Hybrid multistep approach to mega-aortic syndrome: the Lupiae technique

Successful open three-stage repair of multifocal aortic aneurysms in a 34-year-old

Open replacement of multifocal aortic aneurysms is an operative and clinical challenge. Thoughtful consideration of both surgical technique and timing is important to reduce risk of major cardiovascular and neurologic complications. We discuss the management of a 34-year-old male with suspected connective tissue disease admitted with multifocal, giant aneurysms of his right subclavian artery, ascending and aortic arch, descending and abdominal aorta, and right iliac artery. A complex, open three-stage repair was undertaken. Genetic testing revealed a missense MYH11 mutation. We describe our approach and patient outcome.

Open, endovascular or hybrid repair of aortic arch disease: narrative review of diverse strategies with diverse options

OBJECTIVES

The management of aortic arch disease is complex. Open surgical management continues to evolve, and the introduction of endovascular repair is revolutionizing aortic arch surgery. Although these innovative techniques have generated the opportunity for better outcomes in select patients, they have also introduced confusion and uncertainty regarding best practices.

METHODS

In New York, we developed a collaborative group, the New York Aortic Consortium, as a means of cross-linking knowledge and working together to better understand and treat aortic disease. In our meeting in May 2023, regional aortic experts and invited international experts discussed the contemporary management of aortic arch disease, differences in interpretation of the available literature and the integration of endovascular technology into disease management. We summarized the current state of aortic arch surgery in this review article.

RESULTS

Approaches to aortic arch repair have evolved substantially, whether it be methods to reduce cerebral ischaemia, improve haemostasis, simplify future operations or expand options for high-risk patients with endovascular approaches. However, the transverse aortic arch remains challenging to repair. Among our collaborative group of cardiac/aortic surgeons, we discovered a wide disparity in our practice patterns and our management strategies of patients with aortic arch disease.

CONCLUSIONS

It is important to build unique institutional expertise in the context of complex and evolving management of aortic arch disease with open surgery, endovascular repair and hybrid approaches, tailored to the risk profiles and anatomical specifics of individual patients.

[Surgical treatment of mega aorta syndrome: a single-center experience]

OBJECTIVE

To present our experience in the treatment of severe patients with mega aorta syndrome.

MATERIAL AND METHODS

There were 49 patients with mega aorta syndrome for the period from May 2015 to March 2021. All patients underwent total aortic replacement from sinotubular junction (with staged aortic root repair, if necessary) to abdominal aorta bifurcation. All surgeries were elective. All patients were divided into two groups: group I (n=33; 67.3%) - staged replacement, group II (n=16; 32.7%) - one-staged replacement of the aorta via thoracophrenolumbotomy. The primary endpoints were mortality, perioperative parameters and complications. We also analyzed long-term freedom from aortic redo surgery and survival rate.

RESULTS

Both groups were comparable by pre-, intra- and postoperative parameters. The interval between surgeries for staged approach was 7.1±2.3 months. Rehabilitation time considering two stages was longer in group I (13±2 vs. 5.5±1.1 months, p=0.0001). Between-stage mortality rate was 12% (n=4). Intraoperative mortality was absent in both groups. In-hospital mortality was 3% and 12% (p=0.25), overall mortality with between-stage interval - 10.2% and 12% (p=1.000), respectively. The follow-up period was similar (18±22.7 (range 1-71) and 23.3±19.1 (range 1-51) months, respectively (p=0.63)). In group I, 1-year, 3-year and 5-year survival rate considering between-stage mortality was 89% (95% CI 78-100%), 77.1% (95% CI 60.1-98.8%), 77.1% (95% CI 60.1-98.8%), respectively. In group II, 1-year and 3-year survival rate was 86.5% (95% CI 70.5-100%), p_log-rank=0.88. Overall freedom from redo surgery was 92.9% (95% CI 80.3-100%) vs. 90.9% (95% CI 75.4-100%), p_log-rank=0.072.

CONCLUSION

One-stage total aortic replacement via thoracophrenolumbotomy is safe surgical treatment for mega aorta syndrome, especially in young patients with low surgical risk. Favorable outcomes may be expected in specialized centers with extensive experience in aortic surgery. Compared to staged approach, total aortic replacement eliminates the risks of between-stage aortic rupture. Therefore, it is a worthy alternative to other methods.

Staged total arch replacement, followed by fenestrated-branched endovascular aortic repair, for patients with mega aortic syndrome

OBJECTIVE

The aim of the present study was to review the clinical outcomes of a staged approach using total arch replacement (TAR) with an elephant trunk or a frozen elephant trunk, followed by fenestrated-branched endovascular aortic repair (F-BEVAR) for patients with mega aortic syndrome.

METHODS

We reviewed the clinical data and outcomes of 11 consecutive patients (8 men; mean age, 71 ± 7 years) treated by staged TAR and F-BEVAR from January 2014 to December 2018. The F-BEVAR procedures were performed under a prospective, nonrandomized, physician-sponsored investigational device exemption protocol. All patients had had mega aortic syndrome, defined by an ascending aorta, arch, and extent I-II thoracoabdominal aortic aneurysm. The endpoints were 30-day mortality, major adverse events (MAE), patient survival, freedom from reintervention, and freedom from target vessel instability.

RESULTS

Of the 11 patients, 6 had developed chronic postdissection aneurysms after previous Stanford A (three A₁₁, two A₁₀, one A₉) dissection repair and 5 had had degenerative aneurysms with no suitable landing zone in the aortic arch. The thoracoabdominal aortic aneurysms were classified as extent I in four patients and extent II in seven. One patient had died within 30 days after TAR (9.0%). However, none of the remaining 10 patients who had undergone F-BEVAR had died. First-stage TAR resulted in MAE in three patients (27%), including one spinal cord injury. The mean length of stay was 12 ± 6 days. The mean interval between TAR and F-BEVAR was 245 ± 138 days with no aneurysm rupture during the interval. Second-stage F-BEVAR was associated with MAE in two patients (20%), including spinal cord injury in one patient from spinal hematoma due to placement of a cerebrospinal fluid drain. The mean follow-up period was 14 ± 10 months. At 2 years postoperatively, patient survival, primary patency, secondary patency, and freedom from renal-mesenteric target vessel instability was 80% ± 9%, 94% ± 6%, 100%, and 86% ± 8%, respectively. No aortic-related deaths occurred during the follow-up period. Four patients had required reintervention, all performed using an endovascular approach.

CONCLUSIONS

A staged approach to treatment of mega aortic syndrome using TAR and F-BEVAR is a feasible alternative for selected high-risk patients. Larger clinical experience and longer follow-up are needed.

Hybrid repair of extensive thoracic aortic aneurysms

OBJECTIVES

METHODS

This was a multicentre, observational study. Data were collected prospectively between January 2002 and March 2019 and analysed retrospectively. Inclusion criteria for the final analysis were the treatment of elective or urgent ETAA performed in a single-stage or a planned two-stage approach. Early and late survival rates were the primary outcomes.

RESULTS

Indications for repair were degenerative ETAA in 27 (64.3%) patients and dissection-related ETAA in 15 (35.7%). The mean aortic diameter was 68 ± 16 mm (interquartile range 60–75). Five (11.9%) patients had a single-stage repair; and 37 underwent a two-stage approach. Three (7.1%) patients died in-hospital. The median follow-up was 49 months (range 0–204). During the follow-up period, 4 (9.5%) patients underwent aortic reintervention after a median of 32 months; however, no aortic rupture of the treated segment occurred. Overall, the estimated survival rate was 85% ± 6% [95% confidence interval (CI) 70.8–93] at 12 and 36 months and 69.5% ± 9% (95% CI 49.7–84) at 60 months.

CONCLUSIONS

Hybrid repair of ETAA had satisfactory early results in this cohort of patients. At the midterm follow-up, the aneurysm-related mortality rate was acceptable with the reconstruction proving to be durable and safe with few distal aortic events.

Hybrid Repair for Mega-Aortic Syndrome due to Giant Cell Aortitis in a Heart Failure Patient

The present report describes a case of mega-aortic syndrome accompanied with severe aortic regurgitation in a 75-year-old man who underwent a two-stage hybrid repair. Intraoperative pathologic findings at the first repair, consisting of Bentall operation and total arch replacement with a Lupiae graft, aided the identification of the giant cell aortitis. Despite complicating hemorrhagic stroke, steroid therapy was initiated and endovascular repair was subsequently completed. Over more than 2 years of follow-up, the patient continued steroid therapy and is doing well without any reintervention.

Hybrid three-stage repair of mega aorta with Lupiae technique: tips and tricks

Mega aorta syndrome (MAS) poses a complex clinical challenge: the involvement of the ascending aorta, aortic arch, descending thoracic and abdominal aorta with extension below the origin of renal arteries requires almost total replacement of the aorta. The modality of treatment remains still controversial. Different aortic debranching techniques have been developed to re-route the origin of epiaortic and visceral vessels and achieve an optimal landing zone for implantation of subsequent endovascular grafts. We illustrate the Lupiae technique as a further evolution of the aortic debranching and hybrid repair of a mega aorta. It was developed with the purpose to exclude a very long segment of diseased aorta by implanting two or more endoprostheses between two surgically-generated landing zones. We describe a series of 27 patients treated by this hybrid three-stage mega-aorta repair; the tips and tricks discussed here facilitate a safe and effective procedure, enable treatment of frail patients and help to avoid life-threatening complications.

Hybrid three-stage repair of mega-aortic syndrome with the Lupiae technique: 10-year results

Background

Mega-aortic syndrome (MAS) is a rare disease carrying a poor prognosis if treated conservatively. Open repairs of these aneurysms are invasive, while totally endovascular repairs are associated with higher rates of late reintervention due to endoleaks, compromising long-term prognosis. We describe the 10-year results of a hybrid three-stage approach to MAS using the Lupiae technique.

Methods

Between 2006 and 2016, 27 patients with MAS extending from the ascending aorta to the iliac arteries (MAS type III) underwent: (I) a surgical aortic arch debranching, using the Vascutek Lupiae™ multibranched graft to create a proximal Dacron landing zone; (II) an abdominal aorta debranching to create a distal Dacron landing zone and (III) the implantation of multiple endovascular stents to exclude any residual aneurysm between the two landing zones.

Results

One patient died following the first stage, and another following the second stage of the repair (overall mortality 7.4%). The interval between the first and the second stage was 58.3±16.1 days. The interval between the second and the third stage was 47.7±13.1 days. Four-year survival was 88.6%±6.2% while 10-year survival was 51.7%±17.9%. One patient had a type III endoleak after the third stage that self-resolved within 6 months without intervention. No patient had type I or II endoleaks and none underwent redo procedures. Mean follow-up was 5.9±3.6 years and completeness was 100%.

Conclusions

Three-stage hybrid repairs using the Lupiae technique can be safely performed in MAS type III patients. Short intervals between the stages should mitigate the risk of rupture during the waiting periods and may enhance patient compliance, but to achieve this, the burden and the complexity of the first stage must be carefully weighted. Our strategy improves the long-term survival of these patients compared to their natural history and is less invasive than an open repair. The adoption of Dacron landing zones appears to be associated with very low rates of reintervention due to endoleaks.

Hybrid aortic repair with antegrade supra-aortic and renovisceral debranching from ascending aorta

Aortic dissection is a life threatening condition. Hybrid repair has been described for the treatment of complex aortic pathology such as thoracoabdominal aortic aneurysms (TAAA) and type A and B dissections, although open and total endovascular repair are also possible. Open surgery is still associated with substantial perioperative morbi-mortality rates, thus less invasive techniques such as endovascular repair and hybrid procedures can achieve good results in centers with experience. We present the case of a patient with a chronic type B dissection and TAAA degeneration that was treated in a single stage hybrid procedure with antegrade supra-aortic and renovisceral debranching from the ascending aorta and TEVAR. At three-year follow up, the patient is free of intervention-related complications.

The megaaortic syndrome: Progression of ascending aortic aneurysm or a disease of distinct origin?

BACKGROUND

Thoracic aortic aneurysm (TAA) is an often asymptomatic disease with fatal outcome, such as dissection or rupture. The megaaortic syndrome (MAS) is an extensive dilatation of the whole aorta with low incidence but high lethal outcome with unknown pathophysiology so far.

METHODS AND RESULTS

We compared aortic tissue of patients with sporadic TAAs and MAS of the ascending aorta with non-aneurysmal control tissues. Specimens of MAS patients showed a significantly reduced thickness of the media but an increased thickness of the intima compared to control tissue and TAAs with moderate dilatation. Advanced media degeneration however was detectable in both, TAAs with enhanced luminal diameter and MAS specimens, accompanied by reduced medial smooth muscle cell-density. Further specimens of MAS were characterized by massive atherosclerotic lesions in contrast to specimens of sporadic TAA patients. Infiltrations of macrophages in atherosclerotic lesions but also in the media adjacent to the adventitia were significantly elevated in tissue of TAAs with dilatation ≤6cm. Of note, atherosclerotic plaque-associated macrophages as well as those in the external media produce huge amounts of MMP-9 which is possibly involved in media degeneration and tissue destruction.

CONCLUSIONS

Taken together these results demonstrate that the pathology of MAS shows similarities with that of TAAs but pathological differences in the ascending aorta, suggesting that MAS might be a disease of different origin.