Clinical results of endovascular stent graft repair for fifty cases of thoracic aortic aneurysms

Between February 1995 and December 1997, 50 cases (55 lesions) of thoracic aortic aneurysms including 20 cases of aortic dissections were treated with an endovascular technique using the stent grafts. All patients were treated in the operating room under general anesthesia and the stent grafts were implanted through 18 Fr. or 20 Fr. sheathes via femoral arteries under fluoroscopic guidance. The stent graft was composed of several units of self-expanding stainlesssteel Z stents covered with an ultra-thin polyester fabric. Stent graft deployment was technically successful in 53 of 55 lesions (delivery success rate: 96.4%). Exclusion of the aneurysms and entry closing without endoleak were achieved within two weeks after the operation in 43 of 53 lesions (initial success rate: 81.1%). Endoleak was found in 10 lesions (minor endoleak: 8 and major endoleak: 2 lesions). Two patients died in the periopertive period of delivery failures as injury to external iliac artery and damage to the delivery sheath caused by tortuous and narrow access routes. Endovascular stent graft repair of thoracic aortic aneurysms is minimally invasive operation in comparison with conventional surgical graft replacement with extracorporeal circulation. These early results suggest that the stent graft repair is possibly safe and useful treatment for the patients of thoracic aortic aneurysms especially in high risk patients. However, careful long-term follow-up is necessary to prove the value and the effects of this endovascular treatment and improvement of the stent graft system and technical training of endovascular surgery for operators are required to reduce the delivery failure and to determin the stent graft repair is reliable treatment.     

Partial debranching hybrid stent graft for distal aortic arch aneurysms

Purpose

To evaluate the early outcomes of treating distal aortic arch aneurysms (DAAAs) with a partial debranching hybrid stent graft, and to analyze the morphology of distances among the supra-aortic branches.

Methods

We used this stent graft to treat DAAA in 12 patients, by debranching the left common carotid artery (LCCA) and the left subclavian artery (LSA). With computed tomography (CT) data on the collective total 28 thoracic aortic aneurysms, the distances from the LSA to the LCCA and those from the LSA to the brachiocephalic artery (BA) were measured using multiplanar reconstruction (MPR) and centerline of flow (CLF) methods.

Results

All procedures were done in two stages and all stent grafts were deployed in zone-1. The devices used were the TALENT in seven patients and the TAG in five patients. There were no operative deaths, paraplegia, or type-1 or -3 endoleaks. One patient suffered minor cerebral infarction. The distance from the LSA to the BA was longer than that from the LSA to the LCCA by10?mm in the CLF method and by 13?mm in the MPR method.

Conclusions

It was possible to achieve a longer proximal landing zone by debranching two supra-aortic branches, the LCCA and the LSA. The partial debranching hybrid stent graft was less invasive and more effective for DAAAs.     

Evolving experience with thoracic aortic stent graft repair

PURPOSE: We reviewed our initial thoracic aorta (TA) stent graft experience in 28 patients from the perspective of treatment with homemade devices (Dacron over Gianturco Z stents; 14 cases) and a commercial device (Excluder; W.L. Gore Co, Flagstaff, Ariz; 14 cases). METHODS: From November 1996 to August 2001, 28 patients with a spectrum of disease (degenerative aneurysm, n = 18; chronic dissection, n = 4; pseudoaneurysm, n = 3, with 1 trauma and 2 anastomotic; intramural hematoma, n = 2; and coarctation, n = 1) underwent TA stent grafting. Clinical parameters included a mean age of 71 years, 12 female (43%) and 16 male (57%) patients, 14 of 28 patients (50%) with major comorbidities that prohibited open repair, and nine of 28 patients (32%) with urgent or ruptured conditions. Seven patients (25%) needed open surgical access to the aorta or iliac artery for either concomitant abdominal aortic aneurysm repair (n = 3) or device deployment (n = 4), and six of 28 patients (21%) needed left subclavian-carotid transposition to provide for an adequate proximal fixation site. Focal (<15 cm) grafts were used in 19 patients, and the remaining patients had at least two thirds of their descending aorta excluded. RESULTS: The procedural mortality rate was 3.5% (1/28 patients); three additional deaths, (1 device-related) occurred during the mean follow-up period of 17 months. Access artery complications occurred in six of 28 patients (21%), with one fatal. No immediate or late open conversions were performed. One patient needed urgent dilation and stenting of a collapsed stent graft 3 weeks after deployment. Serious systemic complications included temporary dialysis (n = 1), congestive heart failure (n = 1), and unstable angina (n = 1). Complete exclusion of the TA lesion was noted in 27 of 28 cases (96%). No cases of spinal cord ischemia were noted. Ease and accuracy of deployment was superior for the second generation (commercial) device. CONCLUSION: TA stent graft repair, although in evolution, appears to be a safe and effective alternative to open repair for many patients with a spectrum of TA disease. Prospective trials for individual diseases will be necessary to define its ultimate role.     

The use of the Anaconda stent graft for abdominal aortic aneurysms

The AnacondaTM is a modular bifurcated stent-graft of woven polyester and nitinol ring stents that has been commercially available since 2005. It was the first truly repositionable stent-graft and features a magnet wire contralateral limb cannulation system. It has excellent fixation and sealing properties and its ring stent construction results in it being highly conformable and therefore applicable in angulated and tortuous anatomy.     

Endovascular stent graft selection for the treatment of abdominal aortic aneurysms

Minimally invasive endovascular techniques for the treatment of abdominal aortic aneurysms (AAA) have significantly reduced the morbidity of these procedures as compared with standard surgical repair. In addition, patients with extensive comorbid medical illnesses in whom standard operative repair is contra-indicated, may be successfully treated using endovascular means. A variety of endovascular stent grafts are currently being used clinically for endovascular AAA repair. The characteristics of these stent grafts vary significantly. In selecting the specific stent graft to be used for endovascular AAA repair, these specific characteristics must be considered particularly with regard to the individual patient's anatomic and physiologic characteristics. The United States Food and Drug Administration (FDA) has approved 4 endovascular stent grafts for the treatment of AAA: the Medtronic AneuRx, the W. L. Gore Excluder, the Cook Zenith and the Guidant Ancure. The Zenith graft received approval for marketing in 2003 and has gained relatively wide usage, in part due to its ability to treat aneurysms with relatively large diameter implantations zones. Also in 2003 the Guidant Corporation withdrew the Ancure graft from marketing and distribution. Enrollment has also been recently completed for the phase II FDA trials of the Medtronic Talent graft and the Cordis Fortron graft. These devices have been approved for use in the European Union and are awaiting FDA panel meeting in the United States. Comparative analysis of several of the available stent grafts has been performed. Results have varied with regard to the need for secondary interventions, aneurysm sac size reduction and the occurrence of continued perfusion of the aneurysm sac. Several significant advances have also occurred recently in stent graft research and development. Of particular significance has been the initiation of the phase I trial of the Trivascular Enovus graft. Deployment of the Trivascular graft may be accomplished through a delivery system that is considerably reduced in profile. The potential for percutaneous application of the graft may be available in the future. The indications for use of endovascular grafts as compared to standard open surgery have not yet been fully defined. Endovascular stent grafts in current use have limitations and their use must be tempered accordingly, until their long-term effectiveness is more completely evaluated. This article describes the general principles of use for endovascular devices for the repair of AAAs. It details the features and results for the devices in current use and highlights the factors that influence the selection of specific stent graft types.     

Endovascular stent graft repair of abdominal and thoracic aortic aneurysms: a ten-year experience with 817 patients

OBJECTIVE: On November 23, 1992, the first endovascular stent graft (ESG) repair of an aortic aneurysm was performed in North America. Following the treatment of this patient, we have continued to evaluate ESG over the past 10 years in the treatment of 817 patients. SUMMARY AND BACKGROUND DATA: Abdominal (AAA) or thoracic (TAA) aortic aneurysms are a significant health concern traditionally treated by open surgical repair. ESG therapy may offer protection from aneurysm rupture with a reduction in procedure morbidity and mortality. METHODS: Over a 10-year period, 817 patients were treated with ESGs for AAA (723) or TAA (94). Patients received 1 of 12 different stent graft devices. Technical and clinical success of ESGs was reviewed, and the incidence of procedure-related complications was analyzed. RESULTS: The mean age was 74.3 years (range, 25-95 years); 678 patients (83%) were men; 86% had 2 or more comorbid medical illnesses, 67% of which included coronary artery disease. Technical success, on an intent-to-treat basis was achieved in 93.8% of patients. Primary clinical success, which included freedom from aneurysm-related death, type I or III endoleak, graft infection or thrombosis, rupture, or conversion to open repair was 65 +/- 6% at 8 years. Of great importance, freedom from aneurysm rupture after ESG insertion was 98 +/- 1% at 9 years. There was a 2.3% incidence of perioperative mortality. One hundred seventy five patients died of causes not related to their aneurysm during a mean follow-up of 15.4 months. CONCLUSIONS: Stent graft therapy for aortic aneurysms is a valuable alternative to open aortic repair, especially in older sicker patients with large aneurysms. Continued device improvements coupled with an enhanced understanding of the important role of aortic pathology in determining therapeutic success will eventually permit ESGs to be a more durable treatment of aortic aneurysms.     

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

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

Endovascular stent graft repair of mycotic aneurysms of the thoracic aorta

Traditional open surgical repair for mycotic aneurysms of the thoracic aorta is associated with significant morbidity and mortality. Endovascular repair has been reported as an alternative treatment in patients with mycotic thoracic aneurysms. This article reports our experience of endovascular stent graft placement in three patients with mycotic aneurysms of the thoracic aorta and compares the results with similar reports on the literature.     

Endovascular stent graft repair of a thoracic aortic gunshot injury

Endovascular treatment approaches offer minimally invasive alternative strategies for the management of vascular injuries. While endovascular stent graft repair of blunt injury to the thoracic aorta is well described, there are few reports of its application for treatment of penetrating injuries of the thoracic aorta. We report the successful treatment of a through-and-through gunshot injury of the thoracic aorta and review how this technology may be applied for the treatment of penetrating thoracic aortic injury.     

Nonanastomotic rupture of thoracic aortic Dacron graft treated by endovascular stent graft placement

A 61-year-old man had a Stanford type A acute aortic dissection, and the total aortic arch was replaced with 22-mm knitted Dacron graft in 1996. In 2006, he underwent mitral valve replacement and tricuspid valve repair due to severe mitral and tricuspid valve regurgitation. Although preoperative computed tomography (CT) scan suggested pseudoaneurysm around the Dacron graft replaced with aortic arch, it could not be repaired concomitantly. Four months later, in view of the technical difficulties of an open surgical procedure, the prosthetic graft failure was repaired by endovascular stent graft consisting of a Gianturco Z stent covered with an UBE woven Dacron graft. However, during a follow-up, aneurysm sac diameter increased without any sings of endoleak in follow-up CT scans. Redo endovascular stent graft placement using a Gore-TAG device was performed. Subsequently, shrinkage of the pseudoaneurysmal sac could be observed.     

Anesthetic management of total aortic arch reconstruction by transluminally placed Inoue endovascular branched stent graft

Two aged patients with aortic arch aneurysm underwent total aortic arch reconstruction using three branched Inoue transluminal endovascular graft. Epidural tubes were placed for intraoperative analgesia the day before operation. General anesthesia was induced with propofol and midazolam, and maintained with sevoflurane in nitrous oxide and oxygen. Laryngeal mask airways were inserted and the patients breathed spontaneously. In the first case, she awoke smoothly without any complications during and after the operation. In the second case, she did not awake after the operation. The CT scan revealed multiple cerebral embolization. She died from multiple organ failure several days after the operation. Endovascular total aortic arch reconstruction with Inoue branched stent graft may be less invasive for aged patients than conventional surgical repair. But long-term mortality and effectiveness for this treatment remain unclear and severe complications such as cerebral infarction may occur. It is very important to let patients awake smoothly after operation and to estimate neurological findings as soon as possible.     

The midterm results of stent graft treatment of thoracic aortic injuries

INTRODUCTION AND OBJECTIVES: Several publications document the technical feasibility of stent graft repair of aortic transection. We report our mid-term results of endovascular repair of thoracic aortic transections using covered stent grafts and compare this to a cohort undergoing open repair during the same time period to demonstrate the shift in practice pattern at our institution. MATERIALS AND METHODS: A retrospective review of patients who sustained blunt thoracic transection was undertaken. Medical records were examined to identify the clinical outcome of the procedure, and follow-up CT scans were reviewed to document adequate treatment of the transection. Outcome measures include procedure-related mortality, neurological morbidity, and successful immediate and mid-term coverage of the thoracic false aneurysm and absence of graft migration or endoleak. RESULTS: From July, 2000 to October, 2004, 27 patients were identified with descending thoracic aortic transection at our level I trauma center. Fourteen patients were managed nonoperatively, five patients underwent thoracotomy and direct aortic repair, and eight patients underwent endoluminal stent graft repair. Of the endovascular group (n=8), repairs were performed with stacked AneuRx aortic cuffs (Medtronic, Inc., Minneapolis, MN) (n = 6), a Gore thoracic aortic stent graft (Thoracic EXCLUDER; W.L. Gore, Flagstaff, AZ) (n=1), or a Medtronic Talent thoracic endograft (Medtronic, Inc.) (n=1). Access for stent graft deployment was the common femoral artery (n=2), iliac artery (n=4), or distal abdominal aorta (n=2). Completion arch aortography and postoperative CT scanning confirmed successful management of the aortic transection in each patient. There were no procedure-related deaths, paraplegia, or stroke. Postoperative complications included a brachial artery thrombosis in one patient as well as an external iliac artery dissection and acute renal failure in a second patient for a complication rate of 37.5%. Two patients died as a result of their injuries unrelated to the stent graft repair. Mean follow-up of 16.6 mo has shown no evidence of endoleak or stent graft migration. Of the open repair group (n=5), one patient died in the operating room during attempted aortic repair, and one patient had a postoperative stroke. CONCLUSIONS: Due to technical success and absence of delayed complications including endoleak and graft migration, stent graft repair of traumatic aortic transection has replaced open aortic repair as the primary treatment modality in the multiply injured trauma patient at our institution. The postoperative complication rate observed in this small series tempers the success to some degree, but the severity of the complications compares favorably with those observed in the open repair group.     

Anaesthetic management of planned or emergency endovascular stent graft surgery for thoracic aneurysms and dissections

We reviewed the intraoperative anaesthetic management and outcome of seven consecutive cases of endovascular stent graft surgery for thoracic aortic aneurysms or dissections over a period of 20 months in our institution. Seven males (median age 63) underwent endovascular stent graft surgery of the thoracic aorta under general anaesthesia. Four were emergency procedures for acute dissection or leaks of thoracic aneurysms. The duration of the procedures ranged from 120 to 300 minutes. Intraoperative stent migration occurred in one patient. Induced hypotension and immobilization were critical during stent deployment. Six out of the seven patients were discharged home between three to 20 days postoperatively. There was no 30-day mortality. One patient died sixty days postoperatively. Anaemia and respiratory complications were the most common postoperative problems encountered. None of the patients sustained spinal cord ischaemia, acute myocardial infarction or renal impairment. Endovascular stent graft surgery of the thoracic aorta is a relatively new alternative to conventional open surgery. Our experience suggests satisfactory short-term outcome even for patients with acute dissection. However, long-term survival and results require further evaluation.     

Repeated transluminal endovascular Inoue stent graft placement for progressive dilatation of prosthetic graft that had been repaired with Inoue stent graft placement for dilatation 23 years after extraanatomical bypass

A 76-year-old man had undergone aneurysm exclusion and ascending abdominal aortic extraanatomical bypass for a thoracoabdominal aortic aneurysm in 1978. In 1983 hemoptysis occurred, and resection and closure of the central stump of the aorta and a left lower lobectomy were performed. Dilatation (ϕ50 mm) of a prosthetic graft (Cooley Graft ϕ18 mm) used for extraanatomical bypass was noted in 2001 and was repaired by placement of an Inoue stent graft. However, the aneurysm diameter increased further (ϕ70 mm), although no endoleak was noted: Placement of an Inoue stent graft covering the whole length of the prosthetic graft was repeated in 2006. The postoperative course was smooth, no endoleak occurred, and the patient was discharged 2 weeks after surgery.     

Delayed onset of ascending paralysis after thoracic aortic stent graft deployment

Delayed spinal cord ischemia after thoracic aortic aneurysm repair is an infrequent but devastating complication. The use of stent grafts to exclude aortic aneurysms is thought to decrease the incidence of the neurologic deficit because there is no period of significant aortic occlusion. We report a case of paraplegia that progressed to quadriplegia occurring 48 hours after the apparently successful deployment of a thoracic aortic stent graft. (J Vasc Surg 2000;31:196-9.)     

Evaluation of spinal cord ischemia in endovascular stent graft repair and surgical operation of descending thoracic or thoracoabdominal aortic aneurysms

Between October 1996 and June 2003, endovascular stent graft repair was performed in 87 patients with descending thoracic aortic aneurysms, graft replacement was performed in 24 patients with thoracoabdominal aortic aneurysms, and endovascular stent graft repair with concomitant surgical bypass of abdominal visceral arteries was performed in 3 patients with thoracoabdominal aortic aneurysms. The retrievable stent graft was inserted and evoked spinal cord potential were monitored in order to predict spinal cord ischemia for stent graft repair. There was no paraplegia or hospital death, although 3 patients had paraparesis in stent graft repair. Two of the 3 patients with paraparesis made a full neurologic recovery. There were no cases of paraplegia or paraparesis in surgical operations with thoracoabdominal aortic aneurysm. The concomitant surgical procedure was a good technique for patients in whom cardiopulmonary bypass could not be used. Our results of stent graft repair and surgical operation for descending thoracic or thoracoabdominal aortic aneurysms were acceptable. The retrievable stent graft was useful for prediction of spinal cord ischemia before endovascular stent graft repair of descending thoracic or thoracoabdominal aortic aneurysm.