Editor's Choice – Open Thoracic and Thoraco-abdominal Aortic Repair After Prior Endovascular Therapy

Abstract

Open TAA(A) repair as a secondary procedure after previous endovascular aortic therapy is an important treatment option even in the endovascular era. It represents a durable treatment that can produce respectable outcomes. Yet the peri-operative morbidity and mortality are relevant and a specialised team and infrastructure are mandatory for these complex procedures. Therefore, centralisation is required.

Offener thorakaler und thorakoabdominaler Aortenersatz vs. f/b(T)EVAR – komplementär oder kompetitiv?

“…B. Typ I EL) der vorherigen endovaskulären Therapie können unter Umständen notwendig werden, Ausdehnung der Pathologien über ehemalige Landezonen hinaus oder Device-assoziierte Probleme (z. B. Stentbruch)[31]. Zusätzlich muss bedacht werden, dass für endovaskuläre Lösungen immer eine ausreichende Verankerungszone (Sealing Zone) in einem gesunden, nicht dilatierten Gefäßsegment vorhanden sein muss (▶ Abb.…”

Invited Commentary

“…2 Similar to the current paper, prior work has demonstrated the most common underlying disease states in patients requiring open repair after TEVAR to be dissection (75% of cases) and connective tissue disease (11%). 5 As pointed out in a recent review, 6 distal thoracic and abdominal aneurysmal degeneration is common after TEVAR for dissection, despite seal of the proximal entry tear, with thoracic dilation in 7% to 84% and abdominal dilation in 10% to 54% of patients across studies. Furthermore, late degeneration was similarly seen whether TEVAR was performed in the acute or chronic setting, with the etiology being persistent false lumen perfusion through distal entry tears downstream from the endografts.…”

“…The final important question raised by this paper is who should be doing these SAI, especially open thoracoabdominal aortic aneurysm (TAAA) repair, which represented 31% of late open SAI, and which remains an important treatment option even in the endovascular era. 5 As demonstrated by the results of Alhussaini and colleagues, 1 who report 30-day mortality, spinal cord ischemia, and stroke rates of 14%, 5%, and 10%, respectively, for their open surgical SAI (presumably the spinal cord ischemia rates are even greater for the TAAA patients as all late open repairs, both proximal and distal, were lumped together for reporting), these complex procedures carry significant risk, and prior investigators 5 have concluded they should be reserved for specialized centers. Many studies demonstrate an inverse relationship between volume and perioperative mortality for both TEVAR and open TAAA repair, 7,8 although surgeon volume appears more important than hospital volume for open TAAA repair.…”

Open Thoracoabdominal Aortic Procedures following Endovascular Intervention

“…Proximal/distal disease progression, with distal progression being the leading cause of conversion in series with a high proportion of postdissecting aortic disease. 7 …”

“…These factors contribute to the higher in-hospital mortality in these patients. 7 As only few studies have previously reported OC after TAA endovascular repair, the aim of this paper is to describe specific features and different scenarios, as well as to provide technical surgical tips emanating from our single-center experience with OC after TEVAR, FEVAR, and BEVAR.…”