Stent-Graft Placement in Atherosclerotic Descending Thoracic Aortic Aneurysms:Midterm Results

Translocation of the supra-aortic vessels and stent grafting of the aortic arch

This is a report on the combined surgical and endovascular treatment of a very large aortic arch aneurysm. In the first step, total arch rerouting was performed with an inversed bifurcated Dacron prosthesis. Brachiocephalic trunk and left subclavian artery were inserted into the two branches of the prosthesis via an end-to-end anastomosis and left common carotid was reinserted into the branch to the left subclavian. In the second step, thoracic endovascular aortic repair was performed. By this combined concept a stable and durable result could be achieved.

Advances in thoracic aortic surgery: arch replacement with axillary cannulation and thoracic stent grafts

During the past decade, significant advances in thoracic surgery have contributed to a decrease in the morbidity and mortality linked to surgery of the thoracic aorta. Drawing from the experiences at the Quebec Heart Institute, the present article focuses on the improvements in surgery of the aortic arch, mainly the use of the 'arch-first technique' and arterial cannulation through the right axillary artery. Furthermore, advances in the treatment of diseases of the descending aorta using thoracic stent grafts are delineated. The importance of establishing dedicated multidisciplinary teams and follow-up clinics to ensure good outcomes in the treatment of these complex diseases is stressed.

Early Results after Staged Hybrid Repair of Thoracoabdominal Aortic Aneurysms

BACKGROUND

The morbidity and mortality rates associated with open thoracoabdominal aortic aneurysm (TAAA) repair are substantial. This study was designed to review our early experience with the hybrid endovascular and, or open approach for TAAA repair.

STUDY DESIGN

Patients undergoing elective hybrid repair of their TAAAs were retrospectively reviewed.

RESULTS

Seventeen patients (mean age 69+/-15 years, male, 76%) underwent visceral and renal revascularization as the first stage of their hybrid repair. The Crawford extent included: II, 2; III, 8; and IV, 7. Perioperative mortality and complication rates after the first stage were 24% and 25%, respectively; the mean intensive care unit stay and total length of stay were 7+/-12 days (range 1 to 45 days) and 22+/-33 days (range 3 to 100 days), respectively. The endovascular aneurysm repair or second stage procedure was performed in 12 of 13 (92%) of the surviving patients, with a mean of 27+/-27 days (range 6 to 99 days) between the procedures. Two patients experienced intraoperative complications during the second stage, but there were no deaths or additional postoperative complications. Patients did not require the intensive care unit, and the overall mean length of stay after the second stage was 2+/-2 days (range 1 to 5 days). The mean postoperative followup among the 11 patients completing both stages was 8+/-12 months (range 1 to 15 months). The primary patency rate for the visceral and renal bypasses was 96% (54 of 56).

CONCLUSIONS

The hybrid approach for patients with TAAAs may reduce complications in the average, low-risk patient and may extend the indications for repair to patients considered higher risk based on age, comorbidities, or anatomic considerations.

Mid-term results of supraaortic transpositions for extended endovascular repair of aortic arch pathologies

OBJECTIVE

To evaluate mid-term results of supraaortic transpositions for extended endovascular repair of aortic arch pathologies.

METHODS

From October 2002 to July 2006, 27 patients (mean age 72 years) with aortic arch diseases were treated (arch aneurysms n=18, type B dissections n=5, perforating ulcers n=4). Strategy for distal arch disease was autologous sequential transposition of the left carotid artery and of the left subclavian artery in 17 patients. Strategy for entire arch disease was total supraaortic rerouting using a reversed bifurcated prosthesis in 10 patients. Endovascular stent-graft placement was performed metachronously thereafter.

RESULTS

Two in-hospital deaths occurred (myocardial infarction on the day prior to discharge n=1, rupture while waiting for stent-graft placement n=1). At completion angiography, all reconstructions were fully patent. Four patients had small type Ia endoleaks, two of them resolving spontaneously. Mean follow-up is 15 months (1-43 months). Three late deaths occurred (myocardial infarction n=2, sudden unknown death n=1). One-year survival was 83% and 3-year survival was 72%, respectively. Redo stent-graft placement was performed in one patient after 25 months (type III endoleak). The remaining patients had normal CT scans with regular perfusion of the supraaortic branches without any signs of endoleaks.

CONCLUSIONS

Mid-term results of alternative treatment approaches in elderly patients with aortic arch pathologies are satisfying. Extended applications provide safe and effective treatment in patients at high risk for conventional repair.

Future of Endograft Surveillance

Frequent and sustained surveillance continues to be mandated for all patients who undergo endovascular repair of the aneurysmal aorta in order to minimize the small but attendant risk of aneurysm rupture. The primary motivation for surveillance includes evaluation of residual aneurysm sac size and presence of endoleak, as well as potential adverse device specific events, such as endograft migration, module disconnection, or component fatigue and failure. The current standard of care and future surveillance modalities after endovascular repair of both abdominal aortic and thoracic aortic aneurysms will be reviewed.

Thoracic Endografts: Procedural Steps, Technical Pitfalls and How to Avoid Them

Recent US Food and Drug Administration (FDA) approval of a thoracic endograft has created explosive interest among physicians to learn to use this minimally invasive technology. The level of interest is similar to the period more than a decade ago, following FDA approval of infrarenal abdominal endografts, which initiated the "endo" revolution among vascular specialists. Many physicians view the descending thoracic aorta as a simple, straight tube and, thus, technically less challenging than endografts for infrarenal abdominal aortic aneurysm. However, the thoracic aorta presents certain unique features that make this a challenging procedure. Technical challenges posed by the thoracic aorta have resulted in a significant time-lag (since release of abdominal aortic aneurysm endografts), testing the ability of engineers and physicians to devise and complete trials successful enough for FDA approval of thoracic endografts. This article addresses the various procedural steps and tips on avoiding pitfalls.

Current status of thoracic aortic endograft repair

The advent and success of endovascular repair of abdominal aneurysms had led to the development of catheter-based techniques to treat thoracic aortic pathology. Such diseases, including thoracic aortic aneurysms, acute and chronic type B dissections,penetrating aortic ulcers, and traumatic aortic transection, challenge surgeons to perform complex operative repairs in high-risk patients. The minimally invasive nature of thoracic endografting may provide an attractive alternative therapy especially in patients deemed unfit for thoracotomy. A worldwide review of thoracic endografting demonstrates encouraging short- and midterm outcomes with significant reductions in morbidity and early mortality.Long-term surveillance will be crucial to discover complications unique to thoracic endovascular interventions and to determine which patients are appropriate candidates for stent-graft therapy.