Surgical correction of failed thoracic endovascular aortic repair

• Published in: Journal of vascular surgery Vol. 47; no. 6; pp. 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: Journal Article
• Language: English
• Published: New York, NY Elsevier Inc 01.06.2008; Elsevier
• 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; Aorta; Cardiovascular disease; Endovascular route; Surgery
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2008.01.003

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, neuromonitoring, and adjunctive modalities to provide organ protection. We recommend that these procedures be performed in centers with experience and the infrastructure to offer these protective measures.