Journal of Vascular Surgery
Volume 48, Issue 5 , Pages 1083-1091, November 2008

Visceral aortic patch aneurysm after thoracoabdominal aortic repair: Conventional vs hybrid treatment

Department of Vascular Surgery, San Raffaele Scientific Institute, Università Vita-Salute San Raffaele, Milan, Italy

Received 18 March 2008; accepted 28 May 2008. published online 11 August 2008.

Article Outline

Objective

Visceral aortic patch (VAP) aneurysm repair following thoracoabdominal aortic aneurysm (TAAA) open treatment carries high morbidity and mortality rates. The aim of this study is to compare the outcomes of our series of patients who underwent redo VAP aneurysm open surgery (conventional group) with a selected group of high-risk patients who underwent, in the same time period from 2001-2007, an alternative hybrid surgical and endovascular approach (hybrid group).

Methods

Conventional group: Twelve patients (11 males, median age 71.5 years, range, 65 to 77 years) underwent VAP aneurysm (median maximum diameter 62 mm, range, 52 to 75 mm) repair with re-inclusion technique via redo thoracophrenolaparotomy or bilateral subcostal laparotomy. Reimplantation of a single undersized VAP or separate revascularization of one or more visceral arteries was performed. Hybrid group: Seven patients (5 males, median age 70 years, range, 63 to 78 years) defined as at high risk for conventional surgery having American Society of Anesthesiology (ASA) class 3 or 4 associated with a preoperative forced expiratory volume in 1 second (FEV1) <50% or an ejection fraction <40%, underwent VAP aneurysm (median maximum diameter 73 mm, range, 62 to 84 mm) repair via median laparotomy, visceral arteries rerouting, and VAP aneurysm exclusion using commercially available thoracic aortic endografts.

Results

Conventional group: Perioperative mortality was 16.7% and major morbidity 33.3%. One perioperative anuria was successfully treated with bilateral renal artery stenting. No paraplegia or paraparesis were observed. At a median follow-up of 2.3 years (range, 1.6-7 years), we observed one case of peri-graft fluid collection with sepsis at postoperative day 46 requiring surgical drainage and prolonged antibiotic therapy and one case of renal failure at day 68 requiring permanent hemodialysis. Hybrid group: perioperative mortality was 14.3% and major morbidity 28.6% with one case of transient delayed paraplegia. At a median follow-up of 1.9 years (range, 0.3-6.8 years), we observed one case of late pancreatitis (46 days postoperatively) resolved with pharmacologic treatment and one death due to an acute visceral grafts thrombosis (78 days postoperatively). We did not observe other procedure-related deaths or complications, VAP aneurysm growth, endoleak, and endograft migration.

Conclusion

Hybrid repair is clearly a feasible alternative to simple observation for patients unfit for redo VAP aneurysm open surgery. However, despite our promising early results, new mid-term specific procedure-related complications have been observed and a widespread use of this technique should be currently limited until longer-term follow-up is available.

 

Thoracoabdominal aortic surgery has significantly evolved over the last decades,1, 2, 3, 4 but the surgical repair of visceral aortic patch (VAP) aneurysms following thoracoabdominal aortic aneurysm (TAAA) with re-inclusion technique is, until now, related to high morbidity and mortality rates (Table I).6, 7, 8, 9, 10, 11, 12, 13, 14

Table I. Literature review of the series of open repair of VAP aneurysms with re-inclusion technique
AuthorsInstitutionYearCasesMortalitySpinal cordRenal failure
Quinones-Baldrich et al2California, USA19971010
Carrel et al3Berne, Switzerland19991000
Gasparis et al4New York, USA20011000
Dardik et al5Baltimore, USA2001525%0%0%
Clouse et al6Boston, USA2003200%50%
Dias et al7Sao Paulo, Brazil20031000
Lombardi et al8Philadelphia, USA2003333%0%0
Tshomba et al25Milan, Italy2004520%0%40%
Suzuki et al9Shizuoka, Japan20051000
Le Maire et al10Texas, USA20061000

A hybrid approach consisting of visceral aortic debranching with rerouting of the visceral arteries and aneurysm exclusion employing straight thoracic endografts has been described in several reports for TAAA.15, 16, 17, 18, 19 An isolated experience of VAP pseudoaneurysm repair with a retrograde revascularization of the visceral vessels with saphenous vein, VAP aneurysm coil embolization and endograft insertion into the previous aortic thoracoabdominal graft has been reported already in 2001 by Juvonen et al,20 more recently, similar experiences for VAP aneurysms have been reported (Table II).21, 22 These isolated reports earn citations having proposed an anecdotic alternative hybrid approach that, compared to the conventional VAP re-grafting and the pure endovascular repair, has several hypothetical advantages in terms of invasiveness and feasibility.

Table II. Literature review of the series of endovascular and hybrid repair of VAP aneurysms
AuthorInstitutionYearCasesMortalitySpinal cordRenal failure
Hybrid treatment
Juvonen et al24Oulu, Finland20011000
Flye et al25St Louis, USA20041000
Bakken et al26Rochester, USA20071000
Pure endovascular treatment
Adam et al21Birmingham, UK20071000

This study prospectively analyzed and contrasted the outcomes of our series of patients who underwent VAP aneurysm repair with re-inclusion technique (conventional group) with a selected group of high-risk patients who underwent, in the same time period, an alternative approach consisting of visceral arteries rerouting and VAP aneurysm endograft exclusion (hybrid group).

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Patients and methods 

Between 1988 and 2008, 344 patients (226 males, median age 63 years, range, 34 to 83 years) underwent treatment of TAAA (321 cases of conventional open repair and 23 hybrid repairs) at our institution.

Among these series, we reviewed 19 patients (16 males, median age 71.3 years, range, 63 to 78 years) who underwent elective VAP aneurysm repair (median maximum diameter 64 mm, range, 52 to 84 mm) between 2001 to 2007 (Table III). All these patients had prior TAAA repair with the visceral vessels attached to the aortic graft as a VAP (distal or proximal beveled anastomosis including visceral vessels or patching of the aorta without tube graft were excluded from this study). Eleven patients (58%) underwent prior TAAA repair at our institution, 8 patients (42%) underwent prior TAAA in a variety of other national centers. In 13 patients, the primary TAAA repair was for atherosclerotic disease and in 6 patients for chronic dissection (2 cases - 10.5% - with a Marfan syndrome). The mean time of detection of the VAP aneurysms was 5.8 ± 2.3 years after the original operation (we defined a VAP aneurysm as having a diameter of 5 cm or more).

Table III. Patients risk factors grading system for cardiovascular risk factors and co-morbidity tabulated according to Society for Vascular surgery/North American Chapter of the International Society for Cardiovascular Surgery (SVS/ISCVS) and according to the Goldman revised cardiac risk index43
Risks factorsOpen repair (n = 12)Hybrid repair (n = 7)
Male115
Age (years)71.5 yrs (r. 65-77)70 yrs (r. 63-78)
ASA score
100
25(41.7%)0
34(33.3%)4(57.1%)
43(25%)3(42.9%)
500
Cardiac risk index⁎
I6(50%)1(14.3%)
II4(33.3%)4(57.1%)
III2(16.7%)2(28.6%)
IV00
Hypertension
0 (diastolic < 90 mm Hg)1(8.3%)1(14.3%)
1 (easily controlled, single drugs)7(58.3%)6(85.7%)
2 (requires 2 drugs)3(25%)0
3 (>2 drugs or uncontrolled)1(8.3%)0
Diabetes
0 (none)11(91.7%)6(85.7%)
1 (adult onset, diet controlled)00
2 (adult onset, oral medication-controlled)01(14.3%)
3 (adult onset, insulin controlled)1(8.3%)0
4 (juvenile onset)00
Smoking
0 (none; abstinence > 10 yrs)3(25%)1(14.3%)
1 (none; abstinence 1-10 yrs)3(25%)2(28.6%)
2 (< 1 pack/day or abstinence >1 yrs)5(41.7%)3(42.9%)
3 (current 1 ≥ pack/day)1(8.3%)1(14.3%)
Hyperlipemia
0 (within normal limits for age)2(16.7%)1(14.3%)
1 (mild elevation, diet controlled)4(33.3%)2(28.6%)
2 (types II, III, or IV, strict diet control)1(8.3%)0
3 (requires drug control)5(41.7%)4(57.1%)
Pulmonary status⁎⁎
01(8.3%)0
14(33.3%)0
25(41.6%)4(57.1%)
32(16.7%)3(42.9%)
Renal status⁎⁎⁎
09(75%)6(85.7%)
13(25%)1(14.3%)
200
300

ASA, American Society of Anesthesiology.

⁎Perioperative cardiac risk, according to the Goldman revised cardiac risk index.43

⁎⁎Pulmonary status: 0 = asymptomatic, normal chest X-ray, pulmonary function test (PFT) 20% of predicted; 1 = asymptomatic or mild dyspnoea on exertion, mild X-ray parenchymal changes, PFT 65 to 80% of predicted; 2 = between 1 and 3; 3 = vital capacity less than 1.85 L, FEV1 less than 35% of predicted, maximal voluntary ventilation less than 28 l/min or less than 50% of predicted, PCO greater than 45 mm Hg, supplemental oxygen use necessary or pulmonary hypertension.

⁎⁎⁎Renal status: 0 = no known renal disease, serum creatinine <1.5 mg/dL, creatinine clearance greater than 50 mL/min; 1 = creatinine 1.5-3.0 mg/dL, clearance 30-50 mL/min; 2 = creatinine 3.0-6.0 mg/dL, clearance 15-30 mL/min; 3 = creatinine >6.0 mg/dL, clearance <15 mL/min or on dialysis or with transplant.

Twelve patients (11 males, median age 71.5 years, range, 65 to 77 years) fit for thoracoabdominal aortic redo procedure underwent conventional VAP aneurysm (median maximum diameter 62 mm, range, 52 to 75 mm) open repair with re-inclusion technique (Table IV). Seven high-risk patients (5 males, median age 70 years, range, 63 to 78 years) underwent VAP aneurysm (median maximum diameter 73 mm, range, 62 to 84 mm) hybrid repair (Table V). The criteria we used from 2001 to define a patient with VAP aneurysm as being at high-risk for conventional re-inclusion technique and to select him for a hybrid treatment, were, according to our anesthesiologists, the occurrence of a class 3 or 4 at the American Society of Anesthesiologists (ASA) classification associated with a preoperative forced expiratory volume in 1 second (FEV1) <50% or an ejection fraction (EF) <40%.

Table IV. San Raffaele Scientific Institute, Università “Vita – Salute” experience: patients underwent operation for VAP aneurysm repair developed after a primary thoracoabdominal aortic aneurysm (TAAA) repair with conventional re-inclusion technique. The results are reported in accordance with the current reporting standards for endovascular aortic repair prepared and revised by the Ad Hoc Committee for Standardized Reporting Practices in Vascular Surgery (SVS/AAVS)23
N°Age (yrs)SexVAP Ø (mm)Previous type TAAARevised patchCSFDMortalityMorbidityMidterm results
#171M64IIICT, SMA, RRA, LRANoNoBleeding (G3)23OK
#277M58IISMA, CT, RRA, (LRA selective revascularization)NoNoRenal Insufficiency (G2)23Death: MI
#372M52III (Chronic dissection, Marfan)CT, SMA, LRA, (RRA selective revascularization)NoYes (MOF)Coagulopathy (G3)23—
#467F68IIICT, SMA, (LRA and RRA selective revascularization)NoNoCardiac (G2)23Death: Stroke
#568M56IVSelective bypassesNoNoNoOK
#674M54IIICT, SMA, RRA, LRANoNoNoOK
#771M63IICT, SMA, RRA, (LRA selective revascularization)NoNoRenal Insufficiency (G2)23Perigraft Collection
Pulmonary (G3)23
#869M74III (Chronic dissection)CT, SMA, (LRA and RRA selective revascularization)NoNoPulmunary (G3)23OK
#974M61II (Chronic dissection)4 branched graftNoNoBleeding (G3)23OK
#1073M68II4 branched graftPreopYes (MOF)No—
#1165M75III4 branched graftNoNoNoRenal Insufficiency (G3) 23
#1277M58II (Chronic dissection)4 branched graftNoNoBleeding (G3)23OK

VAP Ø, Diameter of visceral aortic patch; TAAA, thoracoabdominal aortic aneurysm; CSFD, cerebrospinal fluid drainage, CT, celiac trunk, SMA, superior mesenteric artery; RRA, right renal artery; LRA, left renal artery; MI, myocardial infarction; MOF, multiple organ failure.

Table V. San Raffaele Scientific Institute, Università “Vita – Salute” experience: patients underwent operation for VAP aneurysm repair developed after a primary thoracoabdominal aortic aneurysm (TAAA) repair with hybrid technique. The results are reported in accordance with the current reporting standards for endovascular aortic repair prepared and revised by the Ad Hoc Committee for Standardized Reporting Practices in Vascular Surgery (SVS/AAVS)23
N°Age (yrs)SexVAP Ø (mm)Previous type TAAAOutflow arteriesIn-flow arteryCSFDEndograftMortalityMorbidityMidterm results
#170F64IICT, SMA, RRAAortaPostopValiantNoSpinal Cord Ischemia (G1)23Death: Aortic Arch Rupture
#268M79IIICT, SMA, RRARight iliac a.NoValiantNoBleeding (G3)23 Renal Insufficiency (G1)23Death: Visceral Graft Thrombosis
#377M84IISMA, RRA, LRARight iliac a.NoZenith TX2NoNoOK
#463F62IIICT, SMA, RRA, LRARight iliac a.NoZenith TX2NoBleeding (G3)23Pancreatitis
#567M73II (Chronic dissection, Marfan)CT, SMA, RRA, LRAAortic graftPreopBolton RelayNoNoOK
#674M69IIICT, SMA, RRA, LRARight iliac a.NoValiantYes (MOF)Coagulopathy (G3)23−–
#778M75II (Chronic dissection)CT, SMA, RRA, LRAAortic graftNoZenith TX2NoRenal Insufficiency (G2)23OK

VAP Ø, diameter of visceral aortic patch; TAAA, thoracoabdominal aortic aneurysm; CSFD, cerebrospinal fluid drainage; CT, celiac trunk; SMA, superior mesenteric artery; RRA, right renal artery; LRA, left renal artery; MOF, multiple organ failure.

All the patients were operated under general and epidural anesthesia. Cell salvage, rapid infusers, and transfusion were used in all the patients. Preoperative cerebral spinal fluid drainage (CSFD) was selectively used in 1 patient who underwent open repair in which the arteries participating to collateral network providing spinal cord blood flow were preoperatively reduced and in 1 patient who underwent hybrid repair in which patent re-implanted intercostal arteries were planned to be sacrificed (Table IV, Table V).

Conventional group 

The re-inclusion technique was performed in all the cases, via a redo thoracophrenolaparotomy in 10 cases, and a bilateral subcostal laparotomy in 2 cases. All the visceral arteries and all the renal arteries were preoperatively patent and were always revascularized during the re-inclusion technique. The re-implantation of a single undersized 4-vessel VAP was performed in 2 cases, in which the first VAP had been created with a large amount of aortic tissue externally to the renal arteries and above the celiac trunk, the visceral arteries were not largely displaced and the intraoperative hemodynamic instability and diffuse bleeding induced us to perform the fastest possible procedure. In the other 10 cases, a separate revascularization of one or more visceral arteries was performed. Specifically a 3-vessel VAP (with strictly close celiac trunk, superior mesenteric artery, and one renal artery) with selective revascularization of the other renal artery was performed in 3 cases, and a 2-vessel VAP with selective revascularization of both the renal arteries was performed in 2 cases. Revascularization of all the visceral vessels was performed in 5 cases, in the first case, 4 single separated bypasses were used and in the other 4 cases, a commercially available thoracoabdominal 4-branched graft specific for inline replacement of the visceral aorta (Coselli Thoracoabdominal Graft Gelweave, Vascutek LTD, Renfrewshire, UK) was used for re-grafting (Fig 1). No extracorporeal circulation was used. Before and during supraceliac aortic cross-clamping, diuresis was forced by systemic infusion of furosemide and mannitol (0.5 g/kg). An intraoperative hypothermic perfusion through 9F Pruitt-Inhara occlusion perfusion balloon catheters (LeMaitre-Vascular, Inc, Burlington, Mass) of the celiac and superior mesenteric arteries with cold crystalloid (lactate ringer at 4°C) and of the renal arteries with cold crystalloid (lactate ringer at 4°C) supplemented with mannitol 18% 70 mL and 6-32 methylprednisolone 500 mg was routinely used maintaining the nasopharyngeal temperature always above 35°C using fluid warmer systems in order to reduce the risk of coagulopathy.

  • View full-size image.
  • Fig 1. 

    A, Preoperative angioCT of a patient with previous type II thoracoabdominal aortic aneurysm (TAAA) open repair with a 62 mm VAP aneurysm. B, Intraoperative view of open repair of the VAP aneurysm with separate revascularization of the four visceral vessels with Coselli thoracoabdominal graft (Gelweave, Vascutek LTD, Renfrewshire, UK). C, Six month postoperative angioCT scan demonstrates VAP aneurysm resolution and patency of the four visceral vessels.

Hybrid group 

All patients evaluated for a hybrid repair of the VAP aneurysm received a multislice computed tomography (CT) scan with 1 mm intervals and multiplanar reconstructions (Aquilion 16 and 64; Toshiba Medical Systems, Tokyo, Japan) for planning and sizing. In particular, the intercostal arteries patency was studied, and, when the Adamkiewicz artery was detected, the intercostal artery feeding was planned to be spared. In all the cases, the diameter of previously inserted thoracoabdominal graft measured at preoperative CT scan allowed us to plan an oversizing of at least 10-15%.

All the patients underwent one-stage VAP aneurysm hybrid repair with thoracoabdominal aortic debranching, visceral arteries rerouting with retrograde bypass grafts, and TAAA exclusion using commercially available thoracic endografts as summarized in Table V. All the procedures were performed in the operating room.

The abdominal aorta, common iliac arteries, and the first 2 cm from the origin of the common hepatic artery, superior mesenteric artery, and renal arteries were exposed through a transperitoneal mid-line approach with the patient in a supine position.

We used as donor vessel for the retrograde grafts the infrarenal native or the previously grafted (Fig 2, B) aorta or the right common iliac artery when of good quality. Overall, 25 retrograde visceral bypasses were performed (6 to the celiac trunk, 7 to the superior mesenteric artery, and 12 to renal arteries). We aborted the revascularization of one renal artery for technical concerns (Fig 2) and intentionally planned the covering without revascularization of one renal artery and of one celiac trunk. Synthetic grafts (Dacron graft - 6 and 8 mm diameter) were used in all the cases. We used separate bypass for each recipient vessel, customized “Y” grafts, customized trifurcated grafts, or single bypass with sequential graft technique (Fig 2) related to the specific anatomy of every case. For celiac trunk revascularization, the graft was routed in front of the renal vein behind the pancreas, an arteriotomy was made in the common hepatic artery and an end-to-side anastomosis was made. An end-to-end anastomosis was usually preferred for the superior mesenteric artery, and this type of anastomosis was always used for the renal arteries. Before and during renal artery cross-clamping, diuresis was forced by systemic infusions of furosemide and mannitol (0.5 g/kg). When the time of renal ischemia was longer than 10 minutes for technical issues, such as in case of renal artery endarterectomy or difficult anastomosis, during the renal artery cross-clamping a bolus of 300 mL of cold crystalloid (lactate ringer at 4°C) supplemented with mannitol 18% 70 mL and 6-methylprednisolone 500 mg was perfused into the orifice of the renal artery with an occlusion perfusion balloon catheter (Pruitt- Inhara 9 Fr) maintaining the nasopharyngeal temperature always above the 35°C using fluid warmer systems. Then a continuous perfusion of approximately 500 mL was administered. In all reconstructions, the grafted vessels were ligated proximally to prevent retrograde perfusion of the sac after endovascular exclusion of the aneurysm.

  • View full-size image.
  • Fig 2. 

    A, Preoperative angioCT scan of a patient with previous type III thoracoabdominal aortic aneurysm (TAAA) open repair with a 79 mm VAP aneurysm. Please note the complete displacement of visceral arteries origin with a stenosis at the origin of the celiac trunk (CT) and the superior mesenteric artery (SMA). B, Intraoperative view of the retrograde revascularization from the right common iliac artery of the right renal artery (RRA), of the superior mesenteric artery (SMA), and of the celiac trunk (CT). The right renal artery was dissected and prepared free from retroperitoneal adhesions after Kocker maneuver. Revascularization of the left renal artery was not performed because it could not be dissected safely due to its displacement by the VAP aneurysm and the tight adhesions of retroperitoneal tissue. C, Postoperative CT scan demonstrates complete exclusion with a Valiant stent-graft (blue) of the VAP aneurysm without endoleak and patency of the retrograde revascularization of visceral arteries (red).

The access vessel for endograft insertion in all the cases was the common femoral artery (exposed through an inguinal incision) being of appropriate diameter and of good quality without excessive tortuosity of iliac axis in all the 7 patients selected for hybrid repair. We preferred this access site compared to iliac approach that does not require groin incision, because it allowed a shallower angle of entry of the endograft introducer into the artery and satisfactory hemostasis during the procedure (allowing the arteriotomy to collapse with the introducer in site) without the use of a conduit. A radio-opaque marker was placed at the origin of the more proximal visceral graft when originating from native or grafted abdominal aorta. Three commercially available stent-grafts (Zenith Cook TX2 stent-graft – Cook Inc, Bloomington, Ind; the Valiant thoracic stent-graft – Medtronic, Minneapolis, Minn; Bolton Relay – Bolton Medical, Sunrise, Fla) were used and 1 or 2 stent-grafts were deployed in each patient (Table V). A completion aortography was carried out after deployment of the endografts. Stent-graft ballooning was performed selectively. The access sites were repaired by direct suture.

Postoperative follow-up 

All the patients in both groups were evaluated with postprocedure contrast CT scans with scheduled follow-up imaging at 3 and 6 months and yearly thereafter. Clinical follow-up was also done at regular intervals of 6 months.

Based to a prospectively compiled database, we analyzed and compared the outcomes of the two groups. We analyzed the outcomes in our patients, reporting the results of hybrid repair in accordance with the current reporting standards for endovascular aortic repair prepared and revised by the Ad Hoc Committee for Standardized Reporting Practices in Vascular Surgery (SVS/AAVS).23

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Results 

Preoperative comorbidities and risk factors were higher in the hybrid group (Table III) but a statistical analysis comparison was not feasible with such small subsets of patients. Aetiology and extent of prior TAAA repair were not notably different between the two groups (Table IV, Table V). No patients were lost at follow-up.

Conventional group (12 cases) (Table IV, Table VI) 

No intraoperative deaths occurred. The median procedure time was 210 minutes (range, 165 to 301 minutes). A median of 8.7 units of packed red blood cells were transfused for a median blood loss of 1350 mL (range, 850 to 6500 mL). All patients were admitted to the intensive care unit where they stayed for a median of 2 days (range, 1 to 23 days).

Table VI. Thirty-day outcomes in open and hybrid repair of VAP aneurysms
30-day outcomeOpen repair (n = 12)Hybrid repair (n = 7)
Technical success12(100%)7(100%)
Intraoperative death0%0%
Median procedure time210min(range,165-301min)241min(range,187to465min)
Median blood loss1350mL(range,850-6500mL)480mL(range,380-2900mL)
Intensive care unit stay2days(1-23days)3days(1-27days)
30-day deaths2(16.7%)1(14.3%)
30-day major morbidity4(33.3%)2(28.6%)
Mean length of hospital stay9days(range,6-61days)17days(range,13-26days)

There were two deaths on postoperative day 3 and 5 due to multi-organ failure for a total perioperative mortality of 16.7% (compared to 8.4% in our overall series of 321 patients who underwent TAAA open repair).

Postoperative major morbidity included two cases of acute renal failure reversed with temporary postoperative dialysis in 2 patients (16.7%). One patient, in which an undersized VAP was recreated, developed intraoperative bilateral renal artery dissection leading to perioperative anuria and was treated with immediate bilateral renal artery stenting without permanent renal impairment. Respiratory failure requiring intubation for more than 48 hours was observed in 2 patients (16.7%). No case of spinal cord ischemia was observed. The mean length of hospital stay was 9 days (range, 6 to 61 days). The perioperative major morbidity in the group of patients who underwent VAP aneurysm open repair was thus 33.3%, with a combined rate of perioperative renal complications, respiratory failure, and paraplegia of 41.5%, compared to 27.9% in our overall series of 321 patients undergoing TAAA open repair.

At a median follow-up of 4.3 years (range, 1.6-7.9 years) no significant aortic repair-related complications had been reported. We observed one case of peri-graft fluid collection with sepsis on postoperative day 46 requiring surgical drainage and prolonged antibiotic therapy and one case of renal failure on postoperative day 68 requiring permanent hemodialysis. In the 2 patients who underwent undersized 4-vessel VAP recreation, at the last CT follow-up available we observed a slight VAP dilatation compared to the diameter measured at the postprocedure contrast CT scans (respectively of 4 mm at 4 years for an overall VAP diameter of 37 mm in the first patient, and 3 mm at 2 years for an overall VAP diameter of 32 mm in the second patient). No other VAP or branch vessel-related complications were seen. We recorded two unrelated deaths (acute myocardial infarction and stroke, respectively).

Hybrid group (7 cases) (Table V, Table VI) 

Hybrid repair of VAP aneurysm was technically successful in all the patients. The median procedure time was 241 minutes (range, 187 to 465 minutes). A median of 4.7 units of packed red blood cells were transfused for a median blood loss of 480 mL (range, 380 to 2900 mL). All patients were admitted to the intensive care unit where they stayed for a median of 3 days (range, 1 to 27 days). No endograft access-site adjunctive maneuvers or additional intraoperative cuff placement was required.

There were no intraoperative deaths. One perioperative death (14.3%) was recorded due to coagulopathy. Postoperative major morbidity was of 28.6% with one case of transient delayed paraplegia (2 days postoperatively), which completely resolved with institution of spinal cord fluid drainage and one case of transient doubling of the serum creatinine. The mean length of hospital stay was 17 days (range, 13 to 26 days). At a median follow-up of 1.9 years (range, 0-2.2 years) we observed one case of late pancreatitis (46 days postoperatively) which resolved with medical care and one death due to acute visceral grafts thrombosis 78 days postoperatively during a severe episode of heart failure. We did not observe any other related complications or death, VAP aneurysm growth, endoleak, and endograft migration. One patient died 38 months after VAP hybrid repair during an aortic arch ruptured aneurysm emergency open repair.

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Discussion 

The natural history, growth rate, and risk of rupture of VAP aneurysms have never been completely clarified but it may be hypothesized that VAP aneurysms behave as saccular aneurysms which are at high risk of rupture.5, 24 They are usually considered a rare late complication following TAAA open repair, mainly limited to patients with Marfan syndrome or other connective tissue disorders, but their real incidence is likely underestimated. VAP dilatations and aneurysms are not uncommon after atherosclerotic and dissecting TAAA repair, especially when large tube grafts (diameter greater than 28 mm) with a single large VAP also including the left renal artery.25 Furthermore, since Crawford et al5 proposed his ‘inclusion technique' in 1978, survival of patients has considerably improved, especially in “high-volume” centers operating on relatively young patients with the current multimodality approaches of organ protection.26, 27, 28, 29 So long-term complications such as the VAP degeneration after TAAA repair likely will continue to be a common concern.30, 31

The visceral aortic re-grafting for VAP aneurysm with the re-inclusion technique is a demanding procedure. The redo left-sided thoracotomy is well known to be associated with postoperative respiratory failure especially in case of “frozen chest” in which the risk of severe iatrogenic pulmonary injuries and even aborting the procedure is high.32 During TAAA repair, a redo thoracotomy has been shown to be associated with major bleeding, an increased rate of organ failure, longer total aortic clamping time, longer operation time, and reduced long-term survival.33, 34, 35, 36 Furthermore, if extracorporeal circulation is required, pericardial or proximal aortic adhesions may also increase the technical challenges and risk of major bleeding at the site of outflow cannulation, especially if a left atrium, pulmonary vein, or distal aortic arch re-cannulation is required.34 Also, the retroperitoneal re-dissection is often challenging due to the common local severe inflammation making the VAP difficult to re-dissect and increasing the risk of major bleeding.17

Another main challenge in VAP aneurysm re-grafting is related to the poor quality of the VAP wall. We experienced that when a new undersized VAP is recreated after failed VAP, the risk of major bleeding from the anastomosis after aortic declamping is increased, and we believe also the risk of late recurrent VAP aneurysm to be increased so that this practice should be limited to very particular cases. Also, the ostia of the visceral arteries are commonly severely diseased and the common strategy to reduce the size of revised VAP by stitches into the visceral ostia increases the risk of visceral artery dissection. Our case of postoperative anuria that resolved with immediate bilateral renal arteries stenting was likely related to this mechanism which led to renal artery malperfusion. Custom-made or commercially available branched grafts reduce the aortic tissue used for re-grafting by allowing circumferential selective anastomosis to each visceral vessel with smaller stitches. This surgical option may represent an interesting solution to resolve the problem of VAP perioperative bleeding, artery dissection, and of the recurrent revised VAP dilatation.

Although endovascular branch vessel technology makes pure endovascular TAAA repair technically feasible by preserving visceral end organ perfusion, the use of fenestrated and branched endografts is a complex and time consuming procedure with limited long-term follow-up intervention, currently limited to few institutions.37, 38, 39 Pure endovascular VAP aneurysm repair has been occasionally reported (Table II), but refinement of device design and delivery technique facilitating guide wires engagement and endografting within largely displaced visceral arteries are likely required to make this technology widely available for these kind of lesions.40

Hybrid VAP repair is a more feasible alternative approach and compared to the conventional VAP re-grafting, has several hypothetical advantages. First of all, re-thoracotomy and extensive retroperitoneal redissection to control the previously inserted aortic graft are avoided. Second, the problem of the poor quality of the tissue of the VAP is virtually eliminated because the anastomoses are performed with the visceral arteries 1-3 cm far from the VAP. Moreover, the VAP aneurysms have ideal straight and long “in-graft” proximal and distal necks and in the cases of endografts landed in pre-existing or new aortic tube grafts, endoleak and migration have never been reported.17 However, a significant concern of hybrid approach to VAP aneurysms is renal artery revascularization. The presence of tight adhesion due to the previous aortic surgery and the displacement of visceral arteries due to VAP morphology makes dissection of renal arteries challenging and, in our series, we decided to abort revascularization of one renal artery for this issue.

The avoidance of supraceliac clamping during the hybrid repair and the shortened duration of visceral ischemia compared to the VAP aneurysm regrafting will also potentially improve perioperative hemodynamic stability and reduce hypotension that has recently emerged as an independent risk factor of paraplegia during both endovascular and open thoracic aortic repair.41, 42, 43 The only case of spinal cord ischemia we reported in our series was a delayed transient paraplegia that occurred in 1 patient in the hybrid group in which an intercostal artery patch with a patent intercostal artery was unintentionally partially covered. The delayed symptoms completely resolved with emergent spinal fluid drainage.

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Conclusion 

In our preliminary series of VAP aneurysm hybrid repair, despite the particularly poor condition of the patients we selected, we found encouraging early results with mortality and morbidity rates similar to the conventionally treated patients. However, at mid-term follow-up, new procedure-related complications such as pancreatitis and visceral graft thrombosis were observed. Larger series and longer follow-ups are required in order to establish if ongoing improvements in endovascular techniques and rapidly accumulating experience with hybrid procedures will change our approach to VAP aneurysm repair.

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Author contributions 


Conception and design: YT, LB, RC

Analysis and interpretation: YT

Data collection: YT, LB, RC

Writing the article: YT

Critical revision of the article: YT, LB, EM, GM, RC

Final approval of the article: YT, LB, EM, GM, RC

Statistical analysis: Not applicable

Obtained funding: Not applicable

Overall responsibility: YT, LB, EM, GM, RC

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 Competition of interest: none.

 CME article

PII: S0741-5214(08)00928-2

doi:10.1016/j.jvs.2008.05.079

Journal of Vascular Surgery
Volume 48, Issue 5 , Pages 1083-1091, November 2008

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