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.

A SiMplified bARe-Wire Target Vessel (SMART) Technique for Fenestrated Endovascular Aortic Repair

PURPOSE

The aim of this study was to present a new technique for fenestrated endovascular aortic aneurysm repair (FEVAR) and to review its preliminary results. The SiMplified bARe-wire Target vessel (SMART) technique for FEVAR aims to simplify the procedure by avoiding guiding sheaths into visceral arteries during the main graft deployment.

MATERIALS AND METHODS

The SMART technique requires a 12 to 16Fr contralateral introducer, depending on number of fenestrations-compared with standard 18 to 22Fr for 3 to 4 FEVAR-to achieve target vessel catheterization and stenting during FEVAR by avoiding the use of parallel 6 to 7Fr guiding sheaths into each visceral vessel. Fenestrations are sequentially catheterized, assisted by a steerable sheath. A Rosen wire is maintained in each fenestration, with a single sheath parked in the final target vessel while releasing the fenestrated graft. Data on patients treated for pararenal or thoracoabdominal aortic aneurysms with FEVAR, adopting the SMART technique, were retrospectively reviewed. End points were technical success, intraprocedural variables, 90-day mortality, major adverse events (MAEs), and target vessel patency.

RESULTS

From May 2018 to December 2020, 57 consecutive patients were treated for pararenal or thoracoabdominal aortic aneurysms. Median total procedure time and total fluoroscopy time were 223 (196-271) minutes and 81 (71-94) minutes, respectively. Primary technical success was 96.4% (55/57). No misalignment occurred from graft deployment. The total number of fenestrations was 169, including 54 left and 53 right renal arteries, 43 superior mesenteric arteries and 18 celiac trunks (3.0±0.9 vessels/patient), with target vessel technical success of 98.2%. During the first 90 days, there were no deaths (0%). The MAEs included acute kidney injury (AKI) in 3 patients (5%) with no new dialysis onset, respiratory failure requiring prolonged ventilation in 2 patients (4%), myocardial ischemia in 1 patient (2%), but no lower limb ischemia, stroke, or spinal cord ischemia (SCI) occurred. After a mean follow-up of 14±10 months, there was 1 aortic-related death. Primary and assisted primary target vessel patency was 94.6%±1.8 and 97.0%±1.3% respectively.

CONCLUSIONS

The SMART technique proved to be a safe alternative to standard FEVARs, with excellent technical result and acceptable target vessel patency at mid-term, while reducing the risk for introducer-induced lower limb ischemia, related complications, and morbidity.

CLINICAL IMPACT

This study evalautes the outcome of fenestrated endovascular aortic repair (FEVAR) procedures at Uppsala university hospital using a simplified bare-wire Target vessel (SMART) technique. The SMART technique requires a smaller contralateral introducer compared to standard 18-22Fr for 3-4 FEVAR to achieve target vessel catetherization and stenting. Fifty-seven consecutive patients were treated for pararenal or thoracoabdominal aortic aneurysms. The SMART technique proved to be a safe alternative to standard FEVARs with excellent technical result and acceptable target vessel patency at mid-term, while reducing the risk for introducer-induced lower limb ischemia, related complications, and morbidity.

Early and Mid-Term Outcomes of the Inverted Limb Configuration Below Fenestrated and Branched Endografts: Experience from Two European Centers

PURPOSE

To report a European experience on the use of the Inverted Limb (IL) below fenestrated and branched endografts (FB-EVAR) for the treatment of juxta/pararenal (JP-AAAs), thoracoabdominal (TAAAs), and para-anastomotic aortic aneurysms.

MATERIALS AND METHODS

Between 2016 and 2020, all FB-EVAR with distal IL due to previous open (OSR) or endovascular repair (EVAR) or infrarenal aortic length <76 mm at two European university centers were retrospectively analyzed. Technical success, early and mid-term iliac complications (occlusion; type Ib endoleak [EL]), IL-related complications (type III EL), and reinterventions were assessed as primary endpoints; 30-day mortality, survival and freedom from (FF) overall complications/reinterventions were assessed as secondary outcomes.

RESULTS

Forty-one high-risk patients (male 30%-73%; mean age 71±10 years; ASA 3-4, 41%-100%) underwent FB-EVAR with distal IL for 8 (19.5%) J/P-AAAs and 33 (80.5%) TAAAs. Sixteen (39%) patients with previous aortic treatment (8 OR, 8 EVAR) were included. Preoperative computed tomographic angiography showed infrarenal aortic length <76 mm in all cases. Custom-made endografts were configured as 31 (75.6%) fenestrated-only, 6 (14.6%) branched-only, and 4 (9.8%) fenestrated+branched for an overall of 158 target visceral vessels (TVVs; 3.8±0.7 TVVs/case). The IL main body was planned with 1-stent, 2-stents, and 3-stents in 6 (14.6%), 23 (56.1%), and 12 (29.3%) cases, respectively. Technical success and 30-day mortality were 97.6% (40/41) and 0%. Thirty-day complications occurred in 2 (4.9%) patients: 1 limb occlusion, requiring reintervention, 1 type III EL, spontaneously resolved. Mean follow-up was 21±16 months. Three After 30-day, 3 (7.3%) iliac complications (2 occlusions; 1 type Ib EL) were successfully managed by endovascular reinterventions; no IL-related complications were observed. The patency of TVVs was 96.8%. No correlation between anatomical characteristics, endograft configuration, and primary outcomes was observed, except for 1-stent IL and type III EL (log rank p=0.01). At 1- and 2-year follow-up survival, FF overall iliac/IL-related complications and FF reinterventions were 90% and 80%, 90% and 84%, and 92% and 87%, respectively.

CONCLUSION

The IL configuration allows a safe endovascular treatment of challenging aortic lesions in high-risk patients although needing a number of adjunctive procedures. A short main body of IL could be associated with intraoperative and perioperative type III EL.

CLINICAL IMPACT

Bifurcated endograft with inverted limb configuration increases the feasibility of a total endovascular approach in patients with challenging anatomy. The use of inverted limb overcomes the anatomical limitations of short-body initial grafts and short distance between lowest target artery and the aortic bifurcation, leading the fixation inside the endograft. Although technically demanding, this advanced technology could avoid surgical reinterventions in previous open or endovascular repair that are burdened with higher rates of morbidities and complications.

Unintended Exchange of Target Vessels for Celiac Trunk and Superior Mesenteric Artery Branches in Complex Endovascular Aortic Repair

PURPOSE

The treatment of thoracoabdominal aortic aneurysms (TAAAs) using branched endovascular aortic repair (BEVAR) is safe and effective. During deployment, the superior mesenteric artery (SMA) branch can unintentionally open into the celiac trunk (CT) ostium and switched catheterization of the SMA from the CT branch and the CT from the SMA branch can be used as an alternative technique in these cases. This study aimed to investigate the outcome of exchanging the intended target vessels (TVs) for the CT and SMA branches during BEVAR.

MATERIALS AND METHODS

A single-center retrospective analysis of patients with TAAAs who underwent BEVAR, using off-the-shelf or custom-made devices (CMDs), with an unintended exchange of TVs for the CT and SMA branches was performed.

RESULTS

Between 2014 and 2023, 397 patients were treated with BEVAR for TAAA. Eighteen (4.5%) of those patients were treated with an exchange of TVs for the CT and SMA branches. T-branch was used in 9 cases (50%) and the remaining patients were treated with CMDs. Twelve patients were treated electively, 3 were symptomatic and 3 presented with rupture. Of 36 mesenteric TVs in those 18 patients, 34 (94%) were catheterized successfully, including all 18 SMAs and 16 of the 18 CTs. No branch stenosis or occlusion of the switched mesenteric TVs was detected during follow-up. During 30-day follow-up, 3 patients died and during a median follow-up of 3 (interquartile range [IQR]: 1-15) months 3 more patients died. None of the deaths or the 2 unintended reinterventions was induced by the mesenteric TV exchange. The median hospital stay was 14 (IQR: 9-22) days with a median of 4 (IQR: 2-11) days at the intensive care unit.

CONCLUSION

The exchange of the mesenteric TVs for the CT and SMA branches during BEVAR with off-the-shelf and CMD endografts is feasible with good TV patency and freedom from TV-related reinterventions. This alternative technique should be considered in selected cases when direct catheterization via the intended branch is deemed more time-consuming or not feasible.

CLINICAL IMPACT

This is the first description of using an exchange of target vessels for the celiac trunk and the superior mesenteric artery branches in patients with thoracoabdominal aortic aneurysms undergoing BEVAR, using off-the-shelf or custom-made devices. The high success rate as well as the good clinical results without any branch stenosis or occlusion during follow-up highlight the feasibility of this alternative technique. It could help in challenging cases when catheterization of the intended target vessels is not possible or too time consuming, resulting in higher success rates of BEVAR and better clinical results.

Patterns of collateral arteries to the spinal cord after thoracoabdominal aortic aneurysm repair

OBJECTIVES

To evaluate postoperative patterns of collateral arteries to the spinal cord during occlusion of the segmental arteries supplying the artery of Adamkiewicz (AKA).

METHODS

Between April 2011 and December 2022, 179 patients underwent thoraco-abdominal aortic aneurysm repair; 141 had an identifiable AKA on preoperative multidetector computed tomography (MDCT) scans, 40 underwent thoraco-abdominal aortic aneurysm replacement (TAAR), and 101 underwent thoracic endovascular aortic repair (TEVAR). New postoperative collateral blood pathways invisible on preoperative contrast-enhanced computed tomography scans were identified in 42 patients (10 patients in TAAR vs 32 patients in TEVAR) who underwent preoperative and postoperative MDCT scanning for AKA identification.

RESULTS

The thoracodorsal and segmental arteries were the main collateral pathways in both groups. Th9-initiated collaterals were the most common. Collaterals from the internal thoracic artery were observed in the TEVAR group but not in the TAAR group. One patient in the TEVAR group experienced postoperative paraparesis, which was not observed in the TAAR group. Postoperative paraplegia was more common in the non-Th9-origin group, but this difference was non-significant.

CONCLUSIONS

Thoracodorsal and segmental arteries may be important collateral pathways after TEVAR and TAAR. For thoracodorsal arteries, preserving the thoracodorsal muscle during the approach would be crucial; for segmental arteries, minimizing the area to be replaced or covered would be paramount. An AKA not initiated at the Th9 level poses a high risk of postoperative paraplegia.

Pre-emptive False Lumen Embolization to Prevent Persistent Type II Endoleak in Fenestrated-Branched Endovascular Repair of Post-Dissection Thoracoabdominal Aortic Aneurysms

PURPOSE

The purpose was to describe a technique to promote false lumen (FL) thrombosis in post-dissection thoracoabdominal aortic aneurysms (PD-TAAAs) managed by fenestrated/branched endografting (F/B-EVAR).

TECHNIQUE

A 5/6Fr-90 cm length sheath is advanced from the true lumen (TL) to FL through the most distal entry tear of the infrarenal aorta or iliac arteries. It is parked in the most cranial portion of the FL in the thoracic aorta. Aortic endografts are deployed in the TL excluding all the para-visceral/distal entry tears and target visceral vessels bridging stenting is performed. A selective FL angiography is performed through the 5/6Fr sheath to detect the origin of all segmentary arteries. Embolization of FL is performed from above to below by M-reye pushable coils, obtaining the packaging of FL. After completion angiography, the 5/6Fr sheath is retrieved in external iliac artery and molding ballooning of the distal segment of the aortic/iliac endograft is performed. Between 2019 and 2023, this technique was applied in 11cases with a median number of 73 (interquartile range [IQR=12) coils. Out of 8 (72%) patients with available radiological follow-up at 1 year, 7 exhibited complete FL thrombosis.

CONCLUSIONS

The FL coiling in PD-TAAAs managed by F/B-EVAR is feasible, safe, and effective to promote the complete FL thrombosis.

CLINICAL IMPACT

Preemptive false lumen embolization is a feasible, safe, and effective technique for preventing persistent type II endoleaks after fenestrated-branched endovascular repair of post-dissection thoracoabdominal aortic aneurysms. This technique may be routinely recommended to promote FL thrombosis and aortic remodeling after FB-EVAR in PD-TAAAs, thereby reducing the incidence of reinterventions during follow-up.

Plug-Based Embolization Techniques of Aortic Side Branches during Standard and Complex Endovascular Aortic Repair

Vascular plugs are an evolving family of vessel occluders providing a single-device embolization system for large, high-flow arteries. Nitinol mesh plugs and polytetrafluoroethylene membrane plugs are available in different configurations and sizes to occlude arteries from 3 to 20 mm in diameter. Possible applications during complex endovascular aortic procedures are aortic branch embolization to prevent endoleak or to gain an adequate landing zone, directional branch occlusion, and false lumen embolization in aortic dissection. Plugs are delivered through catheters or introducers, and their technical and clinical results are comparable to those of coil embolization. Plugs are more accurate than coils as repositionable devices, less prone to migration, and have fewer blooming artifacts on postoperative computed tomography imaging. Their main drawback is the need for larger delivery systems. This narrative review describes up-to-date techniques and technology for plug embolization in complex aortic repair.

Endovascular occlusion of segmental arteries feeding the anterior spinal artery to stage endovascular thoracoabdominal aortic repair

Objective

Minimally invasive segmental artery coil embolization was introduced to prevent spinal cord ischemia after endovascular repair of thoracoabdominal aortic aneurysms. There is no consensus on whether the endovascular occlusion of segmental arteries feeding directly the anterior radiculomedullary artery and anterior spinal artery can be safely performed without causing spinal cord ischemia. Our aim was to investigate the feasibility and clinical impact of endovascular occlusion of segmental arteries supplying the anterior spinal artery during minimally invasive segmental artery coil embolization in patients with thoracoabdominal aortic aneurysms.

Methods

Between January 2018 and July 2020, 54 patients (36 male; mean age, 71.1 ± 9.3 years) underwent direct embolization of segmental arteries feeding the anterior radiculomedullary artery before endovascular repair of thoracoabdominal aortic aneurysms. End points included technical success of minimally invasive segmental artery coil embolization of segmental arteries, anterior radiculomedullary artery, neurological complications, and in-hospital mortality after minimally invasive segmental artery coil embolization and endovascular repair of thoracoabdominal aortic aneurysms.

Results

The thoracoabdominal aortic aneurysm classification was type I (n = 8), type II (n = 24), type III (n = 11), and type IV (n = 11). During minimally invasive segmental artery coil embolization, 388 segmental arteries were occluded, each patient having 7.2 ± 3.1 coiled segmental arteries occluding 64.5% (25-100%) of open segmental arteries within the treated aortic segment. Altogether, 66 anterior radiculomedullary arteries were seen originating between Th8 and L3 levels from 85 (21.9%) segmental arteries. In 10 patients (18.5%), 2 large anterior radiculomedullary arteries were identified, and 1 patient (1.9%) showed 3 anterior radiculomedullary arteries on the spinal arteriography. No spinal cord ischemia or procedure-related complications occurred after minimally invasive segmental artery coil embolization. After 47.9 ± 39.4 days, all patients received endovascular repair of their thoracoabdominal aortic aneurysms. There was no in-hospital mortality. One male patient developed incomplete temporary spinal cord ischemia after endovascular repair.

Conclusions

Minimally invasive segmental artery coil embolization of segmental arteries feeding the anterior spinal artery in patients with thoracoabdominal aortic aneurysms to prevent spinal cord ischemia after endovascular repair is feasible and clinically safe.

Physician-modified inner-branched endovascular repair with re-intervention

OBJECTIVES

Treatment of thoracoabdominal aortic aneurysms in high surgical risk patients can be challenging. Reports of physician-modified inner-branched endovascular repair (PMiBEVAR) are increasing. Despite low morbidity and mortality rates, re-interventions for endoleaks with these grafts are serious. There are no reports of additional treatment for PMiBEVAR failure.

METHODS/RESULTS

A 75-year-old man presented to our hospital with a Crawford's type IV thoracoabdominal aortic aneurysm. A PMiBEVAR was performed. Postoperative computed tomographic angiography revealed an endoleak from the inner branch of the right renal artery. A re-intervention was performed with coil embolization of the endoleak. Imaging after re-intervention showed successful obliteration of the endoleak.

CONCLUSIONS

We thereby report a successful case of re-intervention for PMiBEVAR failure.

Motor-Evoked Potential Monitoring With Multi-train Electrical Stimulation During Thoracoabdominal Aortic Aneurysm Surgery: A Case Report

Intraoperative motor-evoked potentials (MEPs) are measured for assessing motor function during surgery. MEP monitoring is often performed in thoracoabdominal aortic aneurysm (TAAA) surgery, but false positives are common and amplification methods are needed to obtain waveforms under severe conditions to assess proper spinal cord function. One method of amplitude amplification in transcranial-stimulated MEP monitoring is multitrain stimulation. There are few reports on multitrain-stimulated MEP monitoring for this surgery. A 57-year-old woman underwent open repair of the thoracoabdominal aorta due to a dissecting aortic aneurysm. After opening the chest, the aneurysm was incised proximally, and anastomosis with an artificial vessel was initiated. The lumbar artery leading to the Adam-Kiewicz artery was reconstructed at a body temperature of 25 °C. However, the single-train stimulation did not produce MEPs. When the measurement was switched to multitrain stimulation, MEPs were elicited in the lower extremity muscle groups and the waveforms were maintained until the end of the measurement. This case illustrates that MEP monitoring using multitrain stimulation during descending thoracic aortic aneurysm surgery can effectively elicit MEPs under challenging conditions, in which conventional single-train stimulation may be insufficient.

"Octafen": A Noninvestigational Alternative Endograft Configuration for the Treatment of Thoracoabdominal Aortic Aneurysms

PURPOSE

To demonstrate the feasibility of Octafen technique, a novel endovascular configuration for the treatment of thoracoabdominal aortic aneurysms (TAAA).

TECHNIQUE

Two patients with complex TAAA and high surgical risk were treated with Octafen endograft configuration in a hybrid operating room with computed tomography (CT)-fluoroscopy image fusion guidance, using 3D-3D fusion techniques to facilitate procedural success. The procedure is a modification of the previously-described Octopus technique for endovascular repair of TAAA. The main advantage of this technique is the ability to use devices to repair a TAAA with the combination of off-the-shelf and noninvestigational custom-made devices. The devices used are readily available to most practicing vascular surgeons, which provides an alternative treatment in case of limited access to investigational devices, in time-sensitive cases, and in patients with limited functional capacity who cannot undergo open repair. In the modification described herein, we use a combination of standard bifurcated endovascular aneurysm repair (EVAR) devices (Excluder; W.L. Gore & Associates, Flagstaff, Arizona) in combination with a 2-vessel renal fenestrated device (Z-Fen; Cook Medical, Bloomington, Indiana). The article describes a step-by-step approach to this technique to elucidate pitfalls, benefits, and advantages.

CONCLUSION

The Octafen technique might offer an alternative option for thoracoabdominal aneurysm treatment circumventing the need for access to custom-made, investigational devices.

CLINICAL IMPACT

In this manuscript, we describe a technique for endovascular repair of thoraco-abdominal aortic aneurysms that involves the combination of off-the-shelf and non-investigational, custom-made devices. The 'Octafen' technique provides a treatment alternative in case of limited access to investigational devices and can be adjusted according to patient anatomy.

High-Grade Infection after Branched Endovascular Aortic Repair in Patient with Recent COVID-19 Hospitalization

In the context of the COVID-19 pandemic, the global healthcare landscape has undergone significant transformations, particularly impacting the management of complex medical conditions such as aortic aneurysms. This study focuses on a 76-year-old female patient with a history of extensive cardiovascular surgeries, including aortic valve replacement, Bentall operation, and Frozen Elephant Trunk procedure, who presented with a type II thoracoabdominal aortic aneurysm post-COVID-19 recovery. A comprehensive frailty assessment using the Modified Frailty Index and a two-phase endovascular approach for aneurysm treatment, considering the patient's frailty and complex medical history was performed. Upon successful aneurysm management, the patient's postoperative course was complicated by COVID-19 reinfection and Enterococcus faecalis superinfection, highlighting the increased risk of bacterial superinfections and the challenges posed by antimicrobial resistance in COVID-19 patients. The study underscores the necessity of vigilant postoperative surveillance and a multidisciplinary approach in managing such complex cases, highlighting the importance of personalized care strategies, integrating cardiovascular and infectious disease management, and adapting healthcare practices to the unique challenges of the pandemic. This case contributes to the evolution of knowledge on managing aortic aneurysms in the COVID-19 era, advocating for patient-centric treatment approaches and continuous research into long-term patient outcomes.

Posttraumatic stress disorder and quality of life in patients after open thoracoabdominal aortic repair

Background: Open thoracoabdominal aortic aneurysm (TAAA) repair is often related to significant morbidity and complications like paraplegia or acute kidney injury. Subsequently, prolonged intensive care stay is common. However, there is a lack of research on post-traumatic stress disorder (PTSD) and the perceived quality of life (QOL) in patients undergoing complex aortic procedures, such as open TAAA repair. Therefore, our study aims to determine the prevalence of PTSD and the current QOLin these patients and whether it is associated with demographic factors or complications following open thoracoabdominal aortic repair. Patients and methods: In this retrospective study, a total of 213 adult surviving patients after open thoracoabdominal aortic repair were contacted with two questionnaires one to assess PTSD and another to evaluate current QOL after open thoracoabdominal aortic repair. 61 patients returned one or both the questionnaires, and 59 patients (97%) answered all questions of the 4-item primary care PTSD section of the survey. In addition to the PTSD screening, patients were sent an SF-36 questionnaire to assess their current quality of life. 60 patients answered the SF-36 questionnaire partially or completely (98%). Results: 27% of patients (16/59) screened positive for PTSD. Electronic medical records were matched to all responding patients. Patients who were screened positive for PTSD spent more days in intensive care (OR, 1.073; 95% CI 1.02-1.13; p=0.005), had a higher frequency of tracheotomy (OR, 6.43; 95% CI 1.87-22.06; p=0.004), sepsis (OR, 5.63; 95% CI 1.56-20.33; p=0.014), as well as postoperative paraparesis (OR, 13.23; 95% CI 1.36-129.02; p=0.019). In patients with postoperative complications, a statistically significant decrease in the overall score was observed for certain categories of the SF-36. Conclusions: The prevalence of PTSD is higher, in comparison to the general population's prevalence, and the quality of life is affected following open thoracoabdominal aortic aneurysm repair, with a significant relation to postoperative complications as well as the length of ICU stay. Further research and screening for PTSD in relation to open TAAA repair is needed to assess its role in patient QOL during follow up.

Open Emergency Repair of a Thoracoabdominal Aortic Aneurysm on a 12-Year-Old Boy With Tuberous Sclerosis

Tuberous sclerosis complex is a neurocutaneous syndrome caused by an autosomal dominant genetic disorder. This condition can lead to the expression of many vascular anomalies especially, in the pediatric population. Likewise, it has been linked with aortic aneurysm development. We report a case of a 12-year-old boy who presented a 97 × 70 mm Crawford type IV thoracoabdominal aortic aneurysm. Satisfactory open surgical repair was performed with an 18-mm multibranched dacron tube graft. Clinical and imaging findings revealed a de novo tuberous sclerosis diagnosis. The patient was discharged uneventfully during a 1-month follow-up.

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.

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.

Evaluation of selected parameters of inflammation, coagulation system, and formation of extracellular neutrophil traps (NETs) in the perioperative period in patients undergoing endovascular treatment of thoracoabdominal aneurysm with a branched device (t-Branch)

Extracellular Neutrophils Traps (NETs) and their formation, known as NETosis, have become pivotal in the pathogenesis of aortic aneurysm development. This study investigates the NETosis markers with the assessment of selected parameters of inflammation and coagulation system in patients with thoracoabdominal aortic aneurysms in the pre-and postop period undergoing t-Branch stent-graft implantation. The study included 20 patients with thoracoabdominal aortic aneurysms. Three markers double-stranded DNA (dsDNA), single-stranded DNA (ssDNA), and citrullinated H3 histones (Cit-H3) were tested at three-time points from patients' blood. The parameters of NETosis, inflammation, and coagulation system were examined in the preoperative period (within 24 h before surgery) and in the postoperative period (on the 3rd and 5th postoperative day). Free-circulating DNA (cfDNA) was isolated from the blood using the MagMAXTM Cell-Free DNA Extraction Kit. Double-stranded DNA (dsDNA) and single-stranded DNA (ssDNA) were then quantified using the Qubit dsDNA HS Assay Kit and the Qubit ssDNA Assay Kit. Cit-H3 concentration was determined by enzyme immunoassay ELISA (Cayman). The results revealed the significance of NETs secretion in response to the complex processes after stent-graft implantation. All NET markers increased shortly after surgery, with histones being the first to return to preoperative levels. The lack of normalization of dsDNA and ssDNA levels to preoperative levels by the last postoperative blood collection demonstrates NETs reorganization. The increase in the number of neutrophils was not related to the expansion of postoperative NETosis. The study reveals a new marker of NETosis, ssDNA, that has not been studied so far. The implantation of a stent graft in a patient with TAAA triggers an inflammatory response manifested by an increase in inflammatory parameters. One of the hallmarks of inflammation is the activation of neutrophil extracellular traps.

Aortic hemodynamic and morphological analysis before and after repair of thoracoabdominal aortic aneurysm using a G-Branch endograft

Background and objective: The G-Branch endograft is a novel multibranched "off-the-shelf" device used to repair thoracoabdominal aortic aneurysms (TAAAs). This report describes the hemodynamic and morphological performance of the G-Branch endograft in a human patient with TAAA. Materials and methods: We retrospectively reviewed the computed tomography angiography scans and clinical data of a woman in whom TAAA was treated using a G-Branch endograft. Patient-specific three-dimensional models were reconstructed, and computational fluid dynamics and morphological and hemodynamic indicators were analyzed before and after implantation of the device. Results: From a morphological perspective, there was an increase in cross-sectional area in the G-Branch endograft and all bridging stent grafts over time. Blood flow was redistributed among the renovisceral arteries, with a decrease in flow rate in the celiac artery and an increase in the left renal artery. Laminar blood flow was smoother and more rapid after implantation of the G-Branch device and remained stable during follow-up. In the bridging stent grafts, flow recirculation zones were found in the bridging zones of the celiac artery and superior mesenteric artery as well as the distal sealing zones of both renal arteries. Furthermore, higher time-averaged wall shear stress and a lower oscillatory index and relative resident time were found in the G-Branch endograft and bridging stent grafts. Quantitative analysis showed obvious reduction in the surface area ratio of the elevated time-averaged wall shear stress area and surface area ratio of the relative resident time after G-branch implantation. Conclusion: The revascularization of branch vessels occurred following G-branch implantation, with improvements arising not only from morphological changes but also from hemodynamic alterations. The long-term performance of the G-Branch endograft needs further investigation and clinical validation.

The result of prospective evaluation of 3-dimensional printing-aided extensive thoracoabdominal aorta repair

OBJECTIVES

Paraplegia is a distressing complication after open thoracoabdominal aortic aneurysm (TAAA) repair, and revascularization of T8-L2-level segmental arteries is considered pivotal to prevent paraplegia. We employed 3-dimensional (3D) printing to efficiently revascularize segmental/visceral arteries and prospectively evaluated its safety and efficacy.

METHODS

From January 1, 2020, to June 30, 2022, we prospectively enrolled patients of extent I, II, or III TAAA repair. Guidance models were 3D-printed based on preoperative computed tomography, and multibranched aortic grafts were manually constructed upon this model before surgery. The composite outcome of operative mortality, permanent stroke, and permanent spinal cord deficit (SCD) was compared with the historical control group (n = 77, in 2015-2020), subjected to similar TAAA repair without 3D printing.

RESULTS

A total of 38 patients (58.6 ± 13.2 years) underwent open TAAA repair with the aid of 3D printing. Extent I, II, and III repairs were performed in 14 (36.8%), 17 (44.7%), and 7 (18.4%), respectively. Concomitant arch repair and bi-iliac reconstruction were performed in 7 (18.4%) and 6 patients (15.8%), respectively. Mean pump time was 107.7 ± 55.5 minutes. Operative mortality, permanent stroke, and permanent SCD each occurred in 1 patient (2.6%), and the incidence of the composite outcome was 7.9% (3/38). In the control group, mean pump time was 166.0 ± 83.9 minutes, significantly longer than the 3D-printing group (P < .001), and operative mortality, permanent stroke, permanent SCD, and the composite outcome occurred in 7 (9.1%), 9 (11.7%), 8 (10.4%), and 19 (24.7%), respectively.

CONCLUSIONS

Open repairs of extensive TAAA with 3D printing showed favorable safety and efficacy, which need further validation by larger studies.

Dual-Lumen Stenting of Dissected Superior Mesenteric Artery During Fenestrated Branched Endovascular Repair of a Post-dissection Thoracoabdominal Aortic Aneurysm

PURPOSE

Long-segment aortic branch dissections have been considered a relative contraindication for fenestrated-branched endovascular aneurysm repair (FB-EVAR). This case report describes a technique of dual-lumen stenting of a fully-dissected superior mesenteric artery (SMA) to preserve patency of the true and false lumens during FB-EVAR.

CASE REPORT

A 67-year-old man presented with a 6.0 cm extent III chronic post-dissection thoracoabdominal aortic aneurysm. The patient had highly-complex anatomy including dissection of the entire SMA. The true and false lumens of the dissected SMA were noted to be supplying different branches, requiring preservation of both lumens. The patient underwent a staged physician-modified FB-EVAR. A modified endograft containing 5 fenestrations and 1 branch cuff was introduced and the celiac, true-lumen SMA, and 3 renal arteries were sequentially catheterized using staggered deployment of the modified endograft. The false lumen SMA stent was catheterized via the branch cuff. Molded parallel grafting ("eye-of-the-tiger") technique was used to achieve double D configuration between the true and false lumens of the SMA.

CONCLUSION

This case demonstrates feasibility of dual-lumen stenting to incorporate dissected target vessels during FB-EVAR while preserving flow to both the true and false lumens and the second-order branches they supply.

CLINICAL IMPACT

We report a novel technique that allows incorporation of branch vessels affected by long segment dissection during fenestrated branched endovascular aortic repairs. This has potential advantage of preserving flow to all secondary branches of the dissected target vessels, while reducing the risk of type Ic endoleak.

Clinical effect of endovascular repair of complex aortic lesions using optimized Octopus surgery

Objective: Complex aortic lesions, especially those involving branches of the visceral artery, remain a challenge to treat. A single-center study using the Octopus technique to evaluate the safety and short-term effects of endovascular repair of complex aortic lesions was reported and documented. Methods: The data of six cases who underwent optimized Octopus surgery in our center from August 2020 to February 2022 were analyzed retrospectively. The choice of operation scheme, operation time, operation complications, and follow-up data were analyzed among them. Results: The average age of the six patients undergoing optimized Octopus surgery was 55.1 ± 17.2 years. Two cases were diagnosed as pararenal aortic aneurysms; four cases were aortic dissection involving the visceral artery. All cases achieved technical success; all visceral arteries were reconstructed as planned. A total of 17 visceral arteries were planned to be reconstructed; five celiac arteries were embolized. Three cases of gutter endoleak were found during the operation without embolization but with follow-up observation. There were two cases of slight damage to renal function and two cases of perioperative death. Other complications, such as intestinal ischemia and spinal cord ischemia, did not occur. Follow-up ranged from 6 months to 30 months. One patient died of gastrointestinal bleeding 6 months after the operation. At the 6 months follow-up, computed tomographic angiography showed that all internal leaks had disappeared. The patency rate of the visceral artery was 100%, and no complications, such as stent displacement and occlusion, occurred during the follow-up period. Conclusion: With fenestrated and branched stent grafts technology not widely available, and off label use not a viable option, Octopus technology for treating complex aortic lesions should be considered. The Octopus technique is an up-and-coming surgical method, but we should recognize its operation difficulty, operation-related complications, and long-term prognosis. We should pay attention to and continue to optimize Octopus technology.

New Preloaded System for Renal and Visceral Arteries in Fenestrated Endografting

AIM/BACKGROUND

The New Preloaded System (NPS) for renal/visceral arteries (TVVs) is an emerging technology in fenestrated endografting (FEVAR) that allows TVVs cannulation and stenting through the same access of the endograft main body. However, only few preliminary experiences are currently available in the literature. The aim of this study is to report the outcomes of NPS-FEVAR in juxta/para-renal (J/P-AAAs) and thoracoabdominal (TAAAs) aneurysms repair.

METHODS

This is a prospective (NCT05224219), single-center/observational study of patients submitted to NPS-FEVAR for J/PAAAs and TAAAs between 2019 and 2022 (July). Definitions and outcomes were evaluated according to the current SVS-reporting standard. Technical success (TS) and TS preloaded related, spinal cord ischemia (SCI), and 30-day mortality were assessed as early endpoints. Survival, freedom from reinterventions (FFRs), and freedom from TTVs-instability (FFTVVs-instability) were analyzed during follow-up.

RESULTS

Among 157 F/B-EVAR cases, 74 (47%) NPS-FEVAR were planned and enrolled in the study [48 (65%) J/P-AAAs; 26 (35%) TAAAs]. The main indication for NPS-FEVAR was the presence of a hostile iliac axis (54%-73%) or the necessity of expeditious pelvic/lower-limb reperfusion for SCI prevention in TAAAs (20%-27%). Overall, 292 TVVs were accommodated by 289 fenestrations and 3 branches; 188 of 289 (65%) fenestrations were preloaded. NPS-FEVAR configuration was from "below" and "from below to above" in 28 (38%) and 46 (62%) cases, respectively. TS and TS preloaded system-related was 96% (71/74) and 99% (73/74), respectively. Target visceral vessels patency at the completion angiography was 99% (290/292). Failures were 2 renal arteries loss and 1 massive bleeding from a percutaneous closure system breakage. The latter patient developed postoperative multiorgans failure and died on the fifth postoperative day, causing only 30-day/in-hospital mortality (1.3%). One (1.3%) patient with a JAAA and preoperative bilateral occlusion of the hypogastric arteries suffered SCI. The median follow-up was 14 (IQR: 8) months. The estimated 3-year survival was 91% with no aneurysm-related mortality during follow-up. The estimated 3-year FFR and FFTVVs-instability were 85 and 92%, respectively.

CONCLUSION

New preloaded system FEVAR is a safe and effective option in the treatment of J/PAAAs and TAAAs in the presence of hostile iliac access or to guarantee an expeditious pelvic/lower limb reperfusion, leading to satisfactory results in terms of TS, early and mid-term clinical outcomes.

CLINICAL IMPACT

New preloaded system for fenestrated and branched endografting allows to increase the feasibility of the advanced endovascular aortic repair in challenging iliac access, thoracoabdominal aneurysm repair and reduce difficulties in target visceral vessels cannulation.

Perioperative neuromonitoring during thoracoabdominal aortic aneurysm open repair: A systematic review

OBJECTIVES

While open surgical repair remains the gold standard for thoracoabdominal aortic aneurysm (TAAA) treatment, there is still no consensus regarding perioperative neuromonitoring technique for prevention of spinal cord ischaemia (SCI).

METHODS

In this systematic review, we aimed to explore the effects and practices of neuromonitoring during the open TAAA repair. A systematic literature search in PubMed, Embase via Ovid, Cochrane library and ClinicalTrialsGov until December 2022 was performed.

RESULTS

A total of 535 studies were identified from the literature search, of which 27 studies including a total of 3130 patients met the eligibility criteria. Most studies (21 out of 27, 78%) investigated the feasibility of motor evoked potentials (MEP), while 15 analysed somatosensory evoked potentials (SSEP) and 2 studies analysed near-infrared spectroscopy (NIRS) during open TAAA repair.

CONCLUSIONS

Current literature suggest that rates of postoperative SCI can be kept at low levels after open TAAA repair with the adequate precautions and perioperative manoeuvres. Neuromonitoring with MEP provides the surgeon objective criteria to direct selective intercostal reconstruction or other protective anaesthetic and surgical manoeuvres. Simultaneous monitoring of MEP and SSEP is a reliable method that can rapidly detect important findings and direct adequate protective manoeuvres during open TAAA repair.

Effects of Iliac Tortuosity Index on Fenestrated Endovascular Aortic Aneurysm Repair for Pararenal and Thoracoabdominal Aortic Aneurysms

PURPOSE

To evaluate the effect of iliac tortuosity on procedural metrics and outcomes of patients with complex aortic aneurysms (cAAs) undergoing repair with fenestrated/branched endografts (f/b-EVAR [endovascular aortic aneurysm repair]).

MATERIAL AND METHODS

The study is a single-center, retrospective review of a prospectively maintained database of patients undergoing aneurysm repair using f/b-EVAR between the years 2013 and 2020 at our institution. Included patients had at least 1 preoperative computed tomography angiography (CTA) available for analysis. Iliac artery tortuosity index (TI) was calculated using centerline of flow imaging from a 3-dimensional work station based on the formula: (centerline iliac artery length / straight-line iliac artery length). The associations between iliac artery tortuosity and procedural metrics, including total operative time, fluoroscopy time, radiation dose, contrast volume, and estimated blood loss (EBL), were evaluated.

RESULTS

During this period, 219 patients with cAAs underwent f/b-EVAR at our institution. Ninety-one patients (74% men; mean age = 75.2±7.7 years) met criteria for inclusion into the study. In this group, there were 72 (79%) juxtarenal or paravisceral aneurysms and 18 (20%) thoracoabdominal aortic aneurysms and 5 patients (5.4%) with failed previous EVAR. The average aneurysm diameter was 60.1±0.74 mm. Overall, 270 vessels were targeted, and 267 (99%) were successfully incorporated, including 25 celiac arteries, 67 superior mesenteric arteries, and 175 renal arteries. The mean total operative time was 236±83 minutes, fluoroscopy time was 87±39 minutes, contrast volume was 81±47 mL, radiation dose 3246±2207 mGy, and EBL was 290±409 mL. The average left and right TIs for all patients were 1.5±0.3 and 1.4±0.3, respectively. On multivariable analysis, the interval estimates suggest positive association between TI and procedural metrics to a certain degree.

CONCLUSIONS

In the current series, we found no definitive association between iliac artery TI and procedural metrics, including operative time, contrast used, EBL, fluoroscopy time, and dose in patients undergoing cAA repair using f/b-EVAR. However, there was a trend toward association between TI and all these metrics on multivariable analysis. This potential association needs to be evaluated in a larger series.

CLINICAL IMPACT

Iliac artery tortuosity should not exclude patients with complex aortic aneurysms from being offered fenestrated or branched stent graft repair. However, special considerations should be taken to mitigate the impact of access tortuosity on alignment of fenestrations with target vessels, including use of extra stiff wires, through and through access and delivering the fenestrated/branched device into another (larger) sheath such as a Gore DrySeal in patients with arteries large enough to accommodate such sheaths.

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.

Biomarkers of Spinal Cord Injury in Patients Undergoing Complex Endovascular Aortic Repair Procedures-A Narrative Review of Current Literature

Complex endovascular aortic repair (coEVAR) of thoracoabdominal aortic aneurysms (TAAA) has greatly evolved in the past decades. Despite substantial improvements of postoperative care, spinal cord injury (SCI) remains the most devastating complication of coEVAR being associated with impaired patient outcome and having an impact on long-term survival. The rising number of challenges of coEVAR, essentially associated with an extensive coverage of critical blood vessels supplying the spinal cord, resulted in the implementation of dedicated SCI prevention protocols. In addition to maintenance of adequate spinal cord perfusion pressure (SCPP), early detection of SCI plays an integral role in intra- and postoperative patient care. However, this is challenging due to difficulties with clinical neurological examinations during patient sedation in the postoperative setting. There is a rising amount of evidence, suggesting that subclinical forms of SCI might be accompanied by an elevation of biochemical markers, specific to neuronal tissue damage. Addressing this hypothesis, several studies have attempted to assess the potential of selected biomarkers with regard to early SCI diagnosis. In this review, we discuss biomarkers measured in patients undergoing coEVAR. Once validated in future prospective clinical studies, biomarkers of neuronal tissue damage may potentially add to the armamentarium of modalities for early SCI diagnosis and risk stratification.

Initial Outcomes of Physician-Modified Inner Branched Endovascular Repair in High-Surgical-Risk Patients

PURPOSE

To report the initial outcomes of physician-modified inner branched endovascular repair (PMiBEVAR) for pararenal aneurysms (PRAs), thoracoabdominal aortic aneurysms (TAAAs), and aortic arch aneurysms in high-surgical-risk patients.

MATERIALS AND METHODS

A total of 10 patients (6 men; median age, 83.0 years) treated using PMiBEVAR were enrolled in this retrospective, single-center study. All patients were at high surgical risk because of severe comorbidities (American Society of Anesthesiologists physical status score≥3 or emergency repair). End points were defined as technical success per patient and per vessel (successful deployment), clinical success (no endoleaks postoperatively), in-hospital death, and major adverse events.

RESULTS

There were 3 PRAs, 4 TAAAs, and 3 aortic arch aneurysms with 12 renal-mesenteric arteries and 3 left subclavian arteries incorporated by inner branches. The technical success rate was 90.0% (9/10) per patient and 93.3% (14/15) per vessel. The clinical success rate was 90% (9/10). There were 2 in-hospital deaths, unrelated to aneurysms. Paraplegia and shower emboli occurred separately in 2 patients. Three patients experienced prolonged ventilation for 3 days after surgery. Aneurysm sac shrinkage occurred in 4 patients, and aneurysm size stabilized in 1 patient during follow-up, more than 6 months later. None of the patients required intervention.

CONCLUSION

PMiBEVAR is a feasible approach for treating complex aneurysms in high-surgical-risk patients. This technology may complement the existing technology in terms of improved anatomical adaptability, no time delay and practicability in many countries. However, long-term durability remains undetermined. Further large-scale and long-term studies are needed.

CLINICAL IMPACT

This is the first clinical study to investigate outcomes of physician-modified inner branched endovascular repair (PMiBEVAR). PMiBEVAR for treating pararenal aneurysm, thoracoabdominal aortic aneurysm, or aortic arch aneurysm is a feasible procedure. This technology is likely to complement existing technology in terms of improved anatomical adaptability (compared to off-the-shelf devices), no time delay (compared to custom-made devices), and the potential to be performed in many countries. On the other hand, surgery time varied greatly depending on the case, suggesting a learning curve and the need for technological innovation to perform more consistent surgeries.

Endovascular Treatment of Ruptured or Symptomatic Thoracoabdominal and Pararenal Aortic Aneurysms Using Octopus Endograft Technique: Mid-Term Clinical Outcomes

OBJECTIVE

To evaluate the effectiveness and safety of using off-the-shelf "Octopus" technique to treat ruptured or symptomatic thoracoabdominal aortic aneurysm (TAAA) and pararenal abdominal aortic aneurysm (PRAAA).

METHODS AND RESULTS

All cases who underwent "Octopus" technique from May 2016 to May 2019 at our center were retrospectively analyzed. A total of 10 cases (8 males) were included. The mean age was 54.5±14.2 years (range: 31-80 years). Eight cases presented as aneurysm rupture or impending rupture accepted emergency repair. Technical success, defined by placement of all endografts as planned, was achieved in all cases. A total of 30 target visceral branches were successfully cannulated, 9 celiac arteries were covered intentionally. Intraoperative endoleak was observed in 6 patients, all of them were gutter leak. During hospital stay, there was no death, no side branch occlusion or spinal cord ischemia. Median follow-up was 30 months (range: 12-50 months). One patient died of lung cancer at 14-month follow-up. There was no secondary endoleak. The primary endoleak were found spontaneously resolved in 3 cases at 7 days, 3-month, and 1-year imaging. One persistent endoleak totally resolved after sealing of gutter spaces at 4-month follow-up. The other 2 persistent endoleak decreased during follow-up, which are still under observation. The branch patency rate was 90.3% (28/31). All the 3 occluded branches were renal arteries. Branch occlusion occurred in 2 cases at 1-month follow-up and 1 case at 2-year follow-up, but renal insufficiency was not observed in these cases. Obvious aneurysm sac shrinkage (≥5 mm) was observed in all cases. The aneurysm size shrunk from 7.6±1.9 to 5.5±1.4 cm. No spinal cord ischemia occurred during follow-up.

CONCLUSION

Treatment of ruptured TAAA and PRAAA with "Octopus" technique is feasible and safe for high surgical risk patients in the absence of fenestrated and branched devices. The long-term clinical outcomes needed to be investigated.

Endovascular Preservation of Segmental Arteries During Treatment of Thoracoabdominal Aortic Aneurysm with Fenestrated/Branched Stent-Grafts: Feasibility and outcome

OBJECTIVES

To evaluate technical success, feasibility, and outcomes of endovascular preservation of segmental arteries (SAs) during fenestrated /branched endovascular aortic repair (F/B-EVAR).

METHODS

A multicenter, retrospective study was conducted on consecutive patients treated with F/B-EVAR and a branch or fenestration for SA preservation. Eleven patients (median age 57, range 45-73; 7 men) were included.

RESULTS

Twelve SAs were preserved. Stent-grafts were custom-made with fenestrations, branches, or a combination of both in 1, 2, and 5 patients. A t-branch was used in 2 patients and physician-modified thoracic stent-graft with a branch was used in 1 patient. Eight branches and 4 fenestrations were used for the preservation of 12 SAs. Four fenestrations and 1 branch for SAs were not bridged and were left for the perfusion of the corresponding SAs. Technical success was achieved in 10/11 (91%) patients. No early mortality occurred. Early morbidities included renal insufficiency without dialysis in 1 patient and partially delayed paraplegia in 1 patient. Pre-discharge computed tomography angiography (CTA) showed patency of all SAs. No early aortic-related re-interventions were required. The median follow-up was 30 (range 10-88) months. Late death occurred in 1 patient. Two SAs occluded in 1 patient with two un-stented fenestrations at 1-year follow-up CTA. This patient did not develop spinal cord ischemia (SCI). Other SAs remained patent during follow-up. One patient with type IIIc endoleak was treated by relining of bridging stents.

CONCLUSION

Endovascular preservation of SAs with F/B-EVAR for thoracoabdominal aortic aneurysm is feasible and safe in selected patients and may add to preventive measures for SCI.

Reappraisal of the role of motor and somatosensory evoked potentials during open distal aortic repair

OBJECTIVE

Intraoperative motor and somatosensory evoked potentials have been applied to monitor spinal cord ischemia during repair. However, their predictive values remain controversial. The purpose of this study was to evaluate the impact of motor evoked potentials and somatosensory evoked potentials on spinal cord ischemia during open distal aortic repair.

METHODS

Our group began routine use of both somatosensory evoked potentials and motor evoked potentials at the end of 2004. This study used a historical cohort design, using risk factor and outcome data from our department's prospective registry. Univariate and multivariable statistics for risk-adjusted effects of motor evoked potentials and somatosensory evoked potentials on neurologic outcome and model discrimination were assessed with receiver operating characteristic curves.

RESULTS

Both somatosensory evoked potentials and motor evoked potentials were measured in 822 patients undergoing open distal aortic repair between December 2004 and December 2019. Both motor evoked potentials and somatosensory evoked potentials were intact for the duration of surgery in 348 patients (42%). Isolated motor evoked potential loss was observed in 283 patients (34%), isolated somatosensory evoked potential loss was observed in 18 patients (3%), and both motor evoked potential and somatosensory evoked potential loss were observed in 173 patients (21%). No spinal cord ischemia occurred in the 18 cases with isolated somatosensory evoked potential loss. When both signals were lost, signal loss happened in the order of motor evoked potentials and then somatosensory evoked potentials. Immediate spinal cord ischemia occurred in none of those without signal loss, 4 of 283 (1%) with isolated motor evoked potential loss, and 15 of 173 (9%) with motor evoked potential plus somatosensory evoked potential loss. Delayed spinal cord ischemia occurred in 12 of 348 patients (3%) with intact evoked potentials, 24 of 283 patients (8%) with isolated motor evoked potentials loss, and 27 of 173 patients (15%) with motor evoked potentials + somatosensory evoked potentials loss (P < .001). Motor evoked potentials and somatosensory evoked potentials loss were each independently associated with spinal cord ischemia. For immediate spinal cord ischemia, no return of motor evoked potential signals at the conclusion of the surgery had the highest odds ratio of 15.87, with a receiver operating characteristic area under the curve of 0.936, whereas motor evoked potential loss had the highest odds ratio of 3.72 with an area under the curve of 0.638 for delayed spinal cord ischemia.

CONCLUSIONS

Somatosensory evoked potentials and motor evoked potentials are both important monitoring measures to predict and prevent spinal cord ischemia during and after open distal aortic repairs. Intraoperative motor evoked potential loss is a risk for immediate and delayed spinal cord ischemia after open distal aortic repair, and somatosensory evoked potential loss further adds predictive value to the motor evoked potential.

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.

Hemodynamic analysis of hybrid treatment for thoracoabdominal aortic aneurysm based on Newtonian and non-Newtonian models in a patient-specific model

The accuracy of the Newtonian model used in retrograde visceral revascularization (RVR) of hybrid surgery for thoracoabdominal aortic aneurysm (TAAA) hemodynamic simulation remains unclear. Noting that an appropriate blood viscosity model is a significant factor to capture hemodynamic changes in numerical studies. Therefore, both Newtonian and non-Newtonian blood viscosity models were adopted in this study to investigate the importance of hemodynamics when non-Newtonian blood property was accounted for in a patient-specific RVR simulation. The results revealed that disturbed flow and unfavorable WSS distribution can be observed in the anastomosis region under both blood viscosity models due to the retrograde flow pattern in the RVR model. However, although the non-Newtonian blood model has negligible effect on flow pattern and pressure drop, there were of significance quantitative and qualitative difference of local normalized helicity and wall shear stress distribution under pulsatile flow condition. In particular, the unfavorable WSS indicators distribution was better matched with a patient-specific follow-up report when non-Newtonian blood viscosity was accounted for. To conclude, the use of a Newtonian blood model is a reasonable approximation to obtain the general features of the flow field under steady flow condition. However, to study the hemodynamic parameters within retrograde flow under pulsatile flow condition, a non-Newtonian model may be more appropriate.

Branched and Fenestrated Aortic Endovascular Grafts

Endovascular repair of abdominal and descending thoracic aortic aneurysms has become the standard of care due to improvements in morbidity and mortality compared to open surgical repair. Late durability, however, remains an issue because persistent endoleaks can lead to continued aneurysm expansion and eventual rupture, sometimes years following the original repair. Branched, fenestrated, and physician-modified endografts in the thoracic arch and thoracoabdominal aorta have extended the seal zone in order to mitigate the risks of proximal and distal endoleaks. This review summarizes the current state of branched, fenestrated, and physician-modified endografts used in complex aortic pathologies.

Open Treatments for Thoracoabdominal Aortic Aneurysm Repair

Thoracoabdominal aortic aneurysms (TAAA) represent a unique pathology that is associated with considerable mortality if untreated. While the advent of endovascular technologies has introduced new modalities for consideration, the mainstay of TAAA treatment remains open surgical repair. However, the optimal conduct of open TAAA repair requires careful consideration of patient risk factors and a collaborative team effort to mitigate the risk of perioperative complications. In this chapter, we briefly outline the history of treating TAAA, preoperative preparation and postoperative care, and our operative techniques for treatment.

The Future of Cardiothoracic Surgical Critical Care Medicine as a Medical Science: A Call to Action

Cardiothoracic surgical critical care medicine (CT-CCM) is a medical discipline centered on the perioperative care of diverse groups of patients. With an aging demographic and an increase in burden of chronic diseases the utilization of cardiothoracic surgical critical care units is likely to escalate in the coming decades. Given these projections, it is important to assess the state of cardiothoracic surgical intensive care, to develop goals and objectives for the future, and to identify knowledge gaps in need of scientific inquiry. This two-part review concentrates on CT-CCM as its own subspeciality of critical care and cardiothoracic surgery and provides aspirational goals for its practitioners and scientists. In part one, a list of guiding principles and a call-to-action agenda geared towards growth and promotion of CT-CCM are offered. In part two, an evaluation of selected scientific data is performed, identifying gaps in CT-CCM knowledge, and recommending direction to future scientific endeavors.

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.

Double-Cuff Bidirectional Branch in Endovascular Aortic Repair: A New Way of Increasing the Flexibility of Inner Branch Endografting

PURPOSE

The purpose of the study was to describe the design and implantation of a branched stent-graft during endovascular aortic repair incorporating double-cuff bidirectional inner branch.

TECHNIQUE

A new double-cuff bidirectional antegrade and retrograde inner branched stent-graft with large diamond-shaped fenestration was designed for incorporation of a splenic artery. The inner cuffs of the branch were accessible using brachial and/or femoral access. The splenic artery was originating from an aortic segment with narrow inner aortic luminal diameter in a patient with extent IV thoracoabdominal aortic aneurysm with bilobed configuration. The retrograde, more distal inner cuff of the branch was extended into the splenic artery using a self-expandable bridging stent-graft from the femoral approach, whereas the antegrade, more proximal inner cuff of the branch was intentionally occluded using an endovascular plug. The recovery was uneventful and a computed tomography angiography 30 days postoperatively showed patency of all the target vessels without signs of endoleaks.

CONCLUSION

This is the first design of a double-cuff bidirectional inner branched stent-graft. The technique can potentially expand the applications of directional branches to patients with more difficult anatomy in the thoracoabdominal or aortic arch segments. Potential indications are patients with target arteries that are not ideally suited for caudally-oriented branches, patients with accessory vessels, or targets with early branch bifurcations.

CLINICAL IMPACT

This report describes the use of a branched endograft with a new double-cuff bidirectional branch that can potentially address many of the limitations of current BEVAR solutions, such as early bifurcations, double arteries with adjacent origins and arteries with less favorable trajectories for the traditional caudally-oriented branches.

Outcomes of descending and thoracoabdominal aortic repair in connective tissue disorder patients

OBJECTIVES

Open surgical repair (OSR) of descending and thoracoabdominal aortic aneurysms carries risks of mortality and major complications. Patients with connective tissue disorders (CTD) are younger and require safe, efficient treatment with long-term durability. This study provides current outcome data to help inform treatment decisions.

METHODS

All OSRs of descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) from January 2011 to July 2021 were included in a retrospective cohort study. Primary outcome measures were early and follow-up mortality and reintervention. Secondary outcome measures were major complications. Kaplan-Meier methods were used to estimate reintervention-free survival.

RESULTS

A total of 26 OSRs (7 DTAA, 19 TAAA) were performed in 23 patients: 20 (77%) Marfan and 6 (23%) Loeys-Dietz syndrome; median age 43 years. Aortic dissection was present in 100% and 3/26 (12%) were urgent. Early mortality was 1/26 (3.8%). No patient suffered spinal cord ischemia, stroke, vocal cord paralysis, or re-exploration for bleeding. The transient respiratory failure occurred in 19% (5/26) and transient renal replacement therapy in 15% (4/26). Renal function normalized in all patients within 3 months. During follow-up (median 4.6, range 0-11 years) there were no deaths and only one re-intervention on a previously operated aortic segment, resulting in 92% reintervention-free survival at 5 years.

CONCLUSIONS

In dedicated units, open surgical DTAA and TAAA repair in patients with CTD can be performed with a very low risk of death, severe complications and, late re-intervention. For CTD patients with reasonable risk, OSR should remain the first line of treatment.

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.

Rescue therapy for symptomatic spinal cord ischemia after thoracic endovascular aortic repair

OBJECTIVE

Spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) can cause permanent neurologic deficits and poor long-term survival. Targeted treatment of new SCI symptoms after TEVAR (rescue therapy [RT]) might improve/resolve neurologic symptoms but few data characterize the association of specific interventions with SCI outcomes. We evaluated the effectiveness of post-TEVAR RT at our tertiary aortic center.

METHODS

Our institutional TEVAR database was reviewed for SCI incidence and details of RT. This included cerebrospinal fluid drainage (CSFD), medical therapy, and optimization of spinal cord oxygen delivery. SCI outcomes were categorized at discharge as paralysis/paraparesis and temporary/permanent.

RESULTS

Nine hundred forty-three TEVAR procedures were performed in 869 patients from 2011 to 2020. Post-TEVAR SCI occurred in 7.8% (n = 74) with permanent paraplegia in 1.5%. Older patient age, chronic obstructive pulmonary disease, and previous abdominal aortic surgery were predictive of SCI. Half (n = 37) of SCI episodes resulted in only temporary paralysis/paraparesis. Rescue postoperative cerebrospinal fluid drains were implanted in 3.7% (n = 35) of procedures and was predicted by higher American Society of Anesthesiologists class, lower serum hemoglobin level, elevated international normalized ratio, bilateral iliac artery occlusion, nonelective procedures, and penetrating atherosclerotic ulcer/intramural hematoma indication. The most commonly used RTs were emergent placement of or increased drainage from an existing cerebrospinal fluid drain (87.8%), induced/permissive hypertension (77.0%), corticosteroid bolus (36.5%), and naloxone infusion (33.8%). Neurologic improvement occurred in 68.9% (n = 51/74). New/increased drainage was associated with improved SCI outcome.

CONCLUSIONS

Permanent paraplegia from post-TEVAR SCI is rare (1.5%). Older patients with comorbidities carry greater post-TEVAR SCI risk. SCI symptoms improved/resolved with CSFD and multimodal RT in 68.9% of patients, but no intervention was independently associated with improvement. TEVAR centers should have robust protocols for timely and safe CSFD placement to augment RT strategies for SCI.

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.

Safety and Efficacy of Intentional Celiac Artery Coverage in Endovascular Management of Thoracoabdominal Aortic Diseases: A Systematic Review and Meta-analysis

PURPOSE

Thoracic endovascular aortic aneurysm repair (TEVAR) has emerged as an attractive alternative option in the treatment of thoracoabdominal aortic aneurysm (TAAA) diseases, reporting lower morbidity and mortality rates compared with open or hybrid repair. A challenging situation arises when the aneurysm involves the celiac artery (CA), precluding a safe distal landing zone. We investigated the safety and efficacy of CA coverage in the treatment of complex TAAA diseases during endovascular management.

MATERIALS AND METHODS

A review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. The electronic bibliographic sources searched were MEDLINE and SCOPUS databases. Primary outcomes of interest were perioperative and 30-day mortality. Any type of endoleak, mesenteric ischemia, perioperative spinal cord ischemia, and reintervention rates were secondary end points. A random-effects meta-analysis was performed. Summary statistics of event risks were expressed as proportions and 95% confidence interval (CI).

RESULTS

Ten observational cohort studies published between 2009 and 2020, reporting a total of 175 patients, were eligible for quantitative synthesis. Indications for TEVAR were primary TAAAs in 82% of patients, aortic dissection in 14% of patients, type Ib endoleak after previous endograft deployment in 3% of patients, and penetrating aortic ulcer in 1 patient. Reintervention rate was 9% (95% CI, 4%-20%) and spinal cord ischemia was 7% (95% CI, 4%--12%). Type II endoleak was the predominant type of endoleak in 10% of patients (95% CI, 4%-22%), followed by type I endoleak in 5% of patients (95% CI, 2%-12%) and type III endoleak in 1% (95% CI, 0%-16%) of patients. Mesenteric ischemia occurred in 6% of patients (95% CI, 3%-10%). Thirty-day mortality was 5% (95% CI, 2%-13%) and the pooled estimate for overall mortality was 21% (95% CI, 14%-31%).

CONCLUSIONS

Celiac artery coverage during TEVAR is a challenging but feasible option for the treatment of TAAA diseases, providing acceptable morbidity and mortality rates. Demonstration of adequate visceral collateral pathways before definitive CA coverage is the sine quo non for the success of the technique.

Protocol for GUo's renovisceral Artery reconstruction-1: a prospective, multicentre, single-arm clinical trial to evaluate the safety and efficacy of a multibRANched sTEnt graft systEm for thoracoabdominal aortic aneurysm (GUARANTEE study)

INTRODUCTION

The multibranched off-the-shelf stent graft is a promising treatment option for thoracoabdominal aortic aneurysm (TAAA). A commercially available, multibranched, off-the-shelf endograft called the t-Branch stent graft has demonstrated favourable midterm outcomes. Another two investigational off-the-shelf endografts, the GORE EXCLUDER Thoracoabdominal Branch Endoprosthesis and E-nside multibranch stent graft system, are still being developed. However, these three endografts have an unsatisfactory anatomic feasibility rate in patients with TAAA. Based on the concept of Guo's renovisceral artery reconstruction-1, a novel, multibranched, off-the-shelf endograft with different configurations has been developed.

METHODS AND ANALYSIS

This prospective, multicentre, single-arm, cohort study will enrol 73 patients with TAAA. Preoperative and postoperative clinical data, as well as CT angiography images at each follow-up timepoint, will be analysed to evaluate the safety and efficacy of this novel, multibranched, off-the-shelf endograft for the treatment of TAAA. The primary safety end point is the major adverse event rate within 30 days after index endovascular aortic repair, including all-cause death, hepatic failure, bowel necrosis, renal failure, stroke, permanent paraplegia, cardiac infarction and respiratory failure. The primary efficacy end point is the successful treatment rate within 12 months after procedure, which is a composite of immediate technical success and no secondary surgical intervention related to TAAA within 12 months after the procedure.

ETHICS AND DISSEMINATION

The protocol has been reviewed and approved by the ethics committee of Chinese PLA General Hospital (reference number: 2021-NO.-007) and each participating hospital. The findings of this study will be disseminated through conference presentations, peer-reviewed journal publications and social media.

TRIAL REGISTRATION NUMBER

NCT05054985.

Outcomes of multibranched off-the-shelf stent graft in elective and urgent/emergent repair of complex aortic aneurysms with narrow internal aortic lumen

OBJECTIVES

To assess the outcomes of Cook t-Branch off-the-shelf multibranched stent graft (Cook Medical, Bloomington, IN, USA) in the treatment of complex aortic aneurysms with narrow internal aortic lumen.

METHODS

Between 2016 and 2020, 48 patients (mean age 73 years) underwent elective or urgent/emergent Cook t-Branch implantation for thoracoabdominal or para/juxtarenal aortic aneurysms in 2 Italian vascular centers. Among these, 20 patients presented a paravisceral/pararenal luminal diameter < 25 mm. Major clinical and radiological outcomes of patients with narrow aortic lumen were compared with patients with larger lumen in a multicenter, non-randomized, retrospective fashion.

RESULTS

The in-hospital mortality was 10% (5% in the elective setting). Spinal cord ischemia occurred in 6% of the cases. During a mean follow-up of 18 months (range 1 - 63), late t-Branch procedure-related mortality and the need for re-intervention was 0% and 12%, respectively. Comparing the outcomes of patients with large internal aortic lumen (Group 1) with patients with small lumen (Group 2), no significant difference was found regarding fluoroscopy time (p = 0.3), technical success (p = 1), early (p = 0.4) and late (p = 1) mortality, spinal cord ischemia (p = 0.2), bowel ischemia (p = 0.5), renal (p = 0.7), cardiac (p = 1), and respiratory complications (p = 1), re-intervention rate (p = 1), and primary patency rate of stented target vessels (p = 1).

CONCLUSION

The use of the Cook t-Branch in our experience was safe and effective in the treatment of complex aortic aneurysms regardless the caliber of the aortic lumen. With all the limitations of a small sample size, this approach has demonstrated to be feasible also when maneuverability is reduced, with low mortality and morbidity, and acceptable re-intervention need. Perioperative mortality remains closely related to clinical presentation. Large-scale studies are needed to confirm these results.

Temporary Reperfusion of the Aneurysm Sac as a Prevention of Spinal Cord Ischemia After Endovascular Treatment of Thoracoabdominal Aortic Aneurysm: Systematic Review and Meta-analysis

BACKGROUND

Spinal cord ischemia (SCI) is still a feared complication for patients suffering from thoracoabdominal aortic aneurysm (TAAA) who undergo endovascular treatment. The aims of this work are to review the available literature on different reperfusion methods of the aneurysm sac, and to analyze whether the different reperfusion methods, also in combination with other factors, are effective in reducing SCI risk and if the impact varies with the patient's age.

METHODS

PubMed/MEDLINE library was searched for studies published until November 2020 concerning TAAA, endovascular repair, and SCI preventive measures. Systematic review and meta-analysis were conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses criteria. Primary outcome consisted of correlation between endovascular repair techniques (type A: single step; type B: staged approach with reperfusion branches; type C: staged sequential approach with positioning of the thoracic component). A logistic-weighted regression for each event (SCI, transient, and permanent) was then performed with type of treatment, age, and interaction between them as input factors. Finally, another logistic-weighted regression was performed to analyze the other relevant factors for which observations are available together with the endovascular technique.

RESULTS

Data from 53 studies with a total of 3095 patients were analyzed. Type A, type B, and type C endovascular strategies were adopted in 75%, 13%, and 12% of studied patients, respectively. Data showed that both type B and type C treatments are associated with lower risk of SCI, with a higher reduction of type C with respect to type B, although this positive trend is limited for elder patients. Moreover, a greater aortic diameter, a reduced aneurysm extent, and the absence of cerebrospinal fluid drainage positioning contribute to lower the risk of SCI. Concerning permanent SCI, both type B and type C are effective in reducing percentages for all ages, with type C treatment more beneficial for younger patients and type B for elder ones.

CONCLUSION

According to the anatomy and the endovascular repair feasibility criteria, staged endovascular treatment appears to offer relevant advantages over single-step treatment in reducing the risk of SCI, regardless of the reperfusion method adopted.

Cannulation of visceral vessels using a steerable sheathin fenestrated and branched aortic endografts

INTRODUCTION

A critical step in the endovascular treatment of complex aortic aneurysm is the cannulation and stenting of renovisceral vessels, especially in cases with a complex anatomy or atherosclerotic lesions. This study aimed to demonstrate the results of renovisceral vessel cannulation using a steerable sheath in fenestrated or branched endovascular aortic procedures (FB-EVAR).

METHODS

Patients undergoing elective FB-EVAR for asymptomatic thoracoabdominal or juxtarenal aneurysm at a single tertiary referral center from 2016 to 2019 were included in this study. Underlying pathologies, renovisceral target vessels (TV), technical success (TS), freedom from reintervention (FFR), and TV patency were assessed. Target vessels were categorized as challenging or non-challenging TV.

RESULTS

Fifty-three patients (median age 73 (Q1, Q3 (68 - 80)); 43 male (81%)) who underwent elective FB-EVAR were included. Indications comprised thoracoabdominal aneurysms (Crawford I-IV) (n = 26; 49%), juxtarenal aneurysms (n = 23; 43.5%) and penetrating aortic ulcers (PAU) (n = 4; 7.5%). Two patients (4%) had prior open aortic surgery, and three patients (6%) had undergone a failed standard EVAR before. Of the 196 treated TV, 131 (67%) were categorized as challenging. Cannulation was successful in 194 of 196 vessels (99%). A total of three TV (1.5%) showed periprocedural complications. No significant difference was found in the rate of intraoperative complications between challenging versus non-challenging TV (p = 0.457). One patient died within 30 days of the procedure (1.9%). No stroke or intestinal ischemia occurred. After 12, 24, and 36 months, the survival rate was 87%, 87%, and 81%, respectively Primary patency after 12 months was 98.6%, and 97.9% of vessels remained FFR during follow-up.

CONCLUSION

Transfemoral, retrograde cannulation of renovisceral vessels using a steerable sheath is feasible and safe and provides good mid-term results, especially in cases with challenging renovisceral vessels. The potential complications of antegrade vascular access can be avoided.

Multi-Branched Thoracoabdominal Endovascular Aortic Repair With Branch Access Through a Left Thoracotomy and Descending Thoracic Aortic Conduit: A Novel and Effective Alternative Access

PURPOSE

To demonstrate an alternative access to perform directional branch catheterization during complex endovascular aortic repair.

TECHNIQUE

Urgent endovascular aortic repair was indicated to treat a symptomatic post dissection thoracoabdominal aneurysm with large infrarenal dilatation with an off-the-shelf t-Branch endograft (Cook Medical, Bloomington, IN, USA). Traditional proximal arterial accesses were not suitable due to a previous aortic arch endograft. A novel approach was performed through a left postero-lateral thoracotomy, isolation of the descending thoracic aorta and anastomosed a polyester graft conduit to allow sheaths passage to the thoracoabdominal aorta with subsequently directional branch catheterization.

CONCLUSION

The descending thoracic aortic conduit technique is an effective alternative for directional branch catheterization and should be considered whenever traditional proximal arterial accesses are not suitable and other endografts configurations not considered due to anatomic limitations.