Thoracoabdominal aortic aneurysm repair: current endovascular perspectives

Abstract

Thoracoabdominal aneurysms account for roughly 3% of identified aneurysms annually in the United States. Advancements in endovascular techniques and devices have broadened their application to these complex surgical problems. This paper will focus on the current state of endovascular thoracoabdominal aneurysm repair, including specific considerations in patient selection, operative planning, and perioperative complications. Both total endovascular and hybrid options will be considered.

I-SWOT as instrument to individually optimize therapy of thoracoabdominal aortic aneurysms

“… CIN  contrast-induced nephropathy, DAZH  German Aortic Center of Hamburg, ICU  intensive care unit, TAAA  thoracoabdominal aortic aneurysm, TAAA I, II, III, IV, and V  refer to the Crawford classification of TAAAExplanatory notes : W4  Bypass or left subclavian artery transposition according to the guidelines [13]; W5  Hostile aortic landing zone (landing zone <2 cm, massive aortic calcification or thrombosis, “gothic aortic arch” anatomy), unsuitable aortic anatomy (aortic kinking, narrow vessel caliber, unfavourable aortic anatomy of outflow vessels), unsuitable access to vessels (calcification, kinking, simultaneous access from multiple vessels); W6  Stent migration, stent collapse (risk factors are small diameter of aortic landing zone, aggressive oversizing, narrow aortic curvature with “bird-beaking” configuration); W7  High radiation exposure, high contrast load with increased risk of allergic reactions, complications due to complex arterial access techniques, contrast - induced nephropathy (CIN) and dialysis with subsequent risk factors for CIN: diabetes mellitus, age > 75 years periprocedural volume depletion, heart failure, cirrhosis or nephrosis, arterial hypertension, proteinuria, pretreatment with nonsteroidal anti-inflammatory drugs (NSAIDs), initial intra-arterial injection of contrast medium [7]; W8  Risk of organ ischemia (stroke, paraparesis, paraplegia especially with endograft >15 cm in length), visceral ischemia, renal artery infarctions; W19  Thoracotomy with aortic clamping, extracorporeal circulation, and unilateral pulmonary ventilation; W20  Patients who generally fulfil at least three of the following criteria: chronic arterial hypertension, chronic obstructive pulmonary disease with FEV1 < 1.0, coronary heart disease with myocardial infarction, stenting or aortocoronary bypass, heart failure with LVEF < 35% and >NYHA I, chronic renal failure with creatinine 1.2 mg/dl, American Society of Anesthesiologists score (ASA) ≥ 3, pre-existing aortic operation with thoracotomy or infrarenal aortic prosthetic grafts [14]…”

“…Let us consider a patient with asymptomatic TAAA where we identify protection against aortic rupture as therapeutic goal. Next, we identify evidence-based consensus recommendations for five distinct therapeutic options as follows [ 7 – 10 ]: conservative therapy (A) implying medicinal therapy with angiotensin II receptor blockers (ARB), angiotensin-converting enzyme inhibitors (ACEI), beta adrenergic blockers (BAB) or calcium channel blockers (CCB), therapy for obstructive sleep apnea syndrome (OSAS), and behavioral modification with avoidance of Valsalva maneuvers or isometric muscle activities. Another option is endovascular therapy using so-called chimney, snorkel, periscope, or sandwich techniques (B) [ 7 ].…”

Retrograde Superior Mesenteric Artery Stenting in Case of SMA Shuttering

“…Given a mortality rate of 3-8% associated with open repair, 1 techniques such as visceral debranching followed by endovascular repair, snorkels/chimneys, and fenestrated and side branch stent grafts have become more widespread in the treatment of thoracoabdominal aortic aneurysms (TAAA). 2 One strategy utilized for extent I and V TAAAs is thoracic endovascular aortic repair (TEVAR) involving coverage of the celiac artery (CA) for distal landing zone extension, which has been shown to be suitable in patients with collaterals from the superior mesenteric artery (SMA). [3][4][5] A potential complication of this approach is the partial coverage, or shuttering, of the SMA, with the potential to cause symptomatic visceral ischemia, which is treated by stenting of the SMA.…”

Physical activity and the risk of abdominal aortic aneurysm: a systematic review and meta-analysis of prospective studies

“…According to the Global Burden of Disease Study aortic aneurysms was estimated to account for 167,200 deaths and 3 million disability-adjusted life years in 2017 5 , 6 . The vast majority of aortic aneurysms are abdominal aortic aneurysms, with only 3% originating in the thorax 7 . In Caucasian populations the prevalence of abdominal aortic aneurysms is 4.7% 8 – 10 , while it is 0.45% in Asian populations 11 .…”