Open repair of thoracoabdominal aortic aneurysms in experienced centers

Physician-Modified Endografts Achieve Similar Patient Survival and Target Visceral Vessel Related Outcomes to Factory-Made Fenestrated Endografts in Treating Complex Aortic Pathology

BACKGROUND

The purpose of this study was to conduct a real-world comparison of visceral stent branch related outcomes and patient survival in physician-modified endografts (PMEGs) versus factory-made fenestrated endografts (FMFEs).

METHODS

After exclusions, 544 PMEG and 1638 FMFE were identified in the Vascular Quality Initiative between 2014 and 2022. The four primary outcomes analyzed with Kaplan-Meier were freedom from mortality, new onset dialysis, visceral ischemia, and visceral stent-graft reintervention in follow-up. Multivariable Cox regression was also performed for visceral reintervention in follow-up utilizing variables with a univariable P < 0.10. Comparison of baseline demographics and co-morbidities in the PMEG versus FMFE group were performed as was univariable risks for perioperative adverse outcomes.

RESULTS

PMEG patients were a more comorbid cohort highlighted by: larger aneurysms; higher mean number of visceral vessels stented; higher rates of hypertension, anemia, prior coronary revascularization, prior open aortic surgery, and greater than 50% stenosis in one of the visceral target arteries (P < 0.01 for all). Further, PMEG patients had a 3-fold higher rate of intervention for a primary pathology of aortic dissection (9.7% vs. 2.3%, P < 0.001). Mean follow-up for survival was 1.9 years for PMEG and 3.0 years for FMFE. Mean follow-up for visceral stent-related data was 1.07 and 1.19 years for PMEG and FMFE, respectively. There was no significant difference between the PMEG and FMFE groups in mortality, new onset dialysis or intestinal ischemia in follow-up. Univariable Kaplan-Meier analysis for freedom from visceral stent branch reintervention showed an increased rate for PMEG (log rank P = 0.002). However, multivariable Cox regression rendered this nonsignificant (hazard ratio [HR] 1.25, P = 0.406) due to significantly more branches being treated on average in the PMEG group (3.48 vessels versus 3.01, P < 0.001). The only variable which achieved multivariable significance in association with visceral stent reintervention was the mean number of vessels stented (HR 2.15, P < 0.001).

CONCLUSION

Physician-modified fenestrated visceral segment endografts achieve similar mid-term freedom from mortality, visceral stent-graft reintervention, new onset dialysis, and intestinal ischemia relative to custom FMFEs. This is despite PMEG patients being a significantly more comorbid cohort, with more visceral vessels involved and more dissection related aneurysms.

Abdominal aortic calcification is associated with impaired fusion after elective spinal fusion

BACKGROUND CONTEXT

The interplay between vascular compromise and spinal pathology has been underexplored in the context of spinal fusion outcomes. Abdominal aortic calcification (AAC) is associated with various degenerative spinal conditions, potentially due to impaired perfusion. However, the relationship between AAC and the success of osseous fusion mass formation following spinal fusion remains unexplored.

OBJECTIVES

To investigate the association between AAC severity and fusion success following posterior lumbar spine fusion surgery.

STUDY DESIGN

Retrospective cohort study.

PATIENT POPULATION

Patients undergoing open posterior lumbar fusion between 2010 and 2021 at a single institution.

OUTCOME MEASURES

Osseous posterolateral fusion (PLF) and interbody fusion (IBF) on computed tomography.

METHODS

The institutional database was queried for patients who underwent open posterior spinal fusion and had postoperative CT scans at ≥12 months. Preoperative standing lateral lumbar radiographs were assessed for aortic calcification using the AAC-24 classification, which is a score between 0 (no AAC) to 24 (most severe AAC). Fusion success was evaluated using the Lenke (PLF) and Bridwell (IBF) classifications on CT. Binary outcomes of fusion success versus impairment were created for PLF and IBF and a combined outcome of either PLF and/or IBF for a third analysis. Multivariable logistic regression was used to identify predictors of impaired fusion, including AAC, age, sex, BMI, smoking, diabetes, number of levels fused, and fusion to the sacrum.

RESULTS

A total of 207 patients were included for analysis. PLF impairment was observed in 28.5%, and IBF impairment in 22.7%. AAC was an independent predictor of impaired PLF (OR 1.10, 95% CI 1.02-1.20; p=.015) and combined PLF/IBF impairment (OR 1.16, 95% CI 1.06-1.29; p=.002). Multivariable analysis revealed, that each one-point increase in the AAC-24 score increased the odds of combined fusion impairment by 16%, and an increase of one standard deviation was associated with approximately a 2-fold increase in risk. Number of levels fused also predicted combined fusion impairment (OR 1.67, 95% CI 1.15-2.48; p=.009). No significant association was found between AAC and IBF impairment alone.

CONCLUSIONS

AAC is independently associated with posterolateral fusion impairment following spinal fusion surgery. routine preoperative assessment of AAC on lateral spine radiographs may help identify patients at higher risk for impaired fusion and guide surgical decision-making. Further studies are needed to validate these findings and evaluate strategies to mitigate this risk.

Spinal cord protection by normothermic artery bypass and visceral-anastomosis-first strategy in thoracoabdominal aortic aneurysm repair

BACKGROUND

Spinal Cord Injury is a disastrous complication of thoracoabdominal aortic aneurysm surgery. This study is to assess the effectiveness and safety normothermic artery bypass and visceral-anastomosis-first strategy for thoracoabdominal aortic aneurysm repair.

METHODS

Normothermic artery bypass and visceral-anastomosis-first strategy prioritizes the reconstruction of visceral and other distal vessels, with intercostal arteries serving as the physiological blood supply at high pressure during this period. Reconstruction of intercostal arteries and proximal anastomosis is then performed, ensuring the longest possible physiological blood supply to the spinal cord. From July 2019 to December 2023, we retrospectively analyzed early postoperative complications in two groups of patients undergoing thoracoabdominal aortic aneurysm repair using the new strategy compared to normothermic iliac artery perfusion, clarifying the protective effects of the new strategy on visceral organs, especially the spinal cord.

RESULTS

The incidence of paraplegia was significantly lower in the NABP group than in the normothermic iliac perfusion (NIP) group (0.00% vs. 9.72%, p = 0.047), and the duration of postoperative mechanical ventilation was significantly lower in the NABP group than in the NIP group (p = 0.004). In addition, we found that the incidence of gastrointestinal adverse events was significantly lower in the NABP group than in the NIP group (7.32% vs. 45.83%, p < 0.001). Typically, patients' lactate levels returned to normal within approximately 48 h postoperatively. Although not statistically significant, lactate fell to normal more quickly in the NABP group after surgery.

CONCLUSIONS

The treatment of thoracoabdominal aortic aneurysm through open surgery is still an important method and remains difficult. The data we have suggests that our approach of normothermic artery bypass and visceral-anastomosis-first strategy can lower the risk of spinal cord injury complications.

Contemporary Outcomes of Open Thoracoabdominal Aortic Aneurysm Repair in the Endovascular Era

OBJECTIVES

Open thoracoabdominal aortic aneurysm (TAAA) repair has been associated with high morbidity and mortality prior to the endovascular era, when repair options were limited. Our institution developed a multidisciplinary protocol to standardize patient selection, operative technique and postoperative care to improve outcomes for open repairs. This study aimed to evaluate the protocol's preliminary benefits by comparing outcomes of open TAAA repair on vs off the protocol.

METHODS

A retrospective review of consecutive patients who underwent TAAA repair at a single institution from 2013-2023 was completed. Patients who underwent open repair were included and stratified by use of the protocol. The primary outcome was a composite of thoracoabdominal aortic aneurysm life-altering events (TALE) including in-hospital mortality, spinal cord ischemia with paraplegia, new onset of dialysis, or stroke. Secondary outcomes included each individual component, length of stay, and non-home discharge.

RESULTS

220 patients underwent TAAA repair at our institution during the study period - 190 endovascular and 30 open. There were 14 in the protocol group and 16 in the non-protocol group. Patient demographics were similar between groups with an overall mean age of 46-years-old. A connective tissue disorder was present in 64% and 50% (P=0.431) of protocol and non-protocol patients, respectively. The majority of the patients in both groups presented with extent II TAAA (64% vs 75%). The composite endpoint occurred in 0% of the protocol group vs 38% of the non-protocol group (P=0.010). Secondary outcomes were dialysis (0% vs 19%, P=0.23), paraplegia (0% vs 19%, P=0.232), stroke (0% vs 0%), in-hospital mortality (0% vs 13%, P=0.171), and non-home discharge (7% vs 50%, P=0.012). Median postoperative length of stay was 8 vs 15 days (P=0.038).

CONCLUSION

In the endovascular era, open TAAA repair can be performed with encouraging outcomes when particular attention is given to patient selection, surgical technique and postoperative care, with rates of mortality, paraplegia, renal failure, and length of stay that rival endovascular repair.

Operative times and outcomes of complex endovascular repairs of thoracoabdominal aneurysms

BACKGROUND

Owing to the significant morbidity and mortality of open thoracoabdominal aortic aneurysm surgery, complex endovascular repairs have become increasingly common, but still carry substantial risk. These repairs require large-bore access, with resultant pelvic and lower extremity ischemia. We, therefore, hypothesized that operative timing would be associated with outcomes, because efficient surgery would limit the ischemic time as well as anesthesia time.

METHODS

We studied all thoracoabdominal aortic aneurysm surgerywith complex endovascular repairs (Crawford types 1, 2, 3, and 5) incorporating at least one branch vessel from 2014 to 2021 in the Vascular Quality Initiative and categorized them into quartiles of total operating time. To account for variations in case complexity and intraoperative events, we performed a subanalysis stratifying each surgeon by their median operating time. Multilevel logistic regression was used to compare perioperative outcomes including mortality, thoracoabdominal life-altering events (a composite of perioperative death, stroke, permanent paralysis and/or dialysis), spinal cord ischemia (SCI), acute kidney injury, major adverse cardiac events, myocardial infarction, and dialysis.

RESULTS

There were 2925 thoracoabdominal aortic aneurysm surgery with complex endovascular repairs during the study period. Procedure times ranged from <204 minutes in the first quartile to >365 minutes in the fourth. Longer cases more commonly involved older patients who were more often female and higher rates of prior stroke and preoperative anemia. They involved larger, more extensive aneurysms, with higher rates of prior aortic surgery, and more commonly used physician-modified endografts or parallel grafting to incorporate more branch vessels. In addition, they were less often staged procedures, and used more spinal drains, femoral cutdowns, and upper extremity access. Operating time decreased as experience increased. In adjusted analyses, the odds of mortality and every morbidity studied increased stepwise with operating time, with 4- to 13-fold higher odds in the highest quartiles. SCI had the strongest association with procedure times, with seven-fold higher odds (odds ratio, 7.2; 95% confidence interval, 2.9-17.9; P < .001) of any SCI in the highest quartile compared to the lowest, and 13-fold higher odds of permanent SCI (OR, 13.1; 95% confidence interval, 3.9-44.7; P < .001). These results were consistent when surgeons were grouped into quartiles by their median operating times. Medium-term mortality was also higher in the upper quartile of operating time (hazard ratio, 2.7; 95% confidence interval, 1.4-5.1; P = .002).

CONCLUSIONS

Longer operating times for complex thoracoabdominal aortic aneurysm surgerywith complex endovascular repairs were associated with markedly higher rates of morbidity and mortality, especially SCI. These results emphasize the importance of expeditious repairs by experienced teams.

Surgeon volumes of endovascular thoracoabdominal aneurysm repairs, but not juxtarenal repairs, are associated with outcomes following endovascular repair of thoracoabdominal aneurysms

OBJECTIVE

Endovascular thoracoabdominal aortic aneurysm (eTAAA) repair remains one of the more technically challenging aspect of vascular surgery, with significant risk of mortality, spinal cord ischemia, and end organ damage. Although fenestrated devices are available for juxtarenal aneurysms, there are no commercially available eTAAA devices on the United States market currently. We therefore studied how the volume of juxtarenal repairs would translate to outcomes of these more complicated aneurysms.

METHODS

We studied all eTAAA repairs (Crawford type 1-3) in the Vascular Quality Initiative from 2014 to 2021 and categorized surgeons into quartiles based on their average annual eTAAA volume and endovascular juxtarenal volume. Our primary outcome was thoracoabdominal life altering events (composite of perioperative death, stroke, permanent spinal cord ischemia, and dialysis). We employed mixed effects logistic regression clustering by center and surgeon.

RESULTS

We identified 5335 repairs from 607 surgeons, with annual average eTAAA volumes of 2629 from 400 surgeons. Quartile 1 involved less than two repairs and quartile 4 involved >12 repairs per year. Repairs at higher quartiles were for larger aneurysms, more commonly employed staged repairs, utilized spinal drains, and more frequently utilized physician-modified endografts, whereas low-volume surgeons most commonly employed parallel grafting. Higher volume surgeons had overall shorter procedural times, fluoroscopy time, and less total contrast. Technical success similarly increased as procedure volume increased. In adjusted analyses, rates of perioperative death, thoracoabdominal life altering events, stroke, acute kidney injury, and major adverse cardiac events were all lower in the highest volume quartile compared with the lowest. However, after accounting for eTAAA volume, surgeon volume of endovascular juxtarenal repairs was not associated with any postoperative outcome, and there was no significant interaction between juxtarenal and eTAAA volume. Medium-term mortality was lowest in patients treated in the top two quartiles of volume (hazard ratio, 0.77; 95% confidence interval, 0.61-0.97; P = .024).

CONCLUSIONS

Surgeon eTAAA experience shows a strong volume-outcome effect on outcomes in the immediate post operative period and in permanent patient-centered outcomes. However, experience in less extensive aneurysms did not directly translate to thoracoabdominal aneurysms. Further study is needed to evaluate the role that commercial graft availability and repair type contributes to these findings.

Correlation Between Lean Psoas Muscle Area and Incidence of Morbidity and Mortality in Patients Undergoing Thoraco-Abdominal Aortic Aneurysm Open Surgery

OBJECTIVE

Sarcopenia is gaining interest in the pre-operative evaluation of patients with thoraco-abdominal aortic aneurysm (TAAA). Lean psoas muscle area (LPMA) has emerged as a way to measure sarcopenia and is a possible predictor of outcomes in endovascular TAAA repair. The aim of this study was to analyse the correlation between LPMA and outcomes of open TAAA repair.

METHODS

Between 2018 and 2022, all consecutive elective patients who underwent open TAAA repair with an available adequate pre-operative computed tomography angiogram (CTA) were analysed retrospectively. The CTA data were used to measure LPMA. Pre- and post-operative variables were collected from all patients. Primary endpoints were death and major adverse events (MAEs) at 30 days and 90 days. The secondary endpoint was follow up mortality rate. Primary and secondary endpoints were correlated with LPMA.

RESULTS

A total of 179 patients were included, and 61.5% (110/179) were treated for extent II and III TAAA. Death at 30 days and 90 days was 6.1% and 8.9%, respectively. At a median follow up of 38 months (range: 12 - 60), the mortality rate was 17.2%. The proportion of patients with MAE occurrence at 30 days and 90 days was 29.1% and 37.4%, respectively. The median LPMA was 330 cm2/Hounsfield unit (HU) (interquartile range 264, 442) and was significantly higher in men than in women (p = .001). Patients were divided according to the LPMA value into sarcopenic (< 350 cm2/HU) and non-sarcopenic (> 350 cm2/HU) groups, and in four quartiles. No statistically significant correlation between LPMA and death or MAEs was observed at 30 days and 90 days, and at follow up, but an increased mortality rate was observed in patients with sarcopenia at 30 days (10%; 9/90) compared with patients without sarcopenia (2.2%, 2/89) (p = .059).

CONCLUSION

In this series of patients who underwent open TAAA repair, LPMA was found to be ineffective as an independent predictor of morbidity and mortality. Further studies are needed to clarify the role of this parameter as a predictor of adverse outcomes.

Early and mid-term results after endovascular repair of thoracoabdominal aortic aneurysms using the off-the-shelf multibranched t-Branch device: a national multi-center study

Objective: The multibranched off-the-shelf Zenith® t-Branch (Cook Medical, Bloomington, IN) device is commonly chosen for endovascular repair of thoracoabdominal aortic aneurysms. The aim of this study was to report early and mid-term outcomes in all patients treated with the t-Branch in Norway; Design and Methods: A retrospective multicenter study with Norwegian centers performing complex endovascular aortic repair was undertaken. T-Branch patients from 2014 to 2020 were included. All postoperative computed tomography angiography images were reviewed, and demographic, anatomical, perioperative and follow-up data were analyzed; Results: Seventy patients were treated in a single-step (n = 55) or staged (n = 15) procedure. Symptomatic presentation was seen in 20 patients, six of which had a contained rupture. Technical success was 87% (n = 59), with failures caused by unsuccessful bridging of target vessels (n = 4), target vessel bleeding (n = 3), persisting type 1c endoleak (n = 1) and t-Branch malrotation (n = 1). 30-day mortality was 9% (n = 6) and was associated with high BMI (p = .038). The spinal cord ischemia rate was 21% (n = 15) and was associated with type II aneurysms (OR 5.4, 95% CI 1.1-26.7, p = .04), smoking (OR 6.0, 95% CI 1.3-27.6, p = .02) and intraoperative blood loss (OR 1.1, 95% CI 1.0-1.3, p = .01). Survival at one, two and three years was 84 ± 4%, 70 ± 6% and 67 ± 6%, respectively. Freedom from aortic-related reinterventions at one, two and three years was 80 ± 5%, 65 ± 7% and 50 ± 8%, respectively; Conclusion: The study showed low early mortality (9%) and satisfactory mid-term survival. Technical success was achieved in acceptable 87% of procedures. The rate of spinal cord ischemia was high, occurring in 21% of patients.

The severity of chronic obstructive pulmonary disease is associated with adverse outcomes after open thoracoabdominal aortic aneurysm repair

OBJECTIVE

We assessed associations between outcomes after open thoracoabdominal aortic aneurysm (TAAA) repair and preoperative airflow limitation stratified by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) spirometric classification of chronic obstructive pulmonary disease (COPD) severity.

METHODS

Among 2368 open elective TAAA repairs in patients with spirometric data, 1735 patients had COPD and 633 did not. Those with COPD were stratified by preoperative respiratory dysfunction as GOLD 1 (forced expiratory volume in the first second of expiration [FEV1] ≥80% of predicted; n = 228), GOLD 2 (50% ≤ FEV1 < 80% of predicted; n = 1215), GOLD 3 (30% ≤ FEV1 < 50% of predicted; n = 260), or GOLD 4 (FEV1 < 30% of predicted; n = 32). Early outcomes included operative mortality and adverse events (operative death or persistent stroke, spinal cord deficit, or renal failure requiring dialysis); associations of outcomes were determined using logistic regression models. Kaplan-Meier analysis compared late survival by the log-rank test.

RESULTS

Pulmonary complications occurred in 38.4% of patients with COPD versus 30.0% without COPD (P < .001). Operative mortality and adverse events were more frequent in patients with COPD than without COPD (7.9% vs 3.8% [P < .001] and 14.9% vs 9.8% [P = .001], respectively). Worsening GOLD severity was independently associated with operative death and adverse event. Survival was poorer in patients with COPD than in those without (61.9% ± 1.2% vs 73.6% ± 1.8% at 5 years; P < .001), particularly in patients with increasing GOLD severity (68.7% ± 3.2% vs 63.7% ± 1.4% vs 51.4% ± 3.2% vs 31.3% ± 8.2% at 5 years; P < .001).

CONCLUSIONS

Patients with COPD are at elevated risk for operative death and adverse events. Staging by GOLD severity aids preoperative risk stratification. Patients with airflow limitations may benefit from optimization before TAAA repair.

The relationship of sex and aortic diameter at the time of acute type A aortic dissection

Objective

Evaluate sex differences in patients undergoing repair of acute type A aortic dissection (ATAAD).

Methods

Sex-stratified, single-center cohort study of patients undergoing ATAAD repair from 1997 to 2022. The primary outcome was aortic diameter at time of presentation with ATAAD. Secondary outcomes were mortality, myocardial infraction, stroke, hemodialysis, tracheostomy, re-exploration for bleeding, a composite of major adverse events, and long-term survival.

Results

In 390 consecutive patients (150 women), men were younger than women (61.0 years; interquartile range [IQR], 50-70 years vs 70.5 years; IQR, 59-78 years; P < .001), had higher body mass index (28.6; IQR, 25.1-32.3 vs 25.4; IQR, 21.9-29.2; P < .001), more frequent peripheral vascular disease (11.7% vs 4.7%; P = .03), renal insufficiency (36.7% vs 22%; P = .003), malperfusion (34.2% vs 18.7%; P = .007), and smoking history (65% vs 44%; P < .001). There was no sex difference in median aortic diameter at the time of ATAAD (men: 5.3 cm; IQR, 4.9-6.1 cm and women: 5.2 cm; IQR, 4.6-5.9 cm; P = .12) even when adjusted for body mass index (men: 5.7 cm; IQR, 5.4-6.1 cm and women: 5.4 cm; IQR, 5.4-6.1 cm; P = .19). There was no sex difference in mortality (4.6% vs 6.0%; P = .70), major adverse events, or 10-year survival (50.3% vs 58.5%; P = .13). On multivariable analysis, there was no interaction between aneurysm size and sex (interaction P = .62). Sex was not associated with major adverse events (odds ratio, 0.75; 95% CI, 0.07-7.39; P = .81).

Conclusions

There was no sex difference in aneurysm size at the time of presentation of ATAAD, even after adjustment for body mass index, and no interaction between aneurysm size and sex, suggesting that aortic diameter remains a reasonable criterion for intervention irrespective of sex.

Determinants of Neurological Outcome Following Elective and Emergency Open Thoracoabdominal Aortic Aneurysm Repair-A Retrospective Multi-Center Study

Background/Objectives: This study aimed to evaluate and establish the incidence of all types of neurological complications at our high-volume reference center for open TAAA repair in the Netherlands and Germany. Additionally, we sought to identify predictors for various neurological complications. Methods: This retrospective study was conducted in accordance with the STROBE guidelines, with the aim of reporting neurological outcomes for all patients who underwent open thoracoabdominal aortic aneurysm repair at two centers (Maastricht-Aachen) from 2000 to 2023, and to examine the association between these outcomes and pre- and perioperative parameters. The primary endpoints of the study were all-cause mortality, spinal cord ischemia (SCI), stroke, intracerebral bleeding (ICB), critical illness polyneuropathy/myopathy (CIP/CIM), and recurrent laryngeal nerve paralysis. Results: A total of 577 patients were operated on for open TAAA repair in two centers. The total in-hospital mortality rate was 20.6%, while the elective cases in-hospital mortality rate was 14.6%. In all, 28.2% of patients experienced neurological complications. The spinal cord ischemia rate was 7.5%, intracerebral bleeding 3.6%, stroke 5.9%, critical illness polyneuropathy 3.5%, and laryngeal nerve paresis 5.7%. Crawford extent II was significantly associated with increased neurological complications (OR 2.05, 95% CI 1.39-3.03, p = 0.003), while Crawford extent III and IV were significantly associated with fewer postoperative neurological complications (OR 0.61 (0.38-0.98) p = 0.04) (OR 0.52 (0.30-0.92) p = 0.02). Preoperative ASA score > 3 (OR 1.76, 95% CI 1.16-2.67, p = 0.007), COPD (OR 1.82, 95% CI 1.19-2.78, p = 0.006), massive intraoperative transfusion (OR 1.48, 95% CI 1.01-2.17, p = 0.04), and reinterventions during hospital stay (OR 1.98, 95% CI 1.36-2.89, p < 0.001) and surgery time (p =< 0.001) were significantly associated with neurological complications. Patients with neurological complications had higher rates of other postoperative morbidities. Conclusions: Neurological complications after open TAAA repair remain a significant concern, with identified risk factors associated with increased morbidity, mortality, and resource utilization. Identifying at-risk patients could potentially lead to a reduction in neurological complications.

Five-year outcomes of fenestrated and branched endovascular repair of complex aortic aneurysms based on aneurysm extent

OBJECTIVE

The aim of this study was to evaluate the 5-year outcomes of fenestrated/branched endovascular aortic repair (F/BEVAR) for the treatment of complex aortic aneurysms stratified by the aneurysm extent.

METHODS

Patients with the diagnosis of complex aortic aneurysm, who underwent F/BEVAR at a single center were included in this study and retrospectively analyzed. The cohort was divided according to the aneurysm extent, comparing group 1 (types I-III thoracoabdominal aneurysms [TAAAs]), group 2 (type IV TAAAs), and group 3 (juxtarenal [JRAAs], pararenal [PRAAs], or paravisceral [PVAAs] aortic aneurysms). The primary endpoints were 30-day and 5-year survival. The secondary endpoints were technical success, occurrence of spinal cord ischemia, primary patency of the visceral arteries, freedom from target vessel instability, and secondary interventions.

RESULTS

Of 436 patients who underwent F/BEVAR between July 2012 and May 2023, 131 presented with types I to III TAAAs, 69 with type IV TAAAs, and 236 with JRAAs, PRAAs, or PVAAs. All cases were treated under a physician-sponsored investigational device exemption protocol with a patient-specific company-manufactured or off-the-shelf device. Group 1 had significantly younger patients than group 2 or 3 respectively (69.6 ± 8.7 vs 72.4 ± 7.1 vs 73.2 ± 7.3 years; P < .001) and had a higher percentage of females (50.4% vs 21.7% vs 17.8%; P < .001). Prior history of aortic dissection was significantly more common among patients in group 1 (26% vs 1.4% vs 0.9%; P < .001), and mean aneurysm diameter was larger in group 1 (64.5 vs 60.7 vs 63.2 mm; P = .033). Comorbidities were similar between groups, except for coronary artery disease (P < .001) and tobacco use (P = .003), which were less prevalent in group 1. Technical success was similar in the three groups (98.5% vs 98.6% vs 98.7%; P > .99). The 30-day mortality was 4.5%, 1.4%, and 0.4%, in groups 1, 2, and 3, respectively, and was significantly higher in group 1 when compared with group 3 (P = .01). The incidence of spinal cord ischemia was significantly higher in group 1 compared with group 3 (5.3% vs 4.3% vs 0.4%; P = .004). The 5-year survival was significantly higher in group 3 when compared with group 1 (P = .01). Freedom from secondary intervention was significantly higher in group 3 when compared with group 1 (P = .003). At 5 years, there was no significant difference in freedom from target vessel instability between groups or primary patency in the 1652 target vessels examined.

CONCLUSIONS

Larger aneurysm extent was associated with lower 5-year survival, higher 30-day mortality, incidence of secondary interventions, and spinal cord ischemia. The prevalence of secondary interventions in all groups makes meticulous follow-up paramount in patients with complex aortic aneurysm treated with F/BEVAR.

Administration of an antibody against apoptosis inhibitor of macrophage prevents aortic aneurysm progression in mice

Apoptosis inhibitor of macrophage (AIM) is known to induce apoptosis resistance in macrophages and to exacerbate chronic inflammation, leading to arteriosclerosis. The role of AIM in aortic aneurysm (AA) remains unknown. This study examined the effects of an anti-AIM antibody in preventing AA formation and progression. In apolipoprotein E-deficient mice, AA was induced by subcutaneous angiotensin II infusion. Mice were randomly divided into two groups: (i) AIM group; weekly anti-murine AIM monoclonal antibody injection (n = 10), and (ii) IgG group; anti-murine IgG antibody injection as control (n = 14). The AIM group, compared with the IgG group, exhibited reduced AA enlargement (aortic diameter at 4 weeks: 2.1 vs. 2.7 mm, respectively, p = 0.012); decreased loss of elastic lamellae construction; reduced expression levels of IL-6, TNF-α, and MCP-1; decreased numbers of AIM-positive cells and inflammatory M1 macrophages (AIM: 1.4 vs. 8.0%, respectively, p = 0.004; M1 macrophages: 24.5 vs. 55.7%, respectively, p = 0.017); and higher expression of caspase-3 in the aortic wall (22.8 vs. 10.5%, respectively, p = 0.019). Our results suggest that administration of an anti-AIM antibody mitigated AA progression by alleviating inflammation and promoting M1 macrophage apoptosis.

National trends in utilization of surgeon-modified grafts for complex and thoracoabdominal aortic aneurysms

INTRODUCTION

Custom-branched/fenestrated grafts are widely available in other countries, but in the United States, they are limited to a handful of centers, with the exception of a 3-vessel juxtarenal device (ZFEN). Consequently, many surgeons have turned to alternative strategies such as physician-modified endografts (PMEGs). We therefore sought to determine how widespread the use of these grafts is.

METHODS

We studied all complex endovascular repairs of complex and thoracoabdominal aortic aneurysms in the Vascular Quality Initiative from 2014 to 2022 to examine temporal trends.

RESULTS

A total of 5826 repairs were performed during the study period: 1895 ZFEN, 3241 PMEG, 595 parallel grafting, and 95 where parallel grafting was used in addition to ZFEN, with a mean of 2.7 ± 0.98 vessels incorporated. Over time, the number of PMEGs steadily increased, both overall and for juxtarenal aneurysms, whereas the number of ZFENs essentially leveled off by 2017 and has remained steady ever since. In the most recent complete year (2021), PMEGs outnumbered ZFENs by over 2:1 overall (567 to 256) and nearly twofold for juxtarenal repairs. In three-vessel cases involving juxtarenal aneurysms, PMEGs were used as frequently as ZFENs (43% vs 43%), whereas the proportion of juxtarenal aneurysms repaired using a four-vessel graft configuration increased from 20% in 2014 to 29% in 2021 (P < .001). The differences in PMEG use were more pronounced as surgeon volume increased. Surgeons in the lowest quartile of volume performed <2 complex repairs annually, evenly split between PMEGs and ZFENs. However, surgeons in the highest quartile of volume performed a median of 18 (interquartile range: 10-21) PMEGs/y, but only 1.6 (interquartile range: 0.8-3.4) ZFENs/y. The number of physician-sponsored investigational device exemption trials of PMEGs has expanded from 1 in 2012 to 8 currently enrolling. As those data are not included in the Vascular Quality Initiative, the true number of PMEGs is likely substantially higher.

CONCLUSIONS

PMEGs have become the dominant endovascular repair modality of complex abdominal and thoracoabdominal aortic aneurysms outside of investigational device exemptions. The field of endovascular aortic surgery and patients with complex aneurysms would benefit from broader publication of PMEG techniques, outcomes, and comparisons to custom-manufactured grafts.

A Case of Anaphylactic Shock Suspected to Be Caused by Bovine Serum Albumin Tissue Adhesive (BioGlue) During Thoracoabdominal Aortic Replacement

Bovine serum albumin (BSA) tissue adhesive (BioGlue, Cryolife Inc., Kennesaw, GA, USA) is often used as a hemostatic adjunct in adult patients undergoing open surgical repair of large vessels, such as the aorta, femoral, and carotid arteries. We present a case of intraoperative anaphylaxis attributed to the use of BioGlue during thoracoabdominal aortic replacement. The patient suddenly developed hypotension, hypoxemia, and airway edema after the BioGlue application. BioGlue is composed of purified BSA and glutaraldehyde. Despite the BSA component being an allergen that can cause anaphylaxis in some patients, reported occurrences of anaphylaxis are extremely rare. We need to recognize BSA tissue adhesive as a potential allergen. In the event of an intraoperative shock, prompt recognition and investigation of the underlying cause are necessary.

Long-term outcomes of thoracic endovascular aortic repair for the treatment of descending thoracic aortic aneurysms: a systematic review and meta-analysis

INTRODUCTION

We undertook a systematic review of the currently published literature on TEVAR for DTAAs and we combined the eligible studies into a meta-analysis with the intention of evaluating the efficacy and the long-term durability of this treatment option.

EVIDENCE ACQUISITION

A systematic search of the literature from January 2015 up to December 2022 was performed according to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. For events during follow-up we calculated the incidence rates (IRs) with 95% confidence intervals (95% CIs) per 100 patient-years (p-ys) as the number of patients with outcome events occurring during the specific time period divided by the total number of p-ys.

EVIDENCE SYNTHESIS

A total of 4127 study titles were identified by the initial search strategy, of which 12 were considered eligible for inclusion in the meta-analysis. A Total of 1976 patients (62% male) were identified among the eligible studies. One-year survival was 90.1% (95% CI 86.3% to 93.0%), 3-year survival was estimated at 80.5% (95% CI 69.2% to 88.4%) and the 5-year survival was estimated at 73.2% (95%CI 64.3% to 80.5%) with significant heterogeneity among studies regarding these outcomes. Regarding freedom from reintervention analysis for 1 year and 5 years was 96.5% (95% CI 94.5% to 97.8%) and 85.4% (95% CI 56.7% to 96.3%) respectively. The pooled late complications IR per 100 p-ys was 55.0 (95% CI 39.1 to 70.9), whereas the pooled IR for late reinterventions per 100 p-ys was 21.2 (95% CI 26.0 to 87.5). Late type I endoleak was reported with a pooled IR of 26.7 per 100 p-ys (95% CI 19.8 to 33.6) and late type III endoleak with a pooled IR of 7.6 per 100 p-ys (95% CI 5.5 to 9.7).

CONCLUSIONS

TEVAR presents a safe and feasible solution for the treatment of DTAA with sustained long-term effectivity. Current evidence supports a satisfactory 5-year survival with low rates of reinterventions.

Outcomes of Staged Repairs of Complex Endovascular Repairs of Thoracoabdominal Aortic Aneurysms

BACKGROUND

Endovascular treatment allows for the staging of thoracoabdominal aortic aneurysm repairs (eTAAAs) in an effort to decrease the risk of spinal cord ischemia (SCI), but data are limited.

METHODS

We studied all eTAAAs in the Vascular Quality Initiative from 2014 to 2021. Inverse probability weighting was used to compare perioperative and long-term outcomes of staged and single-stage repairs. Thoracoabdominal life-altering events (TALEs) are the composite endpoint consisting of death/stroke/permanent SCI/permanent dialysis.

RESULTS

There were 3,258 total operations during the study period. In total, 841 cases (26%) were staged repairs, and 2,417 (74%) were completed in a single stage, but in the cohort of patients with extensive aneurysms, 44% were staged. Staging methods included thoracic endograft (78%), branch (23%), and iliac (5%). Staged repairs were more often employed by high-volume surgeons at high-volume centers; for larger, more extensive aneurysms, with higher rates of prior aortic surgery. After adjustment, staged repair and single-stage treatment were associated with similar odds of all perioperative outcomes and including mortality, TALE, acute kidney injury, stroke, dialysis, and SCI, as well as long-term survival. This was consistent in the subgroups of patients with extensive aneurysms undergoing elective procedures. Of note, first-stage thoracic endografts were associated with 2.6% mortality, 7.3% TALE, 1.5% dialysis, and 4.1% SCI, and 25% of patients did not undergo a second stage. First-stage procedures accounted for one-third of perioperative complications including half of the deaths in the staged cohort.

CONCLUSIONS

Staged eTAAA repairs were associated with similar perioperative and long-term complications to single-stage treatments. However, first stage procedures are associated with significant morbidity and mortality, and one-quarter of patients never complete their repairs. These data demonstrate the necessity of evaluating the outcomes of all patients planned for staged procedures, not only those who make it to the final stage. More data are needed as to the optimal method of spinal cord protection for these challenging aneurysms.

Preparing the spinal cord - priming or preconditioning? A systematic review of experimental studies

Objectives. Paraplegia is devastating complication associated with thoracic and thoracoabdominal aortic aneurysm repair. Vast evidence has been gathered on pre-, peri- and postoperative protective adjuncts aiming to minimize spinal cord ischemia. This review focuses on the pretreatment phase of open surgical or endovascular aortic procedures and gathers the experimental data on the interventional preconditioning and priming methods that increase the spinal cord ischemic tolerance. Design. By the start of March 2021, a systematic review was performed in PubMed, Scopus and Web of Science core collection to identify the articles that reported (i) either an ischemic preconditioning, remote ischemic preconditioning or priming method prior to (ii) experimental spinal cord ischemia performed in endovascular or open surgical fashion mimicking either thoracic, abdominal or thoracoabdominal aortic aneurysm procedures. (iii) The outcomes were reported via neurological, motor-evoked potential, somatosensory-evoked potential, histopathological, immunohistochemical, physiological analysis, or in different combinations of these measurements. Results. The search yielded 7802 articles, and 57 articles were included in the systematic review. The articles were assessed by the evaluated species, the utilized pretreatment, the measured protective effects, and the suggested underlying mechanisms. Conclusions. The reviewed articles showed several possible mechanisms in ischemic and remote ischemic preconditioning for prevention of spinal cord ischemia. The main suggested method for priming was arteriogenetic stimulus. Future studies should confirm these hints of arteriogenetic stimulus with more precise quantification of the protective recruitment process.

Changes in treatment patterns of thoracoabdominal aortic aneurysms in the United States

Background

The introduction of endovascular repair provides an alternative to traditional open repair of thoracoabdominal aortic aneurysms (TAAA). Its utility is not well defined, however. Using a national database, we studied the treatment patterns and outcomes of TAAA to gain insight into its contemporary surgical practice in the United States.

Methods

Records of TAAA patients who received endovascular and open repair were retrieved from the 2002 to 2018 National Inpatient Sample database. Each cohort was stratified into 4 age groups: ≤50, 51 to 60, 61 to 70, and >70 years. Patient characteristics and in-hospital outcomes were compared between the 2 repair modalities. Temporal trends were investigated.

Results

Endovascular repair use increased steadily, whereas open repair volume remained stable until 2012, before declining by 50% by 2018. This appears to be associated with a declining number of open repairs in patients age >60 years. Patients who underwent endovascular repair were older and had a higher Charlson Comorbidity Index (mean, 2.8 ± 1.7 vs 2.5 ± 1.5; P < .001) but lower in-hospital mortality (mean, 8.9% vs 17.1%; P < .001), shorter length of stay (mean, 10.1 ± 12.2 days vs 17.1 ± 17.4 days; P < .001), and fewer postoperative complications. A difference in mortality between open and endovascular repair was observed for patients age >60 years but not for patients age ≤60 years.

Conclusions

There has been a shift in the treatment of TAAA in the United States from open repair-dominant to endovascular repair-dominant. It has increased surgical access for older and more comorbid patients and has led to a decline in the use of open repair while lowering in-hospital mortality.

Simultaneous upper and lower body perfusion using hypothermia during thoracoabdominal aortic surgery

BACKGROUND

In open thoracoabdominal aortic aneurysm (TAAA) repair, we have been performing vascular reconstruction under moderate to deep hypothermia and assisted circulation using simultaneous upper and lower body perfusion. This method is effective for protecting the spinal cord and the brain, heart, and abdominal organs and for avoiding lung damage.

METHODS

TAAA repair was performed under hypothermia at 20-28 °C in 18 cases (Crawford type I in 0 cases, type II in 5, type III in 3, type IV in 4, and Safi V in 6) between October 2014 and January 2023. Cardiopulmonary bypass was conducted by combined upper and lower body perfusion, with perfusion both via the femoral artery and either transapically or via the descending aorta or the left brachial artery.

RESULTS

The ischemic time for the artery of Adamkiewicz and the main segmental arteries was 40-124 min (75 ± 33 min). No spinal cord ischemic injury or brain or heart complications occurred. One patient with postoperative right renal artery occlusion and one with an infected aneurysm required tracheostomy, but the intubation time for the other 16 was 32 ± 33 h. The duration of postoperative intensive care unit stay was 6.5 ± 6.2 days, the length of hospital stay was 29 ± 15 days, and no in-hospital deaths occurred.

CONCLUSIONS

Simultaneous upper and lower body perfusion under moderate to deep hypothermia during thoracoabdominal aortic surgery may avoid not only spinal cord injury, but also cardiac and brain complications.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Outcomes of open repair for descending thoracic and thoracoabdominal aortic aneurysm in recent 10 years: experience of a high-volume centre in Korea

OBJECTIVES

Although recent studies and guidelines suggest the preferred outcomes after surgical repair of thoracic aortic aneurysm (TAA) and thoracoabdominal aortic aneurysm (TAAA), published results are limited to those from high-volume hospitals and based on old data gathered before optimal management was established. Here, we analysed our outcomes over the previous 10 years from cases of open TAA and TAAA repair to offer updated and real-world results of those complex procedures performed in a high-volume centre.

METHODS

From November 2013 to April 2022, 212 consecutive adult patients who underwent open TAA and TAAA repair were enrolled. We analysed early and late outcomes after surgery, including postoperative complications and mortality.

RESULTS

There were 154 (73%) men, and the median age at surgery was 61 years. Intraoperative death occurred in 1 patient due to uncontrolled bleeding. Nine patients (4%) died during follow-up, and the survival estimates at 5 years were 94 ± 3% and 95 ± 3% after descending TAA and TAAA repair, respectively. Ten patients (4%) suffered from spinal cord ischaemic injury (9 with paraplegia and 1 with paresthesia), but permanent paraplegia persisted in only 1 case.

CONCLUSIONS

We report very low postoperative complication rates and excellent early and late survival rates after open TAA and TAAA repair from our recent 10-year data analysis. These findings may assist when choosing treatment options for these complicated diseases.

Suitability of current off-the-shelf devices for endovascular TAAA repair: a systematic review

INTRODUCTION

The aim of the present study is to perform a systematic review of published papers regarding the suitability of the current off-the-shelf (OTS) devices for endovascular thoracoabdominal aortic aneurysm (TAAA) repair.

EVIDENCE ACQUISITION

A systematic review of the MEDLINE database via PubMed was performed in March 2023. All studies reporting the outcomes of the three currently available OTS stent-grafts: the Zenith t-Branch (Cook Medical, Bloomington, IN, USA), the Gore Excluder thoracoabdominal branch endoprosthesis (TAMBE; W.L. Gore & Associates, Flagstaff, AZ, USA) and the E-nside Multibranch Stent-Graft System (Artivion, Kennesaw, GA, USA), were retrieved and further analyzed. The main endpoints were technical success, reintervention rate, and primary branch patency. Theoretical feasibility studies of these OTS devices were also included and separately analyzed.

EVIDENCE SYNTHESIS

A total of 19 studies were published between 2014 and 2023. Thirteen clinical studies and six theoretical feasibility studies were included. Eleven studies reported the clinical outcomes of the t-Branch stent-graft, one detailed the observational results of the use of the E-nside endoprosthesis, and one described the TAMBE stent-graft results. The following data primarily involve the t-Branch device outcomes. A total of 1131 patients that underwent aneurysm repair using an OTS stent-graft were identified. Among those, 1002, 116 and 13 patients received a t-Branch, E-nside, and TAMBE stent-grafts, respectively. A total of 767 (67.8%) were men, with a mean age of 71.6±7.4 years old, and a mean Body Mass Index (BMI) of 26.3±3.8 kg/m2. Technical success ranged from 64% to 100%. A total of 4172 target visceral vessels (TVV) were planned for bridging, with a success rate ranging from 92 to 100%. The total of early and late reinterventions reported were 64 and 48, respectively, mainly due to endoleaks and visceral branch occlusions. Among the theoretical feasibility studies, six described the feasibility of the t-Branch device in a total of 661 patients, two described the E-nside and the TAMBE devices feasibility comprising 351 patients for each stent-graft. The overall feasibility of the t-Branch device varied from 39% to 88%, the E-nside from 43% to 75%, and the TAMBE stent-graft ranged from 33% to 94%.

CONCLUSIONS

This systematic review demonstrated a good suitability for the use of OTS endografts for the treatment of TAAA.

Urgent and emergent repair of complex aortic aneurysms using an off-the-shelf branched device

Introduction

Endovascular repair using off-the-shelf endografts is a viable solution in patients with ruptured or symptomatic complex aortic aneurysms. This analysis aimed to present the peri-operative and follow-up outcomes in urgent and emergent cases managed with the t-Branch multibranched thoracoabdominal endograft.

Methods

Prospectively collected data from all consecutive urgent and emergent cases managed in two aortic centers between January 1st, 2014, to November 30th, 2022, using the t-Branch device (Cook Medical Inc., Bjaeverskov, Denmark) were analyzed. Patients presenting with ruptured aortic complex aneurysms were characterized as emergent and patients with aneurysms >90 mm of diameter, or symptomatic aneurysms were characterized as urgent. Technical success, 30-day mortality, major adverse events (MAE) and spinal cord ischemia (SCI) rates were assessed.

Results

225 patients (36.5% females, 72.5 ± 2.8 years) were included; 73.0% were urgent. The mean aneurysm diameter was 109 ± 3.9 mm and 44.4% were type I-III TAAAs. Females (p = .03), para-renal aneurysms (p = .02) and ASA score IV (p < .001) were more common in emergent cases. Technical success was 97.8%. Thirty-day mortality and MAE rates were 17.8% and 30.6%, respectively. SCI rate was 14.7%, (4.8% paraplegia rate) with 22.2% of patients receiving prophylactic cerebrospinal drainage. Thirty-day mortality (13.3% vs. 26.7%, p = .04) and MAE (26.0% vs. 43.0%, p = .02) were more common among emergent cases while technical success (97.6% vs. 98.3%, p = .9), and SCI (13.3% vs. 18.3%, p = .4) were similar. Survival at 12-months was 83.5% (SE 5.9%) for the urgent and 77.1% (SE 8.2%) for the emergent group (log rank, p = 0.96).

Conclusion

T-Branch represents an effective and safe solution for the management of urgent and emergent cases with complex aortic aneurysms, with high technical success, promising early mortality and SCI rates.

Transcatheter arterial embolization of a type 2 endoleak through the dorsal pancreatic artery after the hybrid repair of a thoracoabdominal aortic aneurysm: A case report

An 83-year-old woman with a history of hybrid repair of thoracoabdominal aortic aneurysm presented with enlargement of the aneurysm due to a type 2 endoleak from the celiac artery. The endoleak cavity was accessed via the dorsal pancreatic artery, and embolization using N-butyl cyanoacrylate and coils was successfully performed. When celiac artery branches are embolized during hybrid repair of a thoracoabdominal aortic aneurysm, attention should be paid to the dorsal pancreatic artery to appropriately determine which branches are to be embolized, because a nonembolized dorsal pancreatic artery may lead to type 2 endoleaks.

Outcomes of Complex Endovascular Treatment of Post-Dissection Aneurysms

OBJECTIVE

Reports of endovascular treatment of chronic post-dissection aneurysms are limited to high volumes centres, posing questions about generalisability.

METHODS

All endovascular repairs of intact pararenal and thoraco-abdominal aneurysms in the Vascular Quality Initiative from 2014 to 2021 were studied, and peri-operative and long term outcomes were compared between repairs of degenerative and post-dissection aneurysms. Peri-operative outcomes were compared using mixed effects logistic regression, and long term outcomes using Medicare linkage.

RESULTS

There were 123 patients who completed treatment for post-dissection aneurysms and 3 635 for degenerative aneurysms, with 36% of post-dissection repairs and 6.7% of degenerative repairs performed in a staged fashion (p < .001). The majority (84%) of post-dissection aneurysms were extensive thoraco-abdominal aneurysms (TAAAs: Crawford Type 1, 2, 3, 5), compared with 22% of degenerative aneurysms (p < .001). Physician modified endografts were the primary repair type for post-dissection (73%), while commercially available fenestrated grafts were the dominant repair for degenerative (48%). The first stage of staged procedures was associated with a 2.8% peri-operative mortality rate, 5.1% spinal cord ischaemia, and 8.9% thoraco-abdominal life altering events (the composite of peri-operative death, stroke, permanent spinal cord ischaemia, and dialysis). Th final stage procedure and fluoroscopy times were similar, but technical success was lower in post-dissection repairs (75% vs. 83%, p = .018), both due to issues with the main endograft or bridging vessels (11% vs. 6.6%, p = .055), and types 1and 3 endoleak at completion (17% vs. 10%, p = .035). In addition, high volume surgeons had two fold higher odds of technical success than their low volume counterparts. Adjusted peri-operative outcomes were similar between pathology types, including when comparisons were restricted to extensive TAAAs. Crude and adjusted three year survival were similar, but three year re-interventions were significantly higher following post-dissection repairs (p < .001).

CONCLUSION

Complex endovascular repair of chronic post-dissection aneurysms is feasible but is associated with high rates of re-interventions and non-trivial rates of lack of technical success. More data are needed to evaluate the long term durability of these procedures, and the utility of centralising these complex procedures.

Comparative Effectiveness of Treatment Modalities for Complex Aortic Aneurysms: A Network Meta-Analysis of Observational Studies

BACKGROUND

To conduct a network meta-analysis comparing multiple treatments for complex aortic aneurysms (CAAs).

METHODS

Medical databases were searched on November 11, 2022. Twenty-five studies (5,149 patients) and four treatments (open surgery [OS], chimney/snorkel endovascular aneurysm repair [CEVAR], fenestrated endovascular aneurysm repair [FEVAR], and branched endovascular aneurysm repair) were selected. Outcomes were branch vessel patency, mortality, and reintervention at short- and long-term followup, and perioperative complications.

RESULTS

Regarding branch vessel patency, OS was the most effective treatment and had higher 24-month branch vessel patency rates than CEVAR (odds ratio [OR], 10.77; 95% confidence interval [CI], 2.08-55.79). FEVAR (OR, 0.52; 95% CI, 0.27-1.00) and OS (OR, 0.39; 95% CI, 0.17-0.93) were better than CEVAR regarding 30-day mortality and 24-month mortality, respectively. Regarding 24-month reintervention, OS was better than CEVAR (OR, 3.07; 95% CI, 1.15-8.18) and FEVAR (OR, 2.48; 95% CI, 1.08-5.73). Regarding perioperative complications, FEVAR had lower acute renal failure rates than OS (OR, 0.42; 95% CI, 0.27-0.66) and CEVAR (OR, 0.47; 95% CI, 0.25-0.92) and lower myocardial infarction rates than OS (OR, 0.49; 95% CI, 0.25-0.97) and was the most effective treatment in preventing acute renal failure, myocardial infarction, bowel ischemia, and stroke, while OS was the most effective treatment in preventing spinal cord ischemia.

CONCLUSIONS

OS might have advantages regarding branch vessel patency, 24-month mortality, and reintervention and is similar to FEVAR regarding 30-day mortality. Regarding perioperative complications, FEVAR might confer advantages in preventing acute renal failure, myocardial infarction, bowel ischemia, and stroke, and OS in preventing spinal cord ischemia.

Outcomes following Management of Complex Thoracoabdominal Aneurysm by an Open Approach

BACKGROUND

In the last decade, advances in surgical techniques, and the introduction of adjuncts for organ protection, have modified the approach for thoracoabdominal aortic aneurysm (TAAA) surgical repair. The aim of this study is to determine whether the contemporary approach influenced the outcomes.

METHODS

From 1989 to 2022, patients who had received elective open surgical repair (OSR) for TAAA at our institution were retrospectively analyzed. This series has been divided in two groups: Group 1 (1989-2009), and Group 2 (2010-2022). Patients included in Group 1 were those treated with a selective use of adjuncts, and Group 2 included patients treated with the systematic use of adjuncts.

RESULTS

A total of 1107 patients were treated (Group 1: 455; Group 2: 652). The surgical management was significantly different between the two groups. The in-hospital mortality was significantly different between the two groups (Group 1: 13.4%, Group 2: 8.1%; p 0.004), as was the rate of permanent spinal cord ischemia (Group 1: 11.9%, Group 2: 7.8%; p 0.023). Renal and respiratory failure were reduced in Group 2, but not significantly.

CONCLUSIONS

The use of the adjuncts enabled the achievement of improvement in mortality and SCI prevention in TAAA OSR. Although a refined surgical technique, mortality and morbidity are still noteworthy in this complex aortic field.

Mouse Model of Spinal Cord Hypoperfusion with Immediate Paralysis Caused by Endovascular Repair of Thoracic Aortic Aneurysm

BACKGROUND

A clinically relevant mouse model of thoracic endovascular aortic repair-induced ischemic spinal cord injury has been lacking since the procedure was first employed in 1991. The hypothesis was that ligation of mouse intercostal arteries would simulate thoracic endovascular aortic repair-induced ischemic spinal cord injury and behavioral deficit. The aim was to create a mouse model of thoracic endovascular aortic repair-induced spinal cord hypoperfusion by ligating five pairs of mouse intercostal vessels.

METHODS

Mice were divided into sham (n = 53) and ligation (n = 60) groups. The procedures called for double ligation of three pairs and single ligation of two pairs of thoracic intercostal arteries in adult C57BL/6 mice. A laser Doppler probe was used in vivo on the spinal cords and intercostal arteries to document the extent of arterial ligation and spinal cord hypoperfusion. The Basso Mouse Scale for Locomotion, histological studies, and electron microscopy demonstrated postligation locomotive and histopathological changes.

RESULTS

Ligation induced a significant and instantaneous drop in blood flow in the intercostal arteries (% change; mean = -63.81; 95% CI, -72.28 to -55.34) and the thoracic spinal cord (% change; mean = -68.55; 95% CI, -80.23 to -56.87). Paralysis onset was immediate and of varying degree, with behavioral deficit stratified into three groups: 9.4% exhibited severe paralysis, 37.5% moderate paralysis, and 53.1% mild paralysis at day 1 (n = 32; P < 0.001). Mild and moderate paralysis was transient, gradually improving over time. Severe paralysis showed no improvement and exhibited a higher mortality rate (83%; n = 15 of 18) compared to moderately (33%; n = 6 of 18) and mildly (24%; n = 6 of 25) paralyzed mice (P < 0.001). The overall ligation group survival rate (84%; n = 46 of 55) was significantly lower than the sham group (100%; n = 48 of 48) with P = 0.003.

CONCLUSIONS

The mouse model generates reproducible spinal cord hypoperfusion and accompanying histopathological ischemic spinal cord damage. The resulting anatomical changes and variable behavioral deficits mimic the variability in radiological and clinical findings in human patients.

EDITOR’S PERSPECTIVE

Effect of Sarcopenia on Mortality and Spinal Cord Ischaemia After Complex Aortic Aneurysm Repair: Systematic Review and Meta-Analysis

OBJECTIVE

Sarcopenia has been related to higher mortality rates after abdominal aortic aneurysm repair. This analysis aimed to assess sarcopenia related mortality and spinal cord ischaemia (SCI) at 30 days, and mortality during the available follow up, in patients with complex aortic aneurysms, managed with open or endovascular interventions.

DATA SOURCES

A search of the English literature, via Ovid, using Medline, EMBASE, and CENTRAL up to 15 June 2022 was done.

REVIEW METHODS

This meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines and preregistered in PROSPERO (CRD42022338079). Observational studies (2000 - 2022), with five or more patients, reporting on sarcopenia related mortality and SCI at 30 days, and midterm mortality after thoraco-abdominal aneurysm repair (open or endovascular), were eligible. The ROBINS-I tool (Risk Of Bias In Non-Randomised Studies of Interventions) was used for risk of bias, and GRADE (Grading of Recommendations, Assessment, Development and Evaluation) for the assessment of evidence quality. The primary outcome was 30 day and midterm mortality, and the secondary outcome was SCI at 30 days, in sarcopenic and non-sarcopenic patients. The outcomes were summarised as odds ratio (OR) with 95% confidence intervals (CIs).

RESULTS

Four retrospective studies (1 092 patients; 40.0% sarcopenic) were included. Thirty day mortality was similar, with low certainty between groups (6% [95% CI 1 - 11] in sarcopenic vs. 5% [95% CI 1 - 9] non-sarcopenic patients [OR 0.30, 95% CI -0.21 - 0.81; p = .94, Ι2 = 0%). The estimated midterm mortality was statistically significantly higher (very low certainty) in sarcopenic patients (25% [95% CI 0.19 - 0.31] vs. 13% [95% CI -0.03 - 0.29] in non-sarcopenic patients (1.11 OR 0.95, 95% CI -0.21 - 2.44; p < .001, Ι2 = 88.32%). SCI was significantly higher (very low certainty) in sarcopenic patients (19%, 95% CI 4 - 34) vs. 7% (95% CI 5 - 20) in non-sarcopenic patients (OR 1.80, 95% CI -0.17 - 3.78; Ι2 = 82.4%), despite an equal distribution of aneurysm type between the groups.

CONCLUSION

Early mortality does not appear to be affected by sarcopenia in patients treated for thoraco-abdominal aneurysms. However, sarcopenia may be associated with higher peri-operative SCI and midterm mortality rates.

The Feasibility of Debranching Aortic Arch and Visceral Arteries with Sutureless Telescoping Anastomoses During Open Aortic Aneurysm Repair

Background

Open repair of aortic aneurysms frequently requires reimplantation of major aortic vessels. Traditional techniques can be time consuming, require meticulous hemostasis, and risk aneurysmal patch degeneration, which can require a challenging reoperation. We describe our experience using a stent graft to create a sutureless anastomosis that obviates these drawbacks.

Methods

Between April 2018 and March 2021, all consecutive adult patients who underwent open repair of the aorta with at least one supra-aortic trunk or visceral vessel reimplanted using the sutureless anastomotic technique were included. Anastomoses were constructed by bridging a branch graft and the target artery with a Viabahn self-expanding stent (W.L. Gore & Associates, Flagstaff, AZ). Clinical information and perioperative outcomes for the patients were collected and analyzed.

Results

Among 26 patients, 50 individual aortic vessels were debranched using sutureless self-expanding stent anastomoses, including 42 visceral vessels and 8 supra-aortic trunk vessels. Technical success was 100%. The median time to complete the anastomosis was 3 minutes, 12 seconds (range, 2-6 minutes). Perioperative mortality was 15% (n = 4). No stent-related complications, such as occlusion, bleeding, stroke, renal failure requiring hemodialysis, bowel ischemia, or the need for anastomotic reintervention, occurred. Follow-up imaging at 1 year revealed a 100% patency rate and no anastomotic stenosis, misalignment, or kinking.

Conclusions

The sutureless anastomosis technique to debranch the aorta during open aortic aneurysm repair is technically feasible and reliably hemostatic and does not require early reintervention. The operative outcomes have been acceptable, and the short-term follow-up imaging findings demonstrated excellent patency without anastomotic kinking. In select cases, sutureless anastomoses are a possible alternative to traditional sutured anastomoses during aortic debranching. Further research is needed to compare the operative times and long-term patency of sutureless anastomosis to those of traditional sutured techniques.

Renal perfusion with histidine-tryptophan-ketoglutarate compared with Ringer's solution in patients undergoing thoracoabdominal aortic open repair

OBJECTIVE

The objective of this study was to compare the efficacy of renal perfusion with Custodiol (Dr Franz-Kohler Chemie GmbH, Bensheim, Germany) versus enriched Ringer's solution for renal protection in patients undergoing open thoracoabdominal aortic aneurysm (TAAA) repair.

METHODS

Ninety consecutive patients scheduled for elective open TAAA repair were enrolled between 2015 and 2017 in a single-center, phase IV, prospective, parallel, randomized, double-blind trial (the CUstodiol versus RInger: whaT Is the Best Agent [CURITIBA] trial), and randomized to renal arteries perfusion with 4°C Custodiol (Dr Franz-Kohler Chemie GmbH, Bensheim, Germany; n = 45) or 4°C lactated Ringer's solution (n = 45). The incidence of acute kidney injury (AKI) in patients undergoing TAAA open surgery using Custodiol renal perfusion versus an enriched Ringer's solution was the primary end point.

RESULTS

Ninety patients completed the study (45 patients in each group). The incidence of postoperative AKI was significantly lower in the Custodiol group (48.9% vs 75.6%; P = .02). In the multivariable model, only the use of Custodiol solution resulted as protective from the occurrence of any AKI (odds ratio, 0.230; 95% confidence interval, 0.086-0.614; P = .003), whereas TAAA type II extent was associated with the development of severe AKI (odds ratio, 4.277; 95% confidence interval, 1.239-14.762; P = .02). At 1-year follow-up, serum creatinine was not significantly different from the preoperative values in both groups.

CONCLUSIONS

The use of Custodiol during open TAAA repair was safe and resulted in significantly lower rates of postoperative AKI compared with Ringer's solution. These findings support safety and efficacy of Custodiol in this specific setting, which is currently off-label.

A comparison of thoracoabdominal aortic aneurysms open repair in patients with or without "shaggy aorta"

OBJECTIVE

In the field of thoracoabdominal aortic aneurysm (TAAA) open surgical repair (OSR), some preoperative characteristics are established risk factors for adverse outcomes, whereas others are supposed to be relevant, but their role still need to be defined; among them, the presence of "shaggy aorta" (SA), an extensive and irregular atheroma within the aorta. The aim of this study is to report the results of a single-center large cohort of patients treated with OSR for TAAA with SA, comparing the outcomes with patients affected by TAAA without SA, and analyzing the impact of the scores for SA on the outcomes.

METHODS

All consecutive patients receiving OSR for TAAA between 2012 and 2021 were retrospectively analyzed. Clinical data from patients with degenerative TAAA were included and analyzed for preoperative characteristics and postoperative outcomes; patients with ruptured TAAA, and patients with aortic dissection were excluded from the analysis. Patients with degenerative aortic aneurysm, thrombus measurement in non-aneurysmal aortic segments (≤40 mm), atheroma thickness ≥5 mm, and finger-like thrombus projection were included in the SA group, whereas the others were included in the non-shaggy aorta group (NSA group). The SA group and NSA group were compared using a propensity-matched comparison. Preoperative computed tomography scans of patients in the SA group were also stratified according to SA grading scores.

RESULTS

A total of 58 patients with SA were identified (male, n = 43 [74.1%], mean age 70.1 ± 7.8 years) among 497 patients with TAAA treated with open surgical repair. After propensity matching, there were 57 patients in the SA group and 57 in the NSA group with correction of all differences in baseline characteristics. Patients in the SA group presented significantly higher in-hospital mortality (SA group, 14.0% vs NSA group, 3.5%; P = .047), postoperative acute renal failure (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease [RIFLE], 3-5) (SA group, 21.1% vs NSA group, 5.3%; P = .013), and postoperative embolization (SA group, 28.1% vs NSA group, 8.8%; P = .008). Spinal cord ischemia and stroke rate were not significantly influenced by the presence of SA. In the SA group, 16 patients (27.6%) with end-organ embolization were compared with 42 patients (72.4%) without a documented embolization considering the grade of aortic "shagginess" and no significant difference was identified (P = .546).

CONCLUSIONS

Despite a better knowledge of the SA disease, new classifications, and intraoperative adjuncts, TAAA patients with SA treated with OSR have worse postoperative outcomes if compared with patients without SA. The presence of SA is a risk factor itself, whereas the grade of "shagginess" seems not to impact on postoperative outcomes.

28-Year Experience with Ruptured and Symptomatic Type I-III Thoracoabdominal Aortic Aneurysms at a Large Tertiary Referral Center

BACKGROUND

Given the relative rarity of ruptured and symptomatic type I-III thoracoabdominal aortic aneurysms (TAAA), data is scarce with regard the outcomes of those who survive to repair. The goal of this study was to determine short and long-term outcomes after open repair of type I-III TAAA surgery for ruptured and symptomatic TAAA and compare the results to elective TAAA repairs.

METHODS

All open type I-III TAAA repairs performed from 1987 to 2015 were evaluated using an institutional database. Charts were retrospectively evaluated for perioperative outcomes: major adverse event (MAE), in-hospital death, spinal cord ischemia (SCI) and long-term survival. Ruptured, symptomatic and elective repair cohorts were created for comparison. Univariate analysis was performed using the Fisher's exact test for categorical variables and analysis of variance (ANOVA) for continuous variables. Logistic regression was used for in-hospital endpoints; survival analysis was performed with Cox proportional hazards modelling and Kaplan-Meier techniques.

RESULTS

Five hundred-sixteen patients had an open type I-III TAAA repair during the study period. Fifty-nine (11.4%) were performed for rupture and 51 (9.9%) were performed for symptomatic aneurysms (RAs). Ruptured and symptomatic groups were more likely to be older, female, and have larger presenting aortic diameters. Most of the ruptured and symptomatic cases were transferred from an outside facility (59.3% and 54.9%, respectively). Intraoperatively, the elective cohort was more likely to receive left heart bypass as an operative adjunct; ruptures were less likely to receive a renal bypass, and operative time was highest for the elective cohort. Perioperative mortality was 18.6% for ruptured, 2.0% for symptomatic, and 7.4% for elective indications. Ruptures were most likely to require new hemodialysis after repair (20.3% vs. 10.3% for elective, P = 0.02). On adjusted analysis, ruptures were more likely to suffer from perioperative death (adjusted odds ratio [AOR]: 4.5, 95% confidence interval (CI): 1.7-11.4) and MAEs (AOR: 2.8, 95% CI: 1.4-5.4). Ruptured and symptomatic aneurysms were not independently associated with SCI; however, preoperative hemodynamic instability was predictive (AOR: 8.7, 95% CI: 1.7-44.2). Both rupture and symptomatic cases were associated with decreased survival on Kaplan-Meier analysis with 5-year survival for ruptures at 35%, symptomatic at 47.7% and elective at 63.7%, P < 0.001. Adjusted hazards of death were 1.2 (95% CI: 0.9-1.8) in the symptomatic cohort and 2.3 (95% CI: 1.5-3.7) in the ruptured cohort.

CONCLUSIONS

Open ruptured and symptomatic type I-III TAAA repairs can be performed with acceptable morbidity and mortality. Most symptomatic and rupture repairs were performed after transfer from another institution. Postoperative SCI is most strongly related to the preoperative hemodynamic status of the patient.

Intraoperative Hemoadsorption (Cytosorb™) during Open Thoracoabdominal Aortic Repair: A Pilot Randomized Controlled Trial

BACKGROUND

The efficacy of cytokine adsorption in controlling the early inflammation cascade after open thoracoabdominal aortic (TAAA) repair has not been investigated. The aim of this pilot randomized controlled trial was to assess the feasibility and effect of perioperative hemoadsorption during open TAAA repair.

METHODS

Patients scheduled for open TAAA repair with the use of cardiopulmonary bypass (CPB) were included. The patients were randomized the day before surgery to either intraoperative hemoadsorption during CPB or standard of care.

RESULTS

A total of 10 patients were randomly assigned to the intervention group, whereas the control group consisted of 17 patients (mean age of the total cohort, 51.1 ± 11.2 years, 67% male, 3 patients not randomized). The majority of baseline and perioperative characteristics were similar, and no device-related adverse events were reported. A trend to shorter ventilation times in the intervention group was observed (median 88 h vs. 510 h, p = 0.08, Δ422). Severe acute respiratory distress syndrome was significantly less in the intervention patients (p = 0.02).

CONCLUSIONS

This is the first pilot study showing that the intraoperative use of hemoadsorption in open TAAA repair patients may be feasible and safe, yet larger trials are needed to evaluate whether intraoperative hemoadsorption is associated with improved clinical outcomes.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Elephant trunk simplifies thoracoabdominal aortic aneurysm repair without impacting operative risk

BACKGROUND AND AIM

An open two-stage elephant trunk (ET) technique may aid in the technical ease of subsequent thoracoabdominal aortic aneurysm (TAAA) repair. We analyze whether the presence of an ET improves outcomes for patients undergoing extent I and II TAAA repair.

METHODS

From September 1997 to October 2020, 469 patients underwent extent I or II TAAA repair. We compared those with prior ET to those without. Primary outcome was composite major adverse events (MAE) including operative mortality, myocardial infarction, permanent spinal cord injury, cerebrovascular accident, need for tracheostomy, and new need for dialysis.

RESULTS

Thirty-eight (8.1%) patients had prior ET and 431 (91.9%) did not. There were no differences in baseline characteristics. The no ET group was more likely to undergo urgent or emergent procedures. Composite MAE occurred in 82 (19%) of the no ET group and 5 (15.8%) of the ET group (p = .785). Operative mortality was 5.5% and not significantly different between the groups (p = 1.00). No patients in the ET group experienced stroke or recurrent laryngeal nerve injury. Median partial bypass and cross-clamp times were significantly greater in the no ET group (28 [24-32] versus 19 [16-22] min; p ≤ .001 and 42 [32-53] versus 30 [25-39] min; p ≤ .001).

CONCLUSIONS

Extent I and II TAAA repair after ET can be safely performed in a tertiary referral center with shorter bypass and cross-clamp times. ET eliminates the need for circulatory arrest or clamping a hostile arch.

Results of the North American Complex Abdominal Aortic Debranching (NACAAD) Registry

BACKGROUND

Hybrid debranching repair of pararenal and thoracoabdominal aortic aneurysms was initially designed as a better alternative to standard open repair, addressing the limitations of endovascular repair involving the visceral aorta. We reviewed the collective outcomes of hybrid debranching repairs using extra-anatomic, open surgical debranching of the renal-mesenteric arteries, followed by endovascular aortic stenting.

METHODS

Data from patients who underwent hybrid repair in 14 North American institutions during 10 years were retrospectively reviewed. Society of Vascular Surgery scores were used to assess comorbidity risk. Early and late outcomes, including mortality, morbidity, reintervention, and patency were analyzed.

RESULTS

A total of 208 patients (118 male; mean age, 71±8 years old) were treated by hybrid repair with extraanatomic reconstruction of 657 renal and mesenteric arteries (mean 3.2 vessels/patient). Mean aneurysm diameter was 6.6±1.3 cm. Thoracoabdominal aortic aneurysms were identified in 163 (78%) patients and pararenal aneurysms in 45 (22%). A single-stage repair was performed in 92 (44%) patients. The iliac arteries were the most common source of inflow (n=132; 63%), and most (n=150; 72%) had 3 or more bypasses. There were 30 (14%) early deaths, ranging widely across sites (0%-21%). A Society of Vascular Surgery comorbidity score >15 was the primary predictor of early mortality (P<0.01), whereas mortality was 3% in a score ≤9. Early complications occurred in 140 (73%) patients and included respiratory complications in 45 patients (22%) and spinal cord ischemia in 22 (11%), of whom 10 (45%) fully recovered. At 5 years, survival was 61±5%, primary graft patency was 90±2%, and secondary patency was 93±2%. The most significant predictor of late mortality was renal insufficiency (P<0.0001).

CONCLUSIONS

Mortality after hybrid repair and visceral debranching is highly variable by center, but strongly affected by preoperative comorbidities and the centers' experience with the technique. With excellent graft patency at 5 years, the outcomes of hybrid repair done at centers of excellence and in carefully selected patients may be comparable (or better) than traditional open or even totally endovascular approaches. However, in patients already considered as high-risk for surgery, it may not offer better outcomes.

The application of modular multifunctional left heart bypass circuit system integrated with ultrafiltration in thoracoabdominal aortic aneurysm repair

Open thoracoabdominal aortic aneurysm (TAAA) repair is a complex and challenging operation with a high incidence of serious complications, and high perioperative mortality and morbidity. Left heart bypass (LHB) is a circulatory support system used to perfuse the distal aorta during TAAA operation, and the advantages of LHB include guaranteeing distal perfusion, reducing the use of heparin, and diminishing the risk of bleeding and postoperative neurological deficits. In China, the circuit for TAAA repair is deficient, and far from the perfusion requirements. We designed a modular multifunctional LHB circuit for TAAA repair. The modular circuit consisted of cannulation pipelines, functional consumables connection pipelines, and accessory pipelines. The accessory pipelines make up lines for selective visceral perfusion and kidney perfusion, suckers and rapid infusion. The circuit can be assembled according to surgical requirements. The ultrafilter and heat exchanger are integrated into the circuit to fulfill the basic demands of LHB. The LHB circuit also has pipelines for selective visceral perfusion to the celiac artery and superior mesenteric artery and renal perfusion pipelines. Meanwhile, the reserved pipelines facilitate the quick switch from LHB to conventional cardiopulmonary bypass (CPB). The reserved pipelines reduce the time of reassembling the CPB circuit. Moreover, the rapid infusion was integrated into the LHB circuit, which can rapid infusion when massive hemorrhage during the open procedures such as exposure and reconstruction of the aorta. The ultrafiltration can diminish the consequent hemodilution of hemorrhage and rapid infusion. A hemoperfusion cartridge also can be added to reduce the systemic inflammatory during operation. The circuit can meet the needs of LHB and quickly switch to conventional CPB. No oxygenator was required during LHB, which reduce the use of heparin and reduce the risk of bleeding. The heat exchanger contributes to temperature regulation; ultrafiltration, arterial filter, and rapid-infusion facilitated the blood volume management and are useful to maintain hemodynamic stability. This circuit made the assembly of the LHB circuit more easily, and more efficient, which may contribute to the TAAA repair operation performed in lower volume centers easily. 26 patients who received TAAA repair under the modular multifunctional LHB from January 2018-March 2022 were analyzed, and we achieved acceptable clinical outcomes. The in-hospital mortality and 30-day postoperative mortality were 15.4%, and the postoperative incidences of paraparesis (4%), stroke (4%), and AKI need hemodialysis (12%) were not particularly high, based on the limited patients sample size in short research period duration.

Thoracoabdominal Aortic Disease and Repair: JACC Focus Seminar, Part 3

Thoracoabdominal aortic disease is a rare but life-threatening condition that requires expert multidisciplinary collaborative management. Intervention is indicated in patients with symptomatic aneurysms or when an aneurysm reaches a certain threshold of diameter or rate of expansion. The strategies for spinal cord and end-organ protection have evolved over several decades, resulting in improved outcomes after repair. Open repair, although invasive, provides definitive and durable repair. Endovascular approaches are rapidly evolving, and the results with fenestrated and branched endografts are promising. Both open repair and endovascular repair require highly specialized expertise, and outcomes are best when repair is undertaken in an elective setting by a dedicated team. Patients with degenerative thoracoabdominal aortic aneurysms and chronic dissections should be followed up closely and referred for elective repair when indicated.

A systematic review and meta-analysis of stroke rates in patients undergoing thoracic endovascular aortic repair for descending thoracic aortic aneurysm and type B dissection

OBJECTIVE

We performed a systematic review and meta-analysis to assess the stroke rates after thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysms and/or dissections.

METHODS

A systematic search of all the literature reported until September 2021 was performed according to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. The pooled perioperative stroke rates and corresponding 95% confidence intervals (CIs) were estimated using fixed or random effect methods.

RESULTS

A total of 878 study titles were identified by the initial search strategy, of which 43 were considered eligible for inclusion in the meta-analysis. A total of 5764 patients (63.5% male) were identified among the eligible studies. The pooled any stroke rate was 4.4% (95% CI, 3.60%-5.28%). However, after procedures without left subclavian artery (LSA) ostial coverage (eg, TEVAR deployed within or distal to zone ≥3), the stroke rate was 3.15% (95% CI, 2.21%-4.22%). For the patients with LSA coverage, the pooled stroke rate was 2.8% (95% CI, 1.69%-4.14%) for patients receiving left subclavian artery revascularization. However, the patients without LSA revascularization had a pooled estimated stroke incidence of 11.8% (95% CI, 5.85%-19.12%).

CONCLUSIONS

Stroke has been a common finding after TEVAR, especially with LSA coverage without revascularization, validating current clinical practice guidelines recommending routine revascularization, when feasible. Additional studies with larger patient numbers that provide separate data regarding the aortic pathology treated, the anatomic location of the stroke and their association with functional recovery and survival are needed.

Fenestrated and Branched Stent-Grafts for the Treatment of Thoracoabdominal Aortic Aneurysms: A Systematic Review and Meta-Analysis

Purpose

To investigate the safety and efficacy of total endovascular repair for thoracoabdominal aortic aneurysms (TAAAs) with fenestrated and branched stent-grafts.

Methods

The MEDLINE, EMBASE, and Cochrane databases were searched between January 2001 and December 2021 to identify literature relevant to the use of fenestrated and branched endografts for the treatment of TAAAs. Studies with <4 cases and those on juxtarenal or pararenal aortic aneurysms were excluded. Meta-analyses were conducted to evaluate spinal cord ischemia (SCI), irreversible SCI, renal insufficiency, dialysis, endoleak, reintervention, target vessel patency, 30-day mortality and overall mortality. Fourteen studies comprising 1,114 patients (mean age 72.42 years, 847 men) were selected. The mean TAAA diameter was 67 mm. The Crawford TAAA classification was type I-III in 759 cases, type IV in 344 cases, and type V in 10 cases. Outcomes of the meta-analysis are reported as proportions and 95% confidence intervals (CIs).

Results

The pooled rates for 30-day mortality and overall mortality were 6% and 18%, respectively. The pooled rate for technical success was 94% (95% CI, 93–96%), for SCI was 8% (95% CI, 7–10%), for irreversible SCI was 6% (95% CI, 4–7%), for reversible SCI was 5% (95% CI, 4–6%), for reversible SCI was 2% (95% CI, 2–3%), for renal insufficiency was 7% (95% CI, 5–10%), for dialysis was 3% (95% CI, 2–4%), for target vessel patency was 98% (95% CI, 97–99%), and for reintervention was 15% (95% CI, 9–24%).

Conclusion

Fenestrated and branched endografts for the treatment of TAAAs are safe and effective with acceptable early results. Lifelong regular follow-up and additional prospective studies are necessary to substantiate whether this technique is valid.

Endovascular versus conventional open surgical repair for thoracoabdominal aortic aneurysms

BACKGROUND

Thoracoabdominal aortic aneurysms (TAAAs) are a life-threatening condition which remain difficult to treat. Endovascular and open surgical repair (OSR) provide treatment options for patients, however, due to the lack of clinical trials comparing these, the optimum treatment option is unknown.

OBJECTIVES

To assess the effectiveness and safety of endovascular repair versus conventional OSR for the treatment of TAAAs.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 26 April 2021. We also searched references of relevant articles retrieved from the electronic search for additional citations.

SELECTION CRITERIA

We considered all published and unpublished randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing endovascular repair to OSR for TAAAs for inclusion in the review. The main outcomes of interest were prevention of aneurysm rupture (participants without aneurysm rupture up to 5 years from intervention), aneurysm-related mortality (30 days and 12 months), all-cause mortality, spinal cord ischaemia (paraplegia, paraparesis), visceral arterial branch compromise causing mesenteric ischaemia or renal failure, and rate of reintervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all titles and abstracts identified from the searches to identify those that met the inclusion criteria. We planned to undertake data collection, risk of bias assessment, and analysis in accordance with Cochrane recommendations. We planned to assess the certainty of the evidence using GRADE.

MAIN RESULTS

No RCTs or CCTs met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

Due to the lack of RCTs or CCTs, we were unable to determine the safety and effectiveness of endovascular compared to OSR in patients with TAAAs and are unable to provide any evidence on the optimal surgical intervention for this cohort of patients. High-quality RCTs or CCTs addressing this objective are necessary, however conducting such studies will be logistically and ethically challenging for this life-threatening disease.

MicroRNA miR-155 Activity in Mouse Choline Acetyltransferase-Positive Neurons Is Critical for the Rate of Early and Late Paraplegia After Transient Aortic Cross-Clamping

Aortic aneurism open repair surgery can cause spinal cord (SC) injury with 5–15% of patients developing paraparesis or paraplegia. Using a mouse model of transient aortic cross-clamping (ACC), we have previously found that the expression of proinflammatory microRNA miR-155 increases in motoneurons (MNs) and endothelial cells (ECs) of ischemic SCs, and that global miR-155 deletion decreases the percentage of paraplegia by 37.4% at 48-h post-ACC. Here, we investigated the cell-specific contribution of miR-155 in choline acetyltransferase-positive (ChAT+) neurons (that include all MNs of the SC) and ECs to SC injury after ACC. Mice lacking miR-155 in ChAT+ neurons (MN-miR-155-KO mice) developed 24.6% less paraplegia than control mice at 48-h post-ACC. In contrast, mice lacking miR-155 in ECs (ECs-miR-155-KO mice) experienced the same percentage of paraplegia as control mice, despite presenting smaller central cord edema. Unexpectedly, mice overexpressing miR-155 in ChAT+ neurons were less likely than control mice to develop early paraplegia during the first day post-ACC, however they reached the same percentage of paraplegia at 48-h. In addition, all mice overexpressing miR-155 in ECs (ECs-miR-155-KI mice) were paraplegic at 48-h post-ACC. Altogether, our results suggest that miR-155 activity in ChAT+ neurons protects the SC against ischemic injury during the first day post-ACC before becoming deleterious during the second day, which indicates that early and late paraplegias arise from different molecular malfunctions. These results point to the need to develop specific protective therapeutics aimed at inhibiting both the early and late deleterious events after open repair surgery of aortic aneurisms.