Surgical treatment for distal aortic arch aneurysm using stent grafting]

To alleviate the invasiveness of surgical treatment for distal aortic aneurysm or dissection, we have been using a stented graft to replace the distal anastomotic suture of the descending aorta. We also developed a new stent graft implanting method for distal aortic aneurysm or dissection which uses cervical branch bypasses from the ascending aorta and requires no extracorporeal circulation. These new surgical treatments for distal arch aneurysm result in low surgical mortality (3.8%) and low surgical morbidity rates (stroke, 7.7%; respiratory complications, 7.7%; no renal complications). These results indicate that these new graft implanting methods using stent graft should be considered as a less-invasive surgical treatment for distal aortic aneurysm or dissection.     

Ortner's syndrome and endoluminal treatment of a thoracic aortic aneurysm: a case report

Left recurrent laryngeal nerve paralysis was first described in 1897 by Ortner in a patient with mitral valve disease. However, this paralysis has also been attributed to other cardiovascular pathologies, such as thoracic aortic aneurysms. In 1971, Parodi introduced the endoluminal technique by inserting endovascular prostheses for the treatment of vascular aneurysms. The authors present a case of acute dysphonia following left recurrent laryngeal nerve paralysis, confirmed by laryngoscopy, in a patient who was diagnosed with a saccular thoracic aortic aneurysm and treated with endovascular prostheses. It was not necessary to perform any additional surgical procedures on the vocal folds because the patient showed sufficient improvement during speech therapy. Follow-up exams at 3 and 6 months demonstrated the lack of any swallowing or respiratory disorders.     

Surgical treatment of thoracoabdominal aortic aneurysm after repairs of descending thoracic or infrarenal abdominal aortic aneurysm.

OBJECTIVE: The outcome of thoracoabdominal aortic aneurysm repair after operations for descending thoracic or infrarenal abdominal aortic aneurysm was investigated. METHODS: Between May 1982 and July 2000, 102 patients underwent thoracoabdominal aortic aneurysm repair. Of these patients, 36 had previously undergone operations for descending thoracic or abdominal aortic aneurysm. To evaluate the influence of previous descending thoracic or infrarenal abdominal aortic aneurysm repair on the results of TAAA replacement, patients were divided into two groups: one group of patients who had previously undergone descending thoracic or infrarenal abdominal aortic aneurysm repair (group I, n=36) and one group of patients who had not previously undergone descending thoracic or infrarenal abdominal aortic aneurysm repair (group II, n=66). RESULTS: Patients with previous descending thoracic or infrarenal abdominal aortic aneurysm repair had more chronic dissection and extensive thoracoabdominal aortic aneurysm. The distal aortic perfusion time and total aortic clamp time were both longer in group I. The total selective visceral and renal perfusion time and operation time did not differ significantly between the two groups. In 30-day mortality rates were 5.5% in group I and 13% in group II. Major postoperative complications included paraplegia in 14% of patients in group I and 3.1% in group II, renal failure requiring hemodialysis in 22% of patients in group I and 19% of patients in group II, respiratory failure in 36% of patients in group I and 30% of patients in group II, postoperative hemorrhage in 11% of patients in group I and 16% of patients in group II. CONCLUSION: The presence of a previous descending thoracic or infrarenal abdominal aortic aneurysm did not adversely affect the outcome of thoracoabdominal aortic aneurysm repair.     

Midterm results of endoluminal stent grafting of the thoracic aorta

The purpose of this study was to evaluate the overall outcome of repair of thoracic aortic lesions with endoluminal grafts. Patients were studied prospectively following the implantation of a thoracic endovascular device. Preoperative imaging was performed by helical computed tomography (CT), angiography, transesophageal ultrasonography, or magnetic resonance imaging. Procedures were performed in an endovascular surgical suite under general anesthesia. All patients were evaluated with CT and chest radiography at discharge and at 1, 6, and 12 months. From December 1999 to November 2001, thirty-two patients were enrolled in the study (mean age 62 years; 20 male and 12 female patients). Seventeen patients had dissections, five patients had ruptured aortic ulcer, five patients had traumatic ruptures, three patients had atherosclerotic aneurysms, and two patients had pseudoaneurysms. An American Society of Anesthesiology score of III or IV was evaluated in 22 (69%) patients. The procedure was performed under emergency conditions in 11 cases. All prostheses were implanted successfully. There were no conversions. Three patients (9%) presented with a neurologic event following the implantation procedure, which was lethal in one case (hemorrhagic stroke). Two other patients died during early follow-up of myocardial infarction and multiorgan failure. The early death rate was 9%. The mean follow-up was 13.5 months. During follow-up, the maximal diameter of the aorta shrunk (> or = 5 mm) in 9 (28%) patients, remained stable in 17 (53%) patients, and increased (> or = 5 mm) in 6 (19%) patients. All patients presenting with an increased diameter were initially treated for dissections. A type 1 endoleak was diagnosed on the discharge CT scan in one patient. It sealed spontaneously thereafter. A type 3 endoleak was diagnosed 3 months after the procedure in one patient. A complementary stent graft was implanted in two patients presenting with a dissection with persistent patent false lumen and aortic enlargement. Three patients died during follow-up (two aneurysm-related and one aneurysm-unrelated death). The morbidity and mortality rates reported in our series related to the preoperative morbid conditions of the patients treated. Thoracic aorta endografting is an alternative to open surgery in this subset of patients.     

One-stage thoracic aortic aneurysm treatment and coronary artery bypass grafting

OBJECTIVE: The treatment of thoracic aortic aneurysm accompanied by ischemic heart disease presents a surgical challenge and has up to now shown a high hospital mortality rate. This report discusses the factors contributing to improved results in these cases. METHODS: We conducted a retrospective analysis of the records of 24 consecutive patients who had undergone replacement of thoracic aorta with combined coronary artery bypass grafting (CABG) between May 1991 and October 1998. Fifteen patients received total arch replacement (Arch-with-CABG Group), and the other 9 patients received the Bentall operation (Bentall-with-CABG Group). These results were compared with those patients who had undergone replacement of the thoracic aorta without CABG (Without-CABG Group). RESULTS: In the combined CABG groups, the overall operative mortality rate was 16.7%. In comparison with the Arch-without-CABG Group, there was a significantly longer cardiopulmonary bypass time and longer selective cerebral perfusion time in the Arch-with-CABG Group. However, no significant difference was observed in postoperative complications between the two groups. In addition, there was no significant difference in either actuarial survival or the cardiac-event-free rate at 5 years between the replacement of thoracic aorta with- and without-CABG Groups (83.1% vs. 90.4%, and 78.5% vs. 77.7%, respectively). No reoperation and no late death were observed during the follow-up period (mean 21.3 months). CONCLUSIONS: We concluded that replacement of the thoracic aorta combined with CABG can be carried out safely, and that revascularization for coronary artery disease is useful for preventing any occurrence of cardiac event.     

Results of endoluminal grafting in an experimental aortic aneurysm model

We studied the impact of an endoluminally placed stented aortic graft on the geometry of a surgically created abdominal aortic dilation (AAD) in nonatherosclerotic mongrel dogs. Patulous iliac vein patch infrarenal aortoplasty produced a fusiform AAD, doubling the aorta diameter. Lumbar and mesenteric aortic tributaries were preserved and no mural thrombus formed. AADs created in 23 dogs were endoluminally excluded through transfemoral placement of a thin-wall Dacron graft 4 ± 2 months later. Balloon-expandable stents were used to anchor each end of the graft to the aorta. The graft was crimped radially in its body and longitudinally at its ends to provide longitudinal and radial expandability in these respective zones. Serial color duplex, angiography, and direct caliper measurements were made. Before graft placement, a 19% ± 11% diameter growth was observed. At graft placement, flow arrest immediately occurred in the space between the graft and the AAD intima in all cases. Although microscopic recanalization of the thrombus in this space was seen at sacrifice 6 and 12 months later, no macroscopic duplex flow was imaged. A 10% ± 11% reduction in AAD diameter was measured at 6 months (p < 0.001), with no further reduction at 12 months. Graft dimensions remained stable. No anastomotic leaks developed. AAD growth stopped during the first year after effective endoluminal exclusion in normotensive dogs despite patent side branches (<1.5 mm internal diameter) and no mural thrombus at the time of graft placement. Whether microscopic recanalization of the thrombus that forms outside the graft has an impact after 1 year remains to be seen. (J Vasc Surg 1996;23:819-31.)     

Type B aortic dissection and thoracoabdominal aneurysm formation after endoluminal stent repair of abdominal aortic aneurysm

Endoluminal stent graft repair of abdominal and thoracic aortic aneurysms is being performed in increasing numbers. The long-term benefits of this technology remain to be seen. Reports have begun to appear regarding complications of stent graft application, such as renal failure, intestinal infarction, distal embolization, and rupture. Many of these complications have been associated with a fatal outcome. We describe a case of acute, retrograde, type B aortic dissection after application of an endoluminal stent graft for an asymptomatic infrarenal abdominal aortic aneurysm. An extent I thoracoabdominal aortic aneurysm subsequently developed and was successfully repaired. Aggressive evaluation of new back pain after such a procedure is warranted. Further analysis of the short-term complications and long-term outcome of this new technology is indicated before universal application can be recommended.     

Long-term results of endoluminal grafting for descending thoracic aortic aneurysms

Objective: This paper describes the long-term results of endoluminal grafting (EG) for the treatment of descending thoracic aortic aneurysms (dTAA). Methods: Until July 2004, EG for dTAA has been applied in 45 cases (male/female, 29/16, 49–86 years old, mean age 67 years old). Locations included the proximal dTAA in 24 cases, and middle or distal dTAA in 21 cases. The stent-grafts (SGs) were constructed of Gianturco Z-stents covered with woven polyester grafts. Results: Deployment of the SGs was successful in 43 of 45 cases (96%) and complete thrombosis of the aneurysm was achieved in 39 cases (87%). Six minor endoleaks (13%), one migration (2%) and one conversion to surgery (2%) occurred. There was no instance of paraplegia nor hospital death. Over a mean 48 month follow-up (range 3 to 90), there were three persistent endoleaks (6%), four secondary endoleaks (8%), one breakage of wire frame (2%). Four cases were converted to open surgery due to secondary endoleak. There were two aneurysmal ruptures at the site where EG was not performed. The cumulative survival rate was 95.6±4.4% at 12 months, 85.7±5.4% at 24 months, and 82.4±6.1% at 36 and 60 months. Conclusion: These results demonstrated that EG is safe and effective in selected dTAA patients. Improvements in patients selection, surgical techniques and equipment will reduce EG related complications and conversion to open repair over the course of the evaluation.     

Endovascular stent grafting for the treatment of blunt thoracic aortic injury

OBJECTIVE: Recent advances of endovascular stent-grafting (ESG) provide a new therapeutic option with minimum surgical damage for blunt aortic injury (BAI) during its acute phase. To clarify the effectiveness of ESG for BAI, a prospective clinical study at a university hospital was conducted. METHODS: All patients with blunt thoracic injury underwent thoracic contrast-enhanced computed tomographic (CT) scan. Six patients age 48.8 +/- 19.8 years, with Injury Severity Scores of 35.8 +/- 8.1, and with BAI were treated according to our protocol. The stent-graft covered by woven Dacron was placed at the injury site. Endoleakage was then checked by aortography and CT scan was again performed once a day on days 7 through 14. RESULTS: All patients had injury of the aortic isthmus. ESG placement was performed within 8 hours after injury except in one (48 hours). The operating time was 159.5 +/- 21.1 minutes and bleeding volume was 105 +/- 26.6 mL. No endoleakage was found. Repeat CT scan revealed disappearance of hematoma. All patients except one had an event-free clinical course. One patient died because of rupture of the ascending aorta on day 6; however, autopsy revealed evidence of the healing process at the injury site sealed by ESG. CONCLUSION: An ESG is a valid therapeutic option with minimal surgical invasion for patients with acute-phase aortic injury.     

Transient paraplegia after stent grafting of a descending thoracic aortic aneurysm treated with cerebrospinal fluid drainage

We present a case of descending thoracic aortic aneurysm repair using an endovascular stent graft, complicated by postoperative paraplegia, which was successfully treated by placing a spinal drain. The case highlights the importance of the concept of collateral flow to the spinal cord and of choosing an anesthetic technique that allows immediate postoperative evaluation of lower extremity neurologic function.     

The role of endovascular grafting technique in the treatment of infrarenal abdominal aortic aneurysm

The objective of this report is to review the author's initial clinical experience with screening a population of patients with abdominal aortic aneurysm, to describe the selection criteria for endovascular repair and to report results from a single institution. The technique of transfemoral repair of abdominal aortic aneurysm uses the endovascular graft system that is currently in a Food and Drugs Administration approved protocol for investigation in the United States. Some 69 patients with abdominal aortic aneurysm were screened in order to find ten suitable candidates. Ten implantations were carried out, of which eight were successful and two required conversion to conventional open aneurysm repair without complication. There were no deaths or complications. It is concluded that tube graft repair by the transfemoral route is feasible and applicable to approximately one patient in seven. The availability of a bifurcated graft will enhance the percentage of aneurysm patients treatable by this technique. Long-term results, at this time, are unknown.     

Colonic epithelial apoptosis during conventional and endoluminal aortic surgery

BACKGROUND: This study characterized the initial modes of colonic mucosal injury during aneurysm surgery and correlated these with proinflammatory cytokine release into the colonic and systemic circulations. METHODS: Twenty-four patients undergoing conventional open aortic aneurysm repair and ten who had endovascular aneurysm repair (EVAR) were recruited. Mucosal biopsies were taken from the sigmoid colon immediately before and after surgery, for histological examination. Inferior mesenteric vein (IMV) and peripheral blood from patients who had conventional surgery was assayed for interleukin (IL) 1 beta, IL-6 and tumour necrosis factor (TNF) alpha. Only peripheral blood from patients who had EVAR was assayed. RESULTS: Conventional aneurysm repair resulted in a threefold increase in columnar epithelial apoptosis. There was a 26-fold increase in IL-6 in IMV blood within 5 min of reperfusion, with an equivalent rise in peripheral blood after 30 min. A 20-fold rise in peripheral blood TNF-alpha was observed after surgery. Splanchnic IL-6 correlated positively with cross-clamp time and increased apoptosis. No histological changes were seen after EVAR. There were no intraoperative cytokine changes during EVAR, although a postoperative increase in IL-6 and TNF-alpha was observed. CONCLUSION: The lack of columnar epithelial apoptosis following EVAR reflects the relatively minor ischaemic injury incurred during this procedure.     

Abdominal aortic aneurysms and concomitant diseases requiring surgical intervention: simultaneous operation vs staged treatment using endoluminal stent grafting

HYPOTHESIS: To investigate whether staged or synchronous treatment of infrarenal abdominal aortic aneurysms (AAAs) and concomitant diseases (CDs) requiring surgical repair plays a clinical role. We considered endovascular aneurysm repair (EVAR) in particular. DESIGN: Review of a prospectively gathered database. SETTING: Tertiary care university teaching hospital. PATIENTS: We reviewed a total of 946 patients receiving elective AAA exclusion from 1980 through 2002. We divided the period into 2 observation intervals: 1980-1994, when only open graft replacement was available (n = 331), and 1995-2002, with 615 patients (326 who had open graft replacement and 289 who had EVAR). With regard to the physical status, expressed by the score from the American Society of Anesthesiologists (Park Ridge, Ill), we recorded in-hospital mortality rates and checked possible differences. MAIN OUTCOME MEASURES: Indications for therapy and mortality rates before and after the availability of EVAR. RESULTS: During the first interval, 14 simultaneous operations were carried out. During the second period, 19 patients received simultaneous operations while 49 underwent staged treatment using EVAR. The overall mortality rate was 3.7%. Irrespective of the American Society of Anesthesiologists classification, the mortality rate for patients who had EVAR was 0% in comparison with 13.6% for patients in American Society of Anesthesiologists class 3 or 4 after open graft replacement (P<.03). CONCLUSIONS: The coincidence of a patient having both an AAA and a CD is rare but should not be neglected. Staged treatment of AAAs using EVAR followed by surgical therapy for CDs can be an effective causal therapy with an acceptable mortality rate provided that suitable aneurysm anatomy exists.     

Emergency endovascular stent grafting for thoracic aortic pathology

Our aim was to report single-center results of emergency endovascular treatment for thoracic aortic disease. From March 1998 to January 2006, 30 acute thoracic EVAR procedures were carried out in 29 patients. One patient received two procedures in different settings. Four patients died before treatment could be initiated. The pathology of aortic lesions included atherosclerotic aneurysm (n = 13), pseudoaneurysm (n = 6), aortic rupture (n = 5), type B dissection (n = 5), aortobronchial or aortoesophageal fistula (n = 4), and intramural hematoma (n = 1). The surgical mortality rate was 21%. Three patients died as a result of technical complications, and three patients died after technically successful procedures. The mean follow-up was 31 +/- 23 months. The late mortality rate was 40% (8 of 20). Four patients died of causes unrelated to the procedure; two patients died at home without autopsy. Two patients died as a consequence of graft infections. Three late nonfatal complications occurred. Two of these resulted in additional treatment: one patient developed a mycotic aneurysm that was treated with additional stent grafting, and one patient developed a type 3 endoleak after 6 years of follow-up and was successfully treated with a bridging stent graft. Endovascular treatment for acute thoracic disease is feasible and associated with a reasonable outcome. In selected cases, it may be considered as a first option.     

Thoracovisceral segment aneurysm repair after previous infrarenal abdominal aortic aneurysm surgery

OBJECTIVE: Repair of thoracovisceral aortic aneurysms (TVAA) after previous open repair of an infrarenal abdominal aortic aneurysm (AAA) poses significant challenges. We sought to better characterize such recurrent aneurysms and to evaluate their operative outcome. METHODS: We reviewed the records and radiographs of 49 patients who underwent repair of TVAAs between 1988 and 2002 after previous repair of an AAA. Visceral artery reconstructions were completed with combinations of beveled anastomoses, inclusion patches, and side arm grafts. In 14 patients visceral endarterectomy was required to treat associated occlusive disease. Sixteen patients had cerebrospinal fluid drainage, and 10 patients had distal perfusion during cross-clamping. RESULTS: Patient mean age was 72 years, and 80% were men. Fifty-one percent of patients had symptomatic disease, and average TVAA diameter was 6.2 cm. Mean time between AAA and TVAA repair was 77 months. Twenty-six percent of aneurysms were restricted to the lower visceral aortic segment, 35% extended to the diaphragm, another 35% extended to the distal or middle thoracic aorta, and 4% involved the entire remaining visceral and thoracic aorta. The 30-day operative mortality rate was 4.1% in patients with nonruptured aneurysms and 50% in patients with ruptured aneurysms, for an overall mortality rate of 8.2%. Fifteen patients (30.6%) had major morbidity, including paresis in two patients and dialysis-dependent renal failure in five patients. At late follow-up, three patients required further aortic operations to treat additional aneurysms, and four patients had fatal aortic ruptures. Two-year and 5-year cumulative survival rates were 61% (+/-7.5%) and 37% (+/-7.8%), respectively. At univariate analysis, operative blood loss was the sole significant predictor of major morbidity (P <.023), and rupture (P <.030, P <.0001) and aneurysm extent (P <.0007, P <.0001) correlated with both operative death and long-term survival. Only aneurysm extent (P <.010, relative risk 37.3) remained a significant predictor of long-term survival at multivariate analysis. CONCLUSION: Elective repair of TVAAs after previous AAA repair can be performed with an acceptable level of operative mortality, though with considerable operative morbidity. Limited long-term survival mandates careful patient selection, and the high mortality associated with ruptured TVAA underscores the need for post-AAA surveillance.     

应用国产整体式分叉型支架腔内治疗肾下型腹主动脉瘤

目的探讨应用国产整体式分叉型支架腔内治疗肾下型腹主动脉瘤的效果。方法回顾性分析2009年9月—2011年6月采用国产整体式分叉型支架腔内隔绝术治疗27例肾下型腹主动脉瘤患者的临床资料。结果 27例腹主动脉瘤腔内修复均获成功,术后随访2～20个月复查CTA,DSA证实:瘤体被完全隔绝,支架无移位、扭曲及内漏现象。结论应用国产整体式分叉型支架腔内治疗肾下型腹主动脉瘤安全有效,与分体式支架相比,其简便、经济、并发症少。