Total Endovascular Repair With Parallel Stent-Grafts for Postdissection Thoracoabdominal Aneurysm After Prior Proximal Repair

Abstract

Purpose: To evaluate the safety and efficacy of total endovascular repair with parallel stent-grafts for postoperative residual dissection thoracoabdominal aortic aneurysm (TAAA). Materials and Methods: A retrospective study was undertaken of 21 patients (mean age 64.0±12.5 years; 17 men) undergoing total endovascular therapy with parallel stent-grafts for postdissection TAAA after prior proximal repair between 2014 and 2016. The preoperative minimum true lumen diameter was 12.3±4.8 mm and the mean extent of dissection was 248.1±48.2 mm. Pre-, intra-, and postoperative medical records were reviewed to assess technical success, spinal cord ischemia, patency of target branch arteries, endoleak, and short-term outcomes of this approach. Results: Technical success was achieved in 17 of 21 patients owing to 4 type I endoleaks at the end of the procedures. A total of 70 branch arteries were revascularized and 14 celiac trunks were covered intentionally without reconstruction. Of 7 intraoperative endoleaks, 2 were managed intraoperatively and 5 (4 type I and 1 type II) disappeared spontaneously within 1 month. No spinal cord or abdominal organ or limb ischemia was observed. Mean follow-up was 16.2±6.1 months. No death or type I or III endoleak occurred during the follow-up; 2 type II endoleaks were observed. Nineteen of the 21 false lumens thrombosed, and the total aortic diameter decreased (57.3±8.4 to 55.3±7.4 mm, p<0.01). Three (4.3%) of 70 target branch arteries occluded during follow-up. The cumulative patency of retrogradely and antegradely revascularized branch arteries was 97.3% vs 100% at 12 months and 91.2% vs 100% at 18 months. Conclusion: Total endovascular therapy with parallel stent-grafts could be an effective alternative in treating postdissection TAAA. Further studies with long-term follow-up and larger sample size are recommended to evaluate the technique.

Fenestrated/Branched Endovascular Repair for Postdissection Thoracoabdominal Aneurysms: A Systematic Review with Pooled Data Analysis

“…Endoleak development is another concern after endovascular repair. The pooled analysis showed an endoleak rate of 33%, which is higher than the corresponding rate of 16% reported by Werlin et al 1 in 19 patients treated with multibranched stent grafts and the rate of 9.5% reported by Liu et al 27 in 21 patients treated with parallel stent grafts. Most of the endoleaks were type IB, which were usually associated with the distal sealing zone of the target vessels and the dissected iliac arteries in the series by Oikonomou et al 9 So, a sealing length of 15 to 20 mm inside the target vessels was advised by Oikonomou et al, 9 and attention should be paid to avoid the possibility of endoleaks.…”

“…Since then, several centers have reported their experiences with the technique, but the numbers of patients from different centers have remained limited because of the difficulties of the technique and the specific anatomical characteristics. Other stent grafts, including parallel, octopus, and multibranched stent grafts, 1,27,28 as well as techniques such as TEVAR combined with false lumen embolization for the PD-TAAA, have recently been reported in small populations of patients, adding promising treatment alternatives. However, both the number of patients and the number of centers able to perform the surgeries remain very limited.…”

Use of 3D Printing to Guide Creation of Fenestrations in Physician-Modified Stent-Grafts for Treatment of Thoracoabdominal Aortic Disease

“…[7][8][9][10][11][12][13][14][15] The introduction of endovascular repair provided a minimally invasive and effective method for the treatment of aortic disease with a low incidence of complications, thus providing a new option for patients with contraindications to surgery. [16][17][18] However, conventional EVAR could not be applied in cases of TAAA with a distal landing zone involving important renovisceral arteries. In recent years, methods for the endovascular repair of TAAA have been developed, with the main techniques involving chimney stent-grafts and customized fenestrated/ branched stent-grafts.…”

“…The introduction of endovascular repair provided a minimally invasive and effective method for the treatment of aortic disease with a low incidence of complications, thus providing a new option for patients with contraindications to surgery. 16–18 However, conventional EVAR could not be applied in cases of TAAA with a distal landing zone involving important renovisceral arteries.…”

Endovascular strategies for post-dissection aortic aneurysm (PDAA)

“…Because of the low requirement for stent-grafts, the technique owes unique advantages in dealing with emergent cases. The technique was applied by Liu J et al to treat 21 post-dissection thoracoabdominal aneurysms [26]. Four cases of type I endoleaks occurred after repair, which disappeared spontaneously within 1 month.…”