Staged endovascular repair of thoracoabdominal aortic aneurysms limits incidence and severity of spinal cord ischemia

O’Callaghan, Adrian; Mastracci, Tara M.; Eagleton, Matthew J.

doi:10.1016/j.jvs.2014.09.011

Cited by 144 publications

(97 citation statements)

References 24 publications

(30 reference statements)

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“…Staging of aortic repair has been shown to be beneficial not only in open and hybrid repair of extensive TAAAs, but also in total endovascular repair of such extensive TAAAs. 21 A two-staged total endovascular repair of Crawford extent II TAAAs was associated with a SCI rate of 11.1% compared with 37.5% when a singlestage repair was performed.…”

Section: Discussionmentioning

confidence: 98%

Staged hybrid repair of extensive thoracoabdominal aortic aneurysms secondary to chronic aortic dissection

Jain

Flohr

Johnston

et al. 2016

Journal of Vascular Surgery

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Section: Discussionmentioning

confidence: 98%

Staged hybrid repair of extensive thoracoabdominal aortic aneurysms secondary to chronic aortic dissection

Jain

Flohr

Johnston

et al. 2016

Journal of Vascular Surgery

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“…We also have a policy of staging long-segment coverage for endovascular thoracoabdominal aneurysm repair to decrease SCI risk 31 ; however, this cannot be done safely in the acute setting. Indeed, these results motivated us to evolve our SCI protocols, 22 which now resemble interventions for open TAAA repair.…”

Section: Discussionmentioning

confidence: 99%

Outcomes of surgeon-modified fenestrated-branched endograft repair for acute aortic pathology

Scali

Neal

Sollanek

et al. 2015

Journal of Vascular Surgery

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Objective Open surgical repair for acute aortic pathologies involving the visceral vessels is associated with morbidity and mortality rates of 40% to 70% and 30% to 60%, respectively. Due to these poor outcomes, the application of fenestrated/branched endovascular aortic repair (F/B-EVAR) has been expanded in this setting; however, durability remains unknown. The purpose of this analysis was to describe outcomes after F/B-EVAR for acute aortic disease. Methods A single center retrospective review of all F/B-EVARs for acute aortic disease was completed. Primary end points included mortality and reintervention-free survival. Secondary end points were patency and freedom from endoleak, as well as change in aneurysm diameter and estimated glomerular filtration rate. Life-tables were used to estimate end points, while mixed statistical models were used to determine aneurysm diameter change. Results Thirty-seven patients (mean age ± standard deviation, 67 ± 10 years; 75% male) underwent F/B-EVAR for acute aortic disease, and median follow-up time was 10.3 months (range, 0.5–31.4 months). Indications included thoracoabdominal aneurysm (65%; n = 24), pararenal aneurysm (17%; n = 6), postsurgical anastomotic pseudoaneurysm (8%; n = 3), dissection (5%; n = 2), and penetrating ulcer (5%; n = 2). Mean preoperative aneurysm diameter was 7.3 ±1.8 cm. All patients were American Society of Anesthesiologists class IV or IV-E, and 38% (n = 14) had history of aortic repair. There were 105 visceral vessels revascularized (celiac, 26; superior mesenteric artery, 29; renal, 50) and 24 (65%) patients underwent three- or four-vessel repair. Technical success was 92% (n = 34), with no intraoperative deaths and one conversion (3%). Median length of stay was 6 days (range, 2–60 days), and postoperative morbidity was 41% (n = 15; spinal cord ischemia, 14% [8% permanent]; pulmonary, 14%; renal, 14%; extremity ischemia, 8%; stroke, 5%; cardiac, 3%; bleeding, 3%) with 30-day mortality of 19% (n = 7; in-hospital, 8%; n = 3). Endoleak was detected at some point in follow-up in 27% (n = 10), and a majority were type II (n = 7). Six (16%) patients underwent reintervention, and no late conversions occurred. Postoperative imaging was available in 27 (73%), and one celiac fenestration lost patency at 12 months. One-year branch vessel patency and freedom from reintervention was 98% ± 6% and 70% ± 9%, respectively. Estimated 1- and 4-year survival were 70% ± 8% and 67% ± 8%, respectively. During follow-up, aortic diameter decreased 0.5 cm (95% confidence interval, 1.1–0.2; P = .1) while estimated glomerular filtration rate decreased by 2 mL/min/1.73 m2. Conclusions F/B-EVAR can be performed to treat a variety of symptomatic and/or ruptured paravisceral aortic pathologies. Perioperative morbidity and mortality can be significant; however, it is less than literature-based outcomes of open repair. Short-term fenestrated/branched graft patency is excellent, but reintervention is frequent, highlighting the need for diligent follow-up. Patients survi...

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“…Similar results are obtained by Bischoff et al [14] who sacrificed the lumbar arteries first, and then covered the thoracic segmental arteries with an endovascular stent graft 7 days later. Retrospective studies in man suggest that the use of a staged approach is safe and may reduce the risk of paraplegia [15,21,22]. These initial data support the rationale to use a segmental approach to treat extensive disease in order to allow the spinal circulation to remodel and thereby decrease the lifetime risk of paraplegia.…”

Section: Discussionmentioning

confidence: 80%

Thoracic endovascular repair first for extensive aortic disease: the staged hybrid approach

Vivacqua

Idrees

Johnston

et al. 2015

Eur J Cardiothorac Surg

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OBJECTIVES: Repair of extensive aortic disease carries a significant risk of death and morbidity, the most feared complication being spinal cord ischaemia. Objectives of this study are to characterize patients, describe repair methods and assess feasibility and safety of hybrid staged repair for treatment of extensive aortic disease. METHODS:From to 2001 to 2013, 22 patients underwent extensive aortic repair that included a thoracic endovascular aortic repair (TEVAR) first followed by an open completion repair extending through the visceral and infrarenal aorta for degenerative aneurysm and dissection. At the time of initial repair, all patients were deemed to be at a high risk for conventional open repair and had extensive disease. Indications for open completion included emergency failure of TEVAR (n = 3), early two-stage approach (n = 6) and delayed disease progression after TEVAR (n = 13). The median interval between stages was 6.5 months. The mean age was 56 ± 14 years, 5 patients had connective tissue disorder and the mean maximum aortic diameter was 58 ± 16 mm preoperatively. RESULTS:There was no death or major complication after initial TEVAR, but the operative mortality rate was 9% (n = 2) after the open procedure. One of these patients died from intraoperative myocardial infarction during emergency repair, and the other had disseminated intravascular coagulation during delayed repair for disease progression after TEVAR. Other complications included paralysis in 1 (4.5%), tracheostomy in 2 (9%) and dialysis in 1 (4.5%), and there was 1 reoperation for bleeding (4.5%). The median follow-up was 37 (range 3.3-93) months and there were no late deaths. There were four late reoperations for proximal disease progression leading to Type 1 endoleak (n = 2), Type A dissection (n = 1) and root aneurysm (n = 1). CONCLUSIONS:Use of a TEVAR-first approach in combination with a staged open repair is a safe and feasible treatment strategy for repair of extensive aortic disease. A staged hybrid approach to aortic repair in patients at high risk for total aortic replacement may limit morbidity.

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Staged endovascular repair of thoracoabdominal aortic aneurysms limits incidence and severity of spinal cord ischemia

Abstract: Staged repair appears both to protect against SCI and to enhance overall survival in extensive aortic repair.

Cited by 144 publications

References 24 publications

Staged hybrid repair of extensive thoracoabdominal aortic aneurysms secondary to chronic aortic dissection

Staged hybrid repair of extensive thoracoabdominal aortic aneurysms secondary to chronic aortic dissection

Outcomes of surgeon-modified fenestrated-branched endograft repair for acute aortic pathology

Thoracic endovascular repair first for extensive aortic disease: the staged hybrid approach

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