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Endovascular treatment for thoracoabdominal aneurysms: outcomes and results

^a Division of Cardiac Surgery, the Heart Lung and Esophageal Surgery Institute, UPMC Presbyterian, Suite C-700, 200 Lothrop St., Pittsburgh, PA 15213, United States
^b Center for Cardiovascular Disease, University of Freiburg, Freiburg, Germany
^c Clinic for Cardiothoracic and Vascular Surgery, University Hospital Mainz, Mainz, Germany

Received 18 September 2007; received in revised form 16 June 2008; accepted 1 July 2008.

^_* Corresponding author. Address: The Heart Lung and Esophageal Surgery Institute, UPMC Presbyterian, Suite C-700, 200 Lothrop Street, Pittsburgh, PA 15213, United States. Tel.: +1 412 648 6648; fax: +1 412 802 8020. (Email: siegenthlaermp{at}upmc.edu).

Objective: Endovascular treatment of thoracoabdominal aortic aneurysms (TAAA) in combination with selective open surgical revascularization may be an alternative to conventional surgical repair. We analyzed our patient outcomes after elective and emergent endovascular TAAA repair. Methods: Mortality and outcome data from 21 consecutive patients treated with endovascular TAAA repair between 2000 and 2006 were reviewed. An integrated neuroprotective approach was used on all patients. Mortality risk estimates for open surgery (OS) were calculated using the published risk assessment models and compared to our outcomes. Results: Of the 21 patients, 9 had acute presentation: acute pain (9), rupture (6), and malperfusion (1). The celiac axis was overstented in 15. Nine hybrid open surgical procedures were performed: visceral/renal arteries (5), infrarenal aorta (3) and complete arch revascularization (1). Eleven patients had previous aortic surgery. Thirty-day mortality rate was 4.8% (1/21, predicted OS value 8.3%), 1-, 2- and 3-year survival was 80%. One hospital death occurred due to ischemic colitis after inferior mesenteric artery overstenting. No patient with acute presentation died during the initial hospital admission. There was no paraplegia (predicted OS rate 11.46%) and one event of delayed temporary paraparesis 3 weeks after hospital discharge corrected with raising the blood pressure. Other neurologic complications included one minor left pontine stroke with complete resolution, postoperative confusion (1) and saphenous nerve injury (1). No new late endoleaks occurred after initial complete aneurysm exclusion. Five patients underwent early (<30 days) and four patients underwent late endovascular reinterventions for persistent endoleak. An additional reintervention included percutaneous stenting of a superior mesenteric artery stenosis. Actual freedom from late reintervention was 81%, and 76% at 1-, 2 and 3-year follow-up. Late major adverse events included one stent infection leading to multi-organ failure and death. Conclusions: Endovascular treatment of thoracoabdominal aneurysms with selective visceral and renal revascularization is associated with low mortality and can only be effectively performed by a surgeon. High-risk patients and those with acute presentation appear to benefit most from this therapy. Early results up to three years of this therapy are encouraging, but further follow up to validate long-term results is required.

Key Words: Thoracoabdominal aneurysm • Endovascular repair • Visceral revascularization