|Year : 2019 | Volume
| Issue : 4 | Page : 242-247
Six years' experience of thoracic endovascular aortic repair in patients with thoracic aortic diseases: A single-center study
Vembu Anand1, Vivek Agrawal1, Rakesh Kumar2, Vikram Patra1, Pranati Swain1, Brijesh Kanti Biswas1, Manvendu Jha1, Girija Nandan Tripathy1
1 Department of Vascular and Endovascular Surgery, Army Hospital (Research and Reffral), Delhi, India
2 Department of Office of DGAFMS Office, Delhi, India
|Date of Submission||30-Apr-2019|
|Date of Decision||01-Jul-2019|
|Date of Acceptance||18-Jul-2019|
|Date of Web Publication||20-Dec-2019|
Dr. Vivek Agrawal
Department of Vascular and Endovascular Surgery, Army Hospital (Research and Reffral), Delhi
Source of Support: None, Conflict of Interest: None
Aim: Thoracic endovascular aortic repair (TEVAR) is evolving as a gold standard therapy for treating complex thoracic aortic diseases (TAD). It has evolved as first-line therapy for descending thoracic aortic aneurysms (DTAA) and Type B aortic dissection (TBAD) with reduced morbidity and mortality. The aim of this study is to evaluate clinical profiles, treatment variation, results, and complications of TEVAR. We have also highlighted the feasibility of performing complex procedures under mobile C-arm with certain innovative methods. Materials and Methods: A total of 43 patients (34 men and 9 women), mean age 59 years; age range 23–81 years, with TBAD and DTAA, who underwent TEVAR at tertiary care center from July 2012 to April 2019 were included in the study. Management strategies applied as per existing recommendations requiring TEVAR with or without debranching. The primary endpoints were technical success, 30-day mortality. The secondary endpoints were death, stroke, or spinal cord ischemia (SCI) and graft-related complications such as endoleak, migration, kinking, or thrombosis. Follow-up was done at 1, 3, 6, and 12 months and thereafter yearly. Follow-up events included death from all causes, neurological deficits, malperfusion syndrome, and reintervention. Results: Of 43 patients, 14 had TBAD and 29 had DTAA. Sixteen required hybrid repair and rest underwent TEVAR alone. Primary technical and assisted primary clinical success was 96% and 100%, respectively. Three patients developed Type I endoleak, covered with thoracic extender. The mortality rate was 9.5%. One had minor stroke and no SCI. Conclusion: TEVAR is reliable, stable, and safe for the treatment of TAD. It continues to evolve rapidly and will likely establish itself as the first-line procedure with reduced perioperative morbidity and mortality. Utility of hybrid theaters cannot be overemphasized, and the possibilities of performing TEVAR in with portable C-arm will enable the procedure to be performed in the smaller center also.
Keywords: Aortic aneurysm, aortic dissection, debranching, hybrid procedure, thoracic endovascular aortic repair
|How to cite this article:|
Anand V, Agrawal V, Kumar R, Patra V, Swain P, Biswas BK, Jha M, Tripathy GN. Six years' experience of thoracic endovascular aortic repair in patients with thoracic aortic diseases: A single-center study. Indian J Vasc Endovasc Surg 2019;6:242-7
|How to cite this URL:|
Anand V, Agrawal V, Kumar R, Patra V, Swain P, Biswas BK, Jha M, Tripathy GN. Six years' experience of thoracic endovascular aortic repair in patients with thoracic aortic diseases: A single-center study. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2020 Jan 25];6:242-7. Available from: http://www.indjvascsurg.org/text.asp?2019/6/4/242/273593
| Introduction|| |
Thoracic aortic diseases (TAD) mainly comprises aortic dissection (AD) and aneurysm requiring emergency or planned intervention in the form of open surgery/thoracic endovascular aortic repair (TEVAR). The gold standard has been open surgery. Open surgery requires general anesthesia (GA), large incision over the thorax and aortic cross-clamping, whereas TEVAR can be done even in LA or spinal anesthesia (SA) with a small incision in the groin without cross-clamping of aorta. Therefore, since past two decades, TEVAR is replacing open surgery due to the ease of procedure, acceptability by the patient over open surgery, and lesser morbidity and mortality. Open surgery, though still is the gold standard and supposedly scores in terms of economy, but may not withstood the test of better and cheaper stent-graft devices.
In our institution, TEVAR is in vogue since 2005. However, the procedure frequency has increased in the past 7 years and we hereby sharing our institutional experience from 2012 to April 2019.
| Materials and Methods|| |
A retrospective review of a prospectively collected database was performed for patients undergoing TEVAR for Type B AD (TBAD) and descending thoracic aortic aneurysm (DTAA) at our center from July 2012 and April 2019. Demography of patients, procedure-related variables, results, complications, and follow-up from 6 months to 6 years were assessed.
After the history and physical examination, diagnosis and preoperative planning were done with the help of computed tomography angiography (CTA) of the chest, abdomen, and pelvis with 0.5–1 mm multiplanar reconstruction [Figure 1]. The decision for intervention in the form of TEVAR with or without debranching taken depending on landing zones, the status of left internal mammary artery (LIMA) and number of spinal cord branches being covered. Dominant vertebral artery and intracranial cross circulation were evaluated in all cases by CT angiogram. We have electively revascularized the left subclavian artery (LSCA) before covering.
|Figure 1: Computed tomography angiogram showing fusiform dilatation of aortic arch and descending thoracic aorta just distal to the origin of the left common carotid artery. Maximum diameter of 10.9 cm. Left subclavian artery arising from the aneurysm. Mediastinal shift present|
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Diameter and morphology of the aneurysm at different levels and its relationship to the side branches were assessed. Landing zone was taken as 20 mm of the healthy proximal and distal aorta. Site of proximal entry tear, its extent and the involvement of important aortic branches like LSCA.
Device diameter was oversized by 10% for dissections and 20% for aneurysms. Oversizing by 10% in AD is as per instruction for use(IFU) of the particular device and we have also taken the additional precaution of having a landing zone of at least 20 mm, which is more than the required landing zone and also gives a longer healthy area to allow for the additional radial force of the 10% oversizing.
The procedure was done under either GA, SA, or local anesthesia (LA), depending on the general condition, comorbidities and risk factors for a particular type of anesthesia. Although GA is preferred in TEVAR, there are occasions when the patient was not fir for GA and was unwilling for LA therefore SA had to be given. This was done in only two patients who had specific contraindications to GA and were not willing for LA. The preference of anesthesia was discussed with the anesthesiologist and a conscious decision was taken in these cases.
We have routinely done LSCA revascularization prior, whenever we have covered the LSCA, thereby minimizing the chances of spinal cord ischemia (SCI). Spinal drainage was done only in selective cases which required long coverage of thoracic aorta. Postprocedure a close watch was kept for its requirement.
Newer technique like intravascular ultrasound (IVUS) is useful but not mandatory for performing TEVAR. Transthoracic echocardiography (TEE) was used by the anesthesiologist in cases where needed.
Femoral artery was exposed and 6 French long sheath inserted. Multipurpose (MP) catheter and hydrophilic guide wire were used to access the abdominal aorta and then advanced under fluoroscopic guidance into ascending aorta. This was replaced with a stiff wire-like Lunderquist. The importance of keeping this guide wire in place during the entire endovascular procedure cannot be overemphasized. The technique of passing Lunderquist wire across the aortic valve was accomplished by either an MP catheter or a pigtail catheter and in the left anterior oblique position a glide wire was gently manipulated by rotating it clockwise and counterclockwise and the pigtail catheter is placed into the left ventricle, over which a Lunderquist wire was placed. This prevents inadvertent damage by the Lunderquist wire. In addition, we routinely use a long sheath to perform arch angiograms, which obviates the need for a pressure injector. We have never needed a pressure injector to perform arch angiograms, which saves considerable cost. The advantage of a long sheath is that TEVAR can be done under mobile C-arm. Although the imaging quality is slightly inferior to a conventional cath laboratory, the overall image quality is enough to perform the procedure safely. In our institution, till November 2018, TEVAR was done under mobile C-arm, which makes this experience unique in terms of feasibility of doing complex aortic procedures under mobile C-arm. Deployment of aortic stents differs from one company to another, but all are self-expandable stents, and we sometimes needed poststenting dilatation in some cases [Figure 2]. During deployment of graft, anethesiologist can do rapid pacing and decrease the mean arterial pressure (MAP) to 80–90 mmHg. This transient lowering of blood pressure reduces the dp/dt in the aorta and the windsock effect, reducing the chance of malposition of graft.
|Figure 2: Angio shoot after debranching and thoracic endovascular aortic repair showing patent carotido–carotid and carotid left subclavian artery bypass and stent in situ leading to the exclusion of aneurysm without endoleak|
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We were always ready with surgical backup, which included going on a left heart bypass and repair of the thoracic aorta with appropriate synthetic graft in conjunction with cardiothoracic surgeon.
The primary endpoints were technical success postdeployment, 30-day all-cause mortality and surgical conversion. The technical success is defined as successful deployment of the stent graft with complete coverage of the primary entry tear or exclusion of aneurysm without Type I endoleak [Figure 3].
|Figure 3: Photograph of patient 1 week after debranching and thoracic endovascular aortic repair|
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The secondary endpoints are procedure-related complications and secondary procedures. This includes Types II to Type IV endoleak and other graft-related complications such as migration, kinking, or thrombosis of stent [Figure 4].
|Figure 4: Computed tomography angio after 1 month of procedure showing stent in situ with the exclusion of aneurysm. Aneurysm has been thrombosed|
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Clinical follow-up included death from all causes, neurological deficits (stroke or transient ischemic attacks), malperfusion, and reintervention. Multislice CTA was performed at 1, 3, 6, and 12 months and yearly thereafter. In patients with deranged renal function test, magnetic resonance imaging was used as an alternative.
| Results|| |
In 7 years, 43 patients underwent TEVAR (34 men and 9 women; mean age, 59 years; age range, 23–81 years) as per pathology divided into two groups [Table 1].
Group I – 29 patients having DTA aneurysm.
Group II – 14 patients with Ch TBAD. Of these, two were leaking.
Twenty-seven patients (83.3%) were smokers. Seventeen patients had hypertension, five were diabetics. Eighteen patients had dyslipidemia, 4 had chronic kidney disease, and 6 patients had coronary artery disease [Table 2].
Twenty-nine patients were detected incidentally while being evaluated for other diseases. Twelve patients had chest pain, and one had hemoptysis and one presented with melaena.
Aortic debranching bypass procedures were performed in patients who were to undergo Zone 0, Zone 1, or Zone 2 deployment. Sixteen patients were subjected to various hybrid procedures along with TEVAR [Table 3].
One patient having synchronous suprarenal abdominal aortic aneurysm was subjected to bilateral renal and superior mesenteric artery bypass and EVAR along with TEVAR [Table 4].
One patient having Type 2 thoracoabdominal aortic aneurysm (TAAA) was subjected to bilateral renal and superior mesenteric artery bypass along with TEVAR.
Two cases reported in emergency with leaking dissections, successful TEVAR could be performed within 2 h of admission.
Primary technical and assisted primary clinical success was 96% and 100%, respectively.
Three cases had Type I endoleak, one had on table which was managed by balloon dilatation. Second developed after 1 month and last after 1 year these two were managed with thoracic extender [Figure 5] and [Figure 6]. These all three cases were of TAAA only and no balloon dilatation was done for AD. At this point, we should remember it is contraindicated in dissections cases to avoid rupture.
|Figure 5: Angiogram showing Type 1B endoleak in after 1 year of thoracic endovascular aortic repair|
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One patient had minor stroke in the form of monoplegia.
There were no graft-related complications such as endotension, thrombosis, migration, graft failure, or kinking.
In our series, we had 4 deaths (9.5%) [Table 5]. One patient had on table rupture of aneurysm, one had perioperative myocardial infraction, and two patients succumbed due to postoperative pulmonary infection and acute respiratory distress syndrome.
Follow-up was done at 1 month, 6 months, 1 year, and annually thereafter.
| Discussion|| |
TAD can be dealt either by open surgery or endovascular method. In a systematic review and meta-analysis by Walsh et al. reported that TEVAR has decrease death rate (5.57% vs. 16.5%), major neurological complications (5.4% vs. 14%), and hospital stay. However, it has no impact on the major reintervention rate. The International Registry of Acute Aortic Dissection concluded that surgical repair for TBAD has 29% in-hospital mortality. Since the US Food and Drug Administration approved TEVAR in 2005, its use has rapidly increased.
Soliman et al. also reported that the combination of TEVAR with medical therapy seems to have a more favorable outcome. A Cochrane review reported that clinical equipoise exists between TEVAR and open repair DTAAs due to the paucity of supporting data.
Open repair of ruptured DTAA has mortality up to 26%. Meta-analysis reported that TEVAR is an emerging preferred choice for ruptured DTAA. In our study, two cases of leaking DTAA were successfully treated with TEVAR.
Symptoms with TAD are few and nonspecific. Most cases are discovered incidentally. Patients may present with chest pain, back pain, or hypertension. They may present with hoarseness, persistent cough due to stretching of the left recurrent laryngeal nerve. Hemoptysis or hematemesis may occur due to erosion into bronchus or the esophagus.
In our series, 10 cases presented with chest pain, 5 with hoarseness of voice, 3 with dysphagia, 2 each with hemoptysis and cough, 1 each with melaena, dyspepsia, and dyspnea.
TAD cases generally have no obvious physical findings. However, in our series, 3 patients had left supraclavicular swelling, which was due to the aneurysmal segment extending into the LSCA. Five of these patients were suspected on routine chest X-ray. CTA is the diagnostic modality of choice, and we have utilized the same with 0.5–1 mm cuts.
Indications for DTAA intervention are diameter ≥5.5 cm, saccular morphology, rapidly expanding aneurysms, symptomatic aneurysms, and rupture. Aneurysm diameter is the most important risk factor for rupture.
For TEVAR, we have taken ≥20 mm proximal and distal landing zones and appropriately sized arterial access to deliver the stent-graft. If landing zones are shorter fenestration or debranching of the involved aortic branch is considered. Hybrid theaters are of immense value for these procedures. Every vascular surgeon should inculcate the skills of endovascular procedure as he is most favorably equipped to perform hybrid procedures and has the capability to manage on table complication. In our series, 16 patients required debranching with TEVAR in a single stage. At few centers, it is done in staged manner [Table 3].
Stroke is an important morbidity after TEVAR. Systematic reviews reported that stroke rates are increased if the LSCA is covered without revascularization. We had stroke in one case due to wire manipulation in arch; however, the patient recovered without intervention.
SCI is also important morbidity associated with thoracic aortic interventions. Hiraoka et al. reported 6.9% SCI after TEVAR. Fifty percent patients recovered completely. Significant risk factors for SCI are rupture, shaggy aorta, coverage from thoracic 8 to thoracic 12, and low peroperative and postoperative MAP. In our study, no case had SCI.
The procedure was done under either GA, SA, or LA. Although GA is preferred in TEVAR, there are occasions when patient was not fit for GA and was unwilling for LA and SA had to be given. This was done in only 6 patients who had specific contraindications to GA and were not willing for LA. One of the largest single-center retrospective studies by Gan et al. reported anesthetic techniques for TEVAR which concluded that 30-day mortality was significantly less in the regional anesthesia (RA) group. There was a trend toward reduction in stroke and days in hospital in the RA group. The incidence of SCI and permanent paraplegia were, however, higher (statistically nonsignificant) in the RA group.
Spinal protection is a useful adjuvant in open thoracic aneurysm repair. However, Hanna et al. conclude that its use is not mandatory in TEVAR and should be selectively used in cases who are high risk for paraplegia as identified by established criteria like, long segment aortic coverage with a history of prior aortic intervention or planned hybrid Crawford extent I to III TAA repair.
Current guidelines for the management of TAD from a number of societies advocate the use of prophylactic cerebrospinal fluid (CSF) drainage with TEVAR for long segment descending thoracic aortic coverage or in patients with prior AAA repair. However, these guidelines are based on data from open thoracic aortic repair and not on evidence from endovascularly treated patients, and systematic reviews of the available evidence have failed to establish CSF drainage as a method of preventing SCI with TEVAR. Moreover, spinal drainage in patients on antiplatelets and anticoagulants are at higher risk of intracranial hemorrhage and other complications.
Newer techniques such as IVUS are a useful tool but not mandatory; hence, we did not include it in our study. TEE was used by the anesthesiologist in cases where needed. Use of Bare AD stent, Candy-Plug technique, and Petticoat technique are all well-known techniques which can be used for proximal and distal device-related complications, but we did not require them in any of our cases.
During deployment of graft anethesiologist should do rapid pacing and keep MAP to 80s–90s mmHg. This transient lowering of blood pressure reduces the dp/dt in the aorta and the windsock effect reducing the chance of malposition of graft. These were integral part of our protocol.
In our study, 30-day mortality was 9.5% (4 cases). Our higher mortality is due to the fact that the few cases were with near rupture of aneurysms and were done as emergencies with poor general condition. Long-term results of the Randomized Investigation of Stent Grafts in AD Trial (INSTEAD-XL trial) also concluded that TEVAR in addition to optimal medical treatment is associated with improved 5-year aorta-specific survival, improved aortic remodeling, and delayed disease progression for stable Type B dissection which gives precedance to the early management of Type B dissection.
In our follow-up from 6 months to 6 years, no patient reported with left upper limb claudication or vertebral steal syndrome, in view of the fact we chose to do a carotid subclavian bypass electively in all cases when the LSCA needed to be covered. Two cases had Type 1 endoleak one after 1 month and other after 1 year both were managed with thoracic extender. In AD cases, thrombosis of false lumen and expansion of true lumen were appreciated.
| Conclusion|| |
TEVAR is evolving into a very enviable alternative to open surgery for TBAD and DTAAs and is being performed in more centers than before in our country. We have tried to analyze our experience in the past few years and inculcate modifications in standard operating procedures, which are adapted to peculiarities and demands of local environment of centers with constraints in technology or hardware requirements. We have also experienced pitfalls in management which have been overcome with experience and strategies are evolving through the years.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]