Delayed open conversion after endovascular abdominal aortic aneurysm: Device-specific surgical approach

none7Objectives: Despite several advances in endoluminal salvage for failed endovascular abdominal aortic repair (EVAR), in our experience an increasing number of cases necessitate delayed open conversion (dOC). Methods: EVAR patients requiring delayed (>30 days) conversion were prospectively collected in a computerized database including demographics, details of aortoiliac anatomy, procedural and clinical success, and postoperative complications. Results: Between 2005 and 2011, 54 patients were treated for aortic stent-graft explantation. Indications included 34 type I and III endoleaks, 13 type II endoleaks with aneurysm growth, 4 cases of material failures, and 3 stent-graft infections. All fit-for-surgery patients with type I/III endoleak underwent directly dOC. Different surgical approaches were used depending on the type of stent-graft. Overall 30-day mortality was 1.9%. Overall morbidity was 31% mainly due to acute renal failure (13 cases). Mean hospitalization was 6 days (range, 5-27 days). Overall survival at mean follow-up of 19 months was 78%. Conclusions: In recent years, the use of EVAR has increased dramatically, including in young patients regardless of their fitness for open repair. dOC after endovascular abdominal aortic aneurysm seems to be a lifesaving procedure with satisfactory initial and mid-term results. © 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.Marone, E.M.; Mascia, D.; Coppi, D.; Tshomba, Y.; Bertoglio, L.; Kahlberg, A.; Chiesa, R.Marone, ENRICO MARIA; Mascia, D.; Coppi, D.; Tshomba, Y.; Bertoglio, L.; Kahlberg, A.; Chiesa, R

Diagnostic laparoscopy for early detection of acute mesenteric ischaemia in patients with aortic dissection

Introduction: Recognition of acute mesenteric ischaemia (AMesI) in patients with aortic dissection (AoD) may be a challenge and exploratory laparotomy is often performed. Methods: We retrospectively analysed our experience with the use of diagnostic laparoscopy (DL) for the early detection of AMesI in patients with AoD, either undergoing medical treatment or after open/endovascular interventions. Results: Between 2004 and 2011, 202 consecutive AoDs were treated in our centre (71 acute type A AoD; 131 acute and chronic type B AoD). Among the 17 (8.4%) patients in which AMesI was suspected, nine (52.9%) were selected for DL. Three DLs were performed during medical treatment of patients with acute type B AoD, six after treatment of AoD (both surgical and endovascular). Three second-look DLs were also performed. Eight DLs were negative, three showed AMesI and the patients underwent successful emergent revascularisation. One DL was not conclusive and laparotomy was required. Among the eight patients not submitted to DL, one case of bowel infarction was recorded. Conclusions: In our series DL was feasible and safe. The low invasiveness and repeatability were the main advantages. Although additional experience is mandatory, DL seems a promising technique for the detection of AMesI in patients with AoD. © 2012 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved

New insights regarding the incidence, presentation and treatment options of aorto-oesophageal fistulation after thoracic endovascular aortic repair: the European Registry of Endovascular Aortic Repair Complications

OBJECTIVES: To review the incidence, clinical presentation, definite management and 1-year outcome in patients with aorto-oesophageal fistulation (AOF) following thoracic endovascular aortic repair (TEVAR). METHODS: International multicentre registry (European Registry of Endovascular Aortic Repair Complications) between 2001 and 2011 with a total caseload of 2387 TEVAR procedures (17 centres). RESULTS: Thirty-six patients with a median age of 69 years (IQR 56-75), 25% females and 9 patients (19%) following previous aortic surgery were identified. The incidence of AOF in the entire cohort after TEVAR in the study period was 1.5%. The primary underlying aortic pathology for TEVAR was atherosclerotic aneurysm formation in 53% of patients and the median time to development of AOF was 90 days (IQR 30-150). Leading clinical symptoms were fever of unknown origin in 29 (81%), haematemesis in 19 (53%) and shock in 8 (22%) patients. Diagnosis could be confirmed via computed tomography in 92% of the cases with the leading sign of a new mediastinal mass in 28 (78%) patients. A conservative approach resulted in a 100% 1-year mortality, and 1-year survival for an oesophageal stenting-only approach was 17%. Survival after isolated oesophagectomy was 43%. The highest 1-year survival rate (46%) could be achieved via an aggressive treatment including radical oesophagectomy and aortic replacement [relative risk increase 1.73 95% confidence interval (CI) 1.03-2.92]. The survival advantage of this aggressive treatment modality could be confirmed in bootstrap analysis (95% CI 1.11-3.33). CONCLUSIONS: The development of AOF is a rare but lethal complication after TEVAR, being associated with the need for emergency TEVAR as well as mediastinal haematoma formation. The only durable and successful approach to cure the disease is radical oesophagectomy and extensive aortic reconstruction. These findings may serve as a decision-making tool for physicians treating these complex patients

Aorto-bronchial and aorto-pulmonary fistulation after thoracic endovascular aortic repair: an analysis from the European Registry of Endovascular Aortic Repair Complications.

OBJECTIVES: To learn upon incidence, underlying mechanisms and effectiveness of treatment strategies in patients with central airway and pulmonary parenchymal aorto-bronchial fistulation after thoracic endovascular aortic repair (TEVAR). METHODS: Analysis of an international multicentre registry (European Registry of Endovascular Aortic Repair Complications) between 2001 and 2012 with a total caseload of 4680 TEVAR procedures (14 centres). RESULTS: Twenty-six patients with a median age of 70 years (interquartile range: 60-77) (35% female) were identified. The incidence of either central airway (aorto-bronchial) or pulmonary parenchymal (aorto-pulmonary) fistulation (ABPF) in the entire cohort after TEVAR in the study period was 0.56% (central airway 58%, peripheral parenchymal 42%). Atherosclerotic aneurysm formation was the leading indication for TEVAR in 15 patients (58%). The incidence of primary endoleaks after initial TEVAR was n = 10 (38%), of these 80% were either type I or type III endoleaks. Fourteen patients (54%) developed central left bronchial tree lesions, 11 patients (42%) pulmonary parenchymal lesions and 1 patient (4%) developed a tracheal lesion. The recognized mechanism of ABPF was external compression of the bronchial tree in 13 patients (50%), the majority being due to endoleak formation, further ischaemia due to extensive coverage of bronchial feeding arteries in 3 patients (12%). Inflammation and graft erosion accounted for 4 patients (30%) each. Cumulative survival during the entire study period was 39%. Among deaths, 71% were attributed to ABPF. There was no difference in survival in patients having either central airway or pulmonary parenchymal ABPF (33 vs 45%, log-rank P = 0.55). Survival with a radical surgical approach was significantly better when compared with any other treatment strategy in terms of overall survival (63 vs 32% and 63 vs 21% at 1 and 2 years, respectively), as well as in terms of fistula-related survival (63 vs 43% and 63 vs 43% at 1 and 2 years, respectively). CONCLUSIONS: ABPF is a rare but highly lethal complication after TEVAR. The leading mechanism behind ABPF seems to be a continuing external compression of either the bronchial tree or left upper lobe parenchyma. In this setting, persisting or newly developing endoleak formation seems to play a crucial role. Prognosis does not differ in patients with central airway or pulmonary parenchymal fistulation. Radical bronchial or pulmonary parenchymal repair in combination with stent graft removal and aortic reconstruction seems to be the most durable treatment strategy

Guidelines on the diagnosis, treatment and management of visceral and renal arteries aneurysms: a joint assessment by the Italian Societies of Vascular and Endovascular Surgery (SICVE) and Medical and Interventional Radiology (SIRM)

: The objective of these Guidelines is to provide recommendations for the classification, indication, treatment and management of patients suffering from aneurysmal pathology of the visceral and renal arteries. The methodology applied was the GRADE-SIGN version, and followed the instructions of the AGREE quality of reporting checklist. Clinical questions, structured according to the PICO (Population, Intervention, Comparator, Outcome) model, were formulated, and systematic literature reviews were carried out according to them. Selected articles were evaluated through specific methodological checklists. Considered Judgments were compiled for each clinical question in which the characteristics of the body of available evidence were evaluated in order to establish recommendations. Overall, 79 clinical practice recommendations were proposed. Indications for treatment and therapeutic options were discussed for each arterial district, as well as follow-up and medical management, in both candidate patients for conservative therapy and patients who underwent treatment. The recommendations provided by these guidelines simplify and improve decision-making processes and diagnostic-therapeutic pathways of patients with visceral and renal arteries aneurysms. Their widespread use is recommended

Endovascular Exclusion of Thoracic Aortic Aneurysms With the 1-and 2-Component Zenith TX2 TAA Endovascular Grafts: Analysis of 2-Year Data From the TX2 Pivotal Trial

Purpose: To compare the midterm results of endovascular treatment of thoracic aortic aneurysms and ulcers in patients who received either a 1-component or 2-component Zenith TX2 stent-graft. Methods: Data were gathered from a prospectively maintained registry for the Zenith TX2 pivotal trial. Among 158 patients who underwent thoracic endovascular aortic repair (TEVAR) between March 2004 and July 2006, 64 received a 1-component stent-graft (group 1) and 94 patients a 2-component device (group 2). Results: In group 2, there were more men (79% vs. 63%; p=0.03), and the patients had more diagnosed (p<0.01) and previously repaired (p<0.01) abdominal aortic aneurysms. Aneurysms in group 2 were significantly larger in both diameter (63 vs. 56 mm, p<0.01) and length (157 vs. 113 mm, p<0.01). Percent of thoracic aorta covered by the stent-graft was greater in group 2 (80% vs. 50%, p<0.01). Patients in group 2 had a significantly longer operation time (124 +/- 48 vs. 100 +/- 39 minutes, p<0.01) and significantly increased estimated blood loss during the procedure (248 +/- 359 vs. 169 +/- 139 mL, p=0.05). Procedural success at 30 days was 95% in group 1 and 85% in group 2 (p=0.06). Postoperative paraplegia and paraparesis were not observed in group 1, but 9 patients in group 2 (p=0.01) were affected. Treatment success, endoleak, migration, secondary intervention rate, and all-cause and aneurysm-related mortality were not significantly different between the groups at 30 days, 1 year, and 2 years. Conclusion: TEVAR using 1 or 2 TX2 components has similar results in terms of mortality and midterm treatment success. Patients treated with 2 components showed increased perioperative morbidity, including paraplegia, which may be related to the greater extent of graft coverage required in this patient group, as well as to male gender, previous aortic repair, longer operating time, and increased blood loss. J Endovasc Ther. 2011; 18: 338-34

Single-center experience with endovascular treatment of acute blunt thoracic aortic injuries

Aim. Endovascular repair of the thoracic aorta (TEVAR) has been recently considered an appealing alternative to open treatment of traumatic aortic injuries. However, the use of this technique in emergency is often limited by hemodynamic instability, severe associated lesions and unavailability of adequate materials. Dedicated stent-grafts are not currently available. We report our results in treating blunt traumas of the thoracic aorta using three different commercially available stent-grafts. Methods. Between 2003 and 2010, 28 patients (22 males, mean age 38.9±12.1 years) underwent TEVAR for a traumatic aortic lesion. A total-body computed tomography angiography (CTA) was performed in all cases to establish the diagnosis of aortic rupture and evaluate associated injuries. After TEVAR, patients were followed-up with CTA of the chest before discharge from the hospital, at 6 months and yearly thereafter. Results. Fifteen patients (54%) were hemodynamically unstable at presentation, and 20 patients (71%) presented severe associated lesions. The mean injury severity score (ISS) was 36.2. Twenty-four patients were treated emergently, whereas four patients underwent prior clinical stabilization of severe associated injuries. Primary technical success rate was 100%. No patient required conversion to open thoracic surgical repair. No paraplegia or stroke was observed. Procedure-related complications included an external iliac artery lesion during introducer sheath removal. The left subclavian artery was intentionally covered in 7 cases (25%), and revascularized in two hemodynamically stable patients prior to stent-graft deployment. Two patients died perioperatively due to multiorgan failure, for a total in-hospital mortality of 7%. Twenty-four patients (92% of survivors) adhered to the follow-up protocol (mean 37.3±17.5 months), and they are all alive without instances of reintervention. Conclusion. In our experience, endovascular treatment of acute traumatic thoracic aortic injuries using different commercially available stent-grafts allows to obtain satisfactory short term results

Strategies to treat thoracic aortitis and infected aortic grafts

Infectious thoracic aortitis is a rare disease, especially since the incidence of syphilis and tuberculosis has dropped in western countries. However, the risk to develop an infectious aortitis and subsequent mycotic aneurysm formation is still present, particularly in case of associated endocarditis, sepsis, and in immunosuppressive disorders. Moreover, the number of surgical and endovascular thoracic aortic repairs is continuously increasing, and infective graft complications are observed more frequently. Several etiopathogenetic factors may play a role in thoracic aortic and prosthetic infections, including hematogenous seeding, local bacterial translocation, and iatrogenous contamination. Also, fistulization of the esophagus or the bronchial tree is commonly associated with these diseases, and it represents a critical event requiring a multidisciplinary management. Knowledge on underlying micro-organisms, antibiotic efficacy, risk factors, and prevention strategies has a key role in the management of this spectrum of infectious diseases involving the thoracic aorta. When the diagnosis of a mycotic aneurysm or a prosthetic graft infection is established, treatment is demanding, often including a number of surgical options. Patients are usually severely compromised by sepsis, and in most cases they are considered unfit for surgery for general clinical conditions or local concerns. Thus, results of different therapeutic strategies for infectious diseases of the thoracic aorta are still burdened with very high morbidity and mortality. In this manuscript, we review the literature regarding the main issues related to thoracic infectious aortitis and aortic graft infections, and we report our personal series of patients surgically treated at our institution for these conditions from 1993 to 2014