Total vs hemi-aortic arch transposition for hybrid aortic arch repair

ObjectiveTo compare the outcomes of total aortic arch transposition (TAAT) vs hemi-aortic arch transposition (HAAT) for hybrid aortic arch repair.MethodsA systematic search was performed using PubMed between November 1998 and May 2010 by two independent observers. Studies included reporting on patients treated by TAAT or HAAT and stent grafting in a proximal landing zone 0 or 1 by Ishimaru, respectively. Further articles were identified by following MEDLINE links, by cross-referencing from the reference lists, and by following citations for these studies. Case reports and case series of less than five patients were excluded. Primary technical and initial clinical success, perioperative, and late morbidity and mortality were extracted per study and were meta-analyzed.ResultsFourteen studies were included in the statistical analysis. The number of reported patients totaled 130 for TAAT/zone 0 and 131 for HAAT/zone 1. The primary technical success rate was significantly higher in zone 0 than 1 (95% vs 83%; odds ratio [OR], 4.0; 95% confidence interval [CI], 1.47-10.88; P = .0069), due to significantly higher primary type I or III endoleak rates in zone 1 (15.48% vs 3.97%; P = .0050). Reintervention rates were significantly higher in zone 1 (25.81% vs 12.00%; P = .0321). Initial clinical success rates were comparable between zone 0 and 1 (88% vs 85%; OR, 1.35; 95% CI, 0.61-3.02; P = .5354). In-hospital mortality was higher in zone 0 than 1 (8.46% vs 4.58%; P = .2212).ConclusionThe more invasive TAAT allows a better landing zone at the cost of higher perioperative mortality, therefore, patient selection is crucial

Endovascular repair of ruptured thoracic aortic aneurysms is associated with high perioperative mortality and morbidity

PurposeTo analyze early and midterm results after endovascular treatment of ruptured thoracic aortic aneurysms (rTAA).MethodsBetween January 1997 and January 2009, a total of 236 patients received thoracic aortic repair in our institution; 23 patients (14 men; median age, 75 years; range, 60-88 years) due to a ruptured thoracic aortic aneurysm (rTAA). Rupture was defined according to computed tomography angiograpy (CTA) criteria with definite sign for hemorrhage outside the aortic wall. Patients with symptomatic TAA but with normal CT scans were excluded. A retrospective analysis of these patients was performed. Median follow up was 28 months (range, 0.1-82.5 months) and included serial aortic imaging at discharge, six, and 12 months and annually thereafter.ResultsTechnical success rate was 87%. The overall in hospital mortality was 48% with predominantly (50%) cardiac complications. Neurological complications occurred in three patients, two patients suffered from a transient ischemic attack (TIA)/stroke, and one patient experienced paraplegia after early conversion to open surgery. Primary endoleaks were seen in four of 25 patients (16%); no secondary endoleak was observed. Early conversion was necessary in two patients caused by an aortoesophageal fistula. The one- and three-year survival rates were 37.3% and 29.9% with no aortic or procedure-related death during follow up. Reintervention was necessary in four of 25 patients (16%). Cox regression analysis revealed preoperative renal insufficiency (hazard ratio [HR] 5.85, P = .0073) as an independent predictor of perioperative death.ConclusionsThe endovascular treatment of ruptured thoracic aortic aneurysms is associated with a high perioperative mortality and morbidity as well as poor midterm survival. Renal insufficency proved to be an independent risk factor for perioperative death

Complications after aortic arch hybrid repair

ObjectivesTo analyze early and midterm complications after hybrid aortic arch repair (HAR).MethodsBetween January 1997 and November 2009 among 259 patients receiving thoracic endovascular aortic repair, HAR has been performed in 47 patients (median age, 64.5 years; range, 41-84). A retrospective analysis was performed. Complete supra-aortic debranching was performed in 15 patients (32%) and partial debranching in 23 patients (49%). Isolated left subclavian artery revascularization prior to thoracic endovascular aortic repair has been used in nine patients (19%). Emergency procedures were performed in 34% of all patients.ResultsThe overall in-hospital mortality was 19% (9/47 patients), 27% after complete and 15.6% after partial debranching. Postoperative complications occurred in 32 patients (68%). Cardiocirculatory complications were observed in seven patients (15%). Pulmonary complications occurred in 12 patients (26%). A total of five patients (11%) experienced renal complications requiring hemodialysis. The stroke rate was 6.3%. Paraplegia was seen in three patients (6%). Proximal type I endoleaks were observed in seven patients. Retrograde aortic arch dissection was seen in three patients (6.3%). Cox proportional hazard regression showed the necessity for an emergency procedure as an independent predictor of death (hazard ratio, 2.9; 95% confidence interval, 1.1-7.5; P = .023). The reintervention rate was 27.6% with three patients requiring open conversion.ConclusionsHybrid aortic arch repair in high-risk patients is associated with a relevant morbidity, mortality, and reintervention rate. Patient selection is crucial and indication should be limited to patients not suitable for conventional aortic arch repair or emergency cases at present. Therefore, we recommend performing HAR only in high-volume centers with cardiovascular surgical cooperation

Reinterventions during midterm follow-up after endovascular treatment of thoracic aortic disease

ObjectivesTo report incidence, indication, and timing of reinterventions after thoracic endovascular aortic repair (TEVAR) and identify subgroups most prone to reinterventions.MethodsBetween January 1997 and March 2010, a total of 264 patients received TEVAR in our institution. During follow-up, 58 patients (39 men, median age 63 years, range 28-87 years) required a total of 68 reinterventions, which represent the study population of this retrospective, single center analysis. The mean follow-up of all 264 patients was 31.2 months (range 0-141 months).ResultsThe overall reintervention rate was 22%: 1-, 3-, and 5-year free reintervention rates were 82% ± 3%, 74% ± 3%, and 70% ± 4%, respectively. Indications for reintervention were predominately endoleaks (41%) and progression of the underlying aortic disease (29%). Reinterventions were performed by endovascular means in 44%, by open repair in 35% (including 11 conversions), and by hybrid procedures in 21%. Multiple logistic regression analysis revealed patients with chronic expanding aortic dissections (odds ratio [OR]: 2.35), hybrid aortic procedures (OR: 2.11), and connective tissue diseases (OR: 7.54) at an increased risk for reintervention. The necessity for reintervention did not influence survival in this cohort (log-rank test P = .1706).ConclusionsTEVAR is associated with a relevant reintervention rate, predominately caused by endoleaks and progression of the aortic pathology. Patients with chronic expanding aortic dissections, hybrid aortic procedures, and connective tissue diseases are at an increased risk for reintervention and should therefore undergo close follow-up

Early and midterm results after endovascular stent graft repair of penetrating aortic ulcers

PurposeTo present early and midterm results after endovascular stent graft repair of patients with penetrating aortic ulcers (PAU).MethodsBetween January 1997 and March 2008, a total of 202 patients received thoracic aortic endografting in our institution, 48 patients (32 men, median age 70 years, range, 48-89) with PAU. A retrospective analysis of these patients was performed. Thirty-one patients (65%) showed an acute aortic syndrome (8 contained rupture, 23 symptomatic). Follow-up scheme included postoperative computed tomography angiography prior to discharge, at 3, 6, and 12 months, and yearly thereafter. Mean follow-up was 31.3 months (1.3-112.6).ResultsTechnical success was achieved in 93.7%. Primary clinical success rate was 81.2%. In-hospital mortality was 14.6%. Perioperative mortality was significantly (P = .036) higher in patients with acute aortic syndrome compared to asymptomatic patients (22.5% vs 0%). Postoperative complications occurred in 15 patients (31%), including 2 patients with minor strokes and 6, respectively, 5 patients with cardiac and/or respiratory complications. Early endoleaks were observed in 9 patients (19%), late endoleaks in another 2 patients. Reintervention was necessary in 4 out of 48 patients (8.4%). The actuarial survival estimates at 1, 3, and 5 years were 78% ± 6%, 74% ± 7%, and 61% ± 10%, respectively. There was no aortic-related death during follow-up. Cox regression showed age (hazard ratio [HR]; 1.08, P = .036) and a maximum aortic diameter >50 mm (HR, 4.92; P = .021) as independent predictors of death.ConclusionEndovascular treatment of penetrating aortic ulcers is associated with a relevant morbidity and mortality rate in frequently highly comorbid patients. Midterm results could prove a sustained treatment success regarding actuarial survival and aortic-related death. Emergencies show a significantly worse outcome, but treatment is still warranted in these symptomatic patients