Survival Benefit of Endovascular Descending Thoracic Aortic Repair for the High-Risk Patient

Patel, Himanshu J.; Shillingford, Michael; Williams, David M.; Upchurch, Gilbert R.; Dasika, Narasimham L.; Prager, Richard L.; Deeb, G. Michael

doi:10.1016/j.athoracsur.2006.12.070

Cited by 46 publications

(28 citation statements)

References 11 publications

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“…Dake et al [2] first reported their experience with the endovascular repair (EVR) of descending aortic aneurysms in 1994. Subsequent reports confirmed that EVR in these patients is feasible and safe [3][4][5][6][7]. The combined results of the European Collaborators on Stent Graft Techniques for Thoracic Aortic Aneurysms and Dissection Repair and of the United Kingdom Thoracic Endograft Registries have reported technical success rates of 87%, with a 4% incidence of paraplegia, a 30-day mortality rate of 5.3% for elective procedures, and of 28% for emergency procedures; aneurysm expansion occurred in 14.5% with an overall 80% survival rate in 1 year [8].…”

Section: Introductionmentioning

confidence: 69%

Lengthening of proximal implantation site during endovascular repair of thoracic aortic aneurysm: Preservation of carotid patency with retrograde trans endograft deployment of a carotid stent

Eid-Lidt¹,

Ramírez²,

Gaspar³

2008

Cathet Cardio Intervent

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Endovascular repair of descending thoracic aortic aneurysms with a reduced proximal implantation site represents a technical challenge. Surgical procedures before endovascular exclusion can be necessary to increase the length of the proximal landing site to avoid type 1 endoleaks. We present a case of endovascular exclusion of a descending thoracic aortic aneurysm with the endograft placed proximal to the left common carotid artery. Flow to this arch was preserved reconstructing the carotid ostium with the retrograde implantation of a carotid stent that was placed extending across an orifice created in the deployed endograft by puncture and balloon dilatation.

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Section: Introductionmentioning

confidence: 69%

Lengthening of proximal implantation site during endovascular repair of thoracic aortic aneurysm: Preservation of carotid patency with retrograde trans endograft deployment of a carotid stent

Eid-Lidt¹,

Ramírez²,

Gaspar³

2008

Cathet Cardio Intervent

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“…3,4) Recently, this less invasive approach has been applied in aortic arch repair together with a variety of transposition techniques of the supra-aortic branches 5) with favorable results. 2,6) In the present case, it was assumed that total arch replacement with hypothermic circulatory arrest concomitant with coronary artery bypass grafting would be profoundly invasive for such a patient on hemodialysis, who hobbled when walking with a cane.…”

Section: Discussionmentioning

confidence: 99%

Aortic Arch Rerouting and OPCAB in a Patient With Situs Inversus Totalis

et al. 2014

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SummaryEndovascular therapy approaches for aortic aneurysm have lowered the mortality and morbidity rates even in highrisk patients; moreover, these approaches are applied in the management of aortic arch pathologies by transposition of the supra-aortic branches. We present the case of a 75-year-old female patient with situs inversus totalis on hemodialysis. The patient underwent off-pump aortic arch rerouting and thoracic endovascular aortic repair concomitant with coronary artery bypass grafting for distal aortic arch aneurysm and ischemic heart disease. (Int Heart J 2014; 55: 278-279) Key words: Endovascular therapy, Minimally invasive procedure A lthough hypothermic circulatory arrest with various forms of cerebral perfusion techniques has decreased the incidence of neurological complications in conventional aortic arch surgery, total arch replacement continues to be associated with significant mortality and morbidity in high-risk patients.1) Recent studies have demonstrated that less invasive approaches using thoracic endovascular aortic repair (TEVAR) of the aortic arch are feasible in patients who are considered to be at high risk for conventional surgical approaches. 2) Case ReportA frail, 75-year-old woman with situs inversus totalis undergoing hemodialysis due to diabetic nephropathy was referred to our institution for the management of a rapidly expanding distal aortic arch aneurysm, which was detected on chest radiography (Figure 1). In addition, she complained of mild chest discomfort during dialysis. Computed tomography (CT) confi rmed a saccular distal aortic arch aneurysm ( Figure 2A) and an incidentally detected left adrenal tumor, which was diagnosed as a pheochromocytoma by a series of serological examinations. Coronary angiography revealed 90% stenosis in the proximal portion of the interventricular branch of the left coronary artery, which is the counterpart of the left anterior descending artery. The patient had no pyrexia, and the infl ammatory parameters were within normal limits on hematological examination. She was also suffering from chronic sinusitis. Bilateral radial and brachial arteries had been used for multiple arteriovenous shunt operations for the preceding 18 years, but all of them had occluded subsequently, and a permanent blood access catheter inserted via the left internal jugular vein was used for hemodialysis.Considering her advanced age, comorbidities, and frailty, off-pump total arch rerouting and endovascular stent grafting with coronary artery bypass grafting were scheduled. We decided to use a saphenous vein to graft the coronary artery in order to shorten the operation time and minimize bleeding. During surgery, the ascending aorta was side-clamped with decreased pressure by snaring the inferior vena cava, a side-toside anastomosis was performed between a trifurcated graft (Hemashield; Maquet, Fairfi eld, NJ, USA) and the aorta, and subsequently, the brachiocephalic and carotid arteries were reconstructed in an end-to-end fashion. In-situ reconstruction of the s...

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“…TEVAR quickly supplemented open surgical reconstruction by expanding the patient population for which repair is considered 2 . The finding that TEVAR has augmented the total number of repairs instead of supplanting open surgical reconstruction, is in some ways explained by the favorable short and mid-term outcomes of TEVAR in so-called ‘high-risk’ or ‘no option’ patients 5, 6 .…”

Section: Introductionmentioning

confidence: 99%

Preoperative prediction of mortality within 1 year after elective thoracic endovascular aortic aneurysm repair

Scali

Chang

Feezor

et al. 2012

Journal of Vascular Surgery

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Objective Thoracic Endovascular Aortic Repair (TEVAR) is known to have a mortality benefit over open repair in patients with descending thoracic aneurysms, and has become a mainstay of therapy. Because death before 1 year after TEVAR likely indicates an ineffective therapy, we have created a predictive model for mortality within 1-year using factors available in the preoperative setting. Methods A registry of 526 TEVARs performed at the University of Florida between September 2000 and November 2010 was queried for patients with degenerative descending thoracic aneurysm as their primary pathology. Procedures with emergent or urgent indications were excluded. Pre-operatively available variables such as baseline co-morbidities, anatomic and procedure specific planning details were recorded. Univariate predictors of mortality were analyzed with multivariable Cox proportional hazards to identify independent predictors of 30-day and 1-year mortality, defined as mortality within 30 days and within one year following TEVAR, respectively. Results A total of 224 patients were identified and evaluated. Thirty-day and 1-year mortality were 3% (n=7) and 15% (n=33). Multivariable predictors of 1-year mortality included: age >70 (p=0.001, HR 5.8, 95% CI 2.1–16.0), adjunctive intra-operative procedures (e.g. brachiocephalic/visceral stents, concomitant arch de-branching procedures) (p=0.001, HR 4.5, 95% CI 1.9–10.8), peripheral arterial disease (PAD; p=0.006, HR 3.0, 95% CI 1.4–6.7), coronary artery disease (CAD; p=0.02, HR 2.4, 95% CI 1.1–4.9), and chronic obstructive pulmonary disease (COPD; p=0.06, HR 1.9, 95% CI 1.0–3.9). A diagnosis of hyperlipidemia was protective (p=0.006, HR 0.4, 95% CI 0.2–0.7). When patients are grouped into those with 0, 1, 2, 3 or 4+ of these risk factors, the predicted one year mortality was 1, 3, 10, 27 and 54%, respectively. Conclusions Factors are available in the pre-operative setting that are predictive of mortality within 1-year after TEVAR, and can guide clinical decision-making regarding the timing of repair. Patients with multiple risk factors such as age ≥70, CAD, COPD, and a need for an extensive procedure involving adjunctive therapies have a high predicted mortality within one year, and may be best served by waiting for a larger aneurysm size to justify the risk of intervention.

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Survival Benefit of Endovascular Descending Thoracic Aortic Repair for the High-Risk Patient

Cited by 46 publications

References 11 publications

Lengthening of proximal implantation site during endovascular repair of thoracic aortic aneurysm: Preservation of carotid patency with retrograde trans endograft deployment of a carotid stent

Lengthening of proximal implantation site during endovascular repair of thoracic aortic aneurysm: Preservation of carotid patency with retrograde trans endograft deployment of a carotid stent

Aortic Arch Rerouting and OPCAB in a Patient With Situs Inversus Totalis

Preoperative prediction of mortality within 1 year after elective thoracic endovascular aortic aneurysm repair

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