Impact of the COVID-19 Pandemic on Complex Aortic Aneurysm Surgery.

INTRODUCTION: This study aimed to evaluate the impact of COVID on total case load and peri-operative outcomes in patients undergoing open surgical repair (OSR) and endovascular repair (ER) of complex aortic aneurysms (cAAs). METHODS: A single-center retrospective analysis of prospective data of patients managed with elective cAA ER or OSR from January 2018 to December 2021 was conducted. A comparative analysis on the impact of the COVID-19 pandemic on the case volume and on the 30-day outcomes was assessed using time periods, before (2018-2019) and during the pandemic (2020-2021). RESULTS: During the 4-year study period, 255 patients with cAA were managed with ER and 576 with OSR. The pandemic did not reduce the cAA ER volume (p=0.12), but a statistically significant reduction in OSR case load was recorded (p=0.04). Following OSR, hospital length of stay (11.1 vs 10.3 days), and early mortality (6.94% vs 4.63%), were similar before and during the pandemic. In the ER cohort, baseline characteristics, early mortality (3.6% vs 4.1%, p=0.976), and morbidity (10% vs 14%, p=0.44), were comparable during the 2 periods. For ER cases, the hospital and intensive care unit (ICU) stay both decreased significantly (8±8-6±7 days, p<0.001 and 2±4 vs 1±6 days p=0.01, respectively) during the pandemic. CONCLUSION: Resource pressures drove modifications in clinical practice to reduce the length of hospitalization, without compromising the clinical outcomes, in patients undergoing ER of cAA. This modification was not effective in patients undergoing OSR that resulted in a significant decrease of this activity. CLINICAL IMPACT: The pandemic did not reduce complex endovascular repair (ER) volume (p=0.12) while a significant reduction in open surgical repair (OSR) case load was recorded (p=0.04). For the endovascular cohort, early mortality (p=0.976) and morbidity (p=0.44) remained stable, while the hospital and intensive care unit (ICU) stay decreased (p<0.001 and p=0.01, respectively) during the pandemic.

Spinal cord ischemia rates and prophylactic spinal drainage in patients treated with fenestrated/branched endovascular repair for thoracoabdominal aneurysms.

OBJECTIVE: Spinal cord ischemia (SCI) is a devastating complication after thoracoabdominal aortic aneurysm (TAAA) repair. The benefit of prophylactic cerebrospinal fluid drainage (pCSFD) to prevent SCI is still under investigation. The aim of this study was to evaluate the SCI rate and the impact of pCSFD following complex endovascular repair (fenestrated or branched endovascular repair [F/BEVAR]) for type I to IV TAAA. METHODS: The STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement was followed. A single-center retrospective study was conducted, including all consecutive patients, managed for TAAA type I to IV using F/BEVAR, between January 1, 2018, and November 1, 2022, for degenerative and post-dissection aneurysms. Patients with juxta- or pararenal aneurysms were excluded, as well as cases managed urgently for aortic rupture or acute dissection. After 2020, pCSFD in type I to III TAAAs was abandoned and replaced by therapeutic CSFD (tCSFD), performed only in patients presenting SCI. The primary outcome was the perioperative SCI rate for the entire cohort and the role of pCSFD for type I to III TAAAs. RESULTS: In total, 198 patients were included (mean age, 71.1±3.4 years; 81.8% males), including 50.5% with type I to III TAAA. The primary technical success was 94.9%. The perioperative mortality was 2.5%. and the major adverse cardiovascular event (MACE) rate was 10.6%; 4.5% presented SCI of any type (2.5% paraplegia). When comparing the SCI group with the remaining cohort, patients with SCI presented higher MACE (66.7% vs 7.9%; P < .001) rate and longer intensive care unit stay (3.5 vs 1 day; P = .002). Following type I to III repair, similar SCI, paraplegia, and paraplegia with no recovery rates were reported in the pCSFD and tCSFD groups (7.3% vs 5.1%; P = .66; 4.8% vs 3.3%; P = .72; and 2% vs 0%; P = .37). CONCLUSIONS: The incidence of SCI after TAAA I to IV endovascular repair was low. SCI was associated with significantly increased MACE and intensive care unit stay. The prophylactic use of CSFD in type I to III TAAAs was not associated with lower SCI rates and may not be justified routinely.

Iatrogenic distal aortic rupture in a patient with vascular Ehlers-Danlos syndrome.

Vascular Ehlers-Danlos syndrome is a rare inherited connective tissue disorder that can result in significant morbidity and mortality. This report details an iatrogenic aortic rupture during an endovascular approach in the management of critical limb ischemia in a 27-year-old woman who presented with acute onset of severe sensory deficit of the left leg. Conversion to open repair with a midline laparotomy and an aortic-left popliteal bypass was performed. In the endovascular era, we highlight that even minimally invasive therapeutic interventions can have devastating adverse events in patients with vascular Ehlers-Danlos syndrome.

Midterm Outcomes of Antegrade In Situ Laser Fenestration of Polyester Endografts for Urgent Treatment of Aortic Pathologies Involving the Visceral and Renal Arteries.

OBJECTIVE: Aortic endografting and antegrade in situ laser fenestration of visceral arteries (LFEVAR) may be considered as an alternative to open surgery for the emergency repair of complex abdominal aortic aneurysms (AAA) in fragile patients. The aim of this article was to evaluate the midterm results of LFEVAR performed with polyester endografts. METHODS: From August 2015 to December 2020, all consecutive LFEVAR performed for non-deferrable treatment of complex AAA were analysed. Polyester endografts were deployed and subsequently fenestrated using an atherectomy laser probe; the fenestrations were enlarged using cutting and semicompliant balloons before implantation of balloon expandable bridging stents into the target vessels. Prospectively collected midterm survival, patency, and re-intervention rates were analysed. RESULTS: Forty four procedures were performed for 11 type 1a endoleaks, five thoraco-abdominal aneurysms, 20 pararenal aneurysms, four segmental renal artery (RA) preservations, three anastomotic aneurysms, and one aortic dissection. One hundred and eight laser fenestrations were performed (26 for the superior mesenteric artery [SMA], 13 for the coeliac trunk, 33 and 31 for the right and left RA, respectively). The median ischaemia duration was 7, 48, 48, and 45 minutes, respectively. The technical success rate was 97%, with no open surgical conversions. The 30 day mortality was 4.5% (n = 2). No spinal cord ischaemia events were observed nor early stent related complications. Kaplan-Meier overall survival at two years was 73%, the aortic related re-intervention free survival was 70%, and the stent related re-intervention free survival was 90.6%. Four target vessel thromboses were detected, of which three were rescued. Three type IIIc endoleaks, one RA false aneurysm, and one SMA stenosis, required re-intervention during a median follow up of 24.7 months. CONCLUSION: Antegrade LFEVAR is feasible, safe, and provides satisfactory early and midterm outcomes for non-deferrable treatment of aortic pathologies involving the visceral segment. Long term data are mandatory to confirm the usefulness of this promising off label technique.

In Situ Fenestrated Thoracic Endovascular Repair Using the Upstream Peripheral Go BackTM Re-Entry Catheter.

PURPOSE: The aim is to present a case of in situ fenestrated thoracic endovascular repair, using a re-entry peripheral catheter, needing urgent repair due to recurrent episodes of hemoptysis because of an aorto-bronchial fistula after previous thoracic endovascular aortic repair (TEVAR). TECHNIQUE: A 74-year-old male with a previous TEVAR presented with hemoptysis, fever, and cachexia. An aorto-bronchial fistula and type Ia endoleak were depicted on computed tomography angiography (CTA). Due to the patient's frail general condition, a proximal TEVAR extension was planned, prior to thoracotomy for debridement, and long-term antibiotics. An in situ fenestrated TEVAR was performed to provide proximal sealing and revascularize the left common carotid and subclavian arteries. For fenestration creation, an Upstream Peripheral Go Back catheter (Bentley, Hechingen, Germany) was used. The Go Back catheter has been approved as a re-entry tool for complex peripheral arterial revascularization. In this case, both fenestrations were successfully created. Proximal seal and target vessel patency were confirmed on CTA. Thoracotomy confirmed aortic exclusion. A wedge lobectomy was performed in combination with pediculated omentectomy to exclude the exposed endograft. CONCLUSION: In urgent cases, where custom-made thoracic devices are unavailable, in situ fenestrations with the Go Back catheter are an alternative to laser fenestrations. CLINICAL IMPACT: Fenestrations are often required in acute TEVAR to achieve a proximal seal in the arch. In situ fenestrations with the Go Back catheter are an alternative to laser fenestrations and PMEGs in this setting.

A Review: Single and MultiBranch Devices for the Treatment of Aortic Arch Pathologies with Proximal Sealing in Ishimaru Zone 0.

Recently published experience has shown that endovascular management of the aortic arch, including sealing in the proximal zones, can be a viable option for patients considered unfit for conventional open repair. Endograft designs vary and include single or multibranch devices, with or without the addition of surgical debranching. Initial reports show that both techniques can be performed with high technical success and acceptable perioperative morbidity and mortality rates in high volume centers. Single branch devices, available off-the-shelf, may provide a treatment option for emergent presentations where patients cannot wait for the design and manufacture of a customized endograft. Double or triple branched endografts are now increasingly implanted in high-volume aortic centers. The purpose of this review is to describe the single and multibranched endovascular devices currently available for aortic arch repair, their associated published outcomes, and to discuss their relative advantages and disadvantages.

Consecutive failing proximal landing zones.

We report the case of a 77-year-old man who presented with successive aortic aneurysms during a 12-year period. He was first treated in 2006 for an abdominal aortic aneurysm with a bifurcated endograft, then in 2016 for a tender type IV thoracoabdominal aortic aneurysm with a proximal aortic cuff with in situ laser fenestrations. He presented in 2018 with a 9-cm distal thoracic aorta aneurysm managed by an off-the-shelf t-Branch endograft (Cook Medical, Bloomington, Ind). The perioperative course was uneventful, and 6-month follow-up computed tomography scan has shown freedom from endoleaks and branch patency. This case illustrates that apparently "healthy" aortic necks can degenerate after endovascular aneurysm repair.

In Situ Antegrade Laser Fenestrations During Endovascular Aortic Repair.

INTRODUCTION: The technique and preliminary outcomes are reported for laser fenestrated endografting (LfEVAR), developed as an alternative procedure for endovascular repair of thoraco-abdominal aortic aneurysms (TAAAs), type IA endoleaks (T1AELs), and pararenal aortic aneurysms (PAAAs). METHODS: Patients with TAAA, T1AEL, and PAAA considered unfit for open repair by a multidisciplinary team and who could not benefit from a custom made device were selected. LfEVAR is a physician modified technique requiring sequential steps. After preliminary stenting of each target artery, a standard stent graft was deployed in the aorta. Laser fenestration was performed using a steerable sheath positioned in the stent graft lumen in front of each target artery ostium. After progressive dilation of the laser fenestration, bridging stents were placed and flared to insure accurate perfusion of the visceral arteries. RESULTS: Between August 2015 and March 2017, 16 consecutive patients were treated using LfEVAR including two TAAAs, four T1AELs, and 10 PAAAs. Thirty-three laser fenestrations were performed with a 94.3% success rate for visceral artery fenestration. The median ischaemic was 7.5 minutes for the superior mesenteric artery, 48 and 50 minutes for the left and right renal arteries, and 125 minutes for the coeliac trunk. Four secondary procedures were required: two endoleaks (type II and III), and two related to fenestrations: one renal stent dislocation, and one renal artery stent stenosis. During a mean follow up of 17 months, no deaths occurred. Follow up computed tomography (CT) scans performed at 30 days, 6, 12, and 18 months were satisfactory (4 endoleaks and two aneurysm enlargements were observed). The follow up CT scan imaging demonstrated 97% primary patency. CONCLUSION: In situ antegrade LfEVAR is feasible and a safe alternative option for high risk inoperable patients or for those not eligible for custom made device endografting, particularly in emergency cases.