Endovascular interventions of the descending thoracic aorta.

Endovascular interventions of the descending thoracic aorta have been established as an alternative to conventional open surgery. Initially, they were limited to elective patients with a high risk profile for open surgery, but soon their use was extended to emergencies as well. In the elective setting, endovascular interventions significantly lowered short-term morbidity and mortality. These excellent perioperative results were reproducible in the emergency setting, thereby leading to superior outcomes for patients treated by endovascular stent grafts when compared to the conventional open surgical approach. However, some questions regarding long-term durability of these devices remain unanswered. Stent-graft failures at mid and long-term follow-up have been reported in the literature. The progressive nature of stent graft-related mid- and long-term complications stresses the need for continued surveillance of these patients.

Author(s): Doss M, Wood JP, Balzer J, Thalhammer A, Martens S, Wimmer-Greinecker G, Vogl T, Moritz A.
in: Herz. 2006 Aug;31(5):429-33
[Article in German] (Endovaskuläre Interventionen der thorakalen Aorta descendens)

PMID: 16944062 [PubMed - indexed for MEDLINE]
Springerlink

Emergency endovascular interventions for acute thoracic aortic rupture: 4 year follow up.

OBJECTIVE: High mortality and paraplegia rates associated with the surgical management of acute thoracic aortic ruptures limit its success. It was our objective to evaluate whether emergency endovascular interventions would improve the outcomes of these patients.

METHODS: Sixty patients aged 28 to 83 years were admitted to our institution with an acute rupture of the thoracic aorta (27 ruptured aneurysms, 15 perforated type B dissections, 18 traumatic ruptures). Twenty-eight patients were treated surgically with cardiopulmonary bypass, and 32 patients were acutely treated with an endovascular stent graft. Medical records were reviewed for prehospital and emergency department data, operative findings, and outcomes. Patients were followed up at yearly intervals with high-resolution multidetector computed tomographic angiography.

RESULTS: Perioperatively, there were 1 death (3.1%) among the 32 patients in the endovascular group and 5 deaths (17.8%) among the 28 patients in the surgical group. There were 4 late deaths in the endovascular group and 1 in the surgical group. There were 2 access failures in the endovascular group. There were 1 stroke in the endovascular group and 1 case of paraplegia in the surgical group. Three patients in the endovascular group had endovascular leaks develop that required reintervention. Two patients in the endovascular group had late thrombosis of the left subclavian artery.

CONCLUSION: Despite encouraging early outcomes, midterm results suggest a trend toward increased reintervention and late complication rates in the endovascular group. Therefore continued surveillance of patients treated with stent grafts is necessary.

Author(s): Doss M, Wood JP, Balzer J, Martens S, Wimmer-Greinecker G, Moritz A.
in: Journal of Thoracic and Cardiovascular Surgery, 2005 Mar;129(3):645-51.

Read at the Thirtieth Annual Meeting of The Western Thoracic Surgical Association, Maui, Hawaii, June 23-26, 2004.

PMID: 15746750 [PubMed - indexed for MEDLINE]

Surgical versus endovascular treatment of acute thoracic aortic rupture: a single-center experience.

BACKGROUND: Surgical management of acute thoracic aortic ruptures is controversial, especially in patients with preexisting comorbidities; associated mortality and paraplegia rates remain high. It was our objective to evaluate whether treating these patients acutely with endovascular stent grafts would improve their outcome.

METHODS: From November 1999 to February 2002 a total of 54 patients, age 28 to 83 years, were admitted to our institution with an acute rupture of the thoracic aorta (24 ruptured aneurysms, 14 perforated type B dissections, 16 traumatic ruptures). Twenty-eight patients were managed surgically using cardiopulmonary bypass (group 1), and 26 patients were treated acutely with an endovascular stent graft (group 2). The resuscitation protocol and interval from onset of symptoms to treatment was comparable in both groups. Medical records were reviewed for prehospitalization and emergency department data, operative findings, and outcomes.

RESULTS: There were 5 of 28 deaths (17.8%) in the surgical group and 1 of 26 deaths (3.8%) in the endovascular group. In the surgical group 1 of 28 patients (3.6%) exhibited paraplegia; there were no cases of paraplegia in the endovascular group. There were 4 of 28 cases (14.3%) of renal failure in group 1 and 1 of 26 (3.8%) in group 2. In group 1, 8 patients (28.6%) required mechanical ventilation for more than 48 hours; there were 2 of 26 patients (7.7%) in group 2 with this ventilatory requirement. Three patients required a repeat thoracotomy for hemorrhage in the surgical group. There were two access failures in the endovascular group.

CONCLUSIONS: In the treatment of acute ruptures of the thoracic aorta, the immediate outcome of patients treated with endovascular stent grafts appears to be better than with management by conventional surgical repair.

Author(s): Doss M, Balzer J, Martens S, Wood JP, Wimmer-Greinecker G, Fieguth HG, Moritz A.
in: Ann Thorac Surg. 2003 Nov;76(5):1465-9; discussion 1469-70.

PMID: 14602268 [PubMed - indexed for MEDLINE]

Emergent endovascular stent grafting for perforated acute type B dissections and ruptured thoracic aortic aneurysms.

BACKGROUND: The purpose of our study was to demonstrate the effectiveness of endovascular stent grafts in the treatment of acutely ruptured thoracic aortic aneurysms and type B dissections as an alternative to the conventional surgical approach in an emergency setting.

METHODS: From January 2001 to October 2001, we deployed 11 emergent endovascular stent grafts into the thoracic aorta. We treated seven ruptured aortic aneurysms and four acutely perforated type B dissections. Aortic rupture was confirmed preoperatively by spiral computed tomography. In all cases, hemothorax was present. The average interval from onset of symptoms to treatment was 28.5 hours. We used nine Talent and two Excluder stent grafts.

RESULTS: Deployment of the stent grafts was successful in nine cases. There were two cases of access failure due to small caliber of iliac arteries, and 1 of these patients died shortly after the procedure was abandoned, At 12 months of follow-up, there were no cases of paraplegia, stent migration, or endoleaks. There was, however, one temporary renal failure, and 2 patients required mechanical ventilation for more than 48 hours.

CONCLUSIONS: Our experiences with emergency endovascular stent grafting show that the procedure is technically feasible, with less morbidity and mortality than conventional open surgery, in high-risk patients.

Author(s): Doss M, Balzer J, Martens S, Wood JP, Wimmer-Greinecker G, Moritz A, Fieguth HG.

in: Ann Thorac Surg. 2003 Aug;76(2):493-8; discussion 497-8.

PMID: 12902092 [PubMed - indexed for MEDLINE]

Emergent endovascular interventions for contained rupture of thoracic aortic aneurysms.

BACKGROUND: The purpose of our study was to assess in an emergency setting the feasibility of endovascular stent graft treatment of contained ruptures of thoracic aortic aneurysms.

METHODS: Seven patients with contained ruptures of thoracic aortic aneurysms from a series of 54 endovascular interventions were treated by the deployment of an aortic stent graft. In all cases, hemothorax was present. Acute deployment was performed with the patient under general anesthesia, and access was gained via the common femoral or iliac arteries. After a follow-up o f 12 months, the patients were evaluated by computed tomography.

RESULTS: One patient died perioperatively. The procedure was technically successful in 5 patients. Perioperatively and at follow-up, there were no cases of paraplegia, stent graft migration, or endoleaks. There were, however, 2 cases of access failure, 1 case of temporary renal failure, and 2 patients who required prolonged mechanical ventilation.

CONCLUSION: The acute treatment of contained ruptures of thoracic aortic aneurysms is feasible. This form of treatment seems to be a promising option in the treatment of these high-risk patients.

Author(s): Doss M, Balzer J, Martens S, Fieguth HG, Vogl T, Moritz A, Wimmer-Greinecker G.

in: Heart Surg Forum. 2003;6(6):E133-7.

PMID: 14721999 [PubMed - indexed for MEDLINE]

Emergency endovascular interventions for ruptured thoracic and abdominal aortic aneurysms.

BACKGROUND: The purpose of our study was to show the effectiveness of endovascular stent grafts in the treatment of acutely ruptured abdominal and thoracic aortic aneurysms as an alternative to the conventional surgical approach in an emergency setting.

METHODS: From October 1996 to October 1998 we deployed 9 emergent endovascular stent grafts–6 in the abdominal aorta and 3 in the thoracic aorta. Aortic rupture was confirmed before surgery with spiral-computed tomographic scan. The average interval from onset of symptoms to treatment was 4.5 hours. We used commercially manufactured stent grafts: 4 Corvita (Corvita Inc/Schneider Corp/Boston Scientific Corp, Natick, Mass), 3 Talent (World Medical Inc, Surise, Fla/Medtronic, Sunnyvale, Calif), and 2 Vanguard (Boston Scientific Corp, Natick, Mass).

RESULTS: Deployment of the stent grafts was successful in all cases. Two patients died in the follow-up period (120 months) from myocardial infarction. No cases were seen of paraplegia or stent migration. However, 2 endoleaks, 1 in-stent stenosis, 1 temporary renal failure, and 1 brief episode of myocardial ischemia occurred.

CONCLUSION: Our experiences with emergency endovascular stent grafting show that the procedure is technically feasible, with less morbidity and mortality than conventional open surgery, in selected patients.

Author(s): Doss M, Martens S, Hemmer W.

in: Am Heart J. 2002 Sep;144(3):544-8.

PMID: 12228794 [PubMed - indexed for MEDLINE]