In-hospital cost-effectiveness analysis of open versus staged fenestrated/branched endovascular elective repair of thoracoabdominal aneurysms.

OBJECTIVE
To describe a single-center experience of "complete aortic repair" consisting of surgical or endovascular total arch replacement/repair (TAR) followed by thoracoabdominal fenestrated-branched endovascular aortic repair (FB-EVAR).


METHODS
We reviewed 480 consecutive patients who underwent FB-EVAR with physician-modified endografts (PMEGs) or manufactured stent-grafts between 2013 and 2022. From those, we selected only patients treated with open or endovascular arch repair and distal FB-EVAR for aneurysms involving the ascending, arch and thoracoabdominal aortic segments (zones 0-9). Manufactured devices were used under an investigational device exemption protocol. Endpoints included early/in-hospital mortality, mid-term survival, freedom from secondary intervention, and target artery instability.


RESULTS
There were 22 patients, 14 men and 8 women with a median age of 72±7 years. Thirteen postdissection and 9 degenerative aortic aneurysms were repaired with a mean maximum diameter of 67±11 mm. Time from index aortic procedure to aneurysm exclusion was 169 and 270 days in those undergoing 2- and 3-stage repair strategies, respectively. The ascending aorta and aortic arch were treated with 19 surgical and 3 endovascular TAR procedures. Three (16%) surgical arch procedures were performed elsewhere, and perioperative details were unavailable. Mean bypass, cross-clamp, and circulatory arrest times were 295±57, 216±63, and 46±11 minutes, respectively. There were 4 major adverse events (MAEs) in 2 patients: both required postoperative hemodialysis, 1 had postbypass cardiogenic shock necessitating extracorporeal membrane oxygenation, and the other required evacuation of an acute-on-chronic subdural hematoma. Thoracoabdominal aortic aneurysm repair was performed with 17 manufactured endografts and 5 PMEGs. There was no early mortality. Six (27%) patients experienced MAEs. There were 4 (18%) cases of spinal cord injury with 3 (75%) experiencing complete symptom resolution before discharge. Mean follow-up was 30±17 months in which there were 5 patient deaths-0 aortic related. Eight patients required ≥1 secondary intervention, and 6 target arteries demonstrated instability (3 IC, 1 IIIC endoleaks; 2 TA stenoses). Kaplan-Meier 3-year estimates of patient survival, freedom from secondary intervention, and target artery instability were 78±8%, 56±11%, and 68±11%, respectively.


CONCLUSION
Complete aortic repair with staged surgical or endovascular TAR and distal FB-EVAR is safe and effective with satisfactory morbidity, mid-term survival, and target artery outcomes.


CLINICAL IMPACT
The presented study demonstrates that repair of the entirety of the aorta - via total endovascular or hybrid means- is safe and effective with low rates of spinal cord ischemia. Cardiovascular specialists within comprehensive aortic teams at should feel confident that staged repair of the most complex degenerative and post-dissection thoracoabdominal aortic aneurysms can be safely performed in their patients with complication profile similar to that of less extensive repairs. Meticulous and intentional case planning is imperative for immediate and long-term success.

Mid-Term Outcomes of "Complete Aortic Repair": Surgical or Endovascular Total Arch Replacement With Thoracoabdominal Fenestrated-Branched Endovascular Aortic Repair.

BACKGROUND
Spinal cord injury (SCI) is detrimental for patients undergoing open or endovascular thoracoabdominal aortic (TAAA) repair. Aim of this survey and modified Delphi consensus was to gather information on current practice and standards in neuroprotection in patients undergoing open and endovascular TAAA.


METHODS
The Aortic Association conducted an international online survey on neuromonitoring in open and endovascular TAAA repair. In a first round an expert panel put a survey on different aspects of neuromonitoring together. Based on the answers from the first round of the survey, 18 Delphi consensus questions were formulated.


RESULTS
56 physicians completed the survey. 45 perform open and endovascular TAAA repair, 3 open TAAA repair and 8 endovascular TAAA repair. At least one neuromonitoring or protection modality is utilized during open TAAA surgery. Cerebrospinal fluid (CSF) drainage was used 97.9%, Near Infrared spectroscopy (NIRS) in 70.8%, and motor evoked potentials or somatosensory evoked potentials (SEP) in 60.4%. Three of 53 centres do not utilize any form of neuromonitoring or protection during endovascular TAAA repair. 92.5% use CSF drainage, 35.8% cerebral or paravertebral NIRS and 24.5% MEPs or SEPs. The utilization of CSF drainage and neuromonitoring varies depending on the extent of TAAA repair.


CONCLUSION
The results of this survey and Delphi consensus show that there is broad consensus on the importance to protect the spinal cord to avoid SCI in patients undergoing open TAAA repair. Those measures are less frequently utilized in patients undergoing endovascular TAAA repair but should be considered, especially in patients that require extensive coverage of the thoracoabdominal aorta.

Practice of Neuromonitoring in open and endovascular thoracoabdominal aortic repair - An international expert-based modified Delphi consensus Study.

We describe the feasibility of a technique for temporary aneurysm sac reperfusion after endovascular single-stage thoracoabdominal aortic aneurysm exclusion, to be used in the case of postoperative spinal cord ischemia. Two cases were treated for impending rupture of a thoracoabdominal aortic aneurysm. Before completion of sac exclusion, a supplementary buddy wire (V-18 control guidewire; Boston Scientific) was advanced in parallel fashion from the left percutaneous femoral access into the aneurysmal sac on the posterior aspect of the endograft. Distal aneurysm exclusion was completed using the main superstiff guidewire, and the femoral access was closed with a percutaneous closure device (ProGlide; Abbott) in standard fashion, leaving in place the sole V-18 guidewire, draped in sterile fashion. In the case of spinal cord ischemia, the "safe-line" can be rapidly used for spinal reperfusion after trans-sealing exchange with a 6F, 65-cm-long Destination sheath (Terumo) connected to a 6F introducer on the contralateral femoral artery. 

http://www.jvscit.org/article/S2468428723001247/pdf

The “safe-line” technique as theoretical additional attempt to mitigate spinal cord ischemia after urgent complete endovascular exclusion of a thoracoabdominal aortic aneurysm

Predictors and Outcomes of Spinal Cord Injury following Complex Branched/Fenestrated Endovascular Aortic Repair in the US Aortic Research Consortium.

To assess outcomes of fenestrated-branched endovascular aortic repair (FB-EVAR) of Extent I-III thoracoabdominal aortic aneurysms (TAAAs) without prophylactic cerebrospinal fluid drainage (CSFD).Prophylactic CSFD has been routinely used during endovascular TAAA repair, but concerns about major drain-related complications gave led to revising this paradigm.We reviewed a multicenter cohort of 541 patients treated for Extent I-III TAAAs by FB-EVAR without prophylactic CSFD. Spinal cord injury (SCI) was graded as ambulatory (paraparesis) or non-ambulatory (paraplegia). Endpoints were any SCI, permanent paraplegia, response to rescue treatment, major drain-related complications, mortality, and patient survival.There were 22 Extent I, 240 Extent II and 279 Extent III TAAAs. Thirty-day mortality was 3%. SCI occurred in 45 patients (8%), paraparesis occurring in 23 (4%) and paraplegia in 22 patients (4%). SCI was more common in patients with Extent I-II compared to Extent III TAAAs (12% vs. 5%, P=0.01). Rescue treatment included permissive hypertension in all patients, with CSFD in 22 (4%). Symptom improvement was noted in 73%. Twelve patients (2%) had permanent paraplegia. Two patients (0.4%) had major drain-related complications. Independent predictors for SCI by multivariate logistic regression were sustained peri-operative hypotension (OR 4.4, 95% CI 1.7-11.1), patent collateral network (OR 0.3, 95% CI 0.1-0.6), and total length of aortic coverage (OR 1.05, CI 95% 1.01-1.10). Patient survival at 3-years was 72±3%.FB-EVAR of Extent I-III TAAAs without CSFD has low mortality and low rates of permanent paraplegia (2%). SCI occurred in 8% of patients, and rescue treatment improved symptoms in 73% of them. 

Hsin-Yi Chen

Papers

Multicenter Study to Evaluate Endovascular Repair of Extent I-III Thoracoabdominal Aneurysms Without Prophylactic Cerebrospinal Fluid Drainage