Technical considerations for late removal of aortic endografts

INTRODUCTION: The endovascular repair of abdominal aortic aneurysms has become increasingly common during the past decade. Despite aggressive attempts to treat endoleak and graft failure with endovascular salvage procedures, some grafts necessitate surgical removal. We reviewed our experience with late endograft explantation in an effort to identify technical maneuvers critical for success. METHODS: Of 110 patients treated with aortic abdominal endografts at the University of Rochester Medical Center between August 1997 and June 2001, five (4.5%) needed late graft removal. Medical records, radiographic files, and case report forms were retrospectively reviewed. RESULTS: One Talent (Medtronic AVE, Santa Rosa, Calif) and four Vanguard (Boston Scientific, Natick, Mass) grafts were removed at a mean of 32.7 months (range, 18 to 44 months) after implantation. One patient underwent conversion for rupture, three for endoleaks (one each with types I, II, and III), and one for stent separation from the graft material without endoleak or aneurysm expansion. Three cases were approached via the midline, one through a bilateral subcostal incision, and one through a retroperitoneal incision. Supraceliac aortic control was used in all patients. Removal of two of the Vanguard grafts necessitated extension of the aortotomy above the level of the renal orifices. One perioperative death occurred. The mean operative blood loss was 4700 mL (range, 1850 to 9000 mL), and length of stay was 19.8 days (range, 7 to 42 days). CONCLUSION: The morbidity and mortality rates associated with late removal of endografts are significant. Removal of Vanguard devices can necessitate extension of the aortotomy above the renal arteries. We believe that control of the aorta well above the proximal fixation site is the key to removal and that continuous aortic exposure via retroperitoneal exposure is the best option in this situation.     

Device-specific outcomes with endografts for thoracic aortic aneurysms

For the endovascular therapy of abdominal aortic aneurysm an increasing number of publications deal with the subject of device-related outcome and aneurysm sac behaviour. The present study was designed to investigate whether, and to what extent, aneurysm sac behaviour of thoracic aortic aneurysms and perioperative outcome is influenced by the different types of stent grafts. Bibliographic search and analysis was performed. A systematic MEDLINE search on thoracic aortic aneurysms produced a total of 2,884 references with abstracts between 1990 and 2004. Restricted by using the additional terms of 'descending' and 'stent graft' the result condensed to 152 papers. Each reference was analyzed according to predetermined criteria. The majority of articles were published in the English language. Two publications summarized the results of nation-wide or continental registers of endoluminally treated patients with descending aortic dissections or thoracic aortic disease. Several series were partial and/or updated reports from the same authors and/or on the same patients. A total of 48 centres reported about the endovascular treatment of more than 3,000 patients with pathological thoracic aortic entities (Approximately 1,650 degenerative thoracic aortic aneurysms, Approximately 1,000 aortic dissections, Approximately 400 miscellaneous aortic pathologies). The heterogeneity among the series precluded any relevant comparison. Only 4 centres have presented study groups of more than 100 treated patients, but 3 series contained several treated aortic pathologies. Without a differentiation to the underlying pathology, the bibliographic research documented a rate of technical success in a range of 76% to 100%. Summarizing the data of par-procedural and in-hospital mortality the bibliographic research documented a mortality rate of 6.8% for all reported procedures. The rate of paraplegia for all procedures was 1.7%. In conclusion the presented bibliographic search and analysis demonstrated the technical feasibility of the endoluminal stent grafting of a great variety of thoracic aortic pathologies. The short-term results are promising, but data of mid-term results are rare and long-term results are missing. Moreover, the question about the influence of different types of stent grafts on the outcome can not be answered.     

Laparoscopic colorectal surgery in urgent and emergent settings

Laparoscopic colectomy (LC) is slowly becoming the standard of care for elective resections. The use of LC in the emergency setting is relatively unstudied. Authors describe their experience with a series of 34 emergent and urgent LC cases for a variety of benign and neoplastic colorectal diseases, admitted from 2007 to 2009 at Emergency Department of a tertiary level hospital, comparing laparoscopic group with matched control open group. Twenty-one LC was performed for benign complicated disease, 12 for malignant disease and 1 for iatrogenic perforation during colonoscopy. Two cases were converted to open procedure (5.8%), the average operative time was 188 minutes (SD 61.84). The average postoperative length of hospital stay was 6.57 days (SD 1.75), with no postoperative mortality and no major morbidity. Results of laparoscopic group compared with 61 patients treated with open colorectal procedure confirm the advantages of laparoscopic approach similar to those established in elective colorectal surgery. With increasing experience, LC would be a feasible and an effective option in nonelective situations lowering complication rate and length of hospital stay.     

Iliac conduit for deploying aortic endografts: an all-autogenous option

Unfavorable iliac anatomy, such as small caliber or circumferential calcification, can cause problems during delivery of aortic endografts and lead to potential complications. An iliac artery conduit "chimney" has been used to deliver the large caliber endoprosthesis using a Dacron graft sewn onto the iliac bifurcation. An all-autogenous revascularization option allows for hypogastric bypass while limiting the use of synthetic graft.     

Minimally invasive surgery is safe and effective for urgent and emergent colectomy

Objective There are a limited number of studies describing the role of minimally invasive colectomy for urgent or emergent conditions of the large bowel. We hypothesize that laparoscopic colectomy in urgent and emergent setting can be performed safely in select settings. Method A cohort of patients treated at a single institution from 2001 to 2006 was identified from a prospective database. Patients who underwent open or minimally invasive surgery (MIS), including laparoscopic (LAP) or hand‐assisted laparoscopic surgery (HALS) colectomy for urgent and emergent conditions were included. Results A total of 68 [open 32, MIS 36 [HALS 22, LAP 14)] patients underwent urgent or emergent colectomy on our colorectal service during the 5‐year time period. Patients with toxic colitis were more often selected for MIS. Patients with colon perforation or large bowel obstruction were more often selected for open surgery. The MIS group had a lower body mass index (BMI), lower American Society of Anesthesiologists fitness grade and was more likely to have been immunosuppressed. There was no difference in patient morbidity between the open and MIS groups. The MIS group had a longer median operative time and fewer cases of prolonged hospitalization. Conclusion We conclude that minimally invasive colectomy by experienced surgeons appears to be safe and effective for appropriately selected patients with emergent and urgent conditions of the large bowel.     

The impact of aortic endografts on renal function

OBJECTIVE: To determine the impact on late postoperative renal function of suprarenal and infrarenal fixation of endografts used to treat infrarenal abdominal aortic aneurysm (AAA). METHODS: Retrospective analysis of 277 patients treated from 2000 to 2003 with three different endografts at two clinical centers. Five patients on dialysis for preoperative chronic renal failure were excluded. Group IF of 135 patients treated with an infrarenal device (Medtronic AneuRx) was compared with group SF of 137 patients treated with a suprarenal device (106 Cook Zenith and 31 Medtronic Talent). Renal function was evaluated by calculating preoperative and latest postoperative creatinine clearance (CrCl) using the Cockcroft formula. Patients who developed a >20% decrease in CrCl were considered to have significantly impaired renal function. RESULTS: There were no significant differences in patient age, sex, aneurysm size, preoperative risk factors, dose of intra- and postoperative contrast, or baseline CrCl (IF: 69.3 mL/min, SF: 71.7 mL/min, P = .4). Follow-up time of 12.2 months was the same in both groups. CrCl decreased significantly during the follow-up period in both groups (IF: 69.3 mL/min to 61.7 mL/min, P < .01; SF: 71.7 mL/min to 64.9 mL/min, P < .03). Postoperative CrCl (IF: 61.7 mL/min, SF: 64.9 mL/min, P = .3), and the rate of CrCl decrease during the follow-up period (IF: -10.9%, SF: -9.5%, P = .2) was not different between the two groups. The number of patients with a >20% decrease in CrCl was not different between the two groups (IF: n = 35 [25.9%], SF: n = 41 [29.9%], P = .46). However, the magnitude of decrease in CrCl in patients with renal impairment was greater in patients treated with suprarenal fixation endografts (SF: -39%) compared with those treated with infrarenal endografts (IF: -31%, P = .005). This greater degree of renal impairment was not due to identifiable differences in preoperative risk factors, age, or baseline CrCl. No patients in these series required dialysis. CONCLUSIONS: Regardless the type of endograft used, there is a 10% decrease in CrCl in the first year after endovascular aneurysm repair. Suprarenal fixation does not seem to increase the likelihood of postoperative renal impairment. Decline in renal function over time after endovascular aortic repair is probably due to multiple factors, and measures known to be effective in protecting kidneys should be considered for these patients. Long-term follow-up with measurement of CrCl, along with renal imaging and regular blood pressure measurements, should be performed to detect possible late renal dysfunction. Prospective studies comparing suprarenal versus infrarenal fixation are needed to confirm those results.     

The feasibility of laparoscopic colectomy in urgent and emergent settings

Background  Laparoscopic colectomy (LC) is slowly becoming the standard of care for elective resections. However, the use of LC in the emergency setting is relatively unstudied. The authors describe their experience with a series of emergent and urgent LC cases for a variety of colorectal pathologies. Methods  This study reviewed 20 consecutive patients who had a laparoscopic emergent or urgent colectomy over a 2-year period. Patient demographics, indications for surgery, operative details, and postoperative complications were examined. Results  Two cases were converted to open procedure, and the mean operative time was 162 min (median, 163 min). The average postoperative length of hospital stay was 8.1 days (median, 6 days). There was one reoperation and three readmissions within 30 days, with no mortality during the follow-up period. Six patients required intensive care unit (ICU) stays after surgery, and 40% of the patients had one or more postoperative complications. Conclusions  With increasing experience, LC is a feasible option in nonelective situations. Further prospective and comparative studies will improve our understanding of the outcomes for emergency LC.     

Iliac fixation inhibits migration of both suprarenal and infrarenal aortic endografts

OBJECTIVE: To evaluate the role of iliac fixation in preventing migration of suprarenal and infrarenal aortic endografts. METHODS: Quantitative image analysis was performed in 92 patients with infrarenal aortic aneurysms (76 men and 16 women) treated with suprarenal (n = 36) or infrarenal (n = 56) aortic endografts from 2000 to 2004. The longitudinal centerline distance from the superior mesenteric artery to the top of the stent graft was measured on preoperative, postimplantation, and 1-year three-dimensional computed tomographic scans, with movement more than 5 mm considered to be significant. Aortic diameters were measured perpendicular to the centerline axis. Proximal and distal fixation lengths were defined as the lengths of stent-graft apposition to the aortic neck and the common iliac arteries, respectively. RESULTS: There were no significant differences in age, comorbidities, or preoperative aneurysm size (suprarenal, 6.0 cm; infrarenal, 5.7 cm) between the suprarenal and infrarenal groups. However, the suprarenal group had less favorable aortic necks with a shorter length (13 vs 25 mm; P < .0001), a larger diameter (27 vs 24 mm; P < .0001), and greater angulation (19 degrees vs 11 degrees ; P = .007) compared with the infrarenal group. The proximal aortic fixation length was greater in the suprarenal than in the infrarenal group (22 vs 16 mm; P < .0001), with the top of the device closer to the superior mesenteric artery (8 vs 21 mm; P < .0001) as a result of the 15-mm uncovered suprarenal stent. There was no difference in iliac fixation length between the suprarenal and infrarenal groups (26 vs 25 mm; P = .8). Longitudinal centerline stent graft movement at 1 year was similar in the suprarenal and infrarenal groups (4.3 +/- 4.4 mm vs 4.8 +/- 4.3 mm; P = .6). Patients with longitudinal centerline movement of more than 5 mm at 1 year or clinical evidence of migration at any time during the follow-up period comprised the respective migrator groups. Suprarenal migrators had a shorter iliac fixation length (17 vs 29 mm; P = .006) and a similar aortic fixation length (23 vs 22 mm; P > .999) compared with suprarenal nonmigrators. Infrarenal migrators had a shorter iliac fixation length (18 vs 30 mm; P < .0001) and a similar aortic fixation length (14 vs 17 mm; P = .1) compared with infrarenal nonmigrators. Nonmigrators had closer device proximity to the hypogastric arteries in both the suprarenal (7 vs 17 mm; P = .009) and infrarenal (8 vs 24 mm; P < .0001) groups. No migration occurred in either group in patients with good iliac fixation. Multivariate logistic regression analysis revealed that iliac fixation, as evidenced by iliac fixation length (P = .004) and the device to hypogastric artery distance (P = .002), was a significant independent predictor of migration, whereas suprarenal or infrarenal treatment was not a significant predictor of migration. During a clinical follow-up period of 45 +/- 22 months (range, 12-70 months), there have been no aneurysm ruptures, abdominal aortic aneurysm-related deaths, or surgical conversions in either group. CONCLUSIONS: Distal iliac fixation is important in preventing migration of both suprarenal and infrarenal aortic endografts that have longitudinal columnar support. Secure iliac fixation minimizes the risk of migration despite suboptimal proximal aortic neck anatomy. Extension of both iliac limbs to cover the entire common iliac artery to the iliac bifurcation seems to prevent endograft migration.     

Use of Zenith TX2 endografts in endovascular abdominal aortic aneurysm repair for large-diameter aortic necks

The purpose of this case report is to describe the use of thoracic endografts in endovascular repair of abdominal aortic aneurysms (AAAs) with large-diameter aortic necks. We present four patients who underwent elective repair of AAAs. Preoperative imaging demonstrated all to have large aortic necks (35-37 mm) precluding treatment with standard abdominal aortic devices. All underwent endovascular treatment, which included the use of a Zenith TX2 endograft (Cook Medical Incorporated, Bloomington, IN, USA) as a proximal aortic cuff. There was 100% technical success. One patient developed gastrointestinal bleeding and a myocardial infarction. All were subsequently discharged home. On follow-up, there was one aneurysm-related death at three months. The remaining three patients are alive at a mean of 25.7 months after their operation. In conclusion, large proximal aortic necks preclude endovascular treatment with standard abdominal endograft components. The use of a thoracic endograft as a proximal aortic cuff is a feasible technique for patients unable to tolerate open aortic reconstruction.     

Endovascular repair of thoracoabdominal aortic aneurysms using fenestrated and branched endografts

Purpose

The study purpose was to review the outcomes of patients treated for thoracoabdominal aortic aneurysms using endovascular repair with fenestrated and branched stent-grafts in a single center.

A systematic review of infected descending thoracic aortic grafts and endografts

ObjectiveThe objective of this study was to collect and critically analyze the current evidence on the modalities and results of treatment of descending thoracic aortic surgical graft (SG) and endograft (EG) infection, which represents a rare but dramatic complication after both surgical and endovascular aortic repair.MethodsA comprehensive electronic health database search (PubMed/MEDLINE, Scopus, Google Scholar, and the Cochrane Library) identified all articles that were published up to October 2017 reporting on thoracic aortic SG or EG infection. Observational studies, multicenter reports, single-center series and case reports, case-control studies, and guidelines were considered eligible if reporting specific results of treatment of descending thoracic aortic SG or EG infection. Comparisons of patients presenting with SG or EG infection and between invasive and conservative treatment were performed. Odds ratio (OR) meta-analyses were run when comparative data were available.ResultsForty-three studies reporting on 233 patients with infected SG (49) or EG (184) were included. Four were multicenter studies including 107 patients, all with EG infection, associated with a fistula in 91% of cases, with a reported overall survival at 2 years of 16% to 39%. The remaining 39 single-center studies included 49 patients with SG infection and 77 with EG infection. Association with aortoesophageal fistula was significantly more common with EG (60% vs 31%; P = .01). In addition, time interval from index procedure to infection was significantly shorter with EG (17 ± 21 months vs 32 ± 61 months; P = .03). Meta-analysis showed a trend of increased 1-year mortality in patients with SG infection compared with EG infection (pooled OR, 3.6; 95% confidence interval, 0.9-14.7; P = .073). Surgical management with infected graft explantation was associated with a trend toward lower 1-year mortality compared with graft preservation (pooled OR, 0.3; 95% confidence interval, 0.1-1.0; P = .056).ConclusionsThoracic aortic EG infection is likely to occur more frequently in association with aortoesophageal fistulas and in a shorter time compared with SG infection. Survival is poor in both groups, especially in patients with SG infection. Surgical treatment with graft explantation seems to be the preferable choice in fit patients.     

Partial and complete explantation of aortic endografts in the modern era

ObjectiveDespite the progressive advancement of devices for endovascular aortic repair (EVAR), endografts continue to fail, requiring explant. We present a single-institutional experience of EVAR explants, characterizing modern failure modes, presentation, and outcomes for partial and complete EVAR explantation.MethodsA retrospective analysis was performed of all EVARs explanted at an urban quaternary center from 2001 to 2020, with one infected endograft excluded. Patient and graft characteristics, indications, and perioperative and long-term outcomes were analyzed. Partial versus complete explants were performed per surgeon discretion without a predefined protocol. This process was informed by patient risk factors; asymptomatic, symptomatic, or ruptured aneurysm presentation; and anatomical or intraoperative factors, including endoleak type.ResultsFrom 2001 to 2020, 52 explants met the inclusion and exclusion criteria. More than one-half (57.7%) were explants of EVAR devices placed at outside institutions, designated nonindex explants. Most patients were male (86.5%), the median age was 74 years (interquartile range, 70-78 years). More than one-half (61.5%) were performed in the second decade of the study period. The most commonly explanted grafts were Gore Excluder (n = 9 grafts), Cook Zenith (n = 8), Endologix AFX (n = 7), Medtronic Endurant (n = 5), and Medtronic Talent (n = 5). Most grafts (78.8%) were explanted for neck degeneration or sac expansion. Five were explanted for initial seal failure, five for symptomatic expansion, and seven for rupture. The median implant duration was 4.2 years, although ranging widely (interquartile range, 2.6-5.1 years), but similar between index and nonindex explants (4.2 years vs 4.1 years). Partial explantation was performed in 61.5%, with implant duration slightly lower, 3.2 years versus 4.4 years for complete explants. Partial explantation was more frequent in index explants (68.2% vs 56.7%). The median length of stay was 8 days. The median intensive care unit length of stay was 3 days, without significant differences in nonindex explants (4 days vs 3 days) and partial explants (4 days vs 3 days). Thirty-day mortality occurred in two nonindex explants (one partial and one complete explant). Thirty-day readmission was similar between partial and complete explants (9.7% vs 5.0%), without accounting for nonindex readmissions. Long-term survival was comparable between partial and complete explants in Cox regression (hazard ratio, 2.45; 95% confidence interval, 0.79-7.56; P = .12).ConclusionsExplants of EVAR devices have increased over time at our institution. Partial explant was performed in more than one-half of cases, per operating surgeon discretion, demonstrating higher blood loss, more frequent acute kidney injury, and longer intensive care unit stays, however with comparable short-term mortality and long-term survival.     

Animal model-based simulation training for three emergent and urgent operations of penetrating thoracic injuries

PurposeTo develop animal models of penetrating thoracic injuries and to observe the effects of the animal model-based training on improving the trainees’ performance for emergent and urgent thoracic surgeries.MethodsWith a homemade machine, animal models of lung injuries and penetrating heart injuries were produced in porcine and used for training of chest tube drainage, urgent sternotomy, and emergent thoracotomy. Coefficient of variation of abbreviated injury scale and blood loss was calculated to judge the reproducibility of animal models. Five operation teams from basic-level hospitals (group A) and five operation teams from level III hospitals (group B) were included to be trained and tested. Testing standards for the operations were established after thorough literature review, and expert questionnaires were employed to evaluate the scientificity and feasibility of the testing standards. Tests were carried out after the training. Pre- and post-training performances were compared. Post-training survey using 7-point Likert scale was taken to evaluate the feelings of the trainees to these training approaches.ResultsAnimal models of the three kinds of penetrating chest injuries were successfully established and the coefficient of variation of abbreviated injury scale and blood loss were all less than 25%. After literature review, testing standards were established, and expert questionnaire results showed that the scientific score was 7.30 ± 1.49, and the feasibility score was 7.50 ± 0.89. Post-training performance was significantly higher in both group A and group B than pre-training performance. Post-training survey showed that all the trainees felt confident in applying the operations and were generally agreed that the training procedure were very helpful in improving operation skills for thoracic penetrating injury.ConclusionsAnimal model-based simulation training established in the current study could improve the trainees’ performance for emergent and urgent thoracic surgeries, especially of the surgical teams from basic-level hospitals.     

Five-year outcomes of physician-modified endografts for repair of complex abdominal and thoracoabdominal aortic aneurysms

ObjectiveThere is paucity of data on the durability of physician modified endografts (PMEGs) for complex abdominal (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs) despite widespread use. The aim of this study was to evaluate and compare the early and long-term outcomes of fenestrated-branched endovascular aortic repair (FB-EVAR) for CAAAs and TAAAs using PMEGs.MethodsWe reviewed clinical data and outcomes of patients treated by FB-EVAR using PMEGs for CAAAs (defined as short-neck infrarenal, juxtarenal, and pararenal AAAs) and TAAAs between 2007 and 2019. All patients were treated by a dedicated team with extensive manufactured device experience. Endpoints included 30-day mortality and major adverse events, patient survival and freedom from aortic-related mortality (ARM), freedom from secondary intervention, target artery (TA) patency, and freedom from TA endoleak and TA instability.ResultsOf 645 patients undergoing FB-EVAR, 156 patients (24%) treated with PMEG (121 males; mean age, 75 ± 8 years) were included. There were 89 CAAAs, 33 extent IV TAAAs and 34 extent I to III TAAAs. A total of 452 renal-mesenteric targets (3.1 ± 1.0 vessels/patient) were incorporated. Patients with TAAAs had significantly (P < .05) larger aneurysms (73 ± 11 vs 68 ± 14 mm), more TAs incorporated (3.4 ± 0.9 vs 2.8 ± 1.0), and more often had previous aortic repair (54% vs 27%). Technical success was higher in patients treated for CAAAs (99% vs 91%; P = .04). Thirty-day and/or in-hospital mortality was 5.7% and was significantly lower for CAAAs compared with TAAAs (2% vs 10%; P = .04), with three of nine early mortalities (33%) among patients treated emergently. After a mean follow-up of 49 ± 38 months, there were 12 aortic-related deaths (7.6%), including nine early deaths (5.7%) from perioperative complications and three late deaths (1.9%) from rupture. At 5 years, patient survival was 41%. Patients treated for CAAAs had higher 5-year freedom from ARM (P = .016), TA instability (P = .05), TA endoleak (P = .01), and TA secondary interventions (P = .05) with a higher, but non-significant, freedom from sac enlargement ≥5 mm (P = .11). Primary and secondary TA patency was 91% ± 2% and 99% ± 1%, respectively. Sac regression ≥5 mm occurred in 67 patients (43%) and was associated with increased survival (hazard ratio, 0.54; 95% confidence interval, 0.37-0.80) compared with those without sac regression.ConclusionsFB-EVAR using PMEGs was performed with acceptable long-term outcomes. Overall patient survival was low due to significant underlying comorbidities. Patients treated for CAAAs had higher freedom from ARM, TA instability, TA endoleak, TA secondary interventions, and a trend towards higher freedom from sac enlargement compared with patients treated for TAAAs. Sac regression was associated with improved patient survival.     

Endovascular management of iliac limb occlusion of bifurcated aortic endografts

Although aortic endograft iliac limb occlusion is an uncommon event, its treatment is problematic because standard surgical thrombectomy risks graft dislodgment or component separation. Although femorofemoral bypass grafting can restore perfusion to the affected limb, its longevity may be inferior to reestablishing patency of the endograft itself and represents a failure of the endograft procedure. With aortic endografts now commercially available, implanting surgeons must be aware of this important complication and well versed in all of the endovascular treatment options. We report three cases of endoluminal management of unilateral iliac limb occlusion of bifurcated aortic endografts.