Superior nationwide outcomes of endovascular versus open repair for isolated descending thoracic aortic aneurysm in 11,669 patients

Anterolateral thoracotomy with partial sternotomy: a feasible approach for treating the complex pathology of the aortic arch

OBJECTIVES

Our goal was to review our surgical experiences in patients with complex pathologies of the aortic arch who have undergone anterolateral thoracotomy with a partial sternotomy (ALPS).

METHODS

From October 2019 to November 2023, a total of 23 patients underwent one-stage repairs of complex pathologies of the aortic arch through the ALPS approach. The mean age was 61.9 ± 16.7 years old. The aortic pathologies were as follows: aorta-related infection in 11 (aorto-oesophageal fistula: 4, graft infection: 6, native aortic infection: 1); aortic dissection in 9 including shaggy aorta in 2, non-dissecting aneurysm in 1, and coarctation of the aorta (CoA) in 2.

RESULTS

Eighteen patients underwent aortic replacement from either the sinotubular junction or the ascending aorta to the descending aorta; 1 patient underwent it from the aortic root to the descending aorta (redo Bentall procedure and extensive aortic arch replacement); 3 patients underwent it from the aortic arch between the left carotid artery and left subclavian artery to the descending aorta; and 1 patient underwent a descending aortic replacement. Ten patients underwent omentopexy, latissimus dorsi muscle flap installation or both procedures. The hospital mortality rate was 13.0% (3/23). The overall survival and freedom from aortic events were 73.3%±10.2% and 74.1%±10.2%, respectively, at the 3-year follow-up. There was an absence of aorta-related deaths, and no recurrent infections were identified.

CONCLUSIONS

The short-term outcomes using the ALPS approach for the treatment of complex pathologies of the aortic arch were acceptable. Further studies will be required to determine the long-term results.

The Call for the "Interventional/Hybrid" Aortic Surgeon: Open, Endovascular, and Hybrid Therapies of the Aortic Arch

Aortic arch pathology is relatively rare but potentially highly fatal and associated with considerable comorbidity. Operative mortality and complication rates have improved over time but remain high. In response, aortic arch surgery is one of the most rapidly evolving areas of cardiac surgery in terms of surgical volume and improved outcomes. Moreover, there has been a surge in novel devices and techniques, many of which have been developed by or codeveloped with vascular surgeons and interventional radiologists. Nevertheless, the extent of arch surgery, the choice of nadir temperature, cannulation, and perfusion strategies, and the use of open, endovascular, or hybrid options vary according to country, centre, and surgeon. In this review article, we provide a technical overview of the surgical, total endovascular, and hybrid repair options for aortic arch pathology through historical developments and contemporary results. We highlight key information for surgeons, cardiologists, and trainees to understand the management of patients with aortic arch pathology. We conclude by discussing training paradigms, the role of aortic teams, and gaps in knowledge, arguing for the need for wire skills for the future "interventional aortic surgeon" and increased research into techniques and novel devices to continue improving outcomes for aortic arch surgery.

Midterm outcomes of open repair versus endovascular descending thoracic aortic aneurysm repair

Objective

The study objective was to evaluate the midterm outcome of thoracic endovascular aortic repair compared with open repair in patients with descending thoracic aortic aneurysm.

Methods

From August 1993 to February 2023, 499 patients with descending thoracic aortic aneurysms underwent open repair (n = 221) or thoracic endovascular aortic repair (n = 278). Of these, 120 matched pairs were identified using propensity score matching based on age, sex, chronic lung disease, stroke, coronary artery disease, diabetes, ejection fraction, dialysis, peripheral vascular disease, prior cardiac surgery, connective tissue disease, and chronic dissection. Primary outcomes were postoperative paralysis, operative mortality, reoperation, and midterm survival.

Results

After matching, the preoperative demographics and comorbidities were balanced in both groups. Intraoperatively, open repair had a lower temperature (18 °C vs 36 °C) and more patients required blood products (66% vs 8%), P < .001. Postoperatively, patients undergoing thoracic endovascular aortic repair had fewer strokes (2.5% vs 9.2%; P = .03), less dialysis (0% vs 3.3%; P = .04), and shorter length of stay (5 days vs 12 days, P < .001), but similar lower-extremity paralysis (2.5% vs 2.5%, P = 1.00) compared with open repair. Furthermore, thoracic endovascular aortic repair had higher 7-year incidence of first reoperation (16.1% vs 3.6%, P < .001) but similar operative mortality (0.8% vs 4.2%; P = .10) and 10-year survival outcome (56%; 95% CI, 43-72 vs 58%; 95% CI, 49-68; P = .55) compared with open aortic repair. The hazard ratio was 0.93 (P = .78) for thoracic endovascular aortic repair for midterm mortality and 6.87 (P < .001) for reoperation.

Conclusions

Open repair could be the first option for patients with descending thoracic aortic aneurysms who were surgical candidates.

Anatomic Utility of Single Branched Thoracic Endograft During Thoracic Endovascular Aortic Repair

INTRODUCTION

Single branched thoracic endografts (SBTEs) have been designed for pathology requiring zone 2 seal during thoracic endovascular aortic repair (TEVAR). Numerous criteria must be met to allow for their implantation. Our aim was to analyze anatomic suitability for a next generation SBTE.

METHODS

We reviewed 150 TEVAR procedures between 2015 and 2019. Proximal seal was: zone 0 in 21 (16%), zone 1 in 4 (3%), zone 2 in 52 (40%), zone 3 in 45 (35%), and zone 4 or distal in 7 (5%). We analyzed the Zone 2 patient's angiograms and CT angiograms using centerline software to measure arterial diameters and length in relation to the left common carotid artery (LCCA), left subclavian artery (LSA) and proximal extent of aortic disease to determine if patients met anatomic criteria of a novel SBTE.

RESULTS

Zone 2 average age was 64.4 ± 16.3 years; 34 patients were male (65%). Indications for repair were aneurysm (N = 9, 17%), acute dissection (N = 14, 27%), chronic dissection with aneurysmal degeneration (N = 7, 13%), intramural hematoma (N = 9, 17%), penetrating aortic ulcer (N = 5, 10%), and blunt traumatic aortic injury (BTAI, N = 8, 15%). LSA revascularization occurred in 27 patients (52%). Overall, 20 (38.5%) of the zone 2 patients met anatomic criteria. Patients with dissection met anatomic criteria less frequently than aneurysm (33% [10 of 30] vs 64% [9 of 14]). Patients treated for BTAI rarely met the anatomic criteria (1 of 8, 13%). The main anatomic constraints were an inadequate distance from the LCCA to the LSA takeoff and from the LCCA to the start of the aortic disease process.

CONCLUSION

Less than half of patients who require seal in zone 2 met criteria for this SBTE. Patients with aneurysms met anatomic criteria more often than those with dissection. The device would have little applicability in treating patients with BTAI.

Association of Thoracic Aortic Aneurysm Versus Aortic Dissection on Outcomes After Thoracic Endovascular Aortic Repair

Background Because thoracic endovascular aortic repair (TEVAR) has become the standard of care for complicated type B aortic dissection (TBAD) and descending thoracic aortic (DTA) aneurysm, it is important to understand outcomes and use of TEVAR across thoracic aortic pathologies. Methods and Results This was an observational study of patients with TBAD or DTA undergoing TEVAR from 2010 to 2018, using the Nationwide Readmissions Database. In-hospital mortality, postoperative complications, admission costs, and 30- and 90-day readmissions were compared between the groups. Mixed model logistic regression was used to identify variables associated with mortality. An estimated total of 12 824 patients underwent TEVAR nationally, of which 6043 had an indication of TBAD and 6781 of DTA. Patients with aneurysms were more likely to be older, women, have cardiovascular disease, and have chronic pulmonary disease compared with patients with TBAD. Weighted in-hospital mortality was higher for TBAD (8% [1054/12 711] versus 3% [433/14 407], P<0.001), compared with DTA, as were all postoperative complications. Patients with TBAD had a higher cost of care during their index admission (57.3 versus 38.8 × $1000, P<0.001), compared with DTA. The 30-day and 90-day weighted readmissions were more frequent for the TBAD group compared with DTA (20% [1867/12 711] and 30% [2924/12 711] versus 15% [1603/14 407] and 25% [2695/14 407], respectively, P<0.001). On multivariable adjustment, TBAD was independently associated with mortality (odds ratio, 2.06 [95% CI, 1.68-2.52]; P<0.001). Conclusions After TEVAR, patients who presented with TBAD had higher rates of postoperative complications, in-hospital mortality, and cost compared with DTA. The incidence of early readmission was substantial for patients undergoing TEVAR, faring worse for those undergoing TEVAR for TBAD as compared with DTA.

Anesthetic Management for Endovascular Repair of Thoracic and Abdominal Aortic Aneurysms

Aortic aneurysms-both abdominal and thoracic-are a significant cause of death and disability in the United States. Endovascular aneurysm repair has since become the preferred operative treatment of most thoracic and abdominal aneurysms because of a lower rate of complications and better outcomes compared with the open approach. Patients who present for endovascular aneurysm repair often have comorbid conditions related to their aortic pathology. These conditions should be evaluated and optimized before the procedure.

Safety of Cerebrospinal Fluid Drainage for Spinal Cord Ischemia Prevention in Thoracic Endovascular Aortic Repair

Objective

Spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) is associated with permanent neurologic deficit and decreased survival. Prophylactic cerebrospinal fluid (CSF) drainage (CSFD) in TEVAR is controversial. We evaluated the usage of CSFD in TEVAR at our tertiary aortic center.

Methods

Our institutional TEVAR database was reviewed to determine the frequency of CSFD usage/complications. Complications were categorized as mild (headache/CSF leak not requiring intervention, urinary retention), moderate (headache/CSF leak requiring intervention, drain malfunction requiring replacement), or severe (intrathecal hemorrhage, CSFD-attributable neurologic deficit). The relationships between CSFD complications and patient/procedural characteristics, CSFD placement timing, and survival were analyzed.

Results

Nine hundred thirty-six TEVAR procedures were performed in 869 patients from 2011 to 2020. Three hundred ninety CSFD drains were placed in 373 (41.7%) TEVAR patients. Most CSFD drains (89.5%) were pre-TEVAR. Most post-TEVAR drains were placed for new SCI symptoms (n = 21). Twenty-five patients (6.4%) suffered 32 CSFD complications. Most (n = 17) were mild in severity. Severe CSFD complications occurred in 5/432 (1.1% CSF drains) patients. No patient/procedural characteristics were predictive of CSFD complications. Post implant CSFD placement for new SCI symptoms conferred an increased risk of CSFD complication (odds ratio, 6.9; 95% CI, 2.42-19.6; P < .01). The long-term survival of the CSFD complication cohort did not differ from the overall population.

Conclusions

Post-TEVAR CSFD placement for new SCI symptoms was associated with substantially greater risk of CSFD complications. Avoidance of post-implant therapeutic drain placement might be the key to prevention of CSFD complications, favoring a strategy of selective pre-implant drain placement in patients at higher risk for SCI.

Thoracic endovascular aortic repair with a right thoracotomy approach

BACKGROUND

The common femoral artery is usually the preferred access route for thoracic endovascular aortic repair (TEVAR). However, if access from the common femoral artery is challenging, other routes must be considered. We report a case of TEVAR performed by approaching the descending thoracic aorta with a right thoracotomy and using the descending thoracic aorta as an access route.

CASE PRESENTATION

A 70-year-old female was diagnosed with a descending thoracic aortic aneurysm (65 mm in diameter), a thoracoabdominal aneurysm (54 mm in diameter), and an abdominal aortic aneurysm (49 mm in diameter). Since the patient had severe chronic obstructive pulmonary disease, one-stage replacement of the thoracoabdominal aortic aneurysm was contraindicated and TEVAR on the descending aorta was selected. A strong tortuous section of the aorta-from the descending aorta to the abdominal aorta-hampered endovascular access to the site from the common femoral artery. A TEVAR approach from the abdominal aorta was also considered; however, an abdominal aortic aneurysm and a transverse colon loop stoma from an earlier surgery presented challenges to this technique. We chose to access the descending thoracic aorta with a thoracotomy from the right 6th intercostal space for TEVAR, because the access route that is not affected by the meandering of the aorta is considered to be the descending aorta with a right thoracotomy. The patient's postoperative course was uneventful after the stent graft was placed. No complications were detected with postoperative contrast-enhanced computed tomography (CT).

CONCLUSIONS

Our findings suggest that TEVAR can be performed by approaching the descending aorta from a right thoracotomy, if variations of vascular anatomy interfere with the more commonly used femoral artery approach.

Endovascular stent grafting and open surgical replacement for chronic thoracic aortic aneurysms: a systematic review and prospective cohort study

Background

The management of chronic thoracic aortic aneurysms includes conservative management, watchful waiting, endovascular stent grafting and open surgical replacement. The Effective Treatments for Thoracic Aortic Aneurysms (ETTAA) study investigates timing and intervention choice.

Objective

To describe pre- and post-intervention management of and outcomes for chronic thoracic aortic aneurysms.

Design

A systematic review of intervention effects; a Delphi study of 360 case scenarios based on aneurysm size, location, age, operative risk and connective tissue disorders; and a prospective cohort study of growth, clinical outcomes, costs and quality of life.

Setting

Thirty NHS vascular/cardiothoracic units.

Participants

Patients aged > 17 years who had existing or new aneurysms of ≥ 4 cm in diameter in the arch, descending or thoracoabdominal aorta.

Interventions

Endovascular stent grafting and open surgical replacement.

Main outcomes

Pre-intervention aneurysm growth, pre-/post-intervention survival, clinical events, readmissions and quality of life; and descriptive statistics for costs and quality-adjusted life-years over 12 months and value of information using a propensity score-matched subsample.

Results

The review identified five comparative cohort studies (endovascular stent grafting patients, n = 3955; open surgical replacement patients, n = 21,197). Pooled short-term all-cause mortality favoured endovascular stent grafting (odds ratio 0.71, 95% confidence interval 0.51 to 0.98; no heterogeneity). Data on survival beyond 30 days were mixed. Fewer short-term complications were reported with endovascular stent grafting. The Delphi study included 20 experts (13 centres). For patients with aneurysms of ≤ 6.0 cm in diameter, watchful waiting was preferred. For patients with aneurysms of > 6.0 cm, open surgical replacement was preferred in the arch, except for elderly or high-risk patients, and in the descending aorta if patients had connective tissue disorders. Otherwise endovascular stent grafting was preferred. Between 2014 and 2018, 886 patients were recruited (watchful waiting, n = 489; conservative management, n = 112; endovascular stent grafting, n = 150; open surgical replacement, n = 135). Pre-intervention death rate was 8.6% per patient-year; 49.6% of deaths were aneurysm related. Death rates were higher for women (hazard ratio 1.79, 95% confidence interval 1.25 to 2.57; p = 0.001) and older patients (age 61–70 years: hazard ratio 2.50, 95% confidence interval 0.76 to 5.43; age 71–80 years: hazard ratio 3.49, 95% confidence interval 1.26 to 9.66; age > 80 years: hazard ratio 7.01, 95% confidence interval 2.50 to 19.62; all compared with age < 60 years, p < 0.001) and per 1-cm increase in diameter (hazard ratio 1.90, 95% confidence interval 1.65 to 2.18; p = 0.001). The results were similar for aneurysm-related deaths. Decline per year in quality of life was greater for older patients (additional change –0.013 per decade increase in age, 95% confidence interval –0.019 to –0.007; p < 0.001) and smokers (additional change for ex-smokers compared with non-smokers 0.003, 95% confidence interval –0.026 to 0.032; additional change for current smokers compared with non-smokers –0.034, 95% confidence interval –0.057 to –0.01; p = 0.004). At the time of intervention, endovascular stent grafting patients were older (age difference 7.1 years; 95% confidence interval 4.7 to 9.5 years; p < 0.001) and more likely to be smokers (75.8% vs. 66.4%; p = 0.080), have valve disease (89.9% vs. 71.6%; p < 0.0001), have chronic obstructive pulmonary disease (21.3% vs. 13.3%; p = 0.087), be at New York Heart Association stage III/IV (22.3% vs. 16.0%; p = 0.217), have lower levels of haemoglobin (difference –6.8 g/l, 95% confidence interval –11.2 to –2.4 g/l; p = 0.003) and take statins (69.3% vs. 42.2%; p < 0.0001). Ten (6.7%) endovascular stent grafting and 15 (11.1%) open surgical replacement patients died within 30 days of the procedure (p = 0.2107). One-year overall survival was 82.5% (95% confidence interval 75.2% to 87.8%) after endovascular stent grafting and 79.3% (95% confidence interval 71.1% to 85.4%) after open surgical replacement. Variables affecting survival were aneurysm site, age, New York Heart Association stage and time waiting for procedure. For endovascular stent grafting, utility decreased slightly, by –0.017 (95% confidence interval –0.062 to 0.027), in the first 6 weeks. For open surgical replacement, there was a substantial decrease of –0.160 (95% confidence interval –0.199 to –0.121; p < 0.001) up to 6 weeks after the procedure. Over 12 months endovascular stent grafting was less costly, with higher quality-adjusted life-years. Formal economic analysis was unfeasible.

Limitations

The study was limited by small numbers of patients receiving interventions and because only 53% of patients were suitable for both interventions.

Conclusions

Small (4–6 cm) aneurysms require close observation. Larger (> 6 cm) aneurysms require intervention without delay. Endovascular stent grafting and open surgical replacement were successful for carefully selected patients, but cost comparisons were unfeasible. The choice of intervention is well established, but the timing of intervention remains challenging.

Future work

Further research should include an analysis of the risk factors for growth/rupture and long-term outcomes.

Trial registration

Current Controlled Trials ISRCTN04044627 and NCT02010892.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 6. See the NIHR Journals Library website for further project information.

Sheath-Anchoring for Rail Guidewire Technique to Advance and Deploy Thoracic Endograft in Hostile Anatomy

BACKGROUND

To describe a bailout technique to advance and precisely deploy thoracic endograft in the ascending aorta in case of difficulty crossing the aortic arch.

CASE REPORTS

A 73-year-old man presented with a large ruptured aneurysms in the descending aorta. During the TEVAR, stent-graft passage through the aortic arch was impossible due to the severe tortuosity of the aorta. The problem has been resolved using the sheath-anchoring rail guidewire (SARG) technique.

RESULTS

Through an axillary access, a snare was used to capture the stiff wire from the femoral access. A sheath was advanced over the stiff wire to the ascending aorta and placed there. By exploiting the grip of the sheath on the stiff in the ascending aorta, it was possible to handle the tension, move the delivery system through the arch and carefully deploy the graft.

CONCLUSION

The SARG is a simple and quick learning technique which can be useful for Physicians dealing with complex aortic arch anatomy.

The Effect of Intravenous and Oral Beta-Blocker Use in Patients with Type B Thoracic Aortic Dissection

BACKGROUND

Beta-blockers have become the cornerstone for medical management in patients with chronic type B aortic dissection (TBAD). However, the effect of being on and/or receiving intravenous beta-blockers during hospitalization on outcomes of surgical repair of TBAD is not fully described. We sought to investigate this association during open surgical repair (OSR) and endovascular (Endo) intervention for nontraumatic TBAD.

METHODS

The Premier Healthcare Database was inquired (June/2009-March/2015). Patients with nontraumatic isolated TBAD were identified via ICD-9-CM diagnosis and procedural codes. Patients with codes that indicated TAAD were excluded. In-hospital mortality, cardiac complications (CHF, MI, arrythmia) and stroke were evaluated. Log binomial regression analyses with bootstrapping were performed to assess the relative risk of adverse outcomes.

RESULTS

A total of 1,752 were admitted for OSR (54.3%) and Endo (45.7%) TBAD repair. Use of oral beta blocker (BB) was 16.0% in OSR and 56.4% in Endo groups. In each arm, patients on BB were more likely to be diabetic, on aspirin or statin and more likely to receive additional IV BB than nonBB patients. There was no significant difference in age, sex, race, or prior history of CHF between BB and nonBB groups. Mortality was proportionally lower in patients on BB in OSR group (7.9% vs. 16.7%; P = 0.006) and Endo (3.3% vs. 9.2%; P < 0.001). The adjusted relative risk for mortality and stroke were significantly lower in oral BB recipients compared with none [aRR (95% CI): 0.53 (0.32-0.90) and 0.46 (0.25-0.87); both P ≤ 0.02]. IV metoprolol was the only IV BB that reduced mortality [aRR (95% CI): 0.62 (0.46-0.85); P = 0.003]. A dose of ≤10 mg was associated with significant mortality reduction: 6.3% (3.0-9.5%) compared with 8.1% (4.6-11.6%) in no IV BB group. Cardiac complications were not affected by BB use.

CONCLUSIONS

For patients with nontraumatic TBAD, use of oral BB was associated with significant protection against in-hospital mortality and stroke following repair. Metoprolol was the only Intravenous BB type associated with improved survival. Further research is warranted to elucidate the effect of beta-blockers on the long-term surgical outcomes of TBAD.

Endovascular repair of descending thoracic aortic aneurysms-a mid-term report from the Global Registry for Endovascular Aortic Treatment (GREAT)

OBJECTIVES

The aim of this study was to evaluate the short- to mid-term outcomes of descending thoracic aortic aneurysm (DTAA) repair from the Gore Global Registry for Endovascular Aortic Treatment (GREAT).

METHODS

This is a multicentre sponsored prospective observational cohort registry. The study population comprised those treated for DTAA receiving GORE thoracic aortic devices for DTAA repair between August 2010 and October 2016. Major primary outcomes were early and late survival, freedom from aorta-related mortality and freedom from aorta-related reintervention.

RESULTS

There were 180 (58.1%) males and 130 (41.9%) females: the mean age was 70 ± 11 years (range 18-92). The median maximum DTAA diameter was 60 mm (interquartile range 54-68.8). Technical success was achieved in all patients. Operative mortality, as well as immediate conversion to open repair, was never observed. At the 30-day window, mortality occurred in 4 (1.3%) patients, neurological events occurred in 4 (1.3%) patients (transient ischaemic attacks/stroke n = 3, paraplegia n = 1) and the reintervention rate was 4.5% (n = 14). Estimated survival was 95.6% [95% confidence interval (CI) 92.6-97.4] at 6 months, 92.7% (95% CI 89.1-95.2) at 1 year and 57.3% (95% CI 48.5-65.1) at 5 years. Freedom from aorta-related mortality was 98.3% (95% CI 96.1-99.3) at 6 months, 98.3% (95% CI 96.1-99.3) at 1 year and 92.2% (95% CI 83.4-96.4) at 5 years. Freedom from thoracic endovascular aortic repair (TEVAR)-related reintervention at 5 years was 87.2% (95% CI 81.2-91.4).

CONCLUSIONS

TEVAR for DTAAs using GORE thoracic aortic devices is associated with a low rate of device-related reinterventions and is effective at preventing aorta-related mortality for up to 5 years of follow-up.

CLINICAL REGISTRATION NUMBER

NCT number: NCT01658787.

SUBJECT COLLECTION

161, 164.

Effectiveness of endovascular versus open surgical repair for thoracic aortic aneurysm: a systematic review and meta-analysis

INTRODUCTION

Since the approval, the TEVAR is widely used for the repair of thoracic aortic aneurysm. However, the long-term mortality and re-intervention rates compared to OSR are unclear. We aimed to compare the effectiveness of the thoracic endovascular aortic repair (TEVAR) with open surgical repair (OSR) specifically for thoracic aortic aneurysms.

EVIDENCE ACQUISITION

We conducted a comprehensive search in MEDLINE, PubMed, EMBASE, CINAHL, PROSPERO, Centre for Reviews and Dissemination, and the Cochrane Library up to November 2020. The main outcomes were early mortality, mid-to-long-term survival, and re-intervention. The quality of the evidence was assessed using the GRADE methodology. All analyses were performed using RevMan with the random effect model and Comprehensive Meta-Analysis software.

EVIDENCE SYNTHESIS

One systematic review and 15 individual studies were included. Pooled analysis showed that 30-day mortality, stroke, renal failure, and pulmonary complications were significantly lower in TEVAR vs. open surgery. The pooled rate of re-intervention significantly favored the OSR. The long-term survival and mortality favored TEVAR and OSR in one and two studies, respectively, but was non-significant in 7 analyzes.

CONCLUSIONS

Early clinical outcomes including the 30-day mortality, stroke, renal failure, and pulmonary complications significantly favored the TEVAR. However, the mid-to-long-term re-intervention rate favored the OSR and long-term survival was inconsistent among the studies. The quality of evidence was very low. More studies with longer follow-ups are needed. The use of TEVAR should be decided by taking into account other factors including patient characteristics and preferences, cost, and surgeon expertise.

Laser-assisted "Scissor" Technique to Facilitate Thoracic Endovascular Aortic Repair for Chronic Type B Aortic Dissection

INTRODUCTION

There has been an increase in utilization of thoracic endovascular aortic repair (TEVAR) to treat aneurysms with chronic dissection. Despite significant progress, TEVAR is hindered by persistent perfusion of the false lumen and aneurysm growth. Various techniques to address false lumen perfusion exist. We preset our experience of laser fenestration with disruption of the dissection flap to facilitate TEVAR and avoid persistent retrograde false lumen perfusion.

METHODS

Review a technique to treat patients with thoracic aortic aneurysm complicated by chronic dissection. This is an adjunct to a TEVAR procedure with final goal to treat the aneurysm and avoid retrograde false lumen perfusion. Under IVUS guidance, we performed a Phillips/Spectranetics laser fenestration of the intimal flap followed by a scissoring technique to obliterate the dissection flap and create a distal seal zone. Stent-grafts placed following flap obliteration allow graft expansion and apposition to the entire outer aortic and avoid retrograde perfusion of the false lumen.

RESULTS

Two patients underwent TEVAR in conjunction with laser obliteration of the dissection flap, including one undergoing primary repair of a chronic Type B dissection with aneurysm, and one as a completion second stage elephant trunk procedure. Technical success was achieved in both cases, with successful implantation of the endograft, and freedom from type I and III endoleaks. Absence of false lumen flow, and patency of the visceral vessels was confirmed on completion angiography. True lumen patency and obliteration of the intimal flap were confirmed by IVUS. Early follow up confirms exclusion of the aneurysm, with no evidence of retrograde perfusion of the false lumen.

CONCLUSIONS

Thoracic aortic aneurysms in the context of chronic dissections can be successfully treated with TEVAR and laser obliteration of the chronic dissection flap to fully exclude the aneurysm and avoid retrograde false lumen perfusion.

Predictors of 30-day readmission and resource utilization after thoracic endovascular aortic repair

OBJECTIVES

The introduction and expansion of thoracic endovascular aortic repair (TEVAR) have revolutionized the treatment of a variety of thoracic aortic diseases. We sought to evaluate the incidence, causes, predictors and costs associated with 30-day readmission after TEVAR in a nationally representative cohort.

METHODS

Adult patients undergoing isolated TEVAR were identified in the National Readmissions Database from 2010 to 2014. Hospital costs were estimated by converting individual hospital charge data adjusted to 2014 consumer price indices. Multivariable logistic regression was utilized to determine hospital- and patient-level factors associated with readmissions.

RESULTS

A total of 24 983 TEVARs were noted during the study period; the average age of the patients was 65 ± 16 years; 40% were women. The most common indication was an intact thoracic aneurysm (43.5%), followed by aortic dissection (30.5%). The average cost of the index admission was $63 644 ± $52 312; the average hospital stay was 11 ± 14 days; the index mortality rate was 6.7%. Readmissions within 30 days occurred in 17.4% of patients. Indications for readmission were varied; the most common aetiologies were cardiac (17.8%), infectious (16.0%) and pulmonary (12.1%). On multivariable analysis, the strongest predictor of readmission was the diagnosis, with a ruptured thoraco-abdominal aneurysm having the highest readmission burden (adjusted odds ratio 2.23, 1.17-4.24; P = 0.015). Notably, hospital volume did not predict index hospital length of stay, costs or 30-day readmissions (all P > 0.10).

CONCLUSIONS

Annual TEVAR volume was not associated with any of the outcomes assessed. Rather, indication for TEVAR was the strongest predictor for many outcomes. As TEVAR becomes increasingly utilized, a focus on cardiac and vascular diseases may reduce readmissions and improve quality of care.

Outcomes of Open v. Endovascular Repair of Descending Thoracic and Thoracoabdominal Aortic Aneurysms

BACKGROUND

Open repair is the standard of care for patients with descending thoracic and thoracoabdominal aortic aneurysms. Although effective, surgery carries a high risk of morbidity and mortality. Endovascular stent-grafts were introduced to treat these aneurysms in patients considered too high risk for open repair. Early results are promising, but later results are incompletely known. Therefore, we sought to compare short- and intermediate-term outcomes of open versus endovascular repair for these aneurysms.

METHODS

From 2000-2010, 1,053 patients underwent open (n=457) or endovascular (n=596) repair of descending thoracic and thoracoabdominal aortic aneurysms at Cleveland Clinic. To balance patient characteristics between these groups, propensity-score matching was performed, yielding 278 well-matched pairs (61% of possible pairs). Endpoints included short- and long-term outcomes.

RESULTS

In matched patients, compared with endovascular stenting, open repair achieved similar in-hospital mortality (n=23/8.3% vs n=21/7.6%, P=.8) and occurrence of paralysis and stroke (n=10/3.6% vs n=6/2.2%, P=.3), despite longer postoperative stay (median 11 vs 6 days), more dialysis-dependent acute renal failure (n=24/8.6% vs n=9/3.3%, P=.008), and prolonged ventilation (n=106/46% vs n=17/6.3%, P<.0001). Open repair resulted in better 10-year survival than endovascular repair (52% vs 33%, P<.0001), and aortic reintervention was less frequent (4% vs 21%, P<.0001). Despite a decrease in the first postoperative year, average aneurysm size did not recover to normal range after endovascular stenting.

CONCLUSIONS

Open repair of descending thoracic and thoracoabdominal aneurysms can achieve acceptable short-term outcomes with better intermediate-term outcomes than endovascular repair.

Drag Forces after Thoracic Endovascular Aortic Repair. General Review of the Literature

BACKGROUND

Despite the great evolution of endograft devices for thoracic endovascular aortic repair (TEVAR), threatening related complication such as graft migration and endoleaks still occur during follow up. The Drag Forces (DF), that is the displacement forces that play a role in graft migration and endoleaks caused by the blood flow against the thoracic graft, can be studied by means of Computational Fluid Dynamics (CFD).

METHOD

A general review of papers found in current literature was performed. CFD studies available on the topic of thoracic aortic diseases and DF were analyzed. All anatomic, hemodynamics or graft related factors which could have an impact on DF were reported.

RESULTS

Different factors deeply influence DF magnitude in the different site of the Ishimaru's zones classification: angulation, tortuosity and length of the landing zone, graft diameter, length and deployment position, blood pressure, pulse waveform, blood viscosity and patient heart rate have been related to the magnitude of DF. Moreover, also the three-dimensional orientation of DF is emerging as a fundamental issue from CFD studies. DF can be divided in sideways and upward components. The former, even of higher magnitude in zone 0, maintain always an orthogonal orientation and does not change in any type of aortic arch; the latter result strictly related to the anatomic complexity of the aortic arch with values up to four times higher in zone 3.

CONCLUSION

Different DF magnitude and orientation could explain how TEVAR have higher rate of migration and endoleaks when we face with more complex aortic anatomies. All these aspects should be foreseen during the planning of TEVAR procedure. In this field, collaboration between physicians and engineers is crucial, as both parts have a primary role in understanding and describing hidden aspects involved in TEVAR procedures.

Hospitalization Cost and In-hospital Outcomes Following Type B Thoracic Aortic Dissection Repair

BACKGROUND

Several studies have reported lower mortality and morbidity after thoracic endovascular aortic repair (TEVAR) when compared to open surgical repair (OSR) in the treatment of type B aortic dissection (TbAD). However, there are few studies in the literature on the cost of both treatment options. Thus, the aim of this study is to focus on in-hospital outcomes and cost associated with TbAD repair procedures in a national database in the United States.

METHODS

A retrospective review of the Premier Healthcare Database (PHD) between June 2009 and March 2015 was performed. ICD-9-CM codes were used to identify patients who underwent OSR or TEVAR for TbAD. Endpoints included in-hospital adverse events, in-hospital mortality and hospitalization cost. Logistic regression models and generalized linear models were used to assess the impact of treatment type on the main outcomes.

RESULTS

Out of 1752 patients with TbAD, 54.3% underwent OSR and 45.7% underwent TEVAR. Patients in the TEVAR group were older [median age, 64 (IQR 54-73) vs. 59 (IQR 49-70), P < 1] and more likely to have preexisting comorbidities. IAE rates were 78.6% for the OSR group compared to 43.1% for the TEVAR group, P < 0.001. Patients in the OSR group showed significantly higher in-hospital mortality (15.3% vs. 5.9%, P < 0.001). After adjusting for potential confounders, OSR was associated with a 5-fold increase in IAE [aOR(95%CI): 4.8 (3.8-6.1), P < 0.001] and a 3-fold increase in in-hospital mortality [aOR(95%CI): 3.3 (2.1-5.1), P < 0.001]. In regards to charges related to the hospital stay, total cost was significantly higher among patients undergoing OSR $53,371 ($39,029-$80,471) vs. TEVAR $45,311 ($31,479-$67,960), P < 0.001.

CONCLUSION

The present study shows that TEVAR presents an advantage in terms of morbidity, mortality and cost when compared to OSR in the treatment of TbAD. However, long-term cost-effectiveness of both procedures remains unknown. Further research is warranted to see whether the superiority of TEVAR is maintained over time.

Splanchnic occlusive disease predicts for spinal cord injury after open descending thoracic and thoracoabdominal aneurysm repair

OBJECTIVE

In the present study, we sought to discern the effects of splanchnic occlusive disease (SOD; renal, superior mesenteric, and/or celiac axis arteries) on spinal cord injury (SCI; paraparesis or paraplegia) and major adverse events (MAE) after descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) open repair.

METHODS

Patients who had undergone DTA/TAAA repair at our institution were dichotomized according to the presence of SOD, which was investigated as a predictive factor of our primary (SCI) and secondary (operative mortality, myocardial infarction, stroke, tracheostomy, de novo dialysis, MAE, survival) endpoints. Risk adjustment used both propensity score matching and multivariable logistic regression.

RESULTS

From July 1997 to October 2019, 888 patients had undergone DTA/TAAA repair, of whom 19 were excluded from our analysis for missing data. SOD was absent in 712 patients and present in 157 patients. The patients with SOD had presented with a greater incidence of preoperative renal impairment (61 [38.9%] vs 175 [24.6%]; P < .01) and peripheral arterial disease (60 [38.2%] vs 162 [22.8%]; P < .01] and decreased left ventricular ejection fraction (45%; interquartile range, 10%; vs 50%; interquartile range, 4%; P < .01). The etiology of aortic disease was more frequently dissection in the SOD group (56.1% vs 43.7%) and more frequently nondissecting aneurysm in the non-SOD group (56.3% vs 43.9%; P < .01). Patients without SOD had presented with aneurysms more cranially located (DTA, 34.0% vs 7.6%; extent I TAAA, 44.0% vs 7.6%). In contrast, patients with SOD had presented with aneurysms more caudally located (extent II TAAA, 36.9% vs 8.6%; extent III TAAA, 30.6% vs 11.0%; extent IV TAAA, 17.2% vs 2.5%; P < .01). Propensity score matching led to 144 pairs, with SOD significantly associated with SCI (10 [6.9%] vs 2 [1.4%]; P = .03) and MAE (47 [32.6%] vs 26 [15%]; P < .01). Ten-year survival was reduced in those with SOD (31.5% vs 45.2%; P < .01). Conditional multivariable regression confirmed SOD to be a predictor of SCI in the matched sample (odds ratio, 6.60; P = .02).

CONCLUSIONS

Our results have shown that SOD is a significant predictor of SCI in patients undergoing open DTA/TAAA repair. The investigation of measures to prolong neuronal ischemia tolerance (eg, hypothermia) is warranted for such patients.

Epidemiology and management of aortic disease: aortic aneurysms and acute aortic syndromes

The aorta is the 'greatest artery', through which oxygenated blood is delivered from the left ventricle to end organs with each cardiac cycle (200 million litres of blood transported in an average lifetime). The aorta can be affected by a wide spectrum of acute factors (such as cocaine use, weight lifting and trauma) and chronic acquired and/or genetic conditions (such as systemic arterial hypertension and phaeochromocytoma), which variously lead to increased aortic wall stress. The medial layer of the aorta can also be subject to abnormalities (such as Marfan syndrome, bicuspid aortic valve, inflammatory vasculitis, atherosclerosis and infections). Despite important advances in diagnostic and therapeutic interventions, data derived from registries and population-based studies highlight that the burden of aortic diseases remains high. Therefore, specific resources need to be allocated to design and implement preventive strategies (healthy lifestyles, modifications to cardiovascular risk factors, and educational and screening programmes) at individual and community levels. In this Review, we discuss the epidemiology, management and outcomes of the most common aortic diseases, namely, aortic aneurysms and acute aortic syndromes.

Black patients have a higher burden of comorbidities but a lower risk of 30-day and 1-year mortality after thoracic endovascular aortic repair

BACKGROUND

Racial disparities in open thoracic aortic aneurysm repair have been well-documented, with Black patients reported to suffer from poor outcomes compared with their White counterparts. It is unclear whether these disparities extend to the less invasive thoracic endovascular aortic repair (TEVAR). This study aims to examine the clinical characteristics, perioperative outcomes, and 1-year survival of Black vs White patients undergoing TEVAR in a national vascular surgery database.

METHODS

The Vascular Quality Initiative database was retrospectively queried to identify all patients who underwent TEVAR between January 2011 and December 2019. The primary outcomes were 30-day mortality and 1-year survival after TEVAR. Secondary outcomes included various types of major postoperative complications. Multivariable logistic regression analyses were performed to identify predictors of 30-day mortality and perioperative complications. Multivariable Cox regression analysis was used to determine the predictors of 1-year survival.

RESULTS

A total of 2669 patients with TEVAR were identified in the Vascular Quality Initiative, of whom 648 were Black patients (24.3%). Compared with White patients, Black patients were younger and had a higher burden of comorbidities, including hypertension, diabetes, congestive heart failure, dialysis dependence, and anemia. Black patients were more likely to be symptomatic, present with aortic dissection, and undergo urgent or emergent repair. There was no statistically significant difference in 30-day mortality between Black and White patients (3.4% vs 4.9%; P = .1). After adjustment for demographics, comorbidities, and operative factors, Black patients were independently associated with a 56% decrease in 30-day mortality risk compared with their White counterparts (odds ratio, 0.44; 95% confidence interval [CI], 0.22-0.85; P = .01) and not associated with an increased risk of perioperative complications (odds ratio, 0.90; 95% CI, 0.68-1.17; P = .42). Black patients also had a significantly better 1-year overall survival (log-rank, P = .024) and were associated with a significantly decreased 1-year mortality (hazard ratio, 0.65; 95% CI, 0.47-0.91; P = .01) after adjusting for multiple clinical factors.

CONCLUSIONS

Although Black patients carried a higher burden of comorbidities, the racial disparities in perioperative outcomes and 1-year survival do not persist in TEVAR.

Complications and Management of the Thoracic Endovascular Aortic Repair

Endovascular treatment in thoracic aortic diseases has increased in use exponentially since Dake and colleagues first described the use of a home-made transluminal endovascular graft on 13 patients with descending thoracic aortic aneurysm at Stanford University in the early 1990s. Thoracic endovascular aneurysm repair (TEVAR) was initially developed for therapy in patients deemed unfit for open surgery. Innovations in endograft engineering design and popularization of endovascular techniques have transformed TEVAR to the predominant treatment choice in elective thoracic aortic repair. The number of TEVARs performed in the United States increased by 600% from 1998 to 2007, while the total number of thoracic aortic repairs increased by 60%. As larger multicenter trials and meta-analysis studies in the 2000s demonstrate the significant decrease in perioperative morbidity and mortality of TEVAR over open repair, TEVAR became incorporated into standard guidelines. The 2010 American consensus guidelines recommend TEVAR to be “strongly considered” when feasible for patients with degenerative or traumatic aneurysms of the descending thoracic aorta exceeding 5.5 cm, saccular aneurysms, or postoperative pseudoaneurysms. Nowadays, TEVAR is the predominant treatment for degenerative and traumatic descending thoracic aortic aneurysm repair. Although TEVAR has been shown to have decreased early morbidity and mortality compared with open surgical repair, endovascular manipulation of a diseased aorta with endovascular devices continues to have significant risks. Despite continued advancement in endovascular technique and devices since the first prospective trial examined the complications associated with TEVAR, common complications, two decades later, still include stroke, spinal cord ischemia, device failure, unintentional great vessel coverage, access site complications, and renal injury. In this article, we review common TEVAR complications with some corresponding radiographic imaging and their management.

Long-term outcomes of intervention between open repair and endovascular aortic repair for descending aortic pathologies: a propensity-matched analysis

BACKGROUND

The long-term complication rates of open repair and thoracic endovascular aortic repair (TEVAR) have not yet been determined. Therefore, this study aimed to compare the long-term outcomes and aortic reintervention rates between open repair and TEVAR in patients with descending thoracic aortic pathologies.

METHODS

Between January 2002 and December 2017, 230 patients with descending thoracic aortic pathologies underwent surgery. Of these, 136 patients were included in this retrospective study: 45 patients (10, 2, and 33 with dissection, penetrating atherosclerotic ulcer, and pseudoaneurysm, respectively) underwent open repair and 91 patients (27, 1, and 63 with dissection, penetrating atherosclerotic ulcer, and pseudoaneurysm, respectively) underwent TEVAR. The primary end points were in-hospital mortality, and short-term complications. The secondary end points were long-term mortality and reintervention rates. Based on the propensity score matching (PSM), 35 patients who underwent open repair were matched to 35 patients who underwent TEVAR (ratio = 1:1).

RESULTS

The mean follow-up period was 70.2 ± 51.9 months. Shorter intensive care unit and hospital stay were seen in the TEVAR group than in the open repair group before and after PSM (p < 0.001 and p < 0.001, respectively). However, in-hospital mortality, and spinal cord ischemia were not significantly different among the two groups (before PSM: p = 0.068 and p = 0.211, respectively; after PSM: p = 0.303 and p = 0.314, respectively). The cumulative all-cause death and aorta-related death showed no significant differences between the two groups (before PSM: p = 0.709 and p = 0.734, respectively; after PSM: p = 0.888 and p = 0.731, respectively). However, aortic reintervention rates were higher in the TEVAR group than in the open repair group before and after PSM (p = 0.006 and p = 0.013, respectively).

CONCLUSION

The TEVAR group was superior in short-term recovery outcomes but had higher reintervention rates compared to the open repair group. However, there were no significant differences in long-term survival between the two groups.

Mid-Term Survival after Thoracic Endovascular Aortic Repair by Indication in the Medicare Population

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) is indicated for treatment of aneurysms, dissections, and traumatic injury. We describe mid-term mortality and reintervention rates in Medicare beneficiaries undergoing TEVAR.

STUDY DESIGN

Patients who underwent TEVAR between 2006 and 2014 were identified by CPT codes in a 20% Medicare sample. Indication for aortic repair (aneurysm, dissection, trauma) was ascertained via ICD-9 codes. Follow-up was evaluated until 2015. Kaplan-Meier survival analysis and Cox regression were used to compare mortality, with reintervention and mortality rates expressed as a composite outcome in a hazard ratio with 95% confidence interval (hazard ratio [HR] 95% CI).

RESULTS

There were 3,095 patients who underwent TEVAR during the study period: 1,465 (47%) for aneurysm, 1,448 (47%) for dissection, and 182 (5.9%) for trauma. Mean patient age was 74.4 years, and 44.5% were female. Median follow-up was 2.7 years. The overall 30-day, 1-year, and 5-year, and 8-year survival rates were 93%, 78%, 49%, and 33%, respectively. Thirty-day mortality was highest in traumatic indications, but overall mortality was highest in patients undergoing TEVAR for aneurysm. Freedom from combined reintervention and mortality at 30 days, 1 year, 5 years, and 8 years was 89%, 73%, 43%, and 29%, respectively. Reintervention was highest in patients undergoing TEVAR for dissection (12.8%), followed by aneurysm (10.0%) and trauma (5.5%). Advanced age (HR 1.03 per year, 95% CI 1.02-1.03), congestive heart failure (CHF) (HR 1.48, 95% CI 1.33-1.65), dementia (HR 1.40, 95% CI 1.14-1.28), and rupture (HR 1.38, 95% CI 1.24-1.54) were associated with mortality.

CONCLUSIONS

Midterm survival is lower in patients who undergo TEVAR for dissection and aneurysm compared with trauma. Aneurysmal disease, advanced age, CHF, dementia, and aortic rupture are associated with mortality and reintervention in TEVAR.

Management of the Left Subclavian Artery in TEVAR for Chronic Type B Aortic Dissection

Objectives:

Left subclavian artery (LSA) revascularization in thoracic endovascular aortic repair (TEVAR) remains controversial. Left subclavian artery coverage without revascularization can cause stroke and death. TEVAR has gained popularity for the treatment of chronic type B aortic dissection (cTBD). Using the Vascular Quality Initiative (VQI) database, we reviewed outcomes of LSA revascularization in TEVAR for cTBD.

Methods:

The VQI registry identified 5683 patients treated with TEVAR from July 2010 to July 2016, including 208 repairs for cTBD. We analyzed outcomes per the Society for Vascular Surgery reporting standards.

Results:

Of the 208 patients, 150 (72.1%) were male with a median age of 65.0 years (interquartile range [IQR], 55.0-72.0). Median aneurysm diameter was 5.7 cm (IQR, 5.0-6.5 cm). Data on the patency of the LSA was available in 131 (63.0%) patients. Twenty-five (19.1%) had occlusion of the LSA without revascularization, while 106 (80.9%) maintained patency or had revascularization. Successful device delivery occurred in all 131 (100%) patients. Maintaining LSA patency did not affect the rate of cerebrovascular accident ( P = .16), spinal cord ischemia ( P = 1.00), or death ( P = 1.00). This was also nonsignificant when analyzing the subgroup of 98 elective cases. There was no difference in the rates of endoleak. Any intervention for the LSA (revascularization or occlusion) led to a longer procedure time (203.6 minutes vs 163.7 minutes, P = .04).

Conclusions:

Maintaining LSA patency during TEVAR for cTBD offers no advantage in perioperative morbidity or endoleak. Occlusion of LSA may be performed safely in this cohort and revascularization reserved for those who have anatomy that compromises perfusion to critical organs.

Early and mid-term results of endovascular treatment of thoracic aorta diseases: a single-center experience

We conducted an analysis to assess early and mid-term outcomes of patients after thoracic endovascular aortic repair (TEVAR) for type B thoracic aorta dissection, descending thoracic aneurysm, or traumatic aortic transection. From January 2016 through December 2018, twenty-seven patients (23 male, 4 female, mean age of 57 years) affected by type B dissection (n = 13 [48.2%]), thoracic aneurysm (n = 9 [33.3%]), and post-traumatic aortic isthmus rupture (n = 5 [18.5%]) were treated using TEVAR with and without left subclavian artery revascularization. All procedures were performed in a hybrid operating room using general (n = 12) or regional (n = 15) anesthesia. A combined brachial artery and bilateral femoral artery access was used in all patients. To achieve adequate proximal thoracic aorta landing zone length, coverage of the left subclavian artery with proximal endovascular plug occlusion was performed in 17 patients (62.9%); including 4 patients undergoing carotid-subclavian artery bypass before TEVAR stent-graft deployment. Primary procedural success rate was 96.3%; 1 patient had a Type Ib endoleak that was treated by distal stent graft extension. Four adverse outcomes occurred in the immediate postoperative period, including 2 cases of left upper arm acute ischemia (7.4%), ischemic stroke (3.7%), and asymptomatic iliac artery dissection (3.7%). During a mean follow-up of 18 months, no graft-related deaths or endoleak occurred. One patient developed symptomatic subclavian steal syndrome 1 month after operation and underwent a left carotid-subclavian artery bypass with symptom resolution. One patient died 6 months after TEVAR due to neoplasm. Our experience indicates TEVAR is a safe and less invasive alternative to open surgery for a spectrum of thoracic aorta diseases, especially for urgent conditions and in patients with high-risk surgical comorbidities.

Endovascular Graft Repair for Blunt Traumatic Disruption of the Thoracic Aorta: Experience at a Nonuniversity Hospital

Blunt thoracic aortic injury (BAI) represents the second leading cause of death from blunt trauma. Admission rates for BAI are extremely low because instant fatality occurs in nearly 75 per cent of patients. Management strategies have transitioned from the more invasive immediate thoracotomy to delayed endograft repair with strict hemodynamic management. In this study, we assess outcomes and complications of open versus endograft repair for BAI at a nonuniversity hospital. Retrospective chart review was conducted on 49 patients admitted to a Level I trauma center who incurred BAI from 2004 to 2011. Collected data points included demographics, mortality, complication rates, and intensive care unit and hospital length of stay (LOS). Twenty-one patients underwent open thoracotomy (OPEN), whereas 28 patients were managed with thoracic endovascular aortic repair (TEVAR). The overall 30-day mortality rate was significantly lower comparing TEVAR to OPEN (7.1 vs 50%, P = 0.028); seven deaths occurred in the OPEN group versus two with TEVAR. Overall complications, including mortality, acute respiratory distress syndrome, renal failure, pneumonia, pulmonary embolism, and cardiac arrest, were fewer after TEVAR (32.1 vs 81.0%, P < 0.001) despite similar injury severity. Survivor hospital LOS (26.0 ± 15.3 vs 27.7 ± 18.7 days, P = 0.79), intensive care unit LOS (13.5 ± 10.9 vs 12.7 ± 8.8 days, P = 0.94), and ventilator days (11.4 ± 13.4 vs 16.4 ± 14.5 days, P = 0.25) were similar. Early nonoperative management with TEVAR for BAIs is a feasible and effective management strategy. Improved patient outcomes over traditional open thoracotomy in the presence of similar injury severity can be seen after TEVAR in the nonuniversity hospital setting.

Thoracic Endovascular Aortic Repair Adverse Events Reported In The Food And Drug Administration Manufacturer And User Facility Device Experience Database

Purpose

The purpose of this study is to identify adverse events (device- and patient-related) associated with thoracic aortic stent graft systems and their timing post-procedure.

Materials and methods

The Food and Drug Administration’s Manufacturer and User Facility Device Experience (FDA-MAUDE) voluntary database was searched for Thoracic Aortic Endovascular Repair (TEVAR) devices reported over the course of 1 year (January 1, 2014 to December 31, 2014). The data abstracted included the indication for treatment, device used, and adverse events.

Results

During 2014, there were 334 original submissions to the FDA-MAUDE database describing 371 adverse events regarding TEVAR devices that met inclusion criteria for this study. All submissions were from manufacturers, and none were from physicians. The most common pathologies treated were thoracic aortic aneurysm (67.6%) and type B aortic dissection (25.1%). The most frequently reported intraoperative, early postoperative (<30 days), and late postoperative (>30 days) events overall were technical device failure, neurologic complications (stroke, paraplegia), and endoleak, respectively. Of note, there were descriptions of retained deployment materials, late graft infections, and aorto-visceral fistula formation up to 3 years postoperatively.

Conclusion

The MAUDE database is a valuable repository for complications and device failures that are not otherwise in the published literature and submitted by manufacturers relating to this relatively new technology.

Impact of left ventricular ejection fraction on the outcomes of open repair of descending thoracic and thoracoabdominal aneurysms

OBJECTIVE

To discern the impact of depressed left ventricular ejection fraction (LVEF) on the outcomes of open descending thoracic aneurysm (DTA) and thoracoabdominal aneurysms (TAAA) repair.

METHODS

Restricted cubic spline analysis was used to identify a threshold of LVEF, which corresponded to an increase in operative mortality and major adverse events (MAE: operative death, myocardial infarction, stroke, spinal cord injury, need for tracheostomy or dialysis). Logistic and Cox regression were performed to identify independent predictors of MAE, operative mortality, and survival.

RESULTS

DTA/TAAA repair was performed in 833 patients between 1997 and 2018. Restricted cubic spline analysis showed that patients with LVEF <40% (n = 66) had an increased risk of MAE (odds ratio [OR], 2.17; 95% confidence interval [CI], 1.22-3.87; P < .01) and operative mortality (OR, 2.72; 95% CI, 1.21-6.12; P = .02) compared with the group with LVEF ≥40% (n = 767). The group with LVEF <40% had a worse preoperative profile (eg, coronary revascularization, 48.5% vs 17.3% [P < .01]; valvular disease, 82.8% vs 49.39% [P < .01]; renal insufficiency, 45.5% vs 26.1% [P < .01]; respiratory insufficiency, 36.4% vs 21.2% [P = .01]) and worse long-term survival (35.5% vs 44.7% at 10 years; P = .01). Nonetheless, on multivariate regression, depressed LVEF was not an independent predictor of operative mortality, MAE, or survival.

CONCLUSIONS

LVEF is not an independent predictor of adverse events in surgery for DTA.

Endovascular Vertebral Artery Transposition Using Flow Reversal Technique for Left Subclavian Artery Stump Syndrome

BACKGROUND

Cerebellar strokes are a rare complication related to thoracic endovascular aortic repair (TEVAR). This can manifest in an indolent manner or as a neurological catastrophe. Often it is unclear when a surgical intervention would be needed. Patients at risk for this relatively rare complication are not easily identified.

CASE

We describe an endovascular option with flow reversal for left vertebral artery transposition using stent grafts for relocating arterial inflow and excluding a floating thrombus at the proximal subclavian artery (SCA) related to a previous TEVAR.

CONCLUSIONS

Ligation of the subclavian artery proximal to the vertebral artery should be considered when performing a carotid subclavian bypass for elective TEVAR. This case details a unique, less invasive approach for vertebral artery transposition and thrombus exclusion in a high-risk patient with previous neck dissection.

Long-term radiation exposure in patients undergoing EVAR: Reflecting clinical day-to-day practice to assess realistic radiation burden

Endovascular repair of aortic aneurysms (EVAR) has become an established treatment option currently applied in an increasing numbers of patients with aortic aneurysms. Advantages include reduced surgical trauma, procedural time, intensive care unit and hospital lengths of stay, blood loss as well as morbidity and mortality.The optimal imaging modalities in EVAR follow-up as well as the appropriate intervals between these follow-ups remain subject of controversial discussion. Objective of this study was the evaluation of the realistic radiation exposure and risk estimate postop EVAR treatment.Of the follow-ups required according to the surveillance schedule during the first year post-EVAR, only 68.3% were actually implemented. Of those required from the second year onwards, an average of 70% was actually performed. During the observation period, each patient underwent a mean of 4.3 CTAs. The median ED calculated from all CTAs was 24. 5 mSv. The minimum and maximum cumulative EDs for the entire observation period were 55 mSv and 310 mSv, respectively.

Outcomes of a Spinal Drain and Intraoperative Neurophysiologic Monitoring Protocol in Thoracic Endovascular Aortic Repair

BACKGROUND

Adjuncts for early detection and treatment of spinal cord ischemia (SCI) in thoracic aortic surgery are supported by robust clinical experience in open repair. The utility of cerebrospinal fluid (CSF) drainage and neurophysiologic monitoring (NPM) in thoracic endovascular aortic repair (TEVAR) is less clear. The purpose of this investigation is to determine the influence of a selective institutional spinal cord protection protocol using prophylactic NPM and CSF on outcomes for standard TEVAR.

METHODS

Patients undergoing standard TEVAR entered into a prospectively maintained database from a single institution from 2007 to 2016 were retrospectively reviewed. Preoperative characteristics, aneurysm extent, and etiology were reviewed. Utilization of CSF drains including volume of fluid removed, duration of drainage, and catheter-related complications were collected. NPM data were reviewed to determine the influence on intraoperative management. Exact logistic regression was used to identify independent predictors of SCI.

RESULTS

Of 223 patients undergoing TEVAR, 130 met inclusion criteria for the study. CSF drains were used in 71 patients (54.6%), and 56 of 130 (43%) had NPM. SCI occurred in 7 patients (5.4%), of whom 5 had partial or complete recovery. Median time to symptoms of SCI was delayed in all cases (median 52 hr, range 8-312), and none of the 4 of 7 patients with adjunct NPM demonstrated intraoperative changes. Intraoperative changes in NPM occurred in 26 (46%), and represented unilateral leg ischemia in all but 2 cases. In both patients, changes consistent with SCI were associated with intraoperative hypotension and resolved with blood pressure augmentation. Neither patient developed postoperative SCI. Median length of stay (22 vs. 9 days, P = 0.012), operative room time (262 vs. 209, P = 0.040), and perioperative mortality (28.6% vs. 4.1%, P = 0.046) were significantly higher for patients with SCI versus those without. Length of aortic coverage was found to be the sole independent predictor of SCI (odds ratio 8.2, P = 0.026). Complications related to CSF drainage occurred in 4 patients (5.6%) with major complications occurring in 2 patients (2.8%), including 1 with an intrathecal hematoma and permanent bilateral paraparesis.

CONCLUSIONS

Selective use of prophylactic CSF drainage in TEVAR was associated with moderate risk and questionable benefit. The use of neurophysiological monitoring allowed for early detection and treatment of spinal ischemia, but its utility is limited by logistical factors and to the minority of patients with intraoperative spinal ischemic events.

Percutaneous transapical access to facilitate complex thoracic endovascular aortic repair

Thoracic endovascular aortic repair (TEVAR) provides an alternative to open surgery for a variety of aortic diseases. However, complex anatomy and previous operations may preclude traditional approaches to TEVAR. Percutaneous transapical access through the left ventricle is a feasible option to facilitate externalized “rail” wire support for complex TEVAR. We present the case of TEVAR for a residual type B aortic dissection facilitated by percutaneous transapical access.

Endovascular treatment of complex diseases of the thoracic aorta-10 years single centre experience

BACKGROUND

Introduction of invasive endovascular techniques constituted a real a breakthrough in the treatment of aortic aneurysm dissection and rupture. We assessed the effectiveness and safety of thoracic endovascular aortic repair (TEVAR) in patients with thoracic aortic pathologies.

METHODS

Between 2007 and 2017, 118 patients with thoracic aortic pathology underwent TEVAR. Among them, 20 (16.9%) patients required hybrid procedures. Stent grafts indication were thoracic aortic aneurysm in 46 (39.0%) patients, type B dissection in 68 (57.6%) patients and other indications in 4 (3.3%). Procedural success rate, in-hospital and late mortality and morbidity were evaluated.

RESULTS

The patients were followed-up for a mean of 55 months (range, 6-118 months). The technical success rate was 96%. Five patients died during the first 30 days after procedure (mortality 4.2%), four due to ischemic stroke followed by multi-organ failure and another one hemodynamically significant type I endoleak. Most of them were noted in the first years of our study. Five others died during post-discharged period. Four patients developed neurological complications, including stroke (n=2; 1.7%) and paraparesis (n=2; 1.7%). There were 6 (5.1%) primary (5 type I and 1 type II) and 3 (2.5%) secondary endoleaks (1 type I and 2 type III). Secondary interventions were required in 8 subjects. There was one case of stent collapse and two retrograde aortic dissection.

CONCLUSIONS

Treatment of descending aortic diseases by using stent graft implantation has become the method of choice, decreasing the risk of open surgery, especially in patients with severe clinical state and comorbidities. However, effectiveness and safety may be achieved by experience team.

Endovascular Versus Open Repair of Intact Descending Thoracic Aortic Aneurysms

BACKGROUND

For the management of descending thoracic aortic aneurysms, recent evidence has suggested that outcomes of open surgical repair may surpass thoracic endovascular aortic repair (TEVAR) in as early as 2 years.

OBJECTIVES

The purpose of this study was to evaluate the comparative effectiveness of TEVAR and open surgical repair in the treatment of intact descending thoracic aortic aneurysms.

METHODS

Using the Medicare database, a retrospective study using regression discontinuity design and propensity score matching was performed on patients with intact descending thoracic aortic aneurysms who underwent TEVAR or open surgical repair between 1999 and 2010 with follow-up through 2014. Survival was assessed with restricted mean survival time. Perioperative mortality was assessed with logistic regression. Reintervention was evaluated as a secondary outcome.

RESULTS

Matching created comparable groups with 1,235 open surgical repair patients matched to 2,470 TEVAR patients. The odds of perioperative mortality were greater for open surgical repair: high-volume center, odds ratio (OR): 1.97 (95% confidence interval [CI]: 1.53 to 2.61); low-volume center, OR: 3.62 (95% CI: 2.88 to 4.51). The restricted mean survival time difference favored TEVAR at 9 years, -209.2 days (95% CI: -298.7 to -119.7 days; p < 0.001) for open surgical repair. Risk of reintervention was lower for open surgical repair, hazard ratio: 0.40 (95% CI: 0.34 to 0.60; p < 0.001).

CONCLUSIONS

Open surgical repair was associated with increased odds of early postoperative mortality but reduced late hazard of death. Despite the late advantage of open repair, mean survival was superior for TEVAR. TEVAR should be considered the first line for repair of intact descending thoracic aortic aneurysms in Medicare beneficiaries.

Appearance of Adipocytes in Thoracic Aortic Aneurysm

Thoracic aortic aneurysm (TAA) is a lethal vascular disease that involves localized dilation of the thoracic aorta. The detailed mechanisms of TAA development and rupture are not fully understood. Recent reports have shown that the abnormal appearance of adipocytes in the vascular wall is associated with abdominal aortic aneurysm (AAA) progression or rupture. However, the presence of adipocytes in the TAA wall remains unknown. In this study, we observed the pathology of thoracic aortae to investigate whether adipocytes abnormally appear in the TAA wall. Abnormal appearance of adipocytes was mainly observed in the adventitia in the TAA vascular walls. The adipocyte area in the vascular wall was significantly increased in the TAA wall compared to the control wall. Destruction of collagen fibers, and increase in areas positive for matrix metalloproteinase (MMP) -2, MMP-9, and Mac387⁺ macrophages were observed in the area around adipocytes in the vascular wall. This study demonstrated the appearance of adipocytes in the TAA wall. The accumulation of adipocytes in AAA wall reportedly facilitates the destruction of fibers surrounding adipocytes, and thereby, leads to vascular wall weakness. Therefore, adipocytes in the TAA wall can be associated with the weakening of the vascular wall as well as the AAA wall. The appropriate control of adipocytes in the vascular wall may prevent weakening of the vascular wall in TAA.

Outcomes Following Non-operative Management of Thoracic and Thoracoabdominal Aneurysms

BACKGROUND

Surgical decision making remains difficult in several patients with aneurysmal disease of the descending thoracic (DT) or thoracoabdominal (TA) aorta. Despite previous studies that have investigated aneurysms treated non-operatively using a prospective growth analysis, completeness and accuracy of follow-up were inconsistent. We aim to describe the survival and freedom from adverse aortic events in patients with DT and TA who did not undergo operative repair.

METHODS

This is a single-center retrospective analysis of all patients with either a descending degenerative atherosclerotic or dissection-related DT or TA aortic lesion who were treated non-operatively from April 2002 to December 2016. We studied patients who did not undergo operative repair of descending degenerative atherosclerotic or dissection-related DT or TA aortic lesion. Primary end points were overall survival and freedom from aortic-related mortality (ARM).

RESULTS

Of the 315 patients diagnosed with DT or TA disease, 56 (18%) did not undergo surgical repair. Mean aneurysm diameter was 65 mm ± 15 (range 50-120; IQR 5.4-7.15). Extent of the aortic aneurysms was DT in 36 (11%) patients and TA in 20 (6%). Median duration of follow-up was 12 months (range 1-108; IQR 3-36). Over the course of the study, 41 (73%) patients died for an overall survival rate of 53% ± 7 at 1 year (95% CI 40-65) and 23% ± 7 at 3 year (95% CI 17-42.5). Aortic-related mortality was 27% (n = 15), significantly higher in patients with aneurysms ≥ 60 mm [n = 13, (39%) vs. n = 2, (9%); P = 0.025; OR = 5.04]. Overall, estimated freedom from ARM was 81% ± 5.5 at 1 year (95% CI 68-89) and 66.5% ± 9 at 3 year (95% CI 48-81). Only TA extent was independently associated with freedom from ARM during the follow-up (P = 0.005; HR: 5.74; 95% CI 1.711-19.729).

CONCLUSIONS

Thoracoabdominal extent of the aneurysmal aortic disease is the most important predictor of ARM in unrepaired DT or TA aortic diseases. Mortality from aortic-related events was significantly more premature than mortality from non-aortic-related mortality.