Wrapping of ascending aortic aneurysm with supra-aortic debranching and endovascular repair for aortic arch aneurysm and ruptured descending thoracic aortic aneurysm

We report a case of a hybrid surgical treatment of a 71-year-old fragile female with severe chronic obstructive pulmonary disease with a 5-year history of progressive back pain and diagnosis of descending thoracic aorta aneurysm (DTAA), but refused operation at first. Since the patient presented with an acute expanding painful pulsatile mass due to a ruptured DTAA contained by the subcutaneous tissue and had a high-risk surgical profile, we agreed that the simplest urgent operation should be performed. Cardiopulmonary bypass with or without deep hypothermic circulatory arrest was ruled out as an option. The initial approach would be permanent bypasses to the supra-aortic trunks and endovascular repair of the ruptured DTAA, but we ran into a problem: the absence of suitable diameter in the ascending aorta to land the prosthesis—zone 0. To overcome this obstacle, we opted to perform a diameter reduction of the ascending aorta by wrapping it with a Dacron tube to create a neck where we could land the endovascular prosthesis. Following this step bypasses from the proximal ascending aorta to the brachiocephalic artery, left common carotid artery and left subclavian artery were created. Since we gained ground to act in zone 0, the first endoprosthesis was landed in the wrapped zone and the aortic arch—from zone 0 to zone 3. The second and third endoprostheses covered the ruptured DTAA above the celiac trunk—zones 4 and 5. Good positioning of the endoprostheses was achieved and we attained procedural success.     

Anesthetic consideration for descending thoracic aortic aneurysm repair

Anesthesia for surgery of the aorta poses some of the most difficult challenges for anesthesiologists. Major hemodynamic and physiologic stresses and sophisticated techniques of extracorporeal support are superimposed on patients with complex medical disease states. In this review, etiologies, natural history, and surgical techniques of thoracic aortic aneurysm are presented. Anesthetic considerations are discussed in detail, including the management of distal perfusion using partial cardiopulmonary bypass. Considerations of spinal cord protection, including management of proximal hypertension, cerebral spinal fluid drainage, and pharmacological therapies, are presented.     

Midterm results of endovascular repair of descending thoracic aortic aneurysms with first-generation stent grafts

OBJECTIVE: Five years after reporting our initial stent-graft repair of descending thoracic aortic aneurysms experience, we determined the 5- to 10-year results of stent-graft treatment and identified risk factors for adverse late outcomes. METHODS: Between 1992 and 1997, 103 patients (mean age 69 +/- 12 years) underwent repair using first-generation (custom-fabricated) stent grafts. Sixty-two patients (60%) were unsuitable candidates for conventional open surgical repair ("inoperable"). Follow-up was 100% complete (mean 4.5 +/- 2.5 years; maximum 10 years). Outcome variables included death and treatment failure (endoleak, aortic rupture, reintervention, and/or aortic-related or sudden death). RESULTS: Overall actuarial survival was 82% +/- 4%, 49% +/- 5%, and 27% +/- 6% at 1, 5, and 8 years. Survival in open surgical candidates was 93% +/- 4% and 78% +/- 6% and at 1 and 5 years compared with 74% +/- 6% and 31% +/- 6% in those deemed inoperable (P <.001). Independent risk factors for death were older age (hazard ratio = 1.1; P =.008), previous stroke (hazard ratio = 2.8; P =.003), and being designated an inoperable candidate (hazard ratio = 1.9; P =.04). Actuarial freedom from aortic reintervention and treatment failure at 8 years was 70% +/- 6% and 39% +/- 8%, respectively. Earlier operative year (hazard ratio = 1.2; P =.07), larger distal landing zone diameter (hazard ratio = 1.1; P =.001), and transposition of the left subclavian artery (hazard ratio = 3.3; P =.008) were determinants of treatment failure. CONCLUSIONS: Survival after aneurysm repair using crude, first-generation stent grafts was satisfactory in good operative candidates but bleak in the inoperable cohort, raising the question of whether asymptomatic patients should have even been treated. Late aortic complications were detected in many patients, reemphasizing the importance of serial imaging surveillance.     

胸降主动脉瘤腔内修复41例治疗体会

目的 总结胸降主动脉瘤腔内修复治疗方法和经验.方法 回顾分析2001年1月至2007年7月41例胸降主动脉瘤患者腔内修复诊治经过、结果和并发症,其中4例行辅助性右-左颈总动脉、左颈总动脉-左锁骨下动脉旁路术,二期(1周后)或一期行腔内修复治疗.结果 41例移植物均被放置在预定位置.2例患者(4.9%)围手术期分别因多器官功能衰竭和急性心肌梗死而死亡.18例患者(43.9%)术后即时造影显示近端Ⅰ型内漏;其中4例内漏量大,行球囊扩张后内漏消失.2例(4.9%)患者围手术期出现急性肾功能不全,1例透析时间超过30 d.其余患者围手术期无脑卒中、截瘫、动脉瘤破裂或肢体严重缺血等并发症.26例(63.4%)患者获随访,随访时间为1～60个月[平均(18.6 ±4.2)个月].1例术后4年发生支架型人工血管移位并发Ⅰ型内漏,1例术后2年于支架型人工血管连接处出现Ⅲ型内漏,均再次行腔内修复治疗.2例死于其他疾病.其余患者术后3个月CT证实瘤腔内完全血栓形成,无支架移位和内漏.随访期间动脉瘤最大直径缩小0～22 mm,平均(8.3±4.5)mm,4例辅助性动脉旁路均通畅.结论 腔内修复治疗胸降主动脉瘤技术上可行,具有创伤小、术后恢复快和并发症少等优点.有条件者,特别对不能耐受传统手术的患者应优先考虑腔内修复治疗.     

Aortic neck morphology after endovascular repair of descending thoracic aortic aneurysms

BACKGROUND: Endovascular repair has emerged as a less-invasive treatment for descending thoracic aortic (DTA) aneurysms. However, the durability of this procedure relies on the stability of proximal and distal fixation sites. This study analyzes 3 years of computed tomography (CT) data on aortic neck morphology after endovascular DTA aneurysm repair. METHODS: Between 1999 and 2001, 139 patients underwent successful endovascular DTA repair as part of a prospective, multicenter clinical trial investigating the Gore TAG thoracic endoprosthesis. Contrast-enhanced, high-resolution CT scans were obtained at 1 (baseline), 12, 24, and 36 months and submitted to an independent core laboratory for image analysis. The aorta was carefully measured by using computerized planimetry and a standardized protocol. Neck diameter was measured at 10-mm intervals for 2 cm above and below the aneurysm and correlated with graft migration and endoleak. RESULTS: The mean proximal neck diameter increased from a baseline of 30.2 +/- 4.6 mm to 32.0 +/- 4.3 mm at 36 months (P <.05), and the annual diameter increase was 0.8, 0.4, and 0.6 mm at 12, 24, and 36 months. The mean distal neck diameter increased from 29.4 +/- 3.8 mm to 32.1 +/- 5.0 mm at 36 months (P <.05), and the annual diameter increase was 1.1, 0.4, and 1.2 mm at 12, 24, and 36 months. At 36 months, freedom from neck dilation of > or =5 mm was 87%, and freedom from migration of > or =10 mm was 83%. An endoleak was present in 11 (9%) of 122 patients at baseline, 7 (7%) of 96 at 12 months, 6 (9%) of 68 at 24 months, and 1 (3%) of 33 at 36 months. Neck dilation was not associated with graft migration or endoleak. CONCLUSIONS: Three years after endovascular repair of DTA aneurysms, there is progressive enlargement of the proximal and distal aortic necks. Although uncommon for patients to develop significant neck dilation, when it does occur, it is not associated with graft migration or endoleak. Continued surveillance of aortic neck morphology after descending thoracic aneurysm endografting is recommended.     

Aortic arch and descending thoracic aortic aneurysms: experience with stent grafting for second-stage "elephant trunk" repair

Reconstruction of aortic arch and descending thoracic aortic aneurysms (TAAs) is technically challenging and associated with significant morbidity and mortality. We report our experience with extensive TAAs using a two-stage "elephant trunk" repair, with the second stage completed using an endovascular stent graft (ESG). Over 6 years, 111 patients underwent ESG treatment of TAAs at Mount Sinai Medical Center. Twelve of these patients were referred for ESG placement for the second stage of elephant trunk reconstruction because comorbidities placed them at high risk of open surgical repair. Our database was analyzed for technical and clinical success and perioperative complications. The mean follow-up was 11.8 months (range 1-64 months). Twelve patients (five women and seven men) with a mean age of 69 +/- 10 years underwent repair of their distal aortic arch and descending TAAs. These aneurysms included nine atherosclerotic aneurysms, one pseudoaneurysm, and two penetrating atherosclerotic ulcers. Three patients were symptomatic. Stent graft repair was technically successful in 91.7% or 11 of 12 patients. Excessive aortic arch tortuosity resulted in failure to deploy a stent graft in one patient. An antegrade approach through the open elephant trunk was used in two patients with severe iliac occlusive disease. Endoleaks (type 2) were identified in two patients with no aneurysm expansion; however, a 14 mm expansion over 1 year occurred in a patient with no identifiable endoleak. One early mortality occurred in a patient with a ruptured 6 cm infrarenal AAA after successful exclusion of the 8 cm TAA. Second-stage elephant trunk reconstruction of an extensive TAA using an ESG is effective in the short term. Its long-term durability remains to be determined.     

Endovascular repair after stent elephant trunk procedure for extensive thoracic aortic aneurysm

Hybrid surgical-endovascular procedure was conducted in a 46-year-old male with extensive thoracic aortic aneurysm. Ascending aorta and arch replacement combined with stent elephant trunk implantation was performed first. An open stent-graft was implanted into the descending aorta. One month later, endovascular repair was conducted. Postoperative CTA showed total coverage of the descending aorta by stent-grafts and the descending aortic aneurysm was totally thrombo-excluded. Stent elephant trunk may be a better alternative to conventional elephant trunk in hybrid surgical-endovascular approaches in treatment of extensive thoracic aortic aneurysm.     

Simplified thoracic aortic aneurysm repair

Descending thoracic and thoracoabdominal aortic operations still represent a challenge for the cardiovascular surgeon. In recent years, endovascular stent grafting has become a popular alternative to a conventional operation in selected patients, but is not always readily available or is technically contraindicated; also, long-term results are unknown. We describe a simplified surgical technique to secure a standard vascular prosthesis by performing a modified “elephant trunk” operation and discuss potential indications for its application.     

Less-invasive thoracic aortic aneurysm repair

To minimize surgical trauma, we performed graft replacement of a descending aortic aneurysm through a minithoracotomy (12 cm) with the use of thoracoscopy and special vascular clamps. Contrast magnetic resonance angiography can be useful for preventing postoperative paraplegia by revealing the Adamkiewicz artery. The patient was satisfied with the postoperative comfort and good cosmetic result. Further refinement of the technique and instrumentation would make this technique a valuable adjunct to conventional thoracic aortic surgery.     

Saccular descending thoracic aortic aneurysm with dysphagia

A 76 year old woman had suffered from chest pain, back pain, and dysphagia for 8 months. She was diagnosed as having a thoracic aortic aneurysm by chest X-ray and chest enhanced computed tomography. Simultaneously, severe dysphagia developed. Chest enhanced computed tomography and chest aortic aortography at our hospital demonstrated a saccular descending thoracic aortic aneurysm. Esophagography demonstrated that the esophagus was compressed by the aneurysm; therefore, a graft replacement for the saccular descending thoracic aortic aneurysm was performed on Feburary 17th, 1998. A left sided 6th intercostal approach was made, and graft replacement for the aneurysm using a 22 mm Hemashield prosthetic graft was performed under temporary bypass from the thoracic aorta just distal to the left subclavian artery and to the left femoral artery. The postoperative course was uneventful, the severe dysphagia improved dramatically, but a pleural effusion of 1000 ml collected 3 weeks after the operation. Surgical cases of saccular descending thoracic aortic aneurysm with dysphagia are rare, and with this in mind, we report this case to the the medical literature.     

The effect of aortic dissection on outcome in descending thoracic and thoracoabdominal aortic aneurysm repair

It is estimated that 20% to 40% of the patients who survive the acute phase of aortic dissection will develop significant aneurysmal dilatation of the descending thoracic or thoracoabdominal aorta. Aortic dissection has long been considered a risk factor for mortality and neurologic deficit following surgical repair of the descending thoracic and/or thoracoabdominal aorta. In this article we review the surgical approach to patients with aortic dissection and thoracoabdominal aortic aneurysms and discuss the impact of adjuncts on survival and neurologic outcome.     

Successful surgery for an acute type A aortic dissection following repair of a descending thoracic aortic aneurysm

Acute type A aortic dissection in the presence of a previously repaired atherosclerotic descending thoracic aortic aneurysm is rarely reported. We experienced a patient who underwent an ascending aortic replacement with reconstruction of the aortic arch 16 months after repair of a descending thoracic aortic aneurysm. We succeeded in the redo operation with comprehensive techniques involving selective cerebral perfusion, deep hypothermia, early antegrade systemic circulation for cerebral protection, and femoro-femoral bypass with occlusion of the descending aorta for lower systemic perfusion as well as renal perfusion. The patient recovered and is doing well one year after the redo operation.