Open aortic surgery after thoracic endovascular aortic repair

Abstract

In the last decade, thoracic endovascular aortic aneurysm repair (TEVAR) has emerged as an appealing alternative to the traditional open aortic aneurysm repair. This is largely due to generally improved early outcomes associated with TEVAR, including lower perioperative mortality and morbidity. However, it is relatively common for patients who undergo TEVAR to need a secondary intervention. In select circumstances, these secondary interventions are performed as an open procedure. Although it is difficult to assess the rate of open repairs after TEVAR, the rates in large series of TEVAR cases (>300) have ranged from 0.4 to 7.9 %. Major complications of TEVAR that typically necessitates open distal aortic repair (i.e., repair of the descending thoracic or thoracoabdominal aorta) include endoleak (especially type I), aortic fistula, endograft infection, device collapse or migration, and continued expansion of the aneurysm sac. Conversion to open repair of the distal aorta may be either elective (as for many endoleaks) or emergent (as for rupture, retrograde complicated dissection, malperfusion, and endograft infection). In addition, in select patients (e.g., those with a chronic aortic dissection), unrepaired sections of the aorta may progressively dilate, resulting in the need for multiple distal aortic repairs. Open repairs after TEVAR can be broadly classified as full extraction, partial extraction, or full salvage of the stent-graft. Although full and partial stent-graft extraction imply failure of TEVAR, such failure is generally absent in cases where the stent-graft can be fully salvaged. We review the literature regarding open repair after TEVAR and highlight operative strategies.

Editor's Choice – European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Vascular Graft and Endograft Infections

“…Partial or total graft explantation. Partial removal of graft material is usually not an option as the whole of the VG or EG needs to be considered to be infected, 109 the only exception being when only part of the VG or EG is documented as being infected through clinical and imaging findings. 109 In a meta-analysis, the one year mortality was 37% (n ¼ 15/ 41) for graft material explantation vs. 85% (n ¼ 17/20) for total or partial graft material preservation.…”

“…Partial removal of graft material is usually not an option as the whole of the VG or EG needs to be considered to be infected, 109 the only exception being when only part of the VG or EG is documented as being infected through clinical and imaging findings. 109 In a meta-analysis, the one year mortality was 37% (n ¼ 15/ 41) for graft material explantation vs. 85% (n ¼ 17/20) for total or partial graft material preservation. 100 In a systematic review and meta-analysis including 96 patients with infected thoracic endografts (41 EG explantation, 55 EG preservation), in hospital mortality was 37% vs. 42%, while late mortality was 46% vs. 82% for EG explantation and EG preservation, respectively.…”

“…Multiple combinations of treatment options have been used to deal with AEsF, including arterial ISR, extra-anatomic bypass with concomitant primary oesophageal repair, or oesophagectomy with cervical oesophagostomy and secondary restoration of gastrointestinal tract continuity. 109,112 Resection of the oesophagus and restoration of gastrointestinal continuity can be performed in a one stage or two stage procedure. The same applies to the vascular reconstruction and resection of the aortic graft.…”

A reproducible swine model of proximal descending thoracic aortic aneurysm created with intra-adventitial application of elastase

“…6,7 Despite great improvement in surgical repair for the treatment of TAA, up to one-third of patients cannot tolerate surgical procedures because of the high risk of complications and invasiveness. 8,9 Considering the potential limitations of surgical and endovascular repair, a deep understanding of the cellular and molecular mechanisms of TAA is necessary in the case of proximal descending aortic aneurysm.…”

Spondylitis transmitted from infected aortic grafts: a review

“…First described by Parodi in 1991, the latter technique consists of percutaneous insertion of a tubular graft within the aneurysmal sac, tethered with metallic stents with the use of special catheters and guidewires through arteriotomies 2. Hence, this minimally invasive procedure has emerged as an appealing treatment option, as compared to conventional open surgery, with comparatively better early outcomes and lower perioperative mortality and morbidity rates 3. However, there has been no reason to believe that endovascular aortic stent grafts would be immune from septic complications 1, 4.…”