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Type II TAAA repair: aortic graft replacement and visceral vessels reattachment by means of Carrel patch (left) and Coselli thoracoabdominal graft (above).
Source publication
Conventional treatment of thoracoabdominal aortic aneurysms (TAAAs) consists of graft replacement with reattachment of the main aortic branches. Over the past 20 years a multimodal approach has gradually evolved to reduce the trauma of surgery by maximizing organ protection, allowing experienced surgical Centers to have better outcomes than previou...
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A ruptured descending thoracic aortic aneurysm (rDTAA) is a life-threatening condition associated with high morbidity and mortality. Endovascular treatment for rDTAA promotes effective aneurysm exclusion with a minimally invasive approach. The authors report a case of a 76-year-old man with hemodynamically unstable 9-cm-diameter rDTAA treated with...
Citations
... It worth noting that the inflow site of grafts for visceral organs should be a healthy artery, usually the infrarenal aorta or the iliac arteries. 18 Herein, we obtained a 20-day post-operative anatomic data from a clinically indicated CTA of a 62-year-old male patient who underwent a RVR surgery at distal abdominal artery (AA), the infrarenal aorta was chosen as the inflow site for RVR and the anastomotic angle was approximately 60 °, as shown in Figure 1 A, using a dual source computed tomography system (Definition Flash, Siemens Healthcare, Forchheim, Germany). The three-dimensional anatomical model was constructed using a commercially available software Mimics (version 14.0, Materialise, Plymouth, MI). ...
... According to the surgical guidelines, the anastomotic angle of bypass needs to have the feasibility of clinical application. 18 An extremely small anastomotic angle may be too difficult to suture for surgeons while an extremely large anastomotic angle can increase the resistance of the grafts, and further lead to downstream insufficient perfusion. 11 In addition, it was reported that reasonable anastomotic angles range from 20 to 90 °. 19 , 20 Accordingly, two another anastomotic angles, namely 45 °and 90 °were chosen as the manipulated RVR models for the comparative study, 20 , 21 as shown in Figure 1 B-D. ...
Introuction:
Hemodynamic effects on the retrograde visceral reconstruction (RVR) for TAAA treatment by anastomotic angle remains unclear. This study aims to qualitatively and quantitatively investigate the effects of different anastomotic angles on hemodynamics and patency.
Methods:
Three RVR models with 45-degree, 60-degree and 90-degree anastomotic angles were reconstructed respectively by manipulating apostoperative patient-specific model. The manipulated models of the RVRs were numerically simulated and analyzed in terms of hemodynamics including theinstant and cumulative patency, flow pattern and indicators based on wall shear stress (WSS).
Results:
Although a smaller anastomotic angle may decrease the patency rate of common iliac arteries, it can improve the visceral perfusion during a cardiac cycle. More importantly, RVR with the smallest anastomotic angle experienced a minimal low time-averaged wall shear stress(TAWSS), high oscillatory shear index(OSI) and relative residence time(RRT) in the anastomosis region, whereas the largest anastomotic angle can introduce more unfavorable WSS in the graft trunk. Furthermore, a spiral flow pattern was observed in the proximal graft trunk of all three models, where no high-risk shear distribution was detected in this region.
Conclusion:
A smaller anastomotic angle may have more benefits of hemodynamic environment in RVR, especially the wall shear stress (WSS) distribution and flow pattern in the graft trunk. We may also suggest that additional stents or an extended cuff for the graft can be used to induce spiral flow intentionally, which can further improve local hemodynamic environment and long-term prognosis.
... renal arteries, celiac trunk, carotid artery and subclavian artery) a hybrid technique could be employed. During a hybrid repair, these vital branches are first passed surgically to a proximal or distal healthy aortic or iliac segment, and then an endograft is deployed [66,67]. ...
The aorta is the largest artery in the body and can have aneurysms, which are focal expansions of the vessel wall that can occur anywhere throughout the artery. These can be classified as thoracic, abdominal or thoracoabdominal aneurysms and can be caused by several etiologies, including degenerative, infectious, and genetic causes. Most aortic aneurysms are asymptomatic and are detected incidentally while looking for other primary diseases with a physical exam finding of a pulsatile mass, or with imaging such as ultrasound, computed tomography, x-rays, or magnetic resonance imaging. When symptoms are present, they are often nonspecific and occur due to inflammation, rapid expansion, compression/erosion of the aneurysm into surrounding structures, or rupture. Uncontrolled aortic aneurysms can lead to fatal outcomes, thus making proper management essential. Management can range from medical treatment to surgical repair based on location, size, rate of expansion, and presence of symptoms.
... Abdominal aortic aneurysm (AAA) is a potentionally life-threatening condition, and without repair it is fatal. Repair is recommended in aneurysm diameter >5.5cm 1 . Endovascular aneurysm repair (EVAR) of AAA has increased gradually since the early 1990s. ...
Measuring the aneurysm sac’s size is vital in postoperative surveillance following endovascular treatment of aortic aneurysms. A three-dimensional ultrasound technique may enable accurate volume measurements. However, there is no validation of any commercially available electro-mechanical 3D ultrasound equipment or of the software used when measuring the volume of the aortic aneurysm sac. This investigation used a phantom model to study a three-dimensional ultrasound technique on aortic aneurysm sac volume measurements. High volume measurement accuracy indicates that this method may be useful for postoperative surveillance following endovascular aortic aneurysm operations. These results must be confirmed in clinical studies.
... [133][134][135][136] The use of extracorporeal left heart bypass or veno-venous bypass is now considered standard of care in several centers for thoracic aortic surgery or complex liver surgery. [137][138][139] Additionally, there are some major oncological surgical procedures involving the inferior vena cava and right atrium (usually in the setting of renal or liver tumor) that currently require CPB support. [140][141][142][143][144][145][146][147][148] Considering the experience in the lung transplantation surgery, a lower complications rate might be expected in case of transition from CPB to ECMO in several types of surgery. ...
Extracorporeal membrane oxygenation (ECMO) is used with increasing frequency to treat severe cardiac or respiratory failure as it can provide respiratory only or combined circulatory and respiratory support. Despite efforts aimed at increasing its diffusion however, ECMO is currently reserved, usually as last resort, in very severe cases, which are managed almost exclusively in the intensive care unit (ICU). Recent improvements in both technology and patients' management is leading to constant improvement in patients' outcome, especially in centers with a high caseload volume and after ensuring careful patients' selection. Moreover, since short ECMO runs are associated with limited complications, there are now several potential situations outside the ICU and outside the cardiac surgery setting where ECMO is being (or could be) successfully employed to provide cardio-respiratory support, including: high-risk structural heart interventions, ventricular tachycardia ablation, cesarean section, trauma, and, most interestingly, non-cardiac elective procedures in patients at high risk for perioperative cardiac or respiratory complications. Given the increased availability and the good outcomes of ECMO, when carefully employed, we are thus moving towards a future in which no patient should be denied diagnostic or therapeutic procedure exclusively due to high cardiorespiratory risk.
... The visceral blood perfusion is then maintained by the pump with occlusion / perfusion catheters (9 Fr) selectively inserted into the celiac trunk and the superior mesenteric artery (400 mL / min). Selective perfusion of the renal arteries is performed with a cold crystalloid solution (Ringer 4 ° C + mannitol 18% 70 mL, 6-methylprednisolone 500 mg in 500 mL) [5]. ...
... In 33.1% of cases treated with Carrel patch, the left renal artery was separately repositioned to the graft either directly or by graft interposition. When the relative distance of the visceral arteries would require a large Carrel patch, a branched graft can be used successfully ( Figure 4) [5]. ...
... This prosthesis allows the reinsertion of a single vessel, reducing the risk of recurrent aortic aneurysm of the aortic flap. In our series, the Coselli branched graft was used in 10.5% of the cases [5]. The Vascutek Triplex™ graft is a new vascular prosthesis and consists of three layers: an internal polyester graft, an outer layer of ePTFE and a central layer of elastomeric membrane ( Figure 5). ...
... Surgical treatment of TAAA is still a therapeutic challenge, although at some centers of excellence mortality rates are now acceptable, approaching 5% [2] . The risks involved in the procedure are greater in urgent situations, such as with symptomatic patients, and mortality rates can approach 35% [6] . Currently, branched/fenestrated endoprostheses appear promising for treatment of TAAA, although the long-term complications and mortality rates are not yet negligible [4] . ...
Advent of antiretroviral therapy has increased survival of patients with human immunodeficiency virus (HIV) infections, with the result that some of these patients now develop degenerative diseases, such as atherosclerotic aneurysms. Degenerative thoracoabdominal aortic aneurysm is rare in HIV patients. In this report, a 63-year-old male patient with HIV submitted to open repair of thoracoabdominal aortic aneurysm. The patient did not suffer any type of complication in the perioperative period and remained well in a 28-month follow-up period. In summary, open repair still remains a good alternative for aortic complex aneurysms even in HIV patients.
... In this limited series, renal function appeared to temporarily decrease during the first postoperative days, consistent with our previously published results 10,37 and with the most recent literature data. 12,38 In considering the perioperative peak decrease of GFR, GHVG patients seemed to present a lesser grade of renal dysfunction compared with SRR patients. ...
The aim of this study was to assess the safety and short-term effectiveness of a novel hybrid vascular graft used to address renal revascularization during open thoracoabdominal aortic aneurysm (TAAA) repair, performing a sutureless distal anastomosis.
Between 2012 and 2013, 25 patients (16 men; mean age, 66 ± 8 years) underwent revascularization of one (24 patients) or both (one patient) renal arteries with the Gore Hybrid Vascular Graft (GHVG; W. L. Gore and Associates, Flagstaff, Ariz) during open TAAA repair. Specific indications included remote location of the ostium of the renal artery, severe atherosclerotic wall degeneration, focal dissection, and stenosis. All surviving patients underwent computed tomography angiography and follow-up visit at 1 month. Preoperative characteristics, intraoperative data, and short-term results were compared with those of 49 concurrent TAAA patients operated on within the same period by standard renal revascularization (SRR) techniques.
All GHVG target renal vessels (26 of 26) were successfully revascularized without technical concerns. No significant differences were found between GHVG and SRR groups in preoperative and intraoperative data, except for a relative prevalence of aortic dissection (28% vs 6%; P = .026) and renal artery stenosis (44% vs 12%; P = .003) in the GHVG group and for intraoperative renal bare stenting that was predominantly used in the SRR group (12% vs 28%; P = .036). The 30-day mortality was 4% in both groups. Postoperative acute renal failure (doubling of creatinine level and creatinine level >3.0 mg/dL) occurred in two GHVG patients (8%) and seven SRR patients (14%; P = not significant). Perioperative peak decrease of estimated glomerular filtration rate was lower in the GHVG group (26 ± 18 mL/min/1.73 m(2) vs 37 ± 22 mL/min/1.73 m(2); P = .034). At 1-month computed tomography angiography, renal artery patency was 92% for the GHVG vessels, 91% for the contralateral to GHVG renal vessels, and 92% for the SRR group arteries. No GHVG-related complications requiring reintervention or cases of new-onset renal failure requiring dialysis were observed at follow-up.
Renal revascularization during open TAAA repair by the GHVG with distal sutureless anastomosis is feasible, especially in cases of aortic dissection, remote location of the renal vessel, and severe atherosclerotic disease of the ostium. Short-term results are satisfactory, at least comparable to those of SRR. Larger series and longer follow-up are needed to assess clinical advantages and durability of this new device.
Thoracic aortic aneurysms present significant challenges to clinicians, especially due to their complex nature and an evolving understanding of the safest and most effective ways to manage this condition in the perioperative setting. Thoracic aortic aneurysms have a prevalence rate of 1.3–8.9% in men and 1.0–2.2% in women, and they are estimated to affect more than five per 100,000 person-years. This is notable because the complications of thoracic aortic aneurysms can be catastrophic. The current understanding of the optimal intraoperative management of thoracic aortic aneurysms is changing, as more evidence becomes available regarding lung protective ventilation and its role in enhancing patient safety and wellbeing. This review strives to provide a brief historical understanding of thoracic aortic aneurysms and highlight some of the key discoveries and advances in the management of this condition. This review then describes an overview of the general anaesthetic principles associated with thoracic aortic aneurysms, including ventilatory modalities and how these impact a patient’s physiology and intraoperative haemodynamics. A brief discussion on one-lung ventilation is then provided, drawing from current literature in the field, to describe the most up-to-date management of thoracic aortic aneurysms.
Surgical management of thoracoabdominal aortic aneurysms is complex. In particular, maintaining adequate spinal cord and reno-visceral protection during the operation can be challenging. We describe here a branch-first technique developed at our institution, endeavoring to minimized renal and visceral organ ischemic time, decrease risk of spinal cord injury, and provide a controlled and uncluttered field in which the surgeon can operate.
Juxta-, suprarenale und Abschnitt-IV-Aneurysmen sind im Vergleich zu abdominalen Aneurysmen selten. In einer großen autoptischen Serie von Patienten mit aortoiliakalen Aneurysmen zeigte sich die folgende relative Häufigkeit nach Lokalisation: abdominale Aorta allein 65 %; thorakale Aorta allein 19 %; abdominale Aorta plus Iliakalarterien 13 %; thorakoabdominale Aorta 2 %; und isolierte Iliakalarterien 1 % (Brunkwall et al. 1989). In einer vergleichenden Studie von 429 Patienten mit abdominalen und juxtarenalen Aortenaneurysmen präsentierten sich 86 % als infrarenal, und 14 % erstreckten sich bis an oder über die Nierenarterien (Ayari et al. 2001). Abschnitt-IV-Aneurysmen werden in 10–26 % der thorakoabdominalen Aortenaneurysmen beschrieben (Cambria 2000). Juxtarenale Aneurysmen sind etwa 3- bis 4-mal häufiger als suprarenale Aneurysmen (Nypaver et al. 1993). Populationsbasierte Studien schätzen die Inzidenz von klinisch offenkundigen abdominalen Aortenaneurysmen auf 21 pro 100.000 Personenjahre und von thorakalen Aortenaneurysmen auf 6 pro 100.000 Personenjahre (Bickerstaff et al. 1982). Epidemiologisch verhalten sich abdominale (inklusive juxta- und suprarenale) Aneurysmen und Abschnitt-IV-Aneurysmen unterschiedlich. Erstere kommen in einem Verhältnis Mann zu Frau von 2:1 bis 6:1, letztere in einem Verhältnis 1:1 bis 4:1 vor. Die Inzidenz von rupturierten abdominalen Aortenaneurysmen in der allgemeinen Bevölkerung wird mit 6,3 pro 100.000, diejenigen bei über 65-Jährigen mit 35,5 pro 100.000 angegeben (Heikkinen et al. 2002). Obwohl man annehmen müsste, dass die Zunahme der elektiven Versorgung die Anzahl der Rupturen senken sollte, konnte dieser Effekt bisher nicht eindeutig nachgewiesen werden (Heller et al. 2000). Auch konnte nicht klar aufgezeigt werden, dass juxta- und suprarenale Aneurysmen häufiger rupturieren würden, wie von einigen Autoren vermutet.
