Search

The aim of this study was to describe the technique and report our single center experience of abdominal aortic aneurysm (AAA) open surgical repair over the last 17 years. From 1993 to 2010, a total of 4347 open surgical procedures for repair of AAA were performed in our center. The details of 3857 (88.7%) patients undergoing infrarenal AAA open repair were analyzed; mean age at the time of surgery was 71.8 years ranging from 58 to 89 years. Among all repairs, 23.7% (914) were performed in women and 24.3% (937) in octogenarians; 3587 (93.0%) procedures were performed for degenerative aneurysms, 146 (3.8%) for inflammatory aneurysms, 100 (2.6%) for dissecting aneurysms, and 19 (0.5%) for other pattern of disease. In 162 cases (4.2%) surgery was performed for ruptured aneurysm. In most cases (N.=2596; 67.3%) infrarenal AAA open repair was performed by means of aorto-aortic bypass using a tube graft. A total of 1261 patients were treated using a bifurcated graft: 417 (33.1%) aorto-iliac bypasses, 530 (42.0%) aorto-femoral bypasses and 314 (24.9%) aorto-iliac-femoral bypasses were performed. In elective aorto-aortic bypass, mean aortic clamping time was 21.3+6.7 minutes. The average duration of the procedure was 126+84 minutes (range, 42-410 minutes). Mean intraoperative bleeding was 803.4+422.7 mL (range 250-3,100). Overall intraoperative mortality was 0.2%. Intraoperative mesenteric ischemia was observed in 3% of cases, all treated with inferior mesenteric artery reimplantation. The rate of intraoperative lower limbs ischemia was 2.2%. One intraoperative acute type A aortic dissection occurred. The overall 30-day mortality was 0.6%. Permanent renal function impairment occurred in 4.3% of cases. The rate of pulmonary complications was 9.8%. Other complications were myocardial infarction, congestive heart failure, late ischemic colitis, late leg ischemia, wound infection, urinary tract infection, and sepsis. Although endovascular techniques have emerged as a less invasive alternative to open repair, short- and long-term outcomes associated to the surgery of infrarenal AAAs remain satisfactory for a large range of patients. "\"The aim of this study was to describe the technique and report our single center experience of abdominal aortic aneurysm (AAA) open surgical repair over the last 17 years. From 1993 to 2010, a total of 4347 open surgical procedures for repair of AAA were performed in our center. The details of 3857 (88.7%) patients undergoing infrarenal AAA open repair were analyzed; mean age at the time of surgery was 71.8 years ranging from 58 to 89 years. Among all repairs, 23.7% (914) were performed in women and 24.3% (937) in octogenarians; 3587 (93.0%) procedures were performed for degenerative aneurysms, 146 (3.8%) for inflammatory aneurysms, 100 (2.6%) for dissecting aneurysms, and 19 (0.5%) for other pattern of disease. In 162 cases (4.2%) surgery was performed for ruptured aneurysm. In most cases (N.=2596; 67.3%) infrarenal AAA open repair was performed by means of aorto-aortic bypass using a tube graft. A total of 1261 patients were treated using a bifurcated graft: 417 (33-1%) aorto-iliac bypasses, 530 (42.0%) aorto-femoral bypasses and 314 (24.9%) aorto-iliac-femoral bypasses were performed. In elective aorto-aortic bypass, mean aortic clamping time was 21.3+6.7 minutes. The average duration of the procedure was 126+84 minutes (range, 42-410 minutes). Mean intraoperative bleeding was 803.4+422.7 mL (range 250-3,100). Overall intraoperative mortality was 0.2%. Intraoperative mesenteric ischemia was observed in 3% of cases, all treated with inferior mesenteric artery reimplantation. The rate of intraoperative lower limbs ischemia was 2.2%. One intraoperative acute type A aortic dissection occurred. The overall 30-day mortality was 0.6%. Permanent renal function impairment occurred in 4.3% of cases. The rate of pulmonary complications was 9-8%. Other complications were myocardial infarction, congestive heart failure, late ischemic colitis, late leg ischemia, wound infection, urinary tract infection, and sepsis. Although endovascular techniques have emerged as a less invasive alter-native to open repair, short- and long-term outcomes associated to the surgery of infrarenal AAAs remain satisfactory for a large range of patients.\""

Background: Thoracoabdominal aortic aneurysm (TAAA) hybrid repair consists of aortic visceral branch rerouting followed by TAAA endograft exclusion. This technique has been shown to represent a technically feasible strategy in selected patients. Methods: We analyzed 52 high-risk patients who underwent hybrid TAAA repair between 2001 and 2012 in our centre with a variety of visceral rerouting configurations and of commercially available thoracic endografts. Thirty-seven simultaneous (71.2%) and 15 staged procedures (21.8%) were performed with a four-vessel revascularization in 18 cases (34.6%), a three-vessel revascularization in 11 cases (21.2%) and a two-vessel revascularization in 23 cases (44.2%). Results: No intraoperative deaths were observed. We recorded a perioperative mortality rate of 13.5% (n=7), including deaths from multiorgan failure (n=2), myocardial infarction (n=2), coagulopathy (n=1), pancreatitis (n=1) and bowel infarction (n=1). Perioperative morbidity rate was 28.8% (n=15), including 2 cases of transient paraparesis and 1 case of permanent paraplegia. Renal failure (n=5), pancreatitis (n=3), respiratory failure (n=3) and dysphagia (n=1) were also observed. At median follow-up of 23.9 months procedure-related mortality rate was 9.6%: two patients died from visceral graft occlusion and three from aortic rupture. There were three endoleaks and one endograft migration, none of which resulted in death. Five patients (9.6%) died as a consequence of unrelated events. Conclusions: Typical complications of conventional TAAA open surgery have not been eliminated by hybrid repair, and significant mortality and morbidity rates have been recorded. Fate of visceral bypasses and incidence of endoleak and other endograft-related complications needs to be carefully assessed. Hybrid TAAA repair should currently be limited to high-risk surgical patients with unfit anatomy for endovascular repair.

Background Despite technical and technological improvements, open repair of aortic arch pathologies is still associated with high mortality and morbidity rates, mainly related to deep hypothermic circulatory arrest and cerebral ischemia. Patients ineligible for traditional open surgery might benefit from a hybrid approach, consisting of aortic arch debranching with rerouting of the supra-aortic trunks and endograft exclusion of the pathological portion of the aortic arch. We report our experience with aortic arch aneurysm hybrid repair. Patients and Methods Between 1998 and 2012, 465 patients underwent TEVAR for thoracic aortic pathologies in our Center. Among this group, 151 patients with aortic arch aneurysm were categorized according to the Ishimaru classification and treated by means of hybrid repair. Most of these patients had been refused by cardiac surgeons as considered “high-risk” for severe comorbidities. For zone 0, the operation was performed through median sternotomy. The ascending aorta was side-clamped and a “Y” graft was tailored for the making of an ascending aorta-innominate artery-left common carotid artery bypass. For zone 1, a carotid-to-carotid or a carotid-to-carotid-to-left subclavian bypass was performed through bilateral cervical access. The absolute indications for left subclavian artery (LSA) revascularization in zones 0 and 1 aneurysms at our Institution were (1) coronary circulation supplied by the LSA through the left internal mammary, (2) inadequate contralateral vertebral artery, (3) young patients, (4) left-handed professionals, and (5) high risk for spinal cord ischemia. For zone 2 patients treated early in our experience, the LSA was revascularized only in selected cases; in our more recent cases, LSA revascularization has been performed routinely, reserving coverage without revascularization to urgent cases. After the surgical stage a commercially available endograft was deployed in the pathological portion of the aortic arch. The preferred timing of procedure was simultaneous. Patients were evaluated in follow-up with chest radiography and contrast CT scans at 1, 6, and 12 months and yearly thereafter. Angiograms were obtained in selected cases (i.e., endoleaks). Clinical follow-up was also performed at regular 6-month intervals. Results One hundred twenty-five atherosclerotic and 26 dissecting aneurysms, were categorized according to Ishimaru’s classification as 35 zones 0, 37 zones 1, and 79 zones 2. Thirty-day mortality in zone 0 was 11.4% (n=4) due to intraoperative stroke in 3 cases and retrograde dissection in 1. Thirty-day mortality was 2.7% (n=1) and 2.5% (n=2) in zone 1 and 2, respectively. The overall rate of type I endoleak was 7.3%. Two zone 2 patients (2.5%) developed spinal cord ischemia. At follow-up (mean 24.5±18 months) two patients treated for zone 1 aneurysm died because of aneurysm rupture. Three patients died for unrelated events. Four cases of acute retrograde type A dissection were observed during follow-up: 3 cases were successfully treated with ascending aorta and arch open repair under hypothermic circulatory arrest, one patient died for ascending aortic rupture before the scheduled operation. Conclusions In selected patients with arch disease, early and midterm outcomes of hybrid repair are promising although mortality, especially in zone 0, is still significant and the risk of retrograde dissection has to be assessed. These results may have practical implications for the ongoing evolution of the hybrid repair as well as for patients fit for traditional surgery.

The search for less invasive therapeutic approaches to thoracoabdominal aortic aneurysms (TAAAs) brought endovascular procedures to establish themselves as alternatives to open surgery in high-risk patients. Aim of this study is to illustrate the hybrid - open and endovascular - treatment of dissecting and non-dissecting TAAAs, and to analyze short and midterm results at our Center. We analyzed 41 high-risk patients who underwent hybrid TAAA repair (dissecting TAAA in 17% of cases) with a variety of visceral rerouting configuration and of commercially available thoracic endografts. Thirty-one simultaneous (76%) and 10 staged procedures (24%) were performed with a four-vessel revascularization in 13 cases (32%), a three-vessel in 9 (22%) and a two-vessel in 19 (46%). No intraoperative deaths were observed in our series, with a technical success in endovascular TAAA repair of 100%. Two patients died in the intersurgical time. A perioperative mortality of 13% and a perioperative morbidity of 32% were recorded, including one case (2.4%) of permanent paraplegia. At a median follow-up of 23.3 months, we observed a visceral graft occlusion rate of 6%, three type II endoleak and one endograft migration. Six patients died for unrelated events. Typical complications of conventional TAAA open surgery have been not eliminated by hybrid repair and still significant mortality and morbidity have been reported. Dissecting etiology did not negatively affect the outcome of hybrid repair in our experience. Fate of visceral bypasses and incidence of endoleak and other endograft-related complications need to be carefully assessed.. Hybrid TAAA repair should nowadays be limited as alternative to simple observation in patients unfit for the conventional open repair. The search for less invasive therapeutic approaches to thoracoabdominal aortic aneurysms (TAAAs) brought endovascular procedures to establish themselves as alternatives to open surgery in high-risk patients. Aim of this study is to illustrate the hybrid - open and endovascular - treatment of dissecting and non-dissecting TAAAs, and to analyze short and midterm results at our Center. We analyzed 41 high-risk patients who underwent hybrid TAAA repair (dissecting TAAA in 17% of cases) with a variety of visceral rerouting configuration and of commercially available thoracic endografts. Thirty-one simultaneous (76%) and 10 staged procedures (24%) were performed with a four-vessel revascularization in 13 cases (32%), a three-vessel in 9 (22%) and a two-vessel in 19 (46%). No intraoperative deaths were observed in our series, with a technical success in endovascular TAAA repair of 100%. Two patients died in the intersurgical time. A perioperative mortality of 13% and a perioperative morbidity of 32% were recorded, including one case (2.4%) of permanent paraplegia. At a median follow-up of 23.3 months, we observed a visceral graft occlusion rate of 6%, three type II endoleak and one endograft migration. Six patients died for unrelated events. Typical complications of conventional TAAA open surgery have been not eliminated by hybrid repair and still significant mortality and morbidity have been reported. Dissecting etiology did not negatively affect the outcome of hybrid repair in our experience. Fate of visceral bypasses and incidence of endoleak and other endograft-related complications need to be carefully assessed.. Hybrid TAAA repair should nowadays be limited as alternative to simple observation in patients unfit for the conventional open repair. OI tshomba, yamume/0000-0001-8316-4702; Bertoglio, Luca/0000-0001-6871-2176 The search for less invasive therapeutic approaches to thoracoabdominal aortic aneurysms (TAAAs) brought endovascular procedures to establish themselves as alternatives to open surgery in high-risk patients. Aim of this study is to illustrate the hybrid - open and endovascular - treatment of dissecting and non-dissecting TAAAs, and to analyze short and midterm results at our Center. We analyzed 41 high-risk patients who underwent hybrid TAAA repair (dissecting TAAA in 17% of cases) with a variety of visceral rerouting configuration and of commercially available thoracic endografts. Thirty-one simultaneous (76%) and 10 staged procedures (24%) were performed with a four-vessel revascularization in 13 cases (32%), a three-vessel in 9 (22%) and a two-vessel in 19 (46%). No intraoperative deaths were observed in our series, with a technical success in endovascular TAAA repair of 100%. Two patients died in the intersurgical time. A perioperative mortality of 13% and a perioperative morbidity of 32% were recorded, including one case (2.4%) of permanent paraplegia. At a median follow-up of 23.3 months, we observed a visceral graft occlusion rate of 6%, three type II endoleak and one endograft migration. Six patients died for unrelated events. Typical complications of conventional TAAA open surgery have been not eliminated by hybrid repair and still significant mortality and morbidity have been reported. Dissecting etiology did not negatively affect the outcome of hybrid repair in our experience. Fate of visceral bypasses and incidence of endoleak and other endograft-related complications need to be carefully assessed. Hybrid TAAA repair should nowadays be limited as alternative to simple observation in patients unfit for the conventional open repair.

Aim. The aim of this study was to report our experience of TAAA open repair over the last 5 years with a routinary multimodal approach used to maximize organ protection. Methods. Since 1991, a total of 388 open surgical repair of the thoracoabdominal aorta were performed in our Center. The details of 254 consecutive patients (176 males; mean age 66.4 years, range 15-82) operated between 2006 and 2011 were analyzed. Within this cohort, there were 52 Crawford extent type I aneurysms, 59 type II, 80 type III and 63 type IV. Cerebrospinal fluid drainage (CSFD), left heart bypass (LHBP), selective visceral perfusion and critical intercostal arteries reattachment have been used in case of extensive aneurysm repair. Results. CSFD and LHBP were employed in 97.3% and 94.6% of patients with type I or II aneurysms and in 71.3% and 53.6% of patients with type III or IV aneurysms, respectively. One hundred fifty-two patients (59.8%) had intercostal artery reattachment. Thirty-day mortality rate was 10.2%. Renal failure necessitating hemodialysis at discharge developed in 13 patients (5.1%); three patients (1.2%) presented mesenteric ischemia. Cardiac complications occurred in 22 patients (8.7%). Overall neurological complications rate was 8.2%, including 9 (3.5%) cases of transient paraparesis/paraplegia and 12 (4.7%) cases of permanent paraplegia. Conclusion. Despite evolving adjunctive strategies, morbidity and mortality rates following TAAA surgical repair are not negligible. Surgical TAAA repair is to be performed in high-volume Centers by experienced surgeons. Conventional treatment is the gold standard for patients fit for open surgery; results of hybrid and endovascular treatment of TAAA are to be compared to it.

Aim. In the last two decades, results of endovascular aortic repair (EVAR) for the treatment of infrarenal abdominal aortic aneurysms (AAAs) have significantly improved thanks to the evolution of stent-grafts and endovascular delivery systems. However, further development is still needed to reduce the incidence of complications and secondary reinterventions. We present our initial experience with the Treovance abdominal aortic stent-graft (Bolton Medical, Barcelona, Spain), a new-generation trimodular endovascular device, developed to increase flexibility, lower profile, improve deployment and sealing mechanisms. Methods. We treated 8 patients with anatomically suitable non-ruptured AAA. Results. Primary technical success was obtained in all patients, and no 30-day device-related complications nor deaths were reported. One patient experienced graft limb occlusion at 3 months, and underwent surgical conversion. At 1-year follow-up (completed in 6 patients), no device-related complications nor type I or III endoleak were observed. Conclusion. Initial personal experience with the Treovance abdominal stent-graft was satisfactory with regard to technical success and short-term clinical results. This new-generation endovascular device performed well even in angulated or heavily calcified anatomies. OI tshomba, yamume/0000-0001-8316-4702

"Aim. In the last decade, several "off-label" indications for thoracic endovascular aortic repair (TEVAR), have modified the way that most surgeons approach thoracic aortic disease. Among these is the so-called hybrid (open and endo) repair. Methods. From 1998 through 2012, 231 aortic arch repairs and 467 thoraco-abdominal aortic repairs were performed at our centre. From 2001 we categorized, according to Ishimaru's classification, a total of 167 aortic arch aneurysms (66.5% atherosclerotic and 33.5% dissecting) as zone 0 (48), zone 1 (37), or zone 2 (82) and, according to Crawford's classification, a total of 52 thoraco-abdominal aortic aneurysms (57% atherosclerotic and 43% dissecting) as type I (20), type II (six), type III (10), type IV (six) or aneurysms of the visceral aortic patch (10) who underwent hybrid repair by means of aortic arch \/ visceral aortic debranching followed by TEVAR. The most of these patients were selected for hybrid repair having increased surgical risk defined as age > 75 yrs, and\/or EF < 20%, and\/or FEV1

Introduction: Current strategies for repair of descending thoracic aortic aneurysms consist of open repair with surgical graft replacement or thoracic endovascular aortic repair. We review and update our overall experience in aortic thoracic diseases and specifically analyzed our outcomes with thoracic endovascular aortic repair in patients with descending thoracic aortic aneurysms. Methods: From 1993 to present a total of 1144 patients were treated in our Center for pathology involving the thoracic aorta. Since 1998, 322 patients underwent thoracic endovascular aortic repair, and among this group, in 188 cases the descending aorta was involved. In 74% of patients treated for a descending thoracic aortic lesion, a degenerative aneurysm was observed. Results: In patients with descending thoracic aortic aneurysms receiving thoracic endovascular aortic repair, our technical success rate, i.e. deployment of endograft with complete exclusion of the lesion/minimal endoleak, was 99.5% (one case required emergent open conversion) with a perioperative mortality of 2.6% (five patients). The rate of spinal cord ischemia, manifesting either as paraplegia or paraparesis, was 4.7%. Delayed onset spinal cord ischemia ameliorated with adequate arterial pressure and cerebrospinal fluid drainage. Conclusions: Our experience of selected patients undergoing thoracic endovascular aortic repair of descending thoracic aorta aneurysms is satisfactory with very low mortality and morbidity. A large use of thoracic endovascular aortic repair is foreseen in the next future.

Introduction Current strategies for operative treatment of a thoracic aortic aneurysm consist of open repair with surgical graft replacement or endovascular exclusion. To reduce mortality and morbidity of open repair, a multimodal approach has gradually evolved by maximizing organ protection. Methods On a total of 1108 patients treated in our Center from 1993 for pathology involving the thoracic aorta, we reviewed the prospectively collected data of 194 consecutive patients who underwent open thoracic aortic aneurysm repair, 104 (54%) for degenerative aneurysms, 65 (34%) for dissections, 25 (12%) for other pattern of disease. Left Heart Bypass was used in 82% of cases, clamp and sew technique in 16%, hypotermic circulatory arrest in 2%. Results Overall perioperative mortality was 4.1%. The rate of pulmonary complications was 8.8%. The rate of cardiac complications, i.e. new onset myocardial necrosis demonstrated by positive blood tests, was 6.2%. The rate of renal complications was 7.2%. Cerebrovascular accident, defined as a new neurologic deficit lasting more than 24 hours confirmed by imaging, occurred in 2.0% of patients. The rate of spinal cord ischemia, manifesting either as paraplegia or paraparesis, was 4.6%. Conclusions Mortality and morbidity rates of open thoracic aortic aneurysm repair are currently satisfactory especially in fit patients. In order to define surgical indications and the role of endovascular repair, consideration of age of the patient, comorbidity, symptoms, life expectancy, likely quality of life (if asymptomatic), aortic diameter, aneurysm morphology, aneurysm extent, suitability of landing zones, and operator experience are all distinctly relevant.