Surgical correction of failed thoracic endovascular aortic repair

Objective The number of thoracic aortic endovascular procedures is increasing rapidly, and the clinical outcome largely depends on the underlying aortic pathology. When primary stent grafting is unsuccessful, secondary endovascular solutions are most often feasible. However, in recurrent endovascula...

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Bibliographic Details
Published in:Journal of vascular surgery 2008-06, Vol.47 (6), p.1195-1202
Main Authors: Langer, Stephan, MD, Mommertz, Gottfried, MD, Koeppel, Thomas A., MD, Schurink, Geert W.H., MD, Autschbach, Rüdiger, MD, Jacobs, Michael J., MD
Format: Article
Language:English
Subjects:
Adult
Aneurysm, Dissecting - diagnostic imaging
Aneurysm, Dissecting - surgery
Aneurysm, False - diagnostic imaging
Aneurysm, False - surgery
Aortic Aneurysm, Thoracic - diagnostic imaging
Aortic Aneurysm, Thoracic - surgery
Aortic Rupture - diagnostic imaging
Aortic Rupture - surgery
Aortography - methods
Biological and medical sciences
Blood and lymphatic vessels
Blood Vessel Prosthesis
Blood Vessel Prosthesis Implantation - adverse effects
Blood Vessel Prosthesis Implantation - instrumentation
Blood Vessel Prosthesis Implantation - methods
Cardiology. Vascular system
Constriction
Device Removal
Diseases of the aorta
Extracorporeal Circulation
Female
Follow-Up Studies
Germany
Heart Arrest, Induced
Humans
Male
Medical sciences
Middle Aged
Minimally Invasive Surgical Procedures
Netherlands
Prosthesis Design
Prosthesis Failure
Reoperation
Stents
Sternum - surgery
Surgery
Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases
Thoracotomy
Time Factors
Tomography, X-Ray Computed
Treatment Failure
Vascular surgery: aorta, extremities, vena cava. Surgery of the lymphatic vessels
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Summary:Objective The number of thoracic aortic endovascular procedures is increasing rapidly, and the clinical outcome largely depends on the underlying aortic pathology. When primary stent grafting is unsuccessful, secondary endovascular solutions are most often feasible. However, in recurrent endovascular failure without further minimally invasive options, conservative treatments or conversion to open surgery are the only remaining therapeutic strategies. Methods In our experience, 106 patients received thoracic aortic endovascular treatment. Five of these patients and three from other centers underwent conversion to open repair because of 4 type Ia endoleaks (3 thoracic aortic aneurysms, 1 traumatic rupture), 2 retrograde type A dissections, 1 type Ib endoleak with contained rupture, and 1 secondary false aneurysm rupture due to stent graft migration. The latter four were surgical emergencies; the other four were urgent or elective procedures. Three patients underwent supracoronary arch replacement through sternotomy. One patient had arch and proximal descending aortic replacement, three had hemiarch and descending aortic replacement, and one had descending aortic replacement through left thoracotomy. Five stent grafts were totally removed, and three endografts were left in situ. All conversions were performed according to a protocol including total extracorporeal circulation (n = 7) or left heart bypass (n = 1), cerebrospinal fluid drainage and monitoring motor-evoked potentials, transcranial Doppler, and electroencephalography. Results All patients survived the surgical procedure. Six patients had an uneventful postoperative course, whereas necrotic cholecystitis developed in one patient who required cholecystectomy and prolonged intensive care stay. One polytrauma patient died from secondary rupture due to prosthesis infection 24 days after stent graft explantation. No stroke, paraplegia, renal failure, or other major complication occurred. With a mean follow-up of 14 months (range, 4-71 months), seven patients are alive without any sign of recurrent aortic problems. Conclusion Failure of thoracic endovascular aortic repair comprises a new aortic pathology. Secondary endovascular treatment is feasible in most patients; however, some patients will require open surgery to repair failures of thoracic endovascular aortic treatment. These procedures constitute a large surgical trauma and require an extensive protocol, including extracorporeal circulation, neurom
ISSN:0741-5214
1097-6809
DOI:10.1016/j.jvs.2008.01.003