascular graft, demonstrating feasibility of thoraco-abdominal aneurysm endoluminal treatment on an in vitro model close to the anatomical conditions observed in human pathology.     

A novel alternative to open conversion for type 1 endoleak resulting in ruptured aneurysm

In this article, a novel technique for the treatment of ruptured abdominal aortic aneurysm secondary to proximal type 1 endoleak as a result of progressive neck dilatation after endovascular aneurysm repair is reported. A 74-year-old man with multiple comorbidities including severe ischemic heart disease, congestive cardiac failure, and chronic renal failure presented with a ruptured abdominal aortic aneurysm. He had an infrarenal endovascular aneurysm repair performed in 1999 and had subsequently developed a proximal type 1 endoleak. At open laparotomy, the placement of 4 nylon ties around the infrarenal aneurysm neck to refashion a seal and exclude the sac from systemic pressurization effectively treated the rupture. In the high-risk patient, ruptured proximal type 1 endoleak can be successfully treated with external banding avoiding the potential morbidity seen with the aortic clamping and blood loss of open conversion.     

Prise en charge des anévrismes thoracoabdominaux de type IV

Background. – Thoracoabdominal aneurysm type IV (TAA IV) represents only a minority of aortic aneurysms, but as it is an entirely abdominally located aneurysm, vascular surgeons are likely to see such aneurysms in their practice. The current surgical management of TAA IV is reviewed.Methods. – A PubMed/Medline-literature search for TAA IV.Results and conclusions. – A detailed preoperative evaluation to determine the rupture and operative risk is required. A threshold size of 5.5–6 cm is recommended for elective repair of TAA IV, which then is adjusted for age and other risk factors. Operative simplicity with the clamp and sew approach to obtain a short aortic cross-clamp time seems to have most support in the literature. The necessity of adjunct treatment to prevent visceral and spinal cord ischemia seems to be needed rarely. Uncomplicated repair has a minimal risk of neurological injury and a low risk of renal failure requiring dialysis in patients without preoperative renal dysfunction or renal artery stenosis. The role of endovascular repair of these aneurysms remains to be established.