© 2013 Wiley Periodicals, Inc.
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Secondary Interventions After Endovascular Thoracic Aortic Repair Spiridon Botsios, M.D.,*,y Johannes Fro¨mke, M.D.,* Gerhard Walterbusch, M.D., Ph.D.,* Karl Schuermann, M.D., Ph.D.,z Sreekumar Subramanian, M.D.,§ Jan Reinstadler, M.D.,* and Guido Dohmen, M.D., Ph.D.* *Department of Thoracic- and Cardiovascular Surgery, St. Johannes Hospital Dortmund, Dortmund, Germany; yFaculty of Health, University Witten/Herdecke, Witten, Germany; zDepartment of Radiology, St. Johannes Hospital Dortmund, Dortmund, Germany; and §Department of Surgery, University of Arizona Medical Center, Tucson, Arizona ABSTRACT Background: Endovascular stent grafting of the descending thoracic aorta has evolved rapidly and is now the standard of care for certain patient subsets. However, the durability of this technique is limited by the development of technique-specific complications at mid-term follow-up. The aim of this study was to evaluate the incidence, techniques, and outcomes of secondary intervention for complications after stent grafting of the descending thoracic aorta. Methods: Between March 2001 and November 2011, 152 patients underwent endovascular thoracic aortic repair (TEVAR). We identified 19 (12.5%) patients from this cohort who required secondary interventions. Results: The indications for TEVAR were type B aortic dissection in 12 patients, thoracic aortic aneurysm in six patients, and intramural hematoma in one patient. The mean time between TEVAR and secondary intervention was 20.49 W 24.90 months (range, 1.2–83 months). A secondary endovascular intervention was required in eleven patient, six patients required secondary surgical therapy, and hybrid procedures were performed in two patients. Endoleaks were the most common indication for a secondary intervention. The 30-day mortality rate was 10.5% (2/19). Two perioperative deaths were observed following surgical therapy. During the mean follow-up of 78.06 W 37.37 months (range, 23–142 months) after TEVAR, four unrelated deaths occurred, two patients were lost to follow-up, and four patients required a further intervention. Conclusions: Secondary intervention after endovascular stent grafting of the descending thoracic aorta was not infrequently required and can be performed with acceptable risks. However, serial, systematic follow-up is essential to detect late complications and to perform secondary procedures, preferably under elective circumstances. doi: 10.1111/jocs.12252 (J Card Surg 2014;29:66–73)
INTRODUCTION Thoracic endovascular aortic repair (TEVAR) was introduced in the early 1990s to reduce surgical risk and offers a therapeutic option to high-risk patients with descending thoracic aortic aneurysms.1 Growing experience with endovascular interventions and continued technological advancements have resulted in a broad spectrum of indications for TEVAR, which now include aortic dissection, traumatic lesions, penetrating atherosclerotic ulcers, and intramural hematomas (IMH).2,3 The short-term advantages of TEVAR include shorter
Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Spiridon Botsios, M.D., Department of Vascular Surgery, Hospital Waldbro¨l, 51545 Waldbro¨l, Germany. Fax: þ49 22 91/82 14 99; e-mail: [email protected]
procedural times, avoidance of thoracotomy and aortic cross-clamping, reduced blood loss, fewer postoperative complications, and more rapid recovery.4,5 Although the short-term benefits of endovascular stent grafting may reduce the significant morbidity and mortality encountered with traditional surgical therapy, the long-term durability of endovascular procedures continues to be a concern. In contrast to conventional surgical therapy, endovascular stent grafting is associated with a significant need for secondary interventional and surgical procedures.6–8 However, there is limited experience with secondary procedures for complications associated with endovascular treatment. The nature and incidence of complications requiring secondary intervention, as well as intervention outcomes, may influence patient selection for TEVAR. The aim of this report was to describe our experience with surgical, endovascular, and hybrid procedures after
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endovascular stent graft placement of the descending thoracic aorta. PATIENTS AND METHODS From March 2001 to November 2011, 152 patients underwent TEVAR for descending aortic pathologies in our hospital. After discharge 19 (12.5%) patients (15 males, four females) with a mean age of 62.95 11.35 years (range, 44–81 years) required 24 secondary interventions. The mean time between TEVAR and secondary intervention was 20.49 24.90 months (range 1.2–83 months). Secondary surgical therapy was required in six patients, 11 patients required secondary endovascular intervention, and hybrid procedures were necessary in two patients. Secondary interventions were defined as additional surgical, endovascular, or hybrid procedures during follow-up. Hybrid procedures consisted of surgical procedures combined with TEVAR. We are unaware of any of our TEVAR patients undergoing subsequent interventions at other institutions. Mean total follow-up for the study group was 78.06 37.37 months (range, 23–142 months) ending in January 2013. The Institutional Review Board, St. Johannes Hospital, Dortmund, approved this retrospective study. Aortic dissection type B The underlying aortic pathology for TEVAR was aortic dissection in 12 male patients with a mean age of 58.08 10.39 years (range, 44–74 years). Secondary endovascular interventions were necessary in seven patients, conventional surgical therapy was required in four patients whose pathology was not amenable to
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interventional treatment, and a hybrid procedure was necessary in one patient. The secondary procedures were performed on an emergency basis in two patients. Indications for secondary intervention, time to reintervention, and outcomes are presented in Table 1. In Patient 1, TEVAR was performed as an emergency acute dissection with a contained rupture. The indication for secondary intervention was intermittent limb ischemia and abdominal pain due to peripheral extension of the dissection into the right common iliac artery two months after the initial procedure. He was successfully treated by placement of an iliac stent. Patient 2 was also treated with TEVAR for a complicated type B dissection with intractable thoracic pain. The patient was admitted to our hospital three months after a successful recovery with sudden-onset chest pain due to a delayed retrograde type A dissection in the aortic arch, which originated from the proximal uncovered part of the stent graft. Surgery was performed under emergency conditions. Surgical exposure was achieved with a left thoracotomy through the fifth intercostal space, and left heart bypass was established by cannulation of the femoral vessels. The patient required descending aortic replacement from just distal to the origin of the left carotid artery and removal of the stent graft. Patient 3 underwent TEVAR for an acute type B aortic dissection with intractable thoracic pain and uncontrollable hypertension. After a follow-up time of 12 months, a distal type I endoleak emerged. The endoleak was due to endovascular extension, and an additional stent graft was performed successfully. Patient 4 complained of new-onset chest pain 48 days after endovascular stent grafting for an acute dissection. A computed tomography (CT) scan showed
TABLE 1 Summary of 12 Patients Who Underwent a Secondary Intervention Following Endovascular Thoracic Aortic Repair (TEVAR) for a Type B Aortic Dissection Patients Indication for Secondary No. (Age/Sex) Intervention Itsi (mo) 1
56 M
2
56 M
3 4
61 M 44 M
5
62 M
6
74 M
7
54 M
8 9 10 11
45 74 52 49
12
70 M
M M M M
Peripheral extension of dissection Acute retrograde type A dissection Endoleak type IB Dilatation of the false lumen Progressive increase in aneurysm size Endoleak type IA Progressive increase in aneurysm size Subclavian steal syndrome Rupture distal Endoleak type IA Progressive increase in aneurysm size Acute retrograde type A dissection
Secondary Interventions
Outcome
2
Stent placement of right iliac artery
Alive
3
Emergency surgical replacement of descending aorta
Alive
12 1.6
Endovascular stent graft placement Endovascular stent graft placement
Alive Alive
60
Surgical replacement of thoracoabdominal aorta
Lost
42
Endovascular stent graft placement—failed
5 2 83 1.2 28 1.2
Surgical replacement of thoracoabdominal aorta Stent placement of left subclavian artery Endovascular stent graft placement Endovascular stent graft placement Hybrid repair: endovascular stent graft placement and surgical replacement of TAAA Emergency surgical replacement of ascending aorta
Itsi (mo), interval between TEVAR and secondary intervention (months); TAAA, thoracoabdominal aortic aneurysm.
Died 36 mo (renal cancer) Alive Alive Alive Alive Lost Alive
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Figure 1. (A) Patient presented with dilatation of the false lumen 48 days after endovascular thoracic aortic repair. (B) Computed tomography scan shows complete sealing of the false lumen after additional stent graft placement.
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dilatation of the false lumen downstream of the initially placed endovascular stent. Placement of an additional stent distal to the first resolved the problem (Fig. 1). Elective surgical therapy with replacement of the thoracoabdominal aorta was required because of a progressive increase in aneurysm size after TEVAR for an acute type B dissection in two patients (Patients 5 and 7) at 60 and 5 months after the initial surgery, respectively. Patient 5 underwent TEVAR for an acute type B aortic dissection and uncontrollable hypertension. Follow-up CT scans 60 months after the intervention revealed a type I endoleak associated with continuous enlargement of the thoracoabdominal aorta (maximal diameter, 8 cm). Patient 7 initially underwent TEVAR for a complicated type B dissection with intractable thoracic pain. After successful recovery, the patient developed recurrent chest pain 5 months after the intervention. A CT scan showed an enlarging descending thoracic aneurysm with a maximum diameter of 6 cm (Fig. 2). Surgical techniques for extensive thoracoabdominal aneurysm operations have been described previously in detail.9 Patient 6 was an emergency treated successfully due to an acute dissection that was complicated by impending rupture and hemothorax. After a 42-month follow-up, a second proximal type I endoleak was diagnosed. Unfortunately, the proximal endoleak persisted because endovascular extension with a second stent graft insertion failed. Although the patient presented an indication for conversion to open surgery, he was considered too high-risk and is under observation. Patient 8 underwent emergency TEVAR for an acute type B aortic dissection because of intractable thoracic
Figure 2. (A) Computed tomography (CT) scan of an acute type B dissection. (B) CT-angiography performed five months after the endovascular thoracic aortic repair demonstrated an increase in aortic diameter of 6 cm.
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ted to our department and underwent secondary interventions for a descending thoracic aortic aneurysm following TEVAR. Secondary surgical therapy was necessary in one patient, and four patients required secondary TEVAR (three distal extensions and one relining). The secondary TEVAR procedures were performed as elective surgery in three of the four patients. A hybrid procedure including secondary TEVAR and arch debranching was necessary in one patient. Indications for secondary interventions, time to reintervention, and outcomes are presented in Table 2. Patient 1 underwent emergent TEVAR for impending aneurysm rupture with hemothorax. After an uneventful recovery, the patient suffered an antegrade dissection of the descending aorta starting at the distal end of the stent graft 10 weeks later, which was successfully treated with additional stent graft placement. Patient 2 also underwent emergency treatment by implantation of two stent grafts for a ruptured aneurysm with hemothorax. After 16 months, the patient presented with new-onset hemothorax because of a type III endoleak between the originally perfectly placed two stent grafts. Emergent deployment of an additional stent graft between the first and second stent was performed successfully. Patient 3 was treated with TEVAR for a symptomatic descending aneurysm with recurrent chest pain. To achieve acceptable fixation of the stent graft because of a short proximal landing zone, a prophylactic left subclavian artery and carotid–carotid bypass was performed. The patient was readmitted to our hospital with a clinical picture of late graft infection 18 months after the endovascular procedure. The infected Dacron grafts were completely removed. However, no ischemic symptoms of the left arm or neurologic sequelae in the vertebrobasilar region were observed. The patient had an uneventful postoperative course. Elective endovascular peripheral extension with a second stent graft insertion was required because of a type IB endoleak after TEVAR for an asymptomatic descending aneurysm in two patients (4, 6) at 43.6 and 8.5 months, respectively.
pain and uncontrollable hypertension. The stent graft intentionally covered the origin of the left subclavian artery to increase the proximal sealing zone. Two months later, steal syndrome in the ipsilateral arm caused by a subtotal stenosis of the origin of the subclavian artery was treated successfully with a stent. Patient 9 was treated with TEVAR for a complicated type B dissection with intractable thoracic pain. After 83 months, he was referred to another hospital with a ruptured aorta below the distal end of the stent graft. The patient required an immediate distal graft extension with two overlapping stent grafts. Patient 10 was primarily treated successfully as an emergency because the acute dissection was complicated with impending rupture and hemothorax. After a five-week follow-up, a second proximal type I endoleak was diagnosed. The proximal endoleak was due to endovascular extension, and two additional stent grafts were successfully placed. Patient 11 was treated with TEVAR for a complicated type B dissection with uncontrollable hypertension. After a 28-month follow-up, an extensive thoracoabdominal aneurysm was present. The patient underwent a staged hybrid repair to minimize operative risk. In the first stage, the patient received a distal graft extension with implantation of one stent graft. An interval open repair of the thoracoabdominal aorta was performed. However, the patient developed permanent paraplegia after the second procedure. Patient 12 was also treated with TEVAR for a complicated type B dissection with intractable thoracic pain. Six weeks after a successful recovery, the patient was admitted to our hospital with sudden-onset chest pain due to delayed retrograde type A dissection into the ascending aorta, which originated from the proximal uncovered part of the stent graft, and surgery was performed under emergency conditions. The patient underwent a supracoronary ascending aortic replacement. Thoracic aortic aneurysms Six patients (two males, four females; mean age, 73.50 5.54 years; range, 68–81 years) were readmit-
TABLE 2 Summary of Six Patients Who Underwent a Secondary Intervention Following Endovascular Thoracic Aortic Repair (TEVAR) for a Thoracic Aortic Aneurysm No.
Patients (Age/Sex)
Indication for Secondary Intervention
Itsi (mo)
Secondary Interventions
Outcome
2.3
Endovascular stent graft placement
Died 63 mo (stroke) Died 58 mo (cardiac failure) Died 55 mo (lung cancer) Alive Died 5 days (cardiac failure) Alive
1
81 F
Antegrade dissection
2
70 M
16
3
80 F
Endoleak type III with contained rupture Infection of carotid-subclavian bypass
4 5
71 F 68 M
Endoleak type IB Impending rupture
43.6 2.3
6
71 F
Endoleak type IB
18
8.5
Itsi (mo), interval between TEVAR and secondary intervention (months).
Emergency endovascular stent graft placement Explanation of subclavian-to-carotid bypass Endovascular stent graft placement Hybrid procedure: arch debranching and stent graft placement Endovascular stent graft placement
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Patient 5 presented with impending rupture of the distal arch 2.3 months after TEVAR for a asymptomatic descending aneurysm and received emergent hybrid repair involving complete arch vessels debranching and endovascular proximal stent graft extension during the same procedure. The patient died five days later due to prolonged cardiac failure.
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the aortic arch seven weeks later. Patient 9 underwent surgery for a type IA endoleak two months after distal graft extension for rupture proximal graft extension. After an additional four months, a CT scan demonstrated a new type III endoleak, which was successfully treated with additional stent graft placement. Thoracic aortic aneurysms
Intramural hematomas A 58-year-old male was initially treated with TEVAR for IMH of the descending thoracic aorta. The patient subsequently underwent coronary artery bypass surgery and replacement of the ascending aorta 41 months later. After an additional 17 months, the patient was readmitted with sudden-onset chest pain. A CT scan demonstrated rupture of the thoracoabdominal aorta at the level of the diaphragm. Emergent removal of the stent graft and a thoracoabdominal aortic replacement with a Dacron prosthesis were performed using left heart bypass. However, the patient died several hours after the procedure due to cardiac failure.
RESULTS Aortic dissection type B The mean interval between TEVAR and the initial secondary procedures was 20.1 27.6 months (range, 1.2–83 months). Secondary interventions were successful in 11 of 12 patients. Treatment failure was seen in Patient 6. All patients were routinely admitted to the surgical intensive care unit postoperatively. The mean length of hospital stay was 17.8 15.6 days (range 1–60 days), and 5.5 7.4 days (range, 1–21 days) in the intensive care unit. Additionally, two cases had further surgical procedures. The first case (Patient 2) required reexploration for bleeding after replacement of the descending aorta. The second case (Patient 5) developed acute limb ischemia after replacement of the thoracoabdominal aorta. The acute extremity ischemia was successfully treated with a prosthesis-femoral artery bypass. Early mortality, defined as either in-hospital or within 30 days, was zero. The mean follow-up after TEVAR was 82.60 41.68 months (range, 25–142 months). Two patients (5 and 11) were lost to follow-up. One nonprocedure-related death was observed during this period. Patient 6 died from renal cell carcinoma 3 years after a failed secondary intervention. Three (25%) patients underwent a total of four reinterventions. Patient 5 presented to our hospital with a clinical picture of a groin infection 12 months after surgical therapy for replacement of the thoracoabdominal aorta and prosthesis-femoral bypass. The prosthesis-femoral Dacron graft was completely removed and an axillofemoral bypass was performed. The followup CT scans of Patient 3 73 months after distal graft extension for a distal type I endoleak revealed a newonset proximal type I endoleak. He underwent revascularization of arch vessels followed by stent grafting of
The mean interval between TEVAR and the first secondary procedures was 15.12 15.44 months (range, 2.3–43.6 months). Early mortality was 16.6% (1/6). Intensive care stay was 4.2 4.1 days (range, 1–12 days), and the mean hospitalization duration was 15.8 6.1 days (range, 10–27 days). The mean follow-up after TEVAR was 69.00 57.48 months (range, 23–99 months). No patient was lost to follow-up. During the follow-up period, one open conversion was performed. Patient 2 had a progressive increase in thoracoabdominal aortic aneurysm size, with a maximal diameter of 10 cm on a follow-up CT scan after successful secondary TEVAR. An elective surgical replacement of the thoracoabdominal aorta was performed 25 months after the secondary TEVAR procedure. Three unrelated deaths were recorded. Patient 1 died from ischemic stroke 63 months after secondary TEVAR. Patient 2 died from congestive cardiac failure 58 months after surgical replacement of the thoracoabdominal aorta. Patient 3 died from lung cancer 55 months after a successful secondary operation. DISCUSSION Two decades after its introduction in the early 1990s, endovascular stent graft placement has become a wellestablished treatment for patients with diverse thoracic aortic pathologies.1–3 Our study confirmed multiple prior reports10–12 of the efficacy of TEVAR, as 19/152 (12.5%) of patients required a secondary intervention at mid-term follow-up. However, with the increasing numbers of interventional thoracic aortic procedures and duration of follow-up, late secondary interventional and surgical procedures for complications after endovascular stent graft placement of the thoracic aorta are increasingly common.12–14 In our series, 12.5% of TEVAR patients required a secondary intervention, consistent with the 5–21% reintervention rates reported recently.7,8 Although both TEVAR and conventional surgical therapy may be associated with similar complications (progressive aneurysm growth or aortic dissection arising from untreated aortic segments), TEVAR is associated with unique complications (endoleak), which may or may not become significant at follow-up. Depending on the nature of the complication, a secondary reintervention can be performed using endovascular techniques. In the present study, 11/19 patients requiring endovascular reintervention had an acceptable indication for endovascular stent grafting, whereas six had indications for surgical repair including aneurismal progression, retrograde type A dissection, acute aortic rupture, and infected graft prosthesis. Two
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received hybrid procedures. Regardless of the approach, secondary interventions after TEVAR were technically feasible and associated with acceptable perioperative morbidity and mortality. Although the late complications of TEVAR have been well described in the literature, limited information regarding the indications for secondary endovascular interventions is available. In our series, an endoleak was the indication for secondary endovascular intervention in 6/19 patients. An endoleak represents the most common complication following endovascular treatment of aortic disease12 with an incidence ranging from 1% to 29% in earlier studies.15–18 Risk factors for development of an endoleak are the presence of a carotid-subclavian bypass, coverage of the left subclavian artery, a larger diameter aneurismal aorta, and extensive aortic coverage with multiple stent grafts.12,15,17 Although endovascular aortic repair is designed to minimize the risk of aortic rupture, persistent endoleak with progressive increase in aneurysm size may unfortunately lead to secondary aortic rupture. However, in our study, late endoleaks with an indication for a reintervention were not uncommon, occurring in six patients. We observed one type III endoleak treated by additional stent graft and five type I endoleaks, of which four were treated successively by an additional stent graft except in one that is still under surveillance after failed endovascular repair. Our experience and that of others consisted of aggressive endovascular techniques for type I and type III endoleaks and observation of type II endoleaks.12,15 The occurrence of (late) endoleak represents one of the major limitations of endovascular treatment and illustrates the need for mandatory lifelong follow-up. Endoleaks may be common and innocuous, whereas retrograde type A dissection (rAAD) is an unusual but potentially lethal complication after TEVAR of the descending aorta. The reported incidence worldwide is 1–2%,14 although a single-center experience involving a relatively small number of interventions reported a rate of 6.8%.19 A recent multicenter study by Eggebrecht et al.20 including 4750 TEVAR procedures performed between 1995 and 2008 revealed a low incidence of rAAD (1.33%) but with an associated mortality of 42%. The observation of this devastating complication not only during or immediately after endovascular treatment but also delayed several months or years after the intervention and the presentation in about 25% of delayed rAAD without symptoms emphasizes the need for a close follow-up examination of these patients. The etiology of retrograde dissection associated with stent graft placement is multifactorial. Possible causes can be classified as procedure or device related, unfavorable aortic-dissection anatomy, patent false lumen, or natural progression of initial aortic disease.21,22 In our study, two patients had a retrograde aortic dissection 1.2 and 3 months, respectively, after successful TEVAR for an acute type B dissection. In the first case, supracoronary ascending aortic replacement in emergency setting was performed on standard cardiopulmonary bypass without circulatory arrest and the stent graft was left in the
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descending aorta. The second case also required emergency open surgery and consisted of complete stent graft removal and replacement of the descending aorta using the left heart bypass technique. The stent graft was adherent to the aortic wall but the entire device could be rather easily removed. This may not always be the case, as a period of circulatory arrest may be necessary to remove those stents that are well incorporated into the vessel wall as reported by Lazar et al.23 The reason for this delayed complication is speculative, but it may have been due to the bare springs of the stent graft device abrading the friable aortic wall in an acute type B dissection. Nevertheless, TEVAR potentially avoids an operation in the setting of a complicated aortic dissection and is designed to achieve false lumen thrombosis, with subsequent expansion of the true lumen and aortic remodeling. In some cases, persistent perfusion in the false lumen leads to progressive aortic dilatation or rupture and represents another limitation of endovascular treatment. Two patients in our series required open surgery, and one hybrid repair was rewired for a progressive increase in the size of a descending aortic aneurysm (in one associated with a type I endoleak) after TEVAR for an acute type B dissection. Risk factors for aneurismal expansion include an initial diameter of >4 cm and a persistent entry into the false lumen.13 Aortic rupture after TEVAR is an uncommon, but a welldescribed, complication in case reports and small series. In most of these cases, rupture is associated with untreated primary or secondary endoleaks.17 We experienced this fatal complication in three of our patients, one of whom survived. Aortic rupture always represents a severe complication, associated with poor clinical outcomes and significant mortality. The fundamental goal of TEVAR is to reduce the risk for rupture, but it is not completely effective in preventing aortic rupture. One of the precursors to aortic rupture after TEVAR may be the accumulation of pressure within the aneurismal sac from a persistent endoleak. Future research designed to identify increased pressure may help prevent this complication.24 In our study, we did not see the phenomenon of ‘‘endovascular collapses.’’ This potentially devastating complication of total or near total stent graft collapse has been reported in association with TEVAR, most frequently for thoracic trauma and rarely for thoracic aneurysms.25 Anatomic factors that may predispose to this phenomenon are small aortic diameters and a steeply angulated arch, a problem most common in young patients, involved in trauma but also technical considerations such as proximal thoracic aortic implanted stent grafts and an excessive oversizing may contribute to the development of collapse.25,26 Today, TEVAR is a therapeutic option with particular benefit for complicated acute type B dissection, ruptured descending aortic aneurysm, or traumatic aortic transactions.27,28 A certain proportion of patients will require reintervention during mid- to long-term follow-up. Although some patients are amenable to repeat endovascular therapy, conventional surgical therapy still represents the optimal therapy for some
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patients. In our experience, two deaths occurred after conventional surgery and after hybrid repair under emergency conditions, underscoring the fact that postoperative clinical and radiological surveillance is essential to recognize adverse morphologic changes and procedure-related complications after successful thoracic aortic endovascular therapy. A risk reduction in these cases can, in all probability, be achieved only by exact timing of the reintervention procedure. The limitations of this study include those inherent to a single-center, retrospective series. The small sample size and varied pathologies of the thoracic aorta did not allow us to draw statistically significant conclusions from our results. Although the endovascular stent placement method has revolutionized aortic surgery, current experience is still largely limited to midterm results. Longer-term studies for this evolving technology are required. CONCLUSION Endovascular stent graft implantation has become the preferred approach for various pathologies of the descending thoracic aorta. However, multiple procedure-related complications may develop over time, emphasizing the importance of continued aortic surveillance to determine the need for secondary endovascular or conventional surgical interventions. Although secondary interventions can be performed safely and successfully, optimal patient selection, advances in graft design, and a careful and precise intervention technique remain essential. The need for conventional surgical therapy cannot be avoided completely. REFERENCES 1. Dake MD, Miller DC, Semba CP, et al: Transluminal placement of endovascular stentgrafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994;331:1729–1734. 2. Dake MD, Kato N, Mitchell RS, et al: Endovascular stentgraft placement for the treatment of acute aortic dissection. N Engl J Med 1999;340:1546–1552. 3. Svensson LG, Kouchoukos NT, Miller DC, et al: Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thorac Surg 2008;85(1 Suppl):1–41. 4. Gopaldas RR, Huh J, Dao TK, et al: Superior nationwide outcomes of endovascular versus open repair for isolated descending thoracic aortic aneurysm in 11,669 patients. J Thorac Cardiovasc Surg 2010;140(5):1001–1010. 5. Cheng D, Martin J, Shennib H, et al: Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease: A systematic review and meta-analysis of comparative studies. J Am Coll Cardiol 2010;55(10):986– 1001. 6. Pamler RS, Kotsis T, Gorich J, et al: Complications after endovascular repair of type B aortic dissection. J Endovasc Ther 2002;9:822–828. 7. Geisb@ usch P, Hoffmann S, Kotelis D, et al: Reinterventions during midterm follow-up after endovascular treatment of thoracic aortic disease. J Vasc Surg 2011;53(6):1528– 1533.
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8. Dumfarth J, Michel M, Schmidli J, et al: Mechanisms of failure and outcome of secondary surgical interventions after thoracic endovascular aortic repair (TEVAR). Ann Thorac Surg 2011;91:1141–1146. 9. Walterbusch G, Fro¨mke J, Sydow M: A simple method to reduce ischemic time of the spinal cord in extensive thoracoabdominal aneurysm operations. Thorac Cardiovasc Surg 2003;51(1):46–48. 10. Grabenwoger M, Fleck T, Ehrlich MP, et al: Secondary surgical interventions after endovascular stent-grafting of the thoracic aorta. Eur J Cardiothorac Surg 2004;26:608– 613. 11. Czerny M, Funovics M, Sodeck G, et al: Long-term results of thoracic endovascular aortic repair in atherosclerotic aneurysms involving the descending aorta. J Thorac Cardiovasc Surg 2010;140(Suppl):S179–S184. 12. Parmer SS, Carpenter JP, Stavropoulos SW, et al: Endoleaks after endovascular repair of thoracic aortic aneurysms. J Vasc Surg 2006;44:447–452. 13. Boeckler D, Schuhmacher H, Ganten M, et al: Complications after endovascular repair of acute symptomatic and chronic expanding Stanford type B aortic dissections. J Thorac Cardiovasc Surg 2006;132:361–368. 14. Girdauskas E, Falk V, Kuntze T, et al: Secondary surgical procedures after endovascular stent grafting of the thoracic aorta: Successful approaches to a challenging clinical problem. J Thorac Cardiovasc Surg 2008;136(5): 1289–1294. 15. Morales JP, Greenberg RK, Lu Q, et al: Endoleaks following endovascular repair of thoracic aortic aneurysm: Etiology and outcomes. J Endovasc Ther 2008;15(6):631– 638. 16. Preventza O, Wheatley GH III, Ramaiah VG, et al: Management of endoleaks associated with endovascular treatment of descending thoracic aortic diseases. J Vasc Surg 2008;48(1):69–73. 17. Piffaretti G, Mariscalco G, Lomazzi C, et al: Predictive factors for endoleaks after thoracic aortic aneurysm endograft repair. J Thorac Cardiovasc Surg 2009;138(4):880–885. 18. Orend KH, Scharrer-Pamler R, Kapfer X, et al: Endovascular treatment in diseases of the descending thoracic aorta: 6-Year results of a single center. J Vasc Surg 2003; 37(1):91–99. 19. Neuhauser B, Czermak BV, Fish J, et al: Type A dissection following endovascular thoracic aortic stent graft repair. J Endovasc Ther 2005;12:74–81. 20. Eggebrecht H, Thompson M, Rousseau H, et al: Retrograde ascending aortic dissection during or after thoracic aortic stent graft placement: Insight from the European registry on endovascular aortic repair complications. Circulation 2009;120(11 Suppl):276–281. 21. Fattori R, Lovato L, Buttazzi K, et al: Extension of dissection in stent graft treatment of type B aortic dissection: Lessons learned from endovascular experience. J Endovasc Ther 2005;12:306–311. 22. Kpodonu J, Preventza O, Ramaiah VG, et al: Retrograde type A dissection after endovascular stenting of the descending thoracic aorta. Is the risk real? Eur J Cardiothorac Surg 2008;33:1014–1018. 23. Lazar HL, Varma PK, Shapira OM, et al: Endograft collapse after thoracic stent-graft repair for traumatic rupture. Ann Thorac Surg 2009;87(5):1582–1583. 24. Parsa CJ, Daneshman MA, Lima B, et al: Utility of remote wireless pressure sensing for endovascular leak detection after endovascular thoracic aneurysm repair. Ann Thorac Surg 2010;89(2):446–452.
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25. Muhs BE, Balm R, White GH, et al: Anatomic factors associated with acute endograft collapse after Gore TAG treatment of thoracic aortic dissection or traumatic rupture. J Vasc Surg 2007;45: 655–661. 26. Jonker FH, Schlosser FJ, Geirsson A, et al: Endograft collapse after thoracic endovascular aortic repair. J Endovasc Ther. 2010;17(6):725–734.
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27. Botsios S, Schuermann K, Maatz W, et al: Complicated acute type B dissections: A single-center experience with endovascular treatment. Thorac Cardiovasc Surg 2010; 58:280–284. 28. Desai ND, Pochettino A, Szeto WY, et al: Thoracic endovascular aortic repair: Evolution of therapy, patterns of use, and results in a 10-year experience. J Thorac Cardiovasc Surg 2011;142(3):587–594.
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ORIGINAL ARTICLE _____________________________________________________________
Secondary Interventions After Endovascular Thoracic Aortic Repair Spiridon Botsios, M.D.,*,y Johannes Fro¨mke, M.D.,* Gerhard Walterbusch, M.D., Ph.D.,* Karl Schuermann, M.D., Ph.D.,z Sreekumar Subramanian, M.D.,§ Jan Reinstadler, M.D.,* and Guido Dohmen, M.D., Ph.D.* *Department of Thoracic- and Cardiovascular Surgery, St. Johannes Hospital Dortmund, Dortmund, Germany; yFaculty of Health, University Witten/Herdecke, Witten, Germany; zDepartment of Radiology, St. Johannes Hospital Dortmund, Dortmund, Germany; and §Department of Surgery, University of Arizona Medical Center, Tucson, Arizona ABSTRACT Background: Endovascular stent grafting of the descending thoracic aorta has evolved rapidly and is now the standard of care for certain patient subsets. However, the durability of this technique is limited by the development of technique-specific complications at mid-term follow-up. The aim of this study was to evaluate the incidence, techniques, and outcomes of secondary intervention for complications after stent grafting of the descending thoracic aorta. Methods: Between March 2001 and November 2011, 152 patients underwent endovascular thoracic aortic repair (TEVAR). We identified 19 (12.5%) patients from this cohort who required secondary interventions. Results: The indications for TEVAR were type B aortic dissection in 12 patients, thoracic aortic aneurysm in six patients, and intramural hematoma in one patient. The mean time between TEVAR and secondary intervention was 20.49 W 24.90 months (range, 1.2–83 months). A secondary endovascular intervention was required in eleven patient, six patients required secondary surgical therapy, and hybrid procedures were performed in two patients. Endoleaks were the most common indication for a secondary intervention. The 30-day mortality rate was 10.5% (2/19). Two perioperative deaths were observed following surgical therapy. During the mean follow-up of 78.06 W 37.37 months (range, 23–142 months) after TEVAR, four unrelated deaths occurred, two patients were lost to follow-up, and four patients required a further intervention. Conclusions: Secondary intervention after endovascular stent grafting of the descending thoracic aorta was not infrequently required and can be performed with acceptable risks. However, serial, systematic follow-up is essential to detect late complications and to perform secondary procedures, preferably under elective circumstances. doi: 10.1111/jocs.12252 (J Card Surg 2014;29:66–73)
INTRODUCTION Thoracic endovascular aortic repair (TEVAR) was introduced in the early 1990s to reduce surgical risk and offers a therapeutic option to high-risk patients with descending thoracic aortic aneurysms.1 Growing experience with endovascular interventions and continued technological advancements have resulted in a broad spectrum of indications for TEVAR, which now include aortic dissection, traumatic lesions, penetrating atherosclerotic ulcers, and intramural hematomas (IMH).2,3 The short-term advantages of TEVAR include shorter
Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Spiridon Botsios, M.D., Department of Vascular Surgery, Hospital Waldbro¨l, 51545 Waldbro¨l, Germany. Fax: þ49 22 91/82 14 99; e-mail: [email protected]
procedural times, avoidance of thoracotomy and aortic cross-clamping, reduced blood loss, fewer postoperative complications, and more rapid recovery.4,5 Although the short-term benefits of endovascular stent grafting may reduce the significant morbidity and mortality encountered with traditional surgical therapy, the long-term durability of endovascular procedures continues to be a concern. In contrast to conventional surgical therapy, endovascular stent grafting is associated with a significant need for secondary interventional and surgical procedures.6–8 However, there is limited experience with secondary procedures for complications associated with endovascular treatment. The nature and incidence of complications requiring secondary intervention, as well as intervention outcomes, may influence patient selection for TEVAR. The aim of this report was to describe our experience with surgical, endovascular, and hybrid procedures after
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endovascular stent graft placement of the descending thoracic aorta. PATIENTS AND METHODS From March 2001 to November 2011, 152 patients underwent TEVAR for descending aortic pathologies in our hospital. After discharge 19 (12.5%) patients (15 males, four females) with a mean age of 62.95 11.35 years (range, 44–81 years) required 24 secondary interventions. The mean time between TEVAR and secondary intervention was 20.49 24.90 months (range 1.2–83 months). Secondary surgical therapy was required in six patients, 11 patients required secondary endovascular intervention, and hybrid procedures were necessary in two patients. Secondary interventions were defined as additional surgical, endovascular, or hybrid procedures during follow-up. Hybrid procedures consisted of surgical procedures combined with TEVAR. We are unaware of any of our TEVAR patients undergoing subsequent interventions at other institutions. Mean total follow-up for the study group was 78.06 37.37 months (range, 23–142 months) ending in January 2013. The Institutional Review Board, St. Johannes Hospital, Dortmund, approved this retrospective study. Aortic dissection type B The underlying aortic pathology for TEVAR was aortic dissection in 12 male patients with a mean age of 58.08 10.39 years (range, 44–74 years). Secondary endovascular interventions were necessary in seven patients, conventional surgical therapy was required in four patients whose pathology was not amenable to
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interventional treatment, and a hybrid procedure was necessary in one patient. The secondary procedures were performed on an emergency basis in two patients. Indications for secondary intervention, time to reintervention, and outcomes are presented in Table 1. In Patient 1, TEVAR was performed as an emergency acute dissection with a contained rupture. The indication for secondary intervention was intermittent limb ischemia and abdominal pain due to peripheral extension of the dissection into the right common iliac artery two months after the initial procedure. He was successfully treated by placement of an iliac stent. Patient 2 was also treated with TEVAR for a complicated type B dissection with intractable thoracic pain. The patient was admitted to our hospital three months after a successful recovery with sudden-onset chest pain due to a delayed retrograde type A dissection in the aortic arch, which originated from the proximal uncovered part of the stent graft. Surgery was performed under emergency conditions. Surgical exposure was achieved with a left thoracotomy through the fifth intercostal space, and left heart bypass was established by cannulation of the femoral vessels. The patient required descending aortic replacement from just distal to the origin of the left carotid artery and removal of the stent graft. Patient 3 underwent TEVAR for an acute type B aortic dissection with intractable thoracic pain and uncontrollable hypertension. After a follow-up time of 12 months, a distal type I endoleak emerged. The endoleak was due to endovascular extension, and an additional stent graft was performed successfully. Patient 4 complained of new-onset chest pain 48 days after endovascular stent grafting for an acute dissection. A computed tomography (CT) scan showed
TABLE 1 Summary of 12 Patients Who Underwent a Secondary Intervention Following Endovascular Thoracic Aortic Repair (TEVAR) for a Type B Aortic Dissection Patients Indication for Secondary No. (Age/Sex) Intervention Itsi (mo) 1
56 M
2
56 M
3 4
61 M 44 M
5
62 M
6
74 M
7
54 M
8 9 10 11
45 74 52 49
12
70 M
M M M M
Peripheral extension of dissection Acute retrograde type A dissection Endoleak type IB Dilatation of the false lumen Progressive increase in aneurysm size Endoleak type IA Progressive increase in aneurysm size Subclavian steal syndrome Rupture distal Endoleak type IA Progressive increase in aneurysm size Acute retrograde type A dissection
Secondary Interventions
Outcome
2
Stent placement of right iliac artery
Alive
3
Emergency surgical replacement of descending aorta
Alive
12 1.6
Endovascular stent graft placement Endovascular stent graft placement
Alive Alive
60
Surgical replacement of thoracoabdominal aorta
Lost
42
Endovascular stent graft placement—failed
5 2 83 1.2 28 1.2
Surgical replacement of thoracoabdominal aorta Stent placement of left subclavian artery Endovascular stent graft placement Endovascular stent graft placement Hybrid repair: endovascular stent graft placement and surgical replacement of TAAA Emergency surgical replacement of ascending aorta
Itsi (mo), interval between TEVAR and secondary intervention (months); TAAA, thoracoabdominal aortic aneurysm.
Died 36 mo (renal cancer) Alive Alive Alive Alive Lost Alive
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Figure 1. (A) Patient presented with dilatation of the false lumen 48 days after endovascular thoracic aortic repair. (B) Computed tomography scan shows complete sealing of the false lumen after additional stent graft placement.
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dilatation of the false lumen downstream of the initially placed endovascular stent. Placement of an additional stent distal to the first resolved the problem (Fig. 1). Elective surgical therapy with replacement of the thoracoabdominal aorta was required because of a progressive increase in aneurysm size after TEVAR for an acute type B dissection in two patients (Patients 5 and 7) at 60 and 5 months after the initial surgery, respectively. Patient 5 underwent TEVAR for an acute type B aortic dissection and uncontrollable hypertension. Follow-up CT scans 60 months after the intervention revealed a type I endoleak associated with continuous enlargement of the thoracoabdominal aorta (maximal diameter, 8 cm). Patient 7 initially underwent TEVAR for a complicated type B dissection with intractable thoracic pain. After successful recovery, the patient developed recurrent chest pain 5 months after the intervention. A CT scan showed an enlarging descending thoracic aneurysm with a maximum diameter of 6 cm (Fig. 2). Surgical techniques for extensive thoracoabdominal aneurysm operations have been described previously in detail.9 Patient 6 was an emergency treated successfully due to an acute dissection that was complicated by impending rupture and hemothorax. After a 42-month follow-up, a second proximal type I endoleak was diagnosed. Unfortunately, the proximal endoleak persisted because endovascular extension with a second stent graft insertion failed. Although the patient presented an indication for conversion to open surgery, he was considered too high-risk and is under observation. Patient 8 underwent emergency TEVAR for an acute type B aortic dissection because of intractable thoracic
Figure 2. (A) Computed tomography (CT) scan of an acute type B dissection. (B) CT-angiography performed five months after the endovascular thoracic aortic repair demonstrated an increase in aortic diameter of 6 cm.
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ted to our department and underwent secondary interventions for a descending thoracic aortic aneurysm following TEVAR. Secondary surgical therapy was necessary in one patient, and four patients required secondary TEVAR (three distal extensions and one relining). The secondary TEVAR procedures were performed as elective surgery in three of the four patients. A hybrid procedure including secondary TEVAR and arch debranching was necessary in one patient. Indications for secondary interventions, time to reintervention, and outcomes are presented in Table 2. Patient 1 underwent emergent TEVAR for impending aneurysm rupture with hemothorax. After an uneventful recovery, the patient suffered an antegrade dissection of the descending aorta starting at the distal end of the stent graft 10 weeks later, which was successfully treated with additional stent graft placement. Patient 2 also underwent emergency treatment by implantation of two stent grafts for a ruptured aneurysm with hemothorax. After 16 months, the patient presented with new-onset hemothorax because of a type III endoleak between the originally perfectly placed two stent grafts. Emergent deployment of an additional stent graft between the first and second stent was performed successfully. Patient 3 was treated with TEVAR for a symptomatic descending aneurysm with recurrent chest pain. To achieve acceptable fixation of the stent graft because of a short proximal landing zone, a prophylactic left subclavian artery and carotid–carotid bypass was performed. The patient was readmitted to our hospital with a clinical picture of late graft infection 18 months after the endovascular procedure. The infected Dacron grafts were completely removed. However, no ischemic symptoms of the left arm or neurologic sequelae in the vertebrobasilar region were observed. The patient had an uneventful postoperative course. Elective endovascular peripheral extension with a second stent graft insertion was required because of a type IB endoleak after TEVAR for an asymptomatic descending aneurysm in two patients (4, 6) at 43.6 and 8.5 months, respectively.
pain and uncontrollable hypertension. The stent graft intentionally covered the origin of the left subclavian artery to increase the proximal sealing zone. Two months later, steal syndrome in the ipsilateral arm caused by a subtotal stenosis of the origin of the subclavian artery was treated successfully with a stent. Patient 9 was treated with TEVAR for a complicated type B dissection with intractable thoracic pain. After 83 months, he was referred to another hospital with a ruptured aorta below the distal end of the stent graft. The patient required an immediate distal graft extension with two overlapping stent grafts. Patient 10 was primarily treated successfully as an emergency because the acute dissection was complicated with impending rupture and hemothorax. After a five-week follow-up, a second proximal type I endoleak was diagnosed. The proximal endoleak was due to endovascular extension, and two additional stent grafts were successfully placed. Patient 11 was treated with TEVAR for a complicated type B dissection with uncontrollable hypertension. After a 28-month follow-up, an extensive thoracoabdominal aneurysm was present. The patient underwent a staged hybrid repair to minimize operative risk. In the first stage, the patient received a distal graft extension with implantation of one stent graft. An interval open repair of the thoracoabdominal aorta was performed. However, the patient developed permanent paraplegia after the second procedure. Patient 12 was also treated with TEVAR for a complicated type B dissection with intractable thoracic pain. Six weeks after a successful recovery, the patient was admitted to our hospital with sudden-onset chest pain due to delayed retrograde type A dissection into the ascending aorta, which originated from the proximal uncovered part of the stent graft, and surgery was performed under emergency conditions. The patient underwent a supracoronary ascending aortic replacement. Thoracic aortic aneurysms Six patients (two males, four females; mean age, 73.50 5.54 years; range, 68–81 years) were readmit-
TABLE 2 Summary of Six Patients Who Underwent a Secondary Intervention Following Endovascular Thoracic Aortic Repair (TEVAR) for a Thoracic Aortic Aneurysm No.
Patients (Age/Sex)
Indication for Secondary Intervention
Itsi (mo)
Secondary Interventions
Outcome
2.3
Endovascular stent graft placement
Died 63 mo (stroke) Died 58 mo (cardiac failure) Died 55 mo (lung cancer) Alive Died 5 days (cardiac failure) Alive
1
81 F
Antegrade dissection
2
70 M
16
3
80 F
Endoleak type III with contained rupture Infection of carotid-subclavian bypass
4 5
71 F 68 M
Endoleak type IB Impending rupture
43.6 2.3
6
71 F
Endoleak type IB
18
8.5
Itsi (mo), interval between TEVAR and secondary intervention (months).
Emergency endovascular stent graft placement Explanation of subclavian-to-carotid bypass Endovascular stent graft placement Hybrid procedure: arch debranching and stent graft placement Endovascular stent graft placement
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Patient 5 presented with impending rupture of the distal arch 2.3 months after TEVAR for a asymptomatic descending aneurysm and received emergent hybrid repair involving complete arch vessels debranching and endovascular proximal stent graft extension during the same procedure. The patient died five days later due to prolonged cardiac failure.
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the aortic arch seven weeks later. Patient 9 underwent surgery for a type IA endoleak two months after distal graft extension for rupture proximal graft extension. After an additional four months, a CT scan demonstrated a new type III endoleak, which was successfully treated with additional stent graft placement. Thoracic aortic aneurysms
Intramural hematomas A 58-year-old male was initially treated with TEVAR for IMH of the descending thoracic aorta. The patient subsequently underwent coronary artery bypass surgery and replacement of the ascending aorta 41 months later. After an additional 17 months, the patient was readmitted with sudden-onset chest pain. A CT scan demonstrated rupture of the thoracoabdominal aorta at the level of the diaphragm. Emergent removal of the stent graft and a thoracoabdominal aortic replacement with a Dacron prosthesis were performed using left heart bypass. However, the patient died several hours after the procedure due to cardiac failure.
RESULTS Aortic dissection type B The mean interval between TEVAR and the initial secondary procedures was 20.1 27.6 months (range, 1.2–83 months). Secondary interventions were successful in 11 of 12 patients. Treatment failure was seen in Patient 6. All patients were routinely admitted to the surgical intensive care unit postoperatively. The mean length of hospital stay was 17.8 15.6 days (range 1–60 days), and 5.5 7.4 days (range, 1–21 days) in the intensive care unit. Additionally, two cases had further surgical procedures. The first case (Patient 2) required reexploration for bleeding after replacement of the descending aorta. The second case (Patient 5) developed acute limb ischemia after replacement of the thoracoabdominal aorta. The acute extremity ischemia was successfully treated with a prosthesis-femoral artery bypass. Early mortality, defined as either in-hospital or within 30 days, was zero. The mean follow-up after TEVAR was 82.60 41.68 months (range, 25–142 months). Two patients (5 and 11) were lost to follow-up. One nonprocedure-related death was observed during this period. Patient 6 died from renal cell carcinoma 3 years after a failed secondary intervention. Three (25%) patients underwent a total of four reinterventions. Patient 5 presented to our hospital with a clinical picture of a groin infection 12 months after surgical therapy for replacement of the thoracoabdominal aorta and prosthesis-femoral bypass. The prosthesis-femoral Dacron graft was completely removed and an axillofemoral bypass was performed. The followup CT scans of Patient 3 73 months after distal graft extension for a distal type I endoleak revealed a newonset proximal type I endoleak. He underwent revascularization of arch vessels followed by stent grafting of
The mean interval between TEVAR and the first secondary procedures was 15.12 15.44 months (range, 2.3–43.6 months). Early mortality was 16.6% (1/6). Intensive care stay was 4.2 4.1 days (range, 1–12 days), and the mean hospitalization duration was 15.8 6.1 days (range, 10–27 days). The mean follow-up after TEVAR was 69.00 57.48 months (range, 23–99 months). No patient was lost to follow-up. During the follow-up period, one open conversion was performed. Patient 2 had a progressive increase in thoracoabdominal aortic aneurysm size, with a maximal diameter of 10 cm on a follow-up CT scan after successful secondary TEVAR. An elective surgical replacement of the thoracoabdominal aorta was performed 25 months after the secondary TEVAR procedure. Three unrelated deaths were recorded. Patient 1 died from ischemic stroke 63 months after secondary TEVAR. Patient 2 died from congestive cardiac failure 58 months after surgical replacement of the thoracoabdominal aorta. Patient 3 died from lung cancer 55 months after a successful secondary operation. DISCUSSION Two decades after its introduction in the early 1990s, endovascular stent graft placement has become a wellestablished treatment for patients with diverse thoracic aortic pathologies.1–3 Our study confirmed multiple prior reports10–12 of the efficacy of TEVAR, as 19/152 (12.5%) of patients required a secondary intervention at mid-term follow-up. However, with the increasing numbers of interventional thoracic aortic procedures and duration of follow-up, late secondary interventional and surgical procedures for complications after endovascular stent graft placement of the thoracic aorta are increasingly common.12–14 In our series, 12.5% of TEVAR patients required a secondary intervention, consistent with the 5–21% reintervention rates reported recently.7,8 Although both TEVAR and conventional surgical therapy may be associated with similar complications (progressive aneurysm growth or aortic dissection arising from untreated aortic segments), TEVAR is associated with unique complications (endoleak), which may or may not become significant at follow-up. Depending on the nature of the complication, a secondary reintervention can be performed using endovascular techniques. In the present study, 11/19 patients requiring endovascular reintervention had an acceptable indication for endovascular stent grafting, whereas six had indications for surgical repair including aneurismal progression, retrograde type A dissection, acute aortic rupture, and infected graft prosthesis. Two
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received hybrid procedures. Regardless of the approach, secondary interventions after TEVAR were technically feasible and associated with acceptable perioperative morbidity and mortality. Although the late complications of TEVAR have been well described in the literature, limited information regarding the indications for secondary endovascular interventions is available. In our series, an endoleak was the indication for secondary endovascular intervention in 6/19 patients. An endoleak represents the most common complication following endovascular treatment of aortic disease12 with an incidence ranging from 1% to 29% in earlier studies.15–18 Risk factors for development of an endoleak are the presence of a carotid-subclavian bypass, coverage of the left subclavian artery, a larger diameter aneurismal aorta, and extensive aortic coverage with multiple stent grafts.12,15,17 Although endovascular aortic repair is designed to minimize the risk of aortic rupture, persistent endoleak with progressive increase in aneurysm size may unfortunately lead to secondary aortic rupture. However, in our study, late endoleaks with an indication for a reintervention were not uncommon, occurring in six patients. We observed one type III endoleak treated by additional stent graft and five type I endoleaks, of which four were treated successively by an additional stent graft except in one that is still under surveillance after failed endovascular repair. Our experience and that of others consisted of aggressive endovascular techniques for type I and type III endoleaks and observation of type II endoleaks.12,15 The occurrence of (late) endoleak represents one of the major limitations of endovascular treatment and illustrates the need for mandatory lifelong follow-up. Endoleaks may be common and innocuous, whereas retrograde type A dissection (rAAD) is an unusual but potentially lethal complication after TEVAR of the descending aorta. The reported incidence worldwide is 1–2%,14 although a single-center experience involving a relatively small number of interventions reported a rate of 6.8%.19 A recent multicenter study by Eggebrecht et al.20 including 4750 TEVAR procedures performed between 1995 and 2008 revealed a low incidence of rAAD (1.33%) but with an associated mortality of 42%. The observation of this devastating complication not only during or immediately after endovascular treatment but also delayed several months or years after the intervention and the presentation in about 25% of delayed rAAD without symptoms emphasizes the need for a close follow-up examination of these patients. The etiology of retrograde dissection associated with stent graft placement is multifactorial. Possible causes can be classified as procedure or device related, unfavorable aortic-dissection anatomy, patent false lumen, or natural progression of initial aortic disease.21,22 In our study, two patients had a retrograde aortic dissection 1.2 and 3 months, respectively, after successful TEVAR for an acute type B dissection. In the first case, supracoronary ascending aortic replacement in emergency setting was performed on standard cardiopulmonary bypass without circulatory arrest and the stent graft was left in the
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descending aorta. The second case also required emergency open surgery and consisted of complete stent graft removal and replacement of the descending aorta using the left heart bypass technique. The stent graft was adherent to the aortic wall but the entire device could be rather easily removed. This may not always be the case, as a period of circulatory arrest may be necessary to remove those stents that are well incorporated into the vessel wall as reported by Lazar et al.23 The reason for this delayed complication is speculative, but it may have been due to the bare springs of the stent graft device abrading the friable aortic wall in an acute type B dissection. Nevertheless, TEVAR potentially avoids an operation in the setting of a complicated aortic dissection and is designed to achieve false lumen thrombosis, with subsequent expansion of the true lumen and aortic remodeling. In some cases, persistent perfusion in the false lumen leads to progressive aortic dilatation or rupture and represents another limitation of endovascular treatment. Two patients in our series required open surgery, and one hybrid repair was rewired for a progressive increase in the size of a descending aortic aneurysm (in one associated with a type I endoleak) after TEVAR for an acute type B dissection. Risk factors for aneurismal expansion include an initial diameter of >4 cm and a persistent entry into the false lumen.13 Aortic rupture after TEVAR is an uncommon, but a welldescribed, complication in case reports and small series. In most of these cases, rupture is associated with untreated primary or secondary endoleaks.17 We experienced this fatal complication in three of our patients, one of whom survived. Aortic rupture always represents a severe complication, associated with poor clinical outcomes and significant mortality. The fundamental goal of TEVAR is to reduce the risk for rupture, but it is not completely effective in preventing aortic rupture. One of the precursors to aortic rupture after TEVAR may be the accumulation of pressure within the aneurismal sac from a persistent endoleak. Future research designed to identify increased pressure may help prevent this complication.24 In our study, we did not see the phenomenon of ‘‘endovascular collapses.’’ This potentially devastating complication of total or near total stent graft collapse has been reported in association with TEVAR, most frequently for thoracic trauma and rarely for thoracic aneurysms.25 Anatomic factors that may predispose to this phenomenon are small aortic diameters and a steeply angulated arch, a problem most common in young patients, involved in trauma but also technical considerations such as proximal thoracic aortic implanted stent grafts and an excessive oversizing may contribute to the development of collapse.25,26 Today, TEVAR is a therapeutic option with particular benefit for complicated acute type B dissection, ruptured descending aortic aneurysm, or traumatic aortic transactions.27,28 A certain proportion of patients will require reintervention during mid- to long-term follow-up. Although some patients are amenable to repeat endovascular therapy, conventional surgical therapy still represents the optimal therapy for some
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patients. In our experience, two deaths occurred after conventional surgery and after hybrid repair under emergency conditions, underscoring the fact that postoperative clinical and radiological surveillance is essential to recognize adverse morphologic changes and procedure-related complications after successful thoracic aortic endovascular therapy. A risk reduction in these cases can, in all probability, be achieved only by exact timing of the reintervention procedure. The limitations of this study include those inherent to a single-center, retrospective series. The small sample size and varied pathologies of the thoracic aorta did not allow us to draw statistically significant conclusions from our results. Although the endovascular stent placement method has revolutionized aortic surgery, current experience is still largely limited to midterm results. Longer-term studies for this evolving technology are required. CONCLUSION Endovascular stent graft implantation has become the preferred approach for various pathologies of the descending thoracic aorta. However, multiple procedure-related complications may develop over time, emphasizing the importance of continued aortic surveillance to determine the need for secondary endovascular or conventional surgical interventions. Although secondary interventions can be performed safely and successfully, optimal patient selection, advances in graft design, and a careful and precise intervention technique remain essential. The need for conventional surgical therapy cannot be avoided completely. REFERENCES 1. Dake MD, Miller DC, Semba CP, et al: Transluminal placement of endovascular stentgrafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994;331:1729–1734. 2. Dake MD, Kato N, Mitchell RS, et al: Endovascular stentgraft placement for the treatment of acute aortic dissection. N Engl J Med 1999;340:1546–1552. 3. Svensson LG, Kouchoukos NT, Miller DC, et al: Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thorac Surg 2008;85(1 Suppl):1–41. 4. Gopaldas RR, Huh J, Dao TK, et al: Superior nationwide outcomes of endovascular versus open repair for isolated descending thoracic aortic aneurysm in 11,669 patients. J Thorac Cardiovasc Surg 2010;140(5):1001–1010. 5. Cheng D, Martin J, Shennib H, et al: Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease: A systematic review and meta-analysis of comparative studies. J Am Coll Cardiol 2010;55(10):986– 1001. 6. Pamler RS, Kotsis T, Gorich J, et al: Complications after endovascular repair of type B aortic dissection. J Endovasc Ther 2002;9:822–828. 7. Geisb@ usch P, Hoffmann S, Kotelis D, et al: Reinterventions during midterm follow-up after endovascular treatment of thoracic aortic disease. J Vasc Surg 2011;53(6):1528– 1533.
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8. Dumfarth J, Michel M, Schmidli J, et al: Mechanisms of failure and outcome of secondary surgical interventions after thoracic endovascular aortic repair (TEVAR). Ann Thorac Surg 2011;91:1141–1146. 9. Walterbusch G, Fro¨mke J, Sydow M: A simple method to reduce ischemic time of the spinal cord in extensive thoracoabdominal aneurysm operations. Thorac Cardiovasc Surg 2003;51(1):46–48. 10. Grabenwoger M, Fleck T, Ehrlich MP, et al: Secondary surgical interventions after endovascular stent-grafting of the thoracic aorta. Eur J Cardiothorac Surg 2004;26:608– 613. 11. Czerny M, Funovics M, Sodeck G, et al: Long-term results of thoracic endovascular aortic repair in atherosclerotic aneurysms involving the descending aorta. J Thorac Cardiovasc Surg 2010;140(Suppl):S179–S184. 12. Parmer SS, Carpenter JP, Stavropoulos SW, et al: Endoleaks after endovascular repair of thoracic aortic aneurysms. J Vasc Surg 2006;44:447–452. 13. Boeckler D, Schuhmacher H, Ganten M, et al: Complications after endovascular repair of acute symptomatic and chronic expanding Stanford type B aortic dissections. J Thorac Cardiovasc Surg 2006;132:361–368. 14. Girdauskas E, Falk V, Kuntze T, et al: Secondary surgical procedures after endovascular stent grafting of the thoracic aorta: Successful approaches to a challenging clinical problem. J Thorac Cardiovasc Surg 2008;136(5): 1289–1294. 15. Morales JP, Greenberg RK, Lu Q, et al: Endoleaks following endovascular repair of thoracic aortic aneurysm: Etiology and outcomes. J Endovasc Ther 2008;15(6):631– 638. 16. Preventza O, Wheatley GH III, Ramaiah VG, et al: Management of endoleaks associated with endovascular treatment of descending thoracic aortic diseases. J Vasc Surg 2008;48(1):69–73. 17. Piffaretti G, Mariscalco G, Lomazzi C, et al: Predictive factors for endoleaks after thoracic aortic aneurysm endograft repair. J Thorac Cardiovasc Surg 2009;138(4):880–885. 18. Orend KH, Scharrer-Pamler R, Kapfer X, et al: Endovascular treatment in diseases of the descending thoracic aorta: 6-Year results of a single center. J Vasc Surg 2003; 37(1):91–99. 19. Neuhauser B, Czermak BV, Fish J, et al: Type A dissection following endovascular thoracic aortic stent graft repair. J Endovasc Ther 2005;12:74–81. 20. Eggebrecht H, Thompson M, Rousseau H, et al: Retrograde ascending aortic dissection during or after thoracic aortic stent graft placement: Insight from the European registry on endovascular aortic repair complications. Circulation 2009;120(11 Suppl):276–281. 21. Fattori R, Lovato L, Buttazzi K, et al: Extension of dissection in stent graft treatment of type B aortic dissection: Lessons learned from endovascular experience. J Endovasc Ther 2005;12:306–311. 22. Kpodonu J, Preventza O, Ramaiah VG, et al: Retrograde type A dissection after endovascular stenting of the descending thoracic aorta. Is the risk real? Eur J Cardiothorac Surg 2008;33:1014–1018. 23. Lazar HL, Varma PK, Shapira OM, et al: Endograft collapse after thoracic stent-graft repair for traumatic rupture. Ann Thorac Surg 2009;87(5):1582–1583. 24. Parsa CJ, Daneshman MA, Lima B, et al: Utility of remote wireless pressure sensing for endovascular leak detection after endovascular thoracic aneurysm repair. Ann Thorac Surg 2010;89(2):446–452.
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25. Muhs BE, Balm R, White GH, et al: Anatomic factors associated with acute endograft collapse after Gore TAG treatment of thoracic aortic dissection or traumatic rupture. J Vasc Surg 2007;45: 655–661. 26. Jonker FH, Schlosser FJ, Geirsson A, et al: Endograft collapse after thoracic endovascular aortic repair. J Endovasc Ther. 2010;17(6):725–734.
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