Endovascular treatment of aortic aneurysms and dissections in patients with genetically triggered aortic diseases

Connective tissue disease (CTD) syndromes involve the ascending, aortic arch, and thoracoabdominal aorta and are associated with higher risk of aortic aneurysm or dissection. Currently, vascular societies generally recommend open repair as the first option for aortic disease in patients with CTD. However, the implementation of endovascular techniques for patients with CTD with aortic pathologies seems to have increased in recent years, mainly in patients of high surgical risk or in urgent situations. Endovascular treatment of aortic arch pathologies in patients with CTD have been feasible in experienced centers; however, the evidence is scarce. Thoracic endovascular aneurysm repair in patients with CTD is more evident; in 15 studies, 304 patients with CTD were treated with thoracic endovascular aneurysm repair with high technical success rates (88% to 100%) and a low early mortality rate (1.6%). During the median follow-up, 33 patients died and 64 patients underwent a re-intervention. In 6 studies, 26 patients with CTD were treated with fenestrated/branched endovascular aneurysm repair for thoracoabdominal aortic aneurysm, with a technical success rate of 100%, without early mortality and morbidity. The endovascular approach to thoracoabdominal aortic aneurysm, especially in post-dissection patients, mandates adjunctive techniques to achieve false lumen thrombosis with various approaches; in our experience, the Candy-Plug technique has been proven to be technically feasible with good outcomes. Endovascular treatment of aortic pathologies in patients with CTD seems to be feasible and safe in high-risk and urgent patients. Re-intervention remains an issue. The constant development of endovascular techniques and devices may provide improved mortality and morbidity outcomes.     

Endovascular treatment of thoracic aortic aneurysms

Endovascular repair of thoracic aortic aneurysms is a promising modality that may someday replace open surgical repair. While stent grafts have been used with moderate success in small to moderate-sized retrospective series, there have been no completed multicenter clinical trials directed at gaining approval from the U.S. Food and Drug Administration. The available data suggest that morbidity and mortality of the procedure may be lowered with endovascular techniques. Paraplegia occurs, but despite the inability to maintain perfusion of intercostal vessels, the rate is at least as low as that associated with open repair. Similar to the minimally invasive repair of infrarenal aneurysms, the trade-off between the open and endovascular approach rests in the necessity to follow patients closely with after endovascular repair. The long-term durability of available devices is unproved, and serial imaging studies must be followed in order to detect device failure prior to the development of devastating clinical sequelae.     

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.     

Endovascular treatment of thoracoabdominal aortic aneurysms

OBJECTIVE: This study assessed the role of multibranched stent grafts for thoracoabdominal aortic aneurysm (TAAA) repair. METHODS: Self-expanding covered stents were used to connect the caudally directed cuffs of an aortic stent graft with the visceral branches of a TAAA in 22 patients (16 men, 6 women) with a mean age of 76 +/- 7 years. All patients were unfit for open repair, and nine had undergone prior aortic surgery. Customized aortic stent grafts were inserted through surgically exposed femoral (n = 16) or iliac (n = 6) arteries. Covered stents were inserted through surgically exposed brachial arteries. Spinal catheters were used for cerebrospinal fluid pressure drainage in 22 patients and for and spinal anesthesia in 11. RESULTS: All 22 stent grafts and all 81 branches were deployed successfully. Aortic coverage as a percentage of subclavian-to-bifurcation distance was 69% +/- 20%. Mean contrast volume was 203 mL, mean blood loss was 714 mL, and mean hospital stay was 10.9 days. Two patients (9.1%) died perioperatively: one from guidewire injury to a renal arterial branch and the other from a medication error. Serious or potentially serious complications occurred in 9 of 22 patients (41%). There was no paraplegia, renal failure, stroke, or myocardial infarction among the 20 surviving patients. Two patients (9.1%) underwent successful reintervention: one for localized intimal disruption and the other for aortic dissection, type I endoleak, and stenosis of the superior mesenteric artery. One patient has a type II endoleak. Follow-up is >1 month in 19 patients, >6 months in 12, and >12 months in 8. One branch (renal artery) occluded for a 98.75% branch patency rate at 1 month. The other 80 branches remain patent. There are no signs of stent graft migration, component separation, or fracture. CONCLUSIONS: Multibranched stent graft implantation eliminates aneurysm flow, preserves visceral perfusion, and avoids many of the physiologic stresses associated with other forms of repair. The results support an expanded role for this technique in the treatment of TAAA.     

Endovascular treatment of thoracic aortic aneurysms

Descending thoracic aortic aneurysms (TAA) and chronic dissections have high morbidity and mortality rates. For 10 years, the evolution of both imaging techniques and aortic stent-graft design has brought a new therapeutic hope for patients at high risk for surgery presenting non-ruptured or emergency cases of TAA. Our goal is to describe the endovascular technique, review its state of the art and compare its mid-term results to those of conventional surgery. We also describe surgical ways to manage complex TAA, involving the aortic arch and/or the celiac aorta, as therapeutic solutions for high risk patients for surgery with unfitted anatomy for endovascular repair. After a review of the literature dealing with the natural history, the etiology, and the surgical treatment, we describe the endovascular devices, the conventional stent-grafting technique and we detail the adjunctive procedures we used to manage complex cases. We then retrospectively report our personal 38-patient experience from October 1999 to February 2003. Thirty-three patients presented with TAA and the average age was 70 years old (35-88), while the male/female ratio was 5.3. All of them were at high risk for surgery, of which 27% required adjunctive procedures to achieve proximal and/or distal neck management. The in-hospital death rate was 9%. We reported no case of paraplegia and only 1 patient with post-operative regressive stroke (3%). All the aneurysmal sacs were successfully excluded without early endoleak. During follow-up period (mean: 2 years; 1-40 months), we observed a late death rate of 10%. All aneurysmal sac remained excluded by the endografts and no stent-graft migration was observed. No late endoleak appeared during the follow-up course, but 1 patient presented a proximal aortic enlargement, which required total transposition of the supra-aortic vessels and stent-graft extension. The endovascular repair of TAA and chronic dissections proved to be feasible and offers hopeful mid-term RESULTS: With a very low morbidity-mortality rate, compared to surgery, the endovascular technique may represent an unquestionable therapeutic options, especially for patients at high risk for surgery. However, long-term results are needed to point out the durability of descending thoracic aortic stent-grafting. Neck management must be encouraged in order to avoid type 1 endoleaks in cases with short landing zones.     

Endovascular treatment of thoracoabdominal aortic aneurysms

Open surgical repair of thoracoabdominal aortic aneurysms (TAAA) bridges the aneurysm with a large, conventional, unstented graft and restores flow to the visceral arteries through short grafts or direct sutured connections between the visceral arterial orifices and the primary conduit. The combination of retrograde visceral bypass and endovascular aneurysm exclusion substitutes an endovascular stent-graft for a standard graft, stented overlaps for sutured anastomoses, and transluminal insertion for direct aortic exposure. Compared to open surgery, the combination treatment requires less dissection, and causes less hemodynamic instability, and lower complication rates, particularly paraplegia. The multi-branched stent-graft substitutes endovascular visceral bypass through branches of the stent-graft for surgical visceral bypass through branches of a conventional extraluminal graft, which has the potential to further reduce surgical dissection, hemodynamic instability, and complication rates. We favor a modular approach in which short, axially oriented cuffs are extended into the visceral arteries, using self-expanding covered stents. In the past year, we have used this approach to implant multi-branched thoracoabdominal stent-graft in 16 patients. In our opinion, this approach will eventually assume a prominent role in the management of TAAA.     

Endovascular treatment of thoracoabdominal aortic aneurysms

Endovascular repair of thoracoabdominal aneurysms using fenestrated and/or branched stent grafts is technically feasible and efficacious but carries a steep learning curve. This innovative surgical approach is associated with less perioperative morbidity than traditional open repair and its early and mid-term outcomes are very favorable. Spinal cord ischemia remains a devastating complication after these procedures, hence the importance of various neuroprotective strategies. Widespread applicability remains limited in the United States, as no custom-made or off-the-shelf endografts are commercially available. Access to these devices remains limited to physician-sponsored or industry-sponsored clinical trials, but results from the Cook p-Branch and Gore Thoracoabdominal Branch Endoprosthesis trials are on the horizon.     

Endovascular treatment of abdominal aortic aneurysms

The management of abdominal aortic aneurysms has been revolutionized by the development of endovascular stent grafts. The deployment of these devices requires precise clinical and endovascular skills. This review aims to provide an overview of the essential aspects of an endovascular repair of an abdominal aortic aneurysm (EVAR), from initial presentation and assessment for the procedure through to follow-up and long-term outcomes. Consideration is also given to the newer devices, e.g. fenestrated and branched stent grafts, which have further expanded the numbers of patients who are suitable for treatment by EVAR. Abdominal aortic aneurysm etiology, screening and open repair is dealt with in the previous article.     

Endovascular treatment of abdominal aortic aneurysms

BACKGROUND: Endovascular treatment of abdominal aortic aneurysms is a rapidly evolving technique that has gained broad acceptance in the treatment of patients with abdominal aortic aneurysms. METHODS: A review of the English literature was done to determine the short- and long-term outcomes of endovascular repair of abdominal aortic aneurysms. Reports of complications such as endoleak, graft migration, graft limb occlusion, aneurysm rupture, and aneurysm enlargement were evaluated. RESULTS: Short-term results of endovascular repair of abdominal aortic aneurysms are excellent. The necessity for open conversions is less than 5%. The cumulative risk of aneurysm rupture is approximately 1% per year. The coverall incidence of graft limb occlusion was 2.8% in the follow-up period. The cumulative risk for a secondary procedure was 12% at 1 year, 24% at 2 years, and 35% at 3 years. Moderate and severe neck angulation was associated with an increased incidence of adverse events in the follow-up period. Endografts have the potential to become infected and develop aortoduodenal fistula. The treatment of ruptured aneurysms with endovascular grafts has been successful and a technique that is increasingly used. CONCLUSION: Endovascular treatment of abdominal aortic aneurysm is an effective technique with excellent short-term results. The long-term results remain to be determined. Ongoing surveillance is necessary to avoid late complications of aneurysm rupture.     

Endovascular repair of abdominal aortic aneurysms in patients with congenital renal vascular anomalies.

PURPOSE: The endovascular repair of abdominal aortic aneurysms (AAAs) has been suggested as an alternative to conventional aortic reconstruction. The presence of anomalous renal vascular anatomy frequently necessitates special planning during conventional aortic replacement and may also create unique challenges for endovascular repair. We analyzed our experience with 24 patients with variant renal vascular anatomies who underwent treatment with aortic endografts to determine the safety and efficacy of this technique in this population. METHODS: During a 6-year period, 204 patients underwent aortic endograft procedures, 24 (11.8%) of whom had variations in renal vascular anatomy. There were 19 men and five women. Each of the 24 patients had variant renal vascular anatomy, which was defined by the presence of multiple renal arteries (n = 32), with or without a renal parenchymal anomaly (horseshoe or solitary pelvic kidney). Twenty patients underwent aneurysm repair with balloon expandable polytetrafluoroethylene grafts, and the remaining patients underwent endograft placement with self-expanding attachment systems. Eighteen patients underwent exclusion and presumed thrombosis of anomalous renal branches to effectively attach the aortic endograft. The decision to sacrifice a supernumerary artery was made on the basis of the vessel size (<3 mm), the absence of coexisting renal insufficiency, and the expectation for successful aneurysm exclusion. RESULTS: The successful exclusion of the AAAs was achieved in all the patients, with the loss of a total of 17 renal artery branches in 12 patients. Small segmental renal infarcts (<20%) were detected in only six of the 12 patients with follow-up computed tomographic scan results, despite angiographic evidence of vessel occlusion at the time of endografting. No evidence of new onset hypertension or changes in antihypertensive medication was seen in this group. No retrograde endoleaks were detected through the excluded renal branches on late follow-up computed tomographic scans. Serum creatinine levels before and after endografting were unchanged after the exclusion of the AAA in all but one patient with multiple renal branches. One patient had a transient rise in serum creatinine level presumed to be caused by contrast nephropathy. CONCLUSION: On the basis of this experience, we recommend the consideration of endovascular grafting for patients with AAAs and anomalous renal vessels when the main renal vascular anatomy can be preserved and when the loss of only small branches (<3 mm) is necessitated in patients with otherwise normal renal functions.     

Endovascular treatment of aortic arch aneurysms.

INTRODUCTION: The aim of this study was to review our clinical experience with endovascular treatment of aortic arch aneurysms using different commercially available grafts (Gore, Talent, Endomed, Cook). METHODS: From 1999 to 2004, 97 patients received endovascular treatment for diseases of the thoracic aorta. In 30 cases (26 males, 4 females) the aortic arch was involved. The left subclavian artery was overstented (Ishimaru zone '2') in 18 cases (60%). Only in the first three cases had the subclavian artery been revascularized. The left common and subclavian arteries were covered (zone '1') in 6 (20%) cases-all had the carotid artery reconstructed, either simultaneously (five cases) or as a staged procedure (one case). Finally, the whole aortic arch was over-stented (zone '0') in 6 (20%) cases, with simultaneous (five cases) or staged (one case) grafting of the supra-aortic vessels from the ascending aorta. RESULTS: Perioperative mortality was 2/30 (7%), due to graft migration (zone '2') and intra-operative stroke (zone '0'), respectively. One minor stroke was observed. No cases of paraplegia were recorded. Three type I endoleaks were observed. Two resolved at 6 months follow-up; one zone '0' graft is still being followed. There was one surgical conversion for endograft failure 2 weeks after implantation. Thus, the technical success rate was 87% (26/30) cases. The mean follow-up time was 23+/-17 months. No new onset endoleaks or aneurysm-related deaths were recorded. CONCLUSIONS: Currently available grafts may be deployed in the aortic arch in most instances. De-branching of the aortic arch with surgical revascularization for zone '0' and '1' seems to be adequate to obtain a satisfactory proximal landing zone.     

Endovascular treatment of abdominal aortic aneurysms.

OBJECTIVE: The purpose of this paper is to briefly review the historical aspects and outcome of endoluminal abdominal aortic aneurysm (AAA) repair and summarise two studies presented at the 1997 and 1998 meetings of the Society for Vascular Surgery. PATIENTS: Between May 1992 and September 1998 the endoluminal method was used to repair arterial aneurysms in 304 patients at the Royal Prince Alfred Hospital, Sydney, a tertiary referral teaching hospital. The study focuses on 243 patients with true AAA who underwent primary repair. There were 17 females and 226 males with a mean age of 72 years. Co-morbidities leading to rejection for conventional open repair were present in 83 patients. The criteria for inclusion included a segment of thrombus-free aorta between the lowermost renal artery and the commencement of the aneurysm of 1.5 cm or greater and iliac arteries that allowed access to the aorta from the groin. The technique involved the delivery of an endograft into the abdominal aorta by means of a sheath inserted through the femoral or iliac artery. Laparotomy associated with conventional open repair was avoided. Outcome measures included clinical examination and contrast-enhanced computed tomography (CT) within 10 days, at 6, 12, 18 months after operation and then annually thereafter. RESULTS: Endografts were successfully deployed in 226 patients. In the remaining 17 patients endoluminal repair was converted to open repair. There were 8 deaths within 30 days of operation giving a perioperative mortality rate of 3.3%. The two studies presented to the Society for Vascular Surgery concern: (i) a concurrent comparison of the endoluminal versus open methods of treating AAA; and (ii) a comparison of adverse events following endoluminal repair of AAA during two consecutive periods of time.     

Endovascular treatment of aortic dissections and thoracic aortic aneurysms

Diseases of the thoracic aorta pose a significant challenge to the surgeon because of the complexity of the disease and the characteristics of the patient population. Frequent comorbidities and increasing age account for mortality rates between 5% and 20% for surgical repair of descending thoracic aortic aneurysms and in excess of 50% for Stanford type B aortic dissections, when complicated by preoperative end-organ ischemia. Endovascular techniques of fenestration, stenting, and stent-grafting have emerged as viable alternatives to conventional surgery in these patients. The authors review their experience using endovascular stent-grafts in the treatment of 103 patients with descending thoracic aortic aneurysms and 19 patients with acute aortic dissections. Fenestration and stenting are also addressed as adjuvant therapies in the treatment of complicated aortic dissections. Actuarial survival for aneurysms was 81% +/- 5% at 1 year and 73% +/- 5% at 2 years. Stent-grafting for acute aortic dissections achieved instant relief of symptoms in 71% of cases with an early procedural mortality of 16%, and endovascular revascularization of ischemic beds was achieved in 93% +/- 4% of cases of peripheral or visceral ischemia. The authors' experience supports the use of endovascular techniques in the treatment of thoracic aortic pathologic conditions. Longer follow-up and results of ongoing trials that use newer devices will help define the indications for their future use.     

Endovascular treatment (EVAR) in patients with abdominal aortic aneurysms and synchronous neoplasms

The association between abdominal aortic aneurysms (AAA) and cancer is becoming more and more frequent, giving rise to several questions regarding the therapeutic and surgical management strategies for both diseases. Endovascular aneurysm repair (EVAR) is the treatment of choice for complex and high-risk patients. In this study we reviewed our experience with patients concomitantly affected by any type of cancer and AAA treated by EVAR at our institution over the last six years. From April 2001 to July 2007, 497 AAA patients underwent open or endografting repair in the 1st Division of General Surgery--Service of Vascular Surgery of the University of Verona. In 53 cases (10.6%) an association with a solid neoplasm was found and 27 of these patients (50.9%) were treated by EVAR. Twenty patients underwent a two-stage approach, with EVAR performed first, while in 5 cases a one-stage approach was preferred on the basis of the general condition of the patients, the site of the tumour to be resected, the logistic possibilities and increased experience of the operators with EVAR. Two patients received chemotherapy after EVAR. There was no in-hospital mortality and four perioperative complications (14.8%) were registered. During a mean follow-up of 25.7 months (range: 2-64 months) 5 deaths occurred, 2 in the short term and 3 in the long term, none of which were related to AAA treatment. Three type-2 endoleaks occurred that sealed spontaneously and 62.9% of the treated aneurysms had a mean 20% decrease in diameter while the others presented no variations. In our experience, EVAR was a safe and effective treatment of AAA patients with concomitant malignancies with a relatively low procedure-related morbidity and no mortality. A simultaneous surgical approach can be achieved safely, performing EVAR as the first step without significant risks. Simultaneous treatment has the advantage of avoiding a second major procedure and eliminates the risk of aortic aneurysm rupture in the postoperative period or during chemotherapy in patients who are usually in poor general condition. Care must be taken with regard to the choice of the device to be used and the possible vascular complications of the visceral circulation. In our opinion, EVAR should be considered the treatment of choice in these patients, taking into account, however, that this treatment is not always feasible in all cases and that in patients with a normal life-expectancy (tumour-cured) it may not always be the right choice. Thus, a multidisciplinary approach is necessary in the individual evaluation of these challenging patients in order to make the right decisions.