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Ann Thorac Surg 1998;66:19-24
© 1998 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Endovascular stent graft repair for aneurysms on the descending thoracic aorta

^a Department of Cardio-Thoracic Surgery, University of Vienna, Vienna, Austria
^b Department of Medicine, University of Vienna, Vienna, Austria
^c Department of Interventional Radiology, University of Vienna, Vienna, Austria

Address reprint requests to Dr Ehrlich, Department of Cardio-Thoracic Surgery, Mount Sinai Medical Center, One Gustave Levy Place, Box 1028, New York, NY 10029
e-mail: (mehrl98000{at}aol.com)

Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. The traditional treatment of aneurysms of the descending thoracic aorta includes posterolateral thoracotomy and aortic replacement with a prosthetic graft. In this study, we report our experiences and results in endovascular stent graft placement as an alternative to surgical repair.

Methods. Between January 1989 and July 1997, a total of 68 patients (24 women) underwent replacement of the thoracic aorta. Mean age at operation was 51 years. Fifty-eight patients underwent conventional surgical treatment. All of these patients were suitable candidates for endovascular stenting; however, no stent graft material was available at the time of operation. Ten patients (1 chronic dissection, 9 atherosclerotic aneurysm) received in the past 8 months the first commercially manufactured endovascular stent graft. The mean diameter of the aneurysms in this group was 7 cm (range, 6 to 8 cm). Two stent patients were operated on using only spinal cord analgesia. All stent grafts were custom designed for each of the 10 patients.

Results. The 30-day mortality in the conventional group was 31% versus 10% in the stent group. Mean length of intervention was 320 minutes in the conventional group versus 150 minutes in the endovascular group. Spinal cord injury occurred in 5 patients (12%) in the surgical group, whereas none of the stented patients developed any neurologic sequelae. Mean intensive care unit stay was 13 days, followed by a mean of 10 days on a ward in the first group compared to 4 days in the intensive care unit and 6 days on the ward in the stent group. One stent was required in 2 patients, two stents were required in 3 patients, and four stents were deployed in 5 patients of our series. Five patients required transposition of the left subclavian artery to achieve a sufficient neck for the proximal placement of the stent. There was complete thrombosis of the thoracic aortic aneurysm surrounding the stent graft in 8 patients (80%). Two patients required restenting as a result of leakage (20%). Stent graft placing was performed through the femoral artery in 8 patients, whereas access was only achieved through the abdominal aorta in 2 patients.

Conclusions. These preliminary results demonstrate that endovascular stent graft replacement might be a promising, cheaper, and safe alternative method in selected patients with descending thoracic aneurysms.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Descending thoracic aortic aneurysms still represent a potentially life-threatening situation. Resection and graft replacement of the pathologically altered aorta is the preferred method of treatment [1–6]. Although great strides have been achieved during the past decades in the management of patients with thoracic aortic aneurysms by new surgical techniques, intraoperative monitoring of somatosensory-evoked potentials, and spinal cord fluid drainage, postoperative morbidity and mortality rates still remain high [7–10]. The afflicted population is usually of older age and present at time of operation with various comorbidities such as hypertension, obstructive pulmonary disease, coronary heart disease, all of which have significant impact on the surgical outcome. Postoperative complications, such as paraplegia, renal and pulmonary insufficiency, contribute to prolonged hospital stays and higher medical cost.

Since the first successful endovascular stent graft placement in an abdominal aortic aneurysm [11], various groups have started to investigate the feasibility of thoracic aortic aneurysmal repair with transluminally placed stent grafts [12, 13]. This study was undertaken to report our initial clinical experience with the repair of descending thoracic aortic aneurysms with a commercially available endovascular stent graft and compare these results with a conventionally treated group.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Patients
Between January 1989 and July 1997, a total of 68 patients underwent replacement of the descending thoracic aorta at the University of Vienna Medical Center. Patients were grouped into two categories based on perioperative management. Group 1 consisted of all patients operated on by conventional surgical treatment. All of the 58 patients in this group were suitable candidates for endovascular stenting; however, no stent graft material was available at the time of operation. Group 2 comprised 10 patients who received in the past 8 months a commercially manufactured endovascular stent-graft. Table 1 summarizes important preoperative characteristics of both groups. Hypertension was the most common preoperative medical disorder with an incidence of 73% in all patients, followed by a history of smoking (66%) and coronary heart disease (33%).

All stent graft patients gave their informed consent in conformance with the protocols approved by the institutional review board of Vienna Hospital. They underwent chest radiography, spiral computed tomographic scanning, and arteriography before the procedure and at intervals after the procedure. Patients eligible for receiving a stent graft had to have at least a 1- to 2-cm long proximal and distal neck. Chronic aortic dissection was not an exclusion criteria in our stent series; however, this procedure was only performed when the false lumen was already completely thrombosed. Acute aortic dissection was a contraindication for stent graft deployment.

The mean stent graft diameter was 36 mm (range, 32 to 40 mm), and the mean length of the device was 104 mm (range, 100 to 120 mm). The preoperative characteristics of the 10 stented patients are shown in Table 2.

View larger version (70K): [in this window] [in a new window]   Fig 1. Stent graft material used in our series.

View larger version (68K): [in this window] [in a new window]   Fig 2. Proximal stent graft deployment at the proximal descending aorta.

View larger version (77K): [in this window] [in a new window]   Fig 3. Typical stent graft after final accomplishment of the procedure.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
The 30-day mortality in the conventional group was 31% versus 10% in the stent group. Table 3 summarizes important postoperative parameters between both groups. Patients treated conventionally by left thoracotomy had longer intensive care unit as well as hospital stays. The duration of the procedure was much shorter in the stented group and there were no neurologic complications associated with endovascular stent graft placement. However, all of our 10 patients in the stent group had proximal descending aneurysms where covering of and as a consequence sacrifice of intercostal arteries with the stent graft is not of so much importance as in distal descending thoracic aortic repair. Three of the 5 patients with spinal complications in the conventional group had extension of the aneurysm into the distal descending aorta with reattachment of intercostal arteries at a level of T-11 and T-12. Four of these 5 patients have been operated with the use of profound hypothermic circulatory arrest and 1 patient had been operated with left heart bypass.

View larger version (146K): [in this window] [in a new window]   Fig 4. Preoperative aortogram from a patient with a descending thoracic and left subclavian aneurysm.

View larger version (156K): [in this window] [in a new window]   Fig 5. Postoperative aortogram from the same patient after transposition of the left subclavian artery and stent graft placement.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
Since 1969, when Dotter [14] inserted stainless steel coils as a vascular stent in canine popliteal arteries, transluminal placement of endovascular stent grafts has been used as a treatment of abdominal aortic aneurysms as well as recently for descending thoracic aneurysms or dissections [12, 15]. Although long-term follow-up is limited at present, early experimental as well as clinical results have been promising [16, 17]. The aim of this minimally invasive technique is to achieve aneurysmal exclusion, to suppress the pressure stress on the aneurysmal sac, and to reduce mortality and morbidity rates compared with those associated with standard surgical treatment. Stent graft placement might be of particular benefit, especially in high-risk patients with descending thoracic aneurysms, because this procedure is easier and less invasive than the conventional surgical approach. It enables avoidance of left thoracotomy with the consequences of lung manipulation and compression as well as phrenic and recurrent nerve injury resulting in prolonged postoperative respiratory support. Coagulopathies associated with deep hypothermia and circulatory arrest can also be avoided by this technique.

If a patient is considered to be a candidate for endovascular stent graft placement, a number of anatomic as well as technical matters have to be taken into account. It is imperative to perform preoperative imaging studies to gain information about the precise vascular access and aneurysmal size. Longitudinal and transverse diameter of the aneurysm provide information that are needed to design a precise stent prosthesis for each individual patient. Furthermore, an aortogram should be performed before the procedure to determine the anatomic relationship to major aortic branches, such as the left subclavian artery or the celiac axis.

The perioperative mortality rate could be decreased in this series from 31% in the conventional-treated group to 10% in the endovascular stent graft group, but did not reach statistical significance owing to the small number of patients in the latter group. These results are similar to a recent stent study carried out by Mitchell and colleagues [12] from Stanford where the mortality rate in 44 patients was 7%. Furthermore, the majority of our patients who received an endovascular stent graft were considered poor candidates for conventional open repair because of various comorbidities such as previous myocardial infarction, hypertension, and coronary heart disease.

The incidence of paraplegia in descending thoracic aneurysms is reported from 0 to 18% [10, 18, 19]. There was no instance of paraplegia in our stent-treated patients. Although there is no opportunity to reimplant intercostal arteries with this new technique, most of these intercostal branches are usually thrombosed in atherosclerotic aneurysms at the time of intervention. It is unknown at this point which effect endoluminal grafting will have on spinal cord injury. However, aortic cross-clamping for a longer period with the consequences of spinal cord hypoperfusion can be avoided by this new procedure.

At this time, there are still pitfalls that have to be addressed with this surgical approach. The first concerns the device itself. In its present state, graft deployment is still relatively inexact and precise stent placement is sometimes hard to achieve. Miniaturization of the stent device has to be developed to prevent complications such as vascular trauma during introduction.

Another problem concerns perigraft leakage. This complication occurred in our study in 2 patients. The main cause of this problem was the limited anatomic suitability in 1 patient, which made it difficult to achieve a precise placement of the stent graft as well as distal migration of one stent after deployment in the second patient. Although it remains uncertain at this stage of knowledge whether leakage into the aneurysmal sack may lead to late aortic rupture, both patients with stent graft leakage had a second procedure right after the first intervention to obliterate the leakage spot.

It is our belief that an absolute contraindication for endovascular stent graft placement is a severe tortuosity of the descending thoracic aorta or iliac arteries where introduction of the stent device to the desired location might be associated with a risk of aortic or arterial rupture. Furthermore, patients with acute aortic dissections were excluded for stent graft placement in our study. Although 1 patient with a chronic dissection, where the false lumen was already thrombosed, received a stent graft, it remains uncertain whether this technique is suitable for this specific patient cohort. Furthermore, should this procedure be limited to patients with a sufficient distal and proximal neck and the absence of nearby important side branches. Therefore, transposition of the left subclavian artery was performed in 5 patients.

Two patients, where stent graft insertion was performed through the femoral artery, were operated on by the use of spinal cord analgesia. It is our belief, however, that this anesthetic technique should be limited to those patients, where access into the vascular system is planned from the groin. Manipulation of the iliac artery or abdominal aorta for graft insertion from a retroperitoneal approach might be associated with severe pain and should be performed only by general anesthesia.

Although our results with stent graft placement on the descending thoracic aorta demonstrated that this method is feasible, there remain questions and long-term considerations. Short- and long-term biologic interactions between prosthesis and aortic wall need further investigation.

In summary, our results demonstrate that insertion of an endovascular stent graft into the descending aorta is feasible, and that intraluminal aneurysm exclusion can be achieved acutely. Further studies need to be performed to determine the long-term effectiveness. This technique may become applicable for treating descending aortic aneurysm, especially in high-risk patients, as this approach is less invasive than the current conventional surgical methods.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Marek Ehrlich Michael Grimm Ernst Wolner Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ehrlich, M. Articles by Havel, M. Search for Related Content PubMed PubMed Citation Articles by Ehrlich, M. Articles by Havel, M.