Hybrid repair of thoracic aortic lesions for zone 0 and 1 in high-risk patients.

PURPOSE: Some patients with aortic arch or descending thoracic aorta pathologies are not suited for open repair because of comorbidities that may increase their risk of procedural complications or death. Endovascular approaches may also be difficult when there are inadequate proximal landing zones in the aortic arch. We report our experience using rerouting techniques with bypass, stenting of the branches, or a combination of both to create a landing area in zones 0 and 1 of the aortic arch. METHODS: Since November 2002, thoracic aortic endoluminal grafts were placed in 38 patients in whom the endograft was deployed in zone 0 (n = 27) or zone 1 (n = 11). A retrospective review is included. RESULTS: There were 11 women and 27 men with a mean age of 65.4 years (range 38-88). Aortic pathology included 12 Stanford type A dissections, 10 aortic arch aneurysms, 8 Stanford type B dissections, 3 descending thoracic aortic aneurysms, 2 aortobronchial fistulas, 1 innominate artery aneurysm and 2 aortic arch pseudoaneurysms. In zone 0, 21 had thoracic debranching with an ascending bypass, three patients had a remote-inflow and three patients had a chimney-stent with carotid-carotid bypass. In zone 1, five patients had a carotid-carotid bypass, one patient had an aortic to left common carotid artery (LCCA) bypass and five patients had chimney-stent on the LCCA. Fifty-eight percent of the patients were symptomatic and 26% emergent. Three patients required hemodialysis postoperatively (7.9%), 18 patients (47.4%) required prolonged mechanical ventilation for respiratory insufficiency. Paraplegia occurred in one patient (2.7%), and five patients suffered a cerebrovascular accident (13.1%). There were four early type I and two type II endoleaks. Overall 30-day mortality was 23.7%. CONCLUSIONS: The hybrid approach for repair of the aortic arch pathologies is feasible in patients unfit for open repair. We present the results of performing different techniques to treat the aortic arch with hybrid repair with antegrade or retrograde inflow, stenting of the branches or a combination of both. Long-term results are unknown, and larger series results and comparative studies are needed to determine safety and efficacy.

The changing management of primary mycotic aortic aneurysms.

OBJECTIVE: The objective of this study is to examine contemporary management of primary mycotic aortic aneurysms in a single center. We have previously reported the management of mycotic aortic aneurysms in 15 patients between 1991 and 2001, and we hypothesized that management would change in the light of the evolution of endovascular aortic repair. METHODS: A review of a prospectively collected database (2002-2009) of all patients presenting with mycotic aneurysms. RESULTS: A total of 19 aneurysms were identified in 17 patients (12 men, 5 women) with a median age of 66.2 years (range, 49-82 years). All were symptomatic, and nine had contained rupture. There were five infrarenal, two juxtarenal, three Crawford type III, four type IV thoracoabdominal aortic aneurysms, and five descending thoracic aneurysms in the series. All thoracic aneurysms were excluded by thoracic endovascular aneurysm repair. Two patients underwent visceral hybrid endografting for type III thoracic aortic aneurysm; the third was treated with open repair. Four patients underwent open type IV repair. Two of the infrarenal aneurysms were treated with bifurcated endovascular aneurysm repair, and the other three and both juxtarenals with open repair with in situ reconstruction. There were three early (17.6%) and three late deaths (17.6%). The median follow-up was 30.5 months (range, 1-102 months). CONCLUSIONS: The results of the latest series show that open surgery is still required in many cases. The introduction of endovascular techniques in the exclusion of mycotic aneurysms can be accomplished with acceptable results, and endovascular treatment has increased the therapeutic options for a difficult condition.