Evaluation of the Optimal Visceral Branch Configuration in Open Thoracoabdominal Aortic Repair by Computed Tomography

Abstract

IntroductionSurgical treatment for Crawford type II-IV thoracoabdominal aneurysms (TAAAs) that require branch reconstruction of the visceral and RAs has been challenging because of the technical complexity and surgical invasiveness. In particular, reducing/avoiding perioperative spinal ischemia, renal failure, respiratory failure, and bleeding complications are important factors for surgical success. [1][2][3][4] In our institution, several modifications have been performed in terms of perioperative spinal protection and surgical technique. The strategy for the perioperative spinal protection has been established, which includes preoperative identification of the Adamkiewicz artery (AKA) using an intraarterial computed tomographic angiography. 5-7) For the surgical technique, in addition to the use of a pre-sewn multiple side-branched aortic graft to eliminate the potential of future aneurismal degeneration of the visceral patch, [8][9][10][11] we have adopted the modification of the length of the side branches. Each side branch pre-sewn to a main tubular aortic graft was intentionally lengthened relative to the vessel anatomy and was sutured to each corresponding Evaluation of the Optimal Visceral Branch Configuration in Open Thoracoabdominal Aortic Repair by Computed TomographyKeiji Kamohara, MD, PhD, Kojiro Furukawa, MD, PhD, Manabu Itoh, MD, Hiroyuki Morokuma, MD, Hideya Tanaka, MD, Nagi Hayashi, MD, and Shigeki Morita, MD, PhD Background: In thoracoabdominal aneurysm (TAAA) repair, our technical modification of visceral reconstruction using longer cut pre-sewn side branches has provided good surgical outcomes. Here, we assessed the long-term durability and patency of revascularized branches using computed tomography (CT) to confirm the validity of our approach. Methods: Early and late CT evaluations were performed in 11 TAAA patients (males: 5; mean age: 60.6 years) using the Coselli graft to evaluate the position of main graft and the diverging pattern and patency of side branches. Seven of 11 were sutured in an extraanatomical fashion using longer cut side branches. Results: In Anatomical (n = 4) and Extra-anatomical (n = 7) groups, the early patency of side branches was not significantly different. Although the late patency of right renal artery (RA) was 100% in both groups, the one of left RA was 60% in Extra-anatomical, while 100% in Anatomical. Furthermore, the main graft in Extra-anatomical was significantly posterior and leftward to the spine with left RA side branch diverging at an acute angle. Conclusions: When a pre-sewn branched graft designed for TAAA is used, the graft should be sutured in a fashion similar to normal patient anatomy to minimize the possibility of kinking of RA side branch for the patency.

Renal Artery Outcomes After Open Repair of Suprarenal or Type IV Thoraco-abdominal Aortic Aneurysms

“…Kulik et al 17 reported excellent results using such a multibranched strategy together with the use of an interposition prosthesis in 57% of cases. 18 The hybrid technique combining open and endovascular surgery is another method which has been used in patients with T4AAA or SRAAA. The hybrid technique has been presented as supposedly less invasive as it eliminates the risk of aortic cross clamping.…”

Long-Term Patency of Visceral Vessels After Thoracoabdominal Aortic Repair

“…Late occlusion involves VVs at different rates, with a significant prevalence of renal arteries compared to other vessels. Renal branch occlusion has been observed in 8-9.6% of cases at midterm follow-up [7,28]. Along with the high individual anatomic variability of the renal artery angle compared with other VVs, additional factors-e.g., respiratory motion and small vessel size-could have an adjunctive stress effect on stents.…”

“…The possible role of different devices employed in VV endovascular reconstruction has not been confirmed in a multicentric series [7], while the mean artery length and anatomic location were considered more likely associated with a poor branch outcome, and this finding could be a touchpoint with possible mechanical factors influencing observed late fate of LRA after open repair-particularly when presewn grafts are used [28].…”

Late patency of reconstructed visceral arteries after open repair of thoracoabdominal aortic aneurysm

“…7 The mean artery length and anatomic location were considered more likely to be associated with a poor branch outcome, and this finding could be a touchpoint with possible mechanical factors influencing the observed late fate of LRA after open repair, particularly when presewn grafts are used. 28…”