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Many large studies have reported mortality rates ranging from 7% to 17%. Cardiac, neurologic, respiratory, and renal complications limit the number of patients who are eligible for open surgery. Recent advances in operative technique and use of adjunctive measures for spinal cord protection have decreased, but not eliminated, the devastating complication of paraplegia. Nonetheless, other peri-procedural complications still exist due to the invasiveness of open thoracoabdominal repair. Endovascular stent-grafting has been applied to the treatment of infrarenal abdominal and descending thoracic aortic aneurysms with success.
A low risk of death and paraplegia after endovascular repair of descending thoracic aneurysms has been reported. Only recently have devices become available for the endovascular management of thoracoabdominal aortic aneurysms where there is extensive involvement of the visceral segment. The potential benefits from endovascular repair include avoidance of aortic cross-clamping and major incisions, minimization of blood loss, diminished postoperative pain, and limitation of visceral, renal, and spinal cord ischemia.
We have been actively involved with the development of fenestrated and branched stent-grafts to target this high-risk patient population with thoracoabdominal aortic aneurysms.
The branched thoracoabdominal stent-graft is a modular system based on the Zenith stent-graft (Cook Inc., Bloomington, IN). The main body component is a custom-designed straight or tapered device with reinforced fenestrations and/or standardized directional helical branches precisely chosen to correlate with the patient's target vessel anatomy based on radiographic assessment of the visceral ostial geometric relationships. Reinforced fenestrations are mated to balloon-expandable covered stents (Jomed; Abbot Labs, Abbott Park, IL), while the directional branches are mated to self-expanding covered stents (Fluency; Bard Inc., Tempe, AZ).
Candidates for endovascular thoracoabdominal aneurysm repair typically are considered to be high risk for open aneurysm repair due to their age, aneurysm morphology, or comorbid conditions. Preoperative assessment typically includes a functional cardiac stress test followed by selective coronary angiography if necessary, transthoracic echocardiography, pulmonary function testing, routine blood work, and a physical examination. A clear understanding of the aortic, iliac, and femoral anatomy is critical to patient selection and device construction. High-resolution computerized tomography (CT) scans of the entire aorta are analyzed with multiplanar reconstructions and centerline of flow measurement techniques on a workstation (TeraRecon Inc., San Francisco, CA), using 3-dimensional (3D) image analysis techniques to assess the aortic morphology. Chronic aortic dissection and severe iliac disease are potential contraindications to a pure endovascular approach, and hybrid-type repairs are considered in these patients if they are not amenable to open surgical repair.
Spinal drainage is selectively employed based on the extent of aortic coverage (type I, II, and III thoracoabdominal aneurysms) or in the setting of prior aortic surgery, internal iliac, or subclavian/vertebral disease where collateral flow to the spinal cord is potentially compromised. Regional anesthesia may be used for patients with significant pulmonary dysfunction. Patients with renal insufficiency routinely receive hydration and N-acetyl cysteine perioperatively.
Spinal drainage is continued for 72 hours or until a CT confirms aneurysm exclusion. Mean arterial pressure is maintained above 85 mm Hg to prevent spinal cord ischemia. Imaging and clinical evaluations are performed at 1, 6, and 12 months and annually thereafter.
Greenberg and coworkers reported the first 50 patient series of branched endografts used to treat thoracoabdominal aortic aneurysms.
Despite the high-risk patient cohort, there was only 1 (2%) perioperative death and 2 cases (4%) of spinal cord ischemia. Roselli and coworkers described 73 patients who underwent fenestrated-branched endograft repair for type I, II, or III (n = 28) and type IV (n = 45) thoracoabdominal aortic aneurysms between 2004 and 2006.
Mean aneurysm size was 7.1 cm. Thirty-day mortality was only 5.5%; mean length of stay was 8.6 days. Major perioperative complications occurred in 11 patients (14%) and included paraplegia (2.7%), renal failure (1.4%), prolonged ventilator support (6.8%), myocardial infarction (5.5%), and minor hemorrhagic stroke (1.4%). Target branch vessel patency was 100%.
The largest series to date of endovascular thoracoabdominal repair has been reported by our group at the Cleveland Clinic.
Greenberg and coworkers compared 352 endovascular thoracoabdominal repairs (ER) with 372 open surgical repairs (SR). Mortality was equivalent at 30 days (5.7% ER versus 8.3% SR, P = 0.2) and at 12 months (15.6% ER versus 15.9% SR, P = 0.9). Spinal cord injury was borderline lower in the endovascular repair group (4.3% ER versus 7.5% SR, P = 0.08). These results are extremely encouraging for the higher risk thoracoabdominal patient. Because of this data, we routinely screen descending or thoracoabdominal aneurysm patients for their anatomic suitability for branched-fenestrated stent-graft repair.
Open surgical repair of 2286 thoracoabdominal aortic aneurysms.