Two-stage combined endovascular and surgical approach for recurrent thoracoabdominal aortic aneurysm.

PURPOSE: To present a 2-stage combined endovascular and surgical approach for recurrent thoracoabdominal aortic aneurysm (TAAA). CASE REPORT: A 78-year-old man with previous surgical repairs of infrarenal abdominal and descending thoracic aortic aneurysms was referred for dysphagia due to an enlarging 9-cm aneurysm extending from the mid thoracic to the suprarenal aorta. Because no suitable endograft was available, an open repair was attempted, but the presence of a "frozen" chest made the redo procedure extremely difficult. A 2-stage treatment was thus decided upon. First, a retrograde bifurcated bypass graft was implanted from the abdominal aortic graft to the superior mesenteric and celiac arteries. Twenty days later, the TAAA was successfully excluded with a stent-graft, during which spinal fluid drainage was performed to prevent paraplegia. At 6 months, computed tomography showed patency of the endoprosthesis and visceral grafts. At 1 year, the patient remains asymptomatic. CONCLUSIONS: This case illustrates that a 2-stage combined endovascular and surgical approach may be a safe and effective alternative to reoperation for recurrent TAAA.     

Treatment of thoracoabdominal aortic aneurysms with a combined endovascular and surgical approach.

AIM: The conventional approach for the repair of thoracoabdominal aneurysms remains complex and demanding and is associated with substantial morbidity and mortality. Moreover, in cases of reoperation the impact can be dramatic either in survival or in quality of life of the patients, albeit the use of adjuncts. A combined endovascular and surgical approach with retrograde perfusion of visceral and renal vessels has been realized in order to minimize intraoperative and postoperative complications. METHODS: Within an experience of 231 aortic stent-grafts between 1995-2000, 4 of the patients with thoracoabdominal aneurysms were treated with a combined endovascular and surgical approach. Three procedures were electively conducted and 1 on emergency basis. Two women, 59 and 68 years old, and 2 men, 68 and 73 years old (maximum aneurysm's diameter was 10, 6, 8 and 9 cm, respectively) were operated with the combined method (the first 2 patients had a previous open repair of a thoracoabdominal aneurysm). The surgical approach was executed in all patients without thoracotomy or re-do retroperitoneal exposure. Revascularization of renal, superior mesenteric (and celiac in 2 cases) arteries was accomplished via transperitoneal bypass grafting. Aneurysmal exclusion was performed by stent-graft deployment. RESULTS: The entire procedure was technically successful in all patients. The 1(st) patient was discharged 6 weeks after the operation, while the postoperative studies revealed the patency of the vessels and no evidence of leak or secondary rupture of the aneurysm; the patient died 3 months after the repair, due to rupture of an aneurysm of the ascending aorta. In the 2(nd) patient, 30 months after the operation, spiral-CT scanning revealed distinct shrinkage of the aneurysm, no graft migration or endoleak and patency of all revascularized vessels. The 3(rd) patient died on the 6th postoperative day due to multiorgan failure after having developed ischemic-related pancreatitis, albeit the successful combined repair. The 4(th) patient followed an uneventful course. No patient experienced any temporary or permanent neurological deficit. CONCLUSION: The combined endovascular and surgical approach is feasible, without cross-clamping of the aorta and with minimized ischemia time for renal and visceral arteries, and seems the appropriate strategy for high risk and previously operated, with a thoracoabdominal trans-diaphragmatic approach, patients.     

Hybrid thoracoabdominal aneurysm repair with simultaneous antegrade visceral revascularization and supra-aortic debranching from the ascending aorta.

PURPOSE: To describe a hybrid technique involving combined antegrade revascularization of both supra-aortic and visceral arteries and complete exclusion of a dissecting thoracoabdominal aortic aneurysm (TAAA). TECHNIQUE: A 46-year-old man had a dissecting TAAA involving the left subclavian artery (LSA) and the descending thoracic and abdominal aorta down to the left common iliac artery. The ascending aorta was the only feasible source of inflow to the cerebral and visceral vessels. Via a median thoracolaparotomy, the supra-aortic and visceral arteries were dissected, and an octopus graft was implanted using 3 bifurcated Dacron grafts. An 18-x9-mm bifurcated Dacron graft was anastomosed in an end-to-side fashion to the ascending aorta, the brachiocephalic trunk, and the left common carotid artery. A 16-x8-mm bifurcated Dacron graft was sutured end-to-side to the celiac artery and superior mesenteric artery. A third 12-x7-mm bifurcated graft was sutured to both renal arteries. In a second step, 3 tapered custom-made thoracic Zenith TX2 endografts were used to repair the thoracic and the thoracoabdominal aorta. A bifurcated Zenith AAA device was used to treat the aneurysm at the level of the infrarenal aorta and both iliac arteries. Despite covering the LSA and all intercostal and lumbar arteries, the patient developed only a temporary paresis of the left leg. Computed tomography showed complete exclusion of the aneurysm and normal flow to the supra-aortic and visceral arteries. CONCLUSION: In selected cases, this hybrid approach using the ascending aorta for antegrade revascularization of cerebral and visceral arteries is feasible, with acceptable perioperative morbidity. However, its role for the treatment of complex thoracoabdominal aortic disease must be evaluated further.     

Type IV Thoraco-Abdominal Aortic Aneurysm (TAAA IV) with Occlusion of Celiac and Superior Mesenteric Arteries in a High Risk Patient: Successful Treatment with a Hybrid Traditional Vascular and Endovascular Procedure

We describe a novel hybrid open and endovascular repair for a dumbbell shaped lower thoracic and abdominal aortic aneurysm (AAA) in a high risk patient, with celiac trunk and superior mesenteric artery occlusions. We used a two-staged approach consisting of an open infrarenal AAA repair with a by-pass to superior mesenteric artery and reimplantation of inferior mesenteric artery. This was followed by an antegrade insertion of a thoracic endograft via a PFTE graft on the thoracic aorta to allow precise deployment of the stent graft above the renal arteries.     

Combined staged procedures for the treatment of thoracoabdominal aneurysms.

PURPOSE: To examine the efficacy of a staged approach for the treatment of thoracoabdominal aneurysms, with open visceral revascularization followed by aortic endografting, in selected patients not considered candidates for conventional surgical repair. METHODS: A retrospective review was conducted of 13 consecutive patients (8 women; mean age 64 years, range 33-77) who underwent visceral bypass followed by endovascular thoracoabdominal stent-graft implantation since 1999. Three patients presented with symptomatic aneurysms and 2 with rupture. Two patients had connective tissue disorders. All patients were deemed unfit for conventional thoracoabdominal repair due to comorbid conditions. The procedures were tailored to the pathology and specific patient anatomical situation: 5 aortic dissections with aneurysmal degeneration and 8 aneurysms (5 Crawford type II, 2 type III, and 1 type IV). RESULTS: The patients underwent retrograde visceral bypass (11 iliovisceral and 2 infrarenal aortic to visceral artery) followed by endovascular aortic relining with Zenith TX2 devices (n=7), homemade endografts (n=5), or a Talent thoracic endograft (n=1). Six patients required either a proximal or distal direct aortic repair (2 infrarenal reconstructions, 3 arch elephant trunk grafts, and 1 ascending aortic repair), while 3 patients also underwent left carotid-subclavian bypass grafting. Two patients developed paraplegia (1 following a ruptured aneurysm), and 2 patients had transient paraparetic events. Two patients had acute renal failure requiring short-term dialysis. Three patients died within 30 days; 2 late aneurysm-related deaths were noted. Three patients developed endoleaks during follow-up. Mean lengths of stay were 13 days (7-30) for the visceral bypass and 12 (3-25) for the endovascular stent-graft. In addition, remaining procedures in 8 patients required a mean of 7 days (0-14) in hospital. CONCLUSION: Staged endovascular and open procedures are feasible for thoracoabdominal aneurysms in patients at prohibitive risk for open thoracoabdominal reconstruction. However, this approach still carries a significant risk of perioperative mortality and morbidity. The potential for less invasive alternatives should be investigated.     

Hybrid endovascular and off-pump open surgical treatment for synchronous aneurysms of the aortic arch, brachiocephalictrunk, and abdominal aorta

A 71-year-old patient was admitted for synchronous aneurysms of the aortic arch, brachiocephalic trunk, and juxtarenal abdominal aorta involving the iliac arteries. The patient first underwent open surgical repair of the juxtarenal abdominal aortic aneurysm by means of aorto-bifemoral bypass. Three months later, he underwent off-pump surgical repair of the aneurysm of the brachiocephalic trunk and bypass grafting from the ascending aorta to the brachiocephalic trunk and the left common carotid artery, followed by successful exclusion of the aneurysm of the aortic arch by deployment of a Zenith TX1 custom-made endograft, inserted through a limb of the aorto-bifemoral graft. Combined endovascular and open surgical treatment is an appealing new alternative to open surgical repair for complex aortic diseases. Debranching of the aortic arch enables endovascular grafting in this area, thereby avoiding cardiopulmonary bypass and circulatory arrest. Staged and simultaneous procedures should be considered for the treatment of complex aortic diseases even in poor-risk patients; however due to the investigative characteristics of these procedures, patient selection and postoperative follow-up should be carried out with utmost attention.     

Endovascular repair of a ruptured descending thoracic aortic aneurysm

Endovascular aneurysm repair has considerable potential advantages over the surgical approach as a treatment for thoracic aortic rupture, in part because open surgical repair of ruptured thoracic aortic aneurysms is associated with high mortality and morbidity rates. We describe the successful endovascular deployment of stent-grafts to repair a contained rupture of a descending thoracic aortic aneurysm in an 86-year-old man whose comorbidities prohibited surgery. Two months after the procedure, magnetic resonance angiography showed a patent stent-graft, a patent left subclavian artery, and complete exclusion of the aneurysm.     

Endovascular repair of ascending aortic pseudoaneurysm: technical considerations of a common carotid artery approach using the Zenith aortic cuff endograft.

PURPOSE: To present a technique for endovascular treatment using Zenith aortic cuff extenders delivered via a left common carotid artery (CCA) approach in a patient with a large symptomatic ascending aortic pseudoaneurysm. CASE REPORT: A 78-year-old man with recent stroke developed worsening exertional dyspnea and chest pain 4 years following coronary artery bypass grafting. Imaging demonstrated a bovine arch and an 8-x12-cm ascending aortic pseudoaneurysm that was compressing the pulmonary arteries. The treatment strategy was to deliver a Zenith aortic cuff to seal the ascending aortic pseudoaneurysm via a left CCA approach. With the patient under general anesthesia, the left CCA was exposed and a transverse arteriotomy was made to introduce the Zenith aortic cuff sheath; the distal CCA was clamped to prevent catheter-related embolization. With its nosecone removed, a 32-x36-mm Zenith aortic cuff was delivered to the ascending aorta via the left CCA and positioned under transient cardiac arrest initiated with intravenous adenosine. A total of 3 Zenith aortic cuffs were placed in the ascending aorta to successfully exclude the pseudoaneurysm. The patient tolerated the procedure well; follow-up imaging showed successful pseudoaneurysm exclusion without endoleak. CONCLUSION: Ascending aortic pseudoaneurysm is a formidable clinical challenge due in part to the significant operative stress in a conventional surgical repair, as well as limited endovascular treatment options. Because there are no approved endovascular devices for ascending aortic aneurysm repair, clinicians may have to rely on endograft components designed for abdominal aortic aneurysms to treat lesions in the ascending aorta.     

Hybrid repair of aortic arch aneurysm

Aneurysms of the transverse aortic arch requiring surgery most often affects elderly patients with multiple co-morbidities and represents a significant challenge to both patient and surgeon. The hybrid approach developed in recent years (debranching followed by endovascular repair) may improve the morbidity and mortality of the population risk. We present the case report of a 72-year-old man with aortic arch aneurysm arising at the origin of the left subclavian artery involving whole caudal segment of an aortic arch with concomitant single vessel coronary disease. The hybrid procedure was carried out in two stages, first (open surgical approach) performing an extra-anatomic bypass – debranching combining with concomitant coronary artery bypass procedure without heart–lung machine and following day deploying the aortic endograft. Postoperative period was uneventful. On the 15th day after hybrid procedure, the patient was discharged in a stabilized condition for ambulatory care. This approach may be an alternative to standard open procedures in high-risk patients with promising midterm results.     

“三文治技术”在腹主动脉瘤腔内修复中保留髂内动脉血流的应用

目的探讨“三文治技术”在合并髂总动脉瘤的腹主动脉瘤患者腔内修复中保留髂内动脉血流的可行性及安全性。方法我们对1例合并双侧髂总动脉瘤的肾下性腹主动脉瘤患者行腔内修复术。该患者由于腹主动脉瘤合并双侧髂总动脉严重扩张,覆膜支架覆盖腹主动脉及髂总动脉瘤的时需覆盖双侧髂内动脉开口,可能造成髂内动脉血流受阻而引起盆腔缺血。我们在进行左髂总动脉腔内修复时应用了“三文治技术”,以覆盖病变血管同时保留一侧髂内动脉血供。结果手术成功地对腹主动脉瘤及双侧髂总动脉瘤进行了覆膜支架的腔内修复,同时保留了髂内动脉血供。结论在复杂腹主动脉瘤髂内修复时,使用“三文治技术”可能是一种有效的保留分支血管血供的方法。     

Traitement hybride des anévrismes de l'arche aortique

BackgroundThe management of aortic arch aneurysms is challenging. If conventional surgery cannot be performed in high risk patients, endovascular treatment is confronted to the problem of endoleaks at long term. However, the hybrid repair combining a first surgical step and a second endovascular step is a new technique recently introduced in the therapeutic alternatives of aortic arch aneurysm but its long-term results are not well known.MethodsWe report a series of four patients who received hybrid treatment for aortic arch aneurysms in our department between 2016 and 2018.ResultsThese were 3 men and 1 woman with an average age of 63 years [55–80 years]. All were hypertensive and only one patient had diabetes. The aneurysm was symptomatic of chest pain in all cases and it was ruptured in only one case. Preoperatively, the hemodynamic state was stable in the four patients with a mean aneurysm diameter of 60 mm [48–79 mm] on CT angiography and the landing zone was zone 0 in all cases. Under general anesthesia, the 1st step was surgical with the performance of an aorto-bicarotid bypass associated with a re-implantation of the left subclavian artery and a disconnection of the supraortic trunks. The 2nd stage was endovascular by the femoral route; with release of an aortic stent graft covering the ostia of all supraortic trunks. The final angiographic check-up showed complete exclusion of the aneurysm in all cases. The immediate postoperative follow-up was straightforward except for the onset of septic shock and death in a patient with an aneurysm ruptured in the left pulmonary branch initially. The mean follow-up was 12 months with a CT scan control which confirms the complete exclusion of the aneurysm and the absence of endoleak.     

Successful treatment of pseudoaneurysms of celiac and superior mesenteric arteries by combined endovascular and surgical approach

Pseudoaneurysm after pancreas resection poses serious complications, including rupture and hemorrhage. Here we report a case of delayed massive hemorrhage from celiac and superior mesenteric arteries, which was successfully treated with a combined endovascular and surgical approach. The patient was a 52-year-old man who presented with pseudoaneurysms of the celiac and superior mesenteric arteries after distal pancreatectomy. Following the detection of sentinel bleeding from the abdominal drain, emergency angiography of the celiac and superior mesenteric arteries revealed stenosis of the celiac artery and pseudoaneurysms in the superior mesenteric artery. We occluded these lesions with a platinum coil, using an interventional radiological technique combined with bypass grafting between the abdominal aorta and the SMA, using the saphenous vein. However, re-bleeding into the abdominal cavity occurred from the proximal SMA pseudoaneurysm. We inserted an endoluminal stent-graft into the abdominal aorta and completed bypass grafting between the aorta and bilateral renal arteries. The hemorrhage ceased and the postoperative course was uneventful. The patient was discharged 34 days after the treatment (149 days after the initial operation). In conclusion, this combined endovascular and surgical approach is feasible and seems appropriate for pseudoaneurysms arising from proximal sites in visceral arteries.     

Combined ascending aortobiiliac bypass and endovascular obliteration in the Bentall procedure for dual aortic aneurysms

Patients with Marfan syndrome who present with a dual aortic aneurysm are not uncommon in clinical practice; however, the management of these patients is a significant challenge. We present a unique case of aortic root aneurysm and challenging infrarenal abdominal aortic aneurysm (AAA) with a short and angulated neck. We performed simultaneous repair using the Bentall procedure and ascending aortobiiliac bypass. Endovascular obliteration of the AAA neck and bilateral common iliac arteries was also performed. The perioperative process was uneventful. Normal functioning of the mechanical valve and complete thrombosis of the AAA sac were confirmed on follow-up computed tomography and echocardiography. This report suggests that combined ascending aortobiiliac bypass and endovascular obliteration with the Bentall procedure for dual aortic aneurysm is a useful surgical strategy for patients with Marfan syndrome. Life-long follow-up and medication ought to be mandatory to prevent incomplete exclusion and bypass occlusion.     

Hybrid treatment for complex aortic problems combining surgery and stenting in the integrated operating theater

OBJECTIVES: Conventional surgical treatment of complex aortic pathologies involving several thoracoabdominal aortic segments necessitates extended incisions or subsequent surgeries, resulting in significant mortality and morbidity rates. The combination of surgery and simultaneous stenting in the operating theater may reduce the surgical trauma. METHODS: A total of nine patients (62 +/- 10 years, range 44-70) underwent a combined surgical and endovascular treatment of thoracic or thoracoabdominal aortic aneurysms or chronic dissection. Five patients were treated with viscero-renal artery translocation followed by transfemoral stenting of the entire thoracoabdominal aorta. Two patients underwent debranching of the supraaortic vessels followed by immediate transfemoral stenting of the aortic arch, and two patients with a history of an ascending aortic aneurysm repair were treated with open surgical debranching of the supraaortic trunks and repair of the ascending aorta and aortic arch with elephant trunk technique. Preoperatively, magnetic resonance imaging was used to check supraaortic and intracranial vessels as well as the completeness of the Circle of Willisi prior to arch stenting and/or supraaortic vessel surgery. Cerebrospinal fluid drainage and induced mild hypertension have been used for one-step thoracoabdominal aortic stenting. RESULTS: Thirty-day mortality rate and incidence of paraplegia was 0%. There was a single reversible perioperative stroke after aortic arch stenting. One patient required temporary renal replacement therapy using continuous arterio-venous hemofiltration. There was one early reoperation at the superior mesenteric artery after viscero-renal translocation. Four type I endoleaks occurred in three patients requiring two interventions. All patients have been discharged to home. CONCLUSION: The innovative combination of simultaneous conventional surgery and stenting reduces the operative burden for patients with complex aortic pathologies involving several segments of the thoracic and thoracoabdominal aorta. Arch debranching and viscero-renal artery translocation may avoid the use of thoracoabdominal incisions, cardiopulmonary bypass techniques, deep hypothermia, and circulatory arrest.     

Endovascular Repair of Innominate Artery True Aneurysm with Extra-Anatomic Revascularization of Right Carotid and Vertebral Arteries — A Case Report

The purpose of this article is to describe the endovascular repair of a large aneurysm of the innominate artery in a patient with a history of chronic renal failure and coronary artery bypass. A 4.5 × 4.8-cm innominate artery aneurysm that extended to the proximal subclavian artery was diagnosed by chest X-ray, computed tomography, computed tomography angiography, and aortic arch angiogram in an 80-year-old man who had problems with his angio access for renal dialysis. Since these aneurysms are potential sources of emboli to the brain, extra-anatomic diversion and revascularization of the right carotid and vertebral arteries were done before endovascular manipulation of the innominate artery. Before discharge, a computed tomography scan showed no evidence of a Type I or major Type II leak. The patient has been doing well as an outpatient. Large innominate artery aneurysms in high-risk patients can be treated successfully by using a combined approach of extra-anatomic revascularization of the right carotid and vertebral artery system, and endovascular repair of the aneurysm. An erratum to this article is available at .     

Endovascular treatment of a thoraco-abdominal aortic aneurysm in case of a specific aortitis

Successful endovascular repair of an aortic aneurysm of the descending thoracic aorta, laying directly cranial of the celiac artery, caused by a spondylodiscitis of the thoracoabdominal spine. While vascular surgeons refused the open resection of the infected aneurysm, endovascular treatment with a stent-graft was performed. Respecting the celiac artery by catheterisation, endovascular treatment was managed without occluding the A. Adamkiewicz. In case of an unknown infection peri- and postoperative treatment was performed of a prolonged antibiotic and corticosteroid therapy. In a follow-up of three months period, there was a complete regression of the inflammatory aneurysm and an improvement of the spondylodiscitis.     

Iatrogenic subclavian artery and aortic dissection with mesenteric ischemia following subclavian artery angioplasty: Endovascular management

Subclavian stenosis affects up to 5% of patients referred for coronary artery bypass grafting. Albeit usually asymptomatic, this condition can cause myocardial ischemia due to a steal phenomenon from the distal subclavian artery when the left internal mammary artery is used as a coronary bypass. We describe a case of proximal subclavian artery angioplasty complicated with aortic dissection and subsequent life‐threatening mesenteric ischemia. For the first time, we illustrate an endovascular approach to both complications consisting in urgent stenting of the celiac trunk and the superior mesenteric artery followed by staged thoracic endovascular aortic repair due to progressive aortic dilatation. © 2015 Wiley Periodicals, Inc.     

Endovascular treatment of aortic aneurysms of the abdominal aorta with covered stents

Abdominal aortic aneurysms are common in the aging population; their surgical treatment is well established and allows good results in specialized centers. Endovascular exclusion of abdominal aortic aneurysms has been shown to be feasible since 1991 and nowadays commercially available bifurcated endografts allow safe exclusion in selected cases. In the last year 22 patients with an aorto-iliac aneurysm received endovascular treatment at our Institution. We included patients with favorable anatomic characteristics (i.e. neck > 15 mm length, and < 28 mm diameter, iliac neck < 12 mm diameter, absence of > 90 degrees iliac or aortic angulation) and, in particular, those with increased surgical risk for systemic pathology (12 patients), or hostile abdomen (9 patients). We employed Vanguard II (Boston Scientific) endovascular grafts introduced through a surgically exposed common femoral artery; the contralateral limb of bifurcated grafts was inserted percutaneously. The endograft was successfully implanted in all cases, requiring additional iliac cuffs for complete aneurysm exclusion in 3 cases. Periprocedural morbidity included one case of thrombosis and one case of pseudoaneurysm of the punctured femoral artery, which required surgical treatment. In one case surgical exposure of the iliac artery was required in order to advance the device into the aorta. In one patient who previously underwent hemicolectomy, postoperative colonic ischemia was observed, and pharmacological treatment was required. Moreover we also observed one case of groin infection that was treated successfully with local wound care and systemic antibiotics, and one late contralateral limb thrombosis that was successfully treated with loco-regional thrombolysis. The mean follow-up was 6.1 months: one patient died because of congestive heart failure. No further morbidity was recorded. A type-II endoleak was observed in one patient, originating from the inferior mesenteric artery with no sac enlargement; this patient is still under observation. In conclusion, with proper clinical selection, commercially available endovascular devices allow safe exclusion of abdominal aortic aneurysms. Long-term follow-up is needed to ascertain the durability of the procedure.     

Combined endovascular stent-graft repair and adjunctive visceral vessel reconstruction for complex thoracoabdominal aortic aneurysms.

AIM: This study demonstrates the therapeutic value of the hybrid open and endovascular procedure in anatomically challenging thoracoabdominal aortic aneurysms (TAAAs) in high-risk patients. METHODS: Between January 2000 and February 2006, 8 patients were treated with open visceral vessel revascularization and endovascular repair for TAAAs. Patient data were available from medical records. Pre- and postoperative physical examination, intra-arterial angiography, and spiral computed tomography scanning was performed in prearranged examinations. RESULTS: A total of 28 visceral bypasses were performed in the 8 patients: 6 patients with complete visceral vessel revascularization and 2 with an aorto-mesenteric-celiac bypass. Aneurysm exclusion was achieved through the deployment of in total 23 stent-grafts. Seven out of the 8 procedures were conducted electively and one under urgent conditions. The mean follow-up period was 21 months. We recorded one procedure-related death due to postoperative hemorrhage resulting from diffuse retroperitoneal bleeding with consecutive multiorgan failure. Moreover, one patient developed acute renal insufficiency, but returned to normal values after temporary hemodialysis. Major adverse events included 2 cases of pneumonia and one myocardial infarction. Two reoperations were performed due to one mesenteric bypass occlusion and one groin hematoma. No neurological complications were observed. CONCLUSION: The combined hybrid endovascular and open surgical approach in the treatment of complex TAAAs remains a feasible and effective operation technique. The less invasive character of the procedure and avoidance of aortic-cross clamping are clear advantages. Nevertheless, further study is mandatory to establish this alternative therapeutic option for complex TAAAs.