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Ростовский Государственный Медицинский Университет
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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3751_Библиотеки_им_академика_М_И_Перельмана

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☆
C.ChoosingtheCorrectGraft
Asmentioned,CTAshouldbeutilizedtoassessthediameteroftheaortabeforeplanningendovascular repair,inorder to choosethe correctsizeandlengthofthegraft.Larger nativethoracicaortasrequire largerdiameterstent-grafts.Nonaneurysmalthoracicaorticpathologies(e.g.,bluntaorticinjures)require smaller stent-grafts. Commercial devices are available in diameters from 21 to 45 mm, which can accommodatevarious typesofaorticpathologies. Fifteentotwenty percentoversizingisrecommended for thoracic aortic endograft; however, excessive oversizing may lead to dreaded retrograde aortic dissection.56 It is important to note that the aortic diameter decreases dramatically in patients with traumaticaorticinjurywithhemodynamicinstabilityduetohypotension.Thisdecreaseinaorticdiameter couldleadtoinaccurateaorticmeasurementsandundersizingoftheendograft.
57
D.DebranchingProcedures
Theneedfordebranchingproceduresforimportantbranchvesselsshouldbedeterminedpreoperatively bystudyingtheproximalanddistallandingzones.
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1.ArchVesselBypass
a. Archvessel bypass needs to be considered when the proximal landing zones involve any of the
aorticarchvessels.Notinfrequently,oneormoreofthearchbranchesmayneedtobecoveredforan adequatesealtobeobtained.Forthesubclavianartery,ameta-analysisof1161patientshasshown thatleftsubclavianarteryrevascularization didnot significantlyreducethe riskofstrokes,spinal cord injury, or mortality.58 In another review, symptoms of upper extremity ischemia requiring subsequentrevascularizationoccurredinonly4%ofpatients.
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b. Preemptiverevascularizationshouldbeperformedinpatientswithadominantleftvertebralartery,
hypoplasticrightvertebralartery,orincompletecircleofWillis,asinterruptionincirculationwould lead to an increased risk of stroke and paraplegia.
60,61
Planned revascularization can also be
consideredinpatients withpatentleftinferiormammaryartery-coronarybypassorfunctioningleft upperextremity dialysis arteriovenous access.62Carotid-subclavian bypass or subclavian-carotid transposition procedures can restore the left subclavian flow. The optimal procedure should be based on duplexultrasonography ofthevertebral andcarotidarteries. However,both procedures havenotproducedabenefitintermsofneurologicaloutcomesandmortality.
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c. If the proximal landing zone is anticipated to cover the left common carotid artery or the
brachiocephalictrunk,open,antegradebypassfromtheascendingaortaorcarotidtranspositioncan beperformed.Alternatively,extra-anatomicbypass(e.g.,carotid-carotidbypass)canbeperformed toavoidsternotomy.
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d. Timingofdebranching procedurecanbe in thesamesetting,orfewdaysbefore theendovascular
procedure.
2.VisceralBypass
a. Celiacarterycoveragemay frequentlybe indicatedinordertogainadequatedistalsealingofthe
grafttoavoidtypeIbendoleak.Celiaccoveragecanposeariskformesentericischemia.However, successful cases of covering the celiac artery have been reported inpatients with a documented patentpancreaticoduodenal system, witha low incidence ofmesenteric ischemia.
66,67
Ina recent
literaturereview,coveringtheceliacartery,withoutdeliberateaccompanyingceiliacembolization,
https://t.me/med1917
resultedinonlythreetypeIIendoleaksin72patients,whichrequiredtreatmentbycoilembolization.
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b. Landingdistaltothesuperiormesentericarteryortherenalvesselsrequiresspecialmeasures,either
by open surgical bypass, use of special fenestrated grafts,69 use of branched grafts,70 or revascularizationusing snorkelorchimneystents
71,72
(Fig.6.8).Debranchingprocedures can also
providebloodflowviaalternativevesselstoallowcoverageofthevisceralsegmentoftheaorta.
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Debranchingprocedurescanbeperformedinthesamesettingorseveraldaysbeforerepair.
FIGURE6.8 TEVARwithdualbranchdeviceforresidualaorticdissectionaftergraftreplacementofascending
aortafortypeAaorticdissection.TEVAR,thoracicendovascularaorticrepair.
Reprintedwithpermissionfrom
KurataniT.Bestsurgicalopt ionforarchextensionofty p eBdissection:theendovascularapproach.AnnCardiothoracSurg.2014;3:292-299.
E.OtherApproaches
Forjuxtarenalaorticaneurysms,fenestratedendovascularaneurysmrepair(FEVAR)continuestoevolve to avoid the need for debranching procedures.
74,75
The Zenith Fenestrated Endovascular Graft (Cook
Medical) is the primarily studied device. The use of accessory stents, such as the chimney/snorkel technique,
76,77
or in situ fenestration of the graft using a needle or laser has also been described,
especiallyinassociationwithemergencysurgerytoavoiddebranchingprocedures.78Branchedgraftsare beinginvestigatedforthoracicorthoracoabdominalaneurysms,79buttherateofrepair-relatedmortality maybehigherthanconventionalgrafts.
VIII.PreoperativePreparation
A.Antibiotics
Practice guidelines recommend antibiotic prophylaxis with Cefazolin within 30 minutes of the skin incision80(vancomycinorclindamycinmaybeusedincaseofpenicillinallergy).Antibioticsshouldbe discontinuedwithin24hoursgiventhelackofprovenbenefitbeyondthattime.
B.RenalInjury
https://t.me/med1917
1.TentofifteenpercentofpatientsfollowingTEVARcansufferacutekidneyinjury(AKI),mostofwhom
aretypeBDescADpatients,typicallytreatedonlyafterorganmalperfusionhasoccurred.81Riskfactors forrenalinjuryarepoorpreoperativekidneyfunction,aneurysmsoftherenalarteries,andneedforblood transfusion.
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2. Contrast-induced nephropathy from use of contrast during CTA can be avoided with appropriate
hydrationbeforeendovascularrepair,andbyadequatepreoperativeplanningoflandingzonestoachieve atightsealwithouttheuseoflargeamountsofcontrast.
C.CerebrospinalFluidDrainage
1. Spinal cord perfusion pressure equals the mean arterial pressure minus the cerebrospinal fluid
pressure. Spinaldrainageaims atdecreasing the pressureinthe subarachnoid space around thespinal cord,therebyincreasingthespinalcordperfusionpressure,anddecreasingtheincidenceofspinalcord ischemiaduringorafterendovascularstentingofthoracicaorta.Thisisachievedviainsertionofadrain attheleveloftheL3-L4discinthesubarachnoidspace.
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2. Data from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair
(EUROSTAR)registryhighlightedthe importance ofcollateralcirculationforthespinalcord perfusion duringendovascularrepair.84Aspinaldrainisindicatedwhenextensivecoverageofthethoracicaortais required,whentherearemultipleinternaliliacarteryocclusions,orwhenthereisapriorhistoryofopen orendovascularrepair.
85–87
In astudywith72patients,the riskofspinalcordischemia was 12.5%in
patients withprior abdominal aortic aneurysmrepair,versus 1.7% in patientswithout prior repair.
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Another retrospective cohort study of endovascular repair of Crawford Type II thoracoabdominal aneurysmsshowedthatstagedrepairwasassociatedwithlowerriskofspinalcordischemia,compared withsinglestagedrepair(11.1%vs37.5%).88Apromisingspinalcoolingcatheterhasbeendeveloped, whichdrainscerebrospinalfluid(CSF)aswellasproducinglocalizedspinalcordhypotension.Clinical applicationofthiscatheterisexpectedsoon.
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IX.TechniqueofPlacement
Endovascular repairofthoracic aortais performed undergeneral anesthesia,whichallows respiratory controlandmorepreciseimaging.IntheEUROSTARregistry,technicalsuccesswasachievedin87%of aneurysmpatientsand89%ofDescADpatients.
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A.AccessVessels
1. Large-bore sheaths needtobe introducedthrough thefemoral artery, typicallybyfemoral cutdown.
Unlike abdominal aortic repair, percutaneous access is usually difficult because of larger devices; however,trialsusingthe“Preclosetechnique”forTEVARhavebeensuccessful.91Itislikelythatinthe future,percutaneousaccesswillbeimplementedforthoracicaneurysmsaswell.
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2. In 3.8%-9.4% of patients, femoral cutdown is not suitable and other access sites are required.
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Tortuous,calcific,ornarrowiliacarteriesmaynotbesuitabletopasssuchlargedevices,soaccesscan beobtainedthroughaniliacconduit,directexposureofthecommoniliacartery,directdeliverythrough the abdominal aorta, or by balloon angioplasty ofthe iliac arteries before procedures. In challenging access situations, antegrade access through the ascending aorta has been described for descending thoracicendografts.
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https://t.me/med1917
B.Deployment
1.Wireaccessisgainedintotheascendingaortaandexchangedforastiffwiretoallowtrackingofthe
device.Positioningthegraftistypicallyachievedunderfluoroscopy,alongwithothertechniquessuchas transesophagealechocardiography(TTE)andintravascularultrasound.95Aftervascularaccesshasbeen obtained, lowering blood pressure is needed only transiently at the moment of deployment. Blood pressureislowered,pharmacologicallyorbyrapidpacing,downtothe60s,inordertopreventthegraft frommovingdistallyowingtopressure(i.e.,wind-sockeffect).
2.Whentheproximallandingzoneinvolvesthearch,a30-60°leftanterioroblique(LAO)projectionis
usedtopreciselysplay outthearch vessels.Forthe distallandingzone neartheceliac trunk,a lateral projection is used. Once the device is deployed in position, the stent-graft is expanded and can be balloonedattheproximalanddistallandingzonestostabilizeinplace.
C.EvaluatingforEndoleaks
Aortographyistypicallyperformedafterdeploymenttoensurecorrectpositioningofthegraft,patencyof branch vessels, aneurysmal sac occlusion, andto checkfor thepresence ofanendoleak,which is the persistenceofflowintheaneurysmsacafterrepair.Removalofthesheathandrepairofthearteriotomy isthenperformed.
D.PostoperativeImaging
It isrecommendedtoobtaina CTAwithin 1 monthoftheprocedure,at6 monthsand then annuallyto evaluate for endograft integrity and location, for persistence of the aneurysm sac, and for late complicationsandendoleaks
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X.Complications
A.PerioperativeMortalityandMorbidity
1.WiththeadvancementofTEVARdevicesandtechniques,perioperativemortalityratesinsomestudies
are lower than in open repair. In a multicenter study for descending thoracic aneurysms in low-risk patients, perioperative mortality rates were 2.1% for endovascular repair versus 11.7% in patients undergoingopenrepair(P<0.001).97AccordingtotheNationalSurgicalQualityImprovementProgram (NSQIP)database,theoperativeindicationsforTEVARprocedurewerenotfoundtobeapredictorof poorpatientoutcome.However,patientspresentingwithemergencyconditions,suchasruptureoraortic dissection,hadhigherratesof30-daymortality(22.6%vs6.2%),98aswellashigherlatemortalityrates.
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2.IntheNSQIPdatabase,perioperativemorbidityassociatedwithTEVARwasfoundtobe9%,
30
with
thecumulativemajormorbidityscoressignificantlylower thantheopengroupat30days(1.3±3.0vs
2.9±3.6,respectively,P<.01).Nodifferenceinsurvivalbetweenmalesandfemaleswasnoted.
100–103
B.Endoleaks
1.Endoleakisatermthatdescribesthepresenceofpersistentflowofbloodintotheaneurysmsacafter
endograft placement, which poses a risk for aneurysm expansion and rupture. Endoleak is usually recognizeduponaortographyafterdeploymentoftheendograft,oratpostprocedureCTscan.However,
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endoleak can appear up to 5 years after repair.
104
Long-term follow-up of patients who underwent
endovascular repair for abdominal aortic aneurysms showed high rates of endoleak development, reaching approximately30%,withanaveragefollow-upof6 years.
105
Thissuggeststhat TEVAR may
recapitulatethehighendoleakratewhenmanylatecasesbecomeavailableforanalysis.
2.Classificationofendoleaksisbasedonthesourceoftheleak
106
(Table6.4),whichhelpsdetermine
theappropriatemanagementplan.TypeIIendoleakisthemostprevalenttypeandisduetopatentaortic branches, especially intercostal and lumbar arteries.
107
Continued aneurysm sac expansion without a
demonstrable endoleak on any imaging modality is referred to as endoleak of undefined origin, also calledtypeVendoleakorendotension.
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Table6.4
ClassificationofEndoleaks
TypeofEndoleak Description
TypeI
Ia
Inadequatesealattheproximalend
Ib
Inadequatesealatthedistalend
Ic
Inadequatesealatiliacoccluder
TypeII Sacfillingviaanaorticbranchvessel
IIa
Singlevessel
IIb
Twovesselsormore
TypeIII Leakthroughadefectingraftfabric
IIIa
Junctionalseparationofthemodularcomponent
IIIb
Holesinvolvingtheendograft
TypeIV Leakthroughporousgraftmaterial TypeV Continuedaneurysmsacexpansionwithoutademonstrableendoleakonanyimagingmodality
3.TherateofendoleakswithTEVARhasbeennotedtobesomewherebetween3.9%
30
and15.6%in
anotherreview.
109
4. It is noted that complex fenestrated, branched, and chimney endografts introduce the potential for
additional modes of failure in terms of component separation and endoleaks. Treatment of endoleaks associatedwiththesedevicesremainschallenging.
110
C.SpinalCordIschemia
1.TEVARcarriesarealriskofspinalcordischemiaandparaplegia,comparabletoratesreportedafter
opensurgicalrepair.Theratesofspinalcordinjuryandparaplegiaafteropenthoracoabdominalaortic repairincontemporaryseriesrangefrom3% to12%,
111–118
andfrom 5%to10% in endovascularand
hybrid procedures.
90,115,119–122
In a retrospective cohort of 724 patients who were treated with either
TEVAR(n=352)oropenrepair(372),forthoracicorthoracoabdominalaneurysms,theratesofspinal
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cordinjurieswerenotsignificantlydifferent(4.3%intheendovasculargroupvs7.5%intheopengroup).
2.Theextentofcoverageoftheaortaisthemajorriskfactorforspinalcordischemia.
111
3. Patients withprior endovascular repair also tend tohavean increased risk, as well as those with
preoperative renal insufficiency.
123
In the European Registry of Endovascular Aortic Repair
Complications (EuREC), simultaneousclosure of atleasttwo vascular territories supplying the spinal cordwasfoundtoincreasetheriskofspinalcordinjury,alongwithlongperioperativehypotension.
124
D.Stroke
Insituationswheretheaneurysmsacextendstothearch,proximallandingzonescancomeinproximityto thecarotid andvertebralarteries, leadingtoembolicstrokesand cerebrovascularcomplications.Prior strokes,alongwiththepresenceofheavyatheromatousburdenintheaorticarch,arestrongriskfactors fordevelopmentofsuchevents.
125
Posteriorcirculationstrokescanresultfromembolireachingthecircle
ofWillisfromthevertebralandsubclavianarteries(subclavianstumpsyndrome).
126
Inonestudywith1002patients,strokeoccurredin4.8%ofpatientsundergoingTEVAR,inwhom,prior revascularization of the subclavian artery seemed to protect against posterior circulation strokes.
127
Another study has foundthe riskofstroke tobe6.25%, with higher ratesofcomplicationsinpatients presentingwithemergentconditions.
128
E.Ischemia
1.Extremityischemia.Althoughinfrequent,coverageoftheleftsubclavianarterycanleadtoischemic
complications, in patients requiring proximal landing in the arch. Planned revascularization of the subclavianarterybeforeTEVARshouldbeconsideredinat-riskpatients;thiscandecreasetheischemic complications,albeitincreasingtheintraoperativemorbidity.
60
2. Visceral ischemia. Coverage of celiac trunkor the superior mesenteric arterycanlead to visceral
ischemiainpatientswiththoracoabdominalaneurysmsinvolvingthesevitalstructures.Carefulplanning of debranching procedures or the use of other intraoperative techniques should be carried out before TEVAR. Renal ischemia and acute kidney injury (AKI) can also occur, with risk factors being preoperative decreasedGFR,extentofthoracoabdominalrepair,andpostoperativetransfusion.
82
F.AccessComplications
Owingtothelargedevices,vascularcomplicationsattheaccesssitesarenotinfrequent.Calcific,small tortuous vessels are at higher risk. When iliac rupture occurs, balloon occlusion can be used for temporaryvascularcontroluntilthearterycanberepaired.
G.PostimplantationSyndrome
Endothelialactivationbythe endograftcanlead toa systemicinflammatoryresponse,characterizedby fever, leukocytosis, and elevation ofinflammatory markers, with the response being more apparent in acuteaorticpathologies.
129,130
XI.LateComplications
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A.SurvivalandOutcomes
1.Medicaredatabaseinformationfrom2005to2010ofmorethan1100patientswhounderwentTEVAR
has revealed the median survival tobe 57.6 months.
131
The early and late incidence of death varied
significantlybyaorticdisease.Patientswithaorticrupture,acuteaorticdissection,andaortictraumahad the highest early incidence of death, whereas late survival was highest in patients with acute aortic dissection, aortic trauma, and isolated thoracic aortic aneurysm, particularly those not requiring subclavianarterycoverage.
2. Combinedexperiencefrom theEUROSTAR andUnitedKingdom Thoracic Endograftregistries has
shownthe 1-yearmortality amongpatients treatedforaortic aneurysmandaortic dissectiontobe20% and10%,respectively.Itisimportanttomentionthatmostofthesepatientshadmultiplecomorbidities andwerenotsurgicalcandidates.
3.Questionsaboutthedurabilityandintegrityoftheseendograftsareyettobeansweredandcontinued
useofregistriesshouldprovidedatafromlong-termfollow-up.
B.MigrationoftheGraft
Caudal migration of the graft canhappen, especially with oversizing, tortuous aortas, and inabilityto obtainappropriatetightsealsatthelandingzones.Inonestudy,therateofmigration(>10mm)was2.8%.
30
Deviceenfoldingorcollapsecanalsooccur,leadingtoocclusionmanifestations.
132
C.SecondaryIntervention
1.Secondaryinterventionisusuallyrequiredafterendoleaks,devicemigration,ororganischemia,with
multiplereportsontheincidenceoftheseimportantcomplications.Inastudywith680patientswhowere treatedwithTEVARfrom2000to2012,reinterventionwasneededin73patients(11.7%),withamedian intervalof210days.Endograftfailuresincludedendoleakin45,proximalaorticevents(retrogradetype Aoraneurysmaldegeneration)in11,distalaorticevents(dissectionoraneurysmaldegeneration)in15, endograftinfectionin3,andothersin6.
133
2.Inanotherreviewof585patients,theneedforsecondaryinterventionwas12%withamedianfollow-
upof5.6months.
134
XII.Conclusion
Endovascular repair of the descending thoracic aorta has witnessed major advancements in the techniques, graft design, and applicability to various aortic pathologies. Careful planning before the procedure is indispensable in order to correctly address the pathology and to avoid complications. Technique of deployment depends on the device type and the pathology addressed. TEVAR has the advantageofabsence of thoracotomyincisionandaortic cross-clamping.Nonetheless, TEVARcarries real risks of morbidity and mortality. Long-term evidence about the reliability and durability ofthese devices remains unelucidated, as registries continue to build follow-up on the patients treated. A multidisciplinary approach is required in management of patients, to choose the best method of management,eitherwithTEVARorwithopenrepair.Openrepairisquitesafeatexperiencecentersand offersanearly“bulletproof”permanencevis-a-visthetreatedaorticsegment.
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