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Totally Endovascular Thoracoabdominal Aneurysm Repair

Timothy A M Chuter¹, David Hartley², Joseph H Rapp¹, Darren B Schneider¹, Jade S Hiramoto¹, Linda M Reilly.^1
1UCSF, San Francisco, CA; ²Cook Australia Research Laboratory, Perth, Australia.

OBJECTIVES: We report totally endovascular thoracoabdominal aortic aneurysm repair using a modular stent-graft with multiple caudally-directed branches to the visceral arteries.

METHODS: We used self-expanding covered stents to connect the caudally-directed cuffs of an aortic stent-graft with the visceral branches of an aortic aneurysm in 16 patients (11 men, 5 women, mean age 77±8 years). All patients were unfit for open repair; 7 had undergone prior aortic surgery. Customized aortic stent-grafts were inserted through surgically exposed femoral (N=12) or iliac (N=4) arteries, while covered stents were inserted through surgically exposed brachial arteries. Spinal catheters were used for CSF pressure monitoring (N=16) and spinal anesthesia (N=10). 6 patients had general anesthesia. Routine follow-up included contrast enhanced CT at 1 week, 1 month, 6 months and 12 months.

RESULTS: The stent-grafts were successfully deployed in all 16 patients, covering 78+15% of total aortic length (from the subclavian orifice to the bifurcation) and involving 57 visceral branches. Four (25%) patients had significant perioperative complications. Two patients, both with severe longstanding COPD, developed pneumonia. One patient developed paraplegia and renal failure, and died after declining dialysis. One patient underwent successful re-intervention for iatrogenic aortic dissection and for Type 1 endoleak. There were no other deaths, complications, re-interventions, or endoleaks. No patient had a stroke, or myocardial infarction. Two patients experienced transient lower extremity weakness during periods of relative hypotension. One renal artery occluded within a month of stent-graft implantation. The only notable events during follow-up (mean 180+78 days) were 1 death from chronic pulmonary disease and 1 case of superior mesenteric artery stenosis (50%) 6 months after stent-graft implantation. All the other branches (98.2%) are widely patent, all the aneurysms are excluded and all the stent-grafts are intact.

CONCLUSIONS: Multi-branched stent-graft implantation eliminates aneurysm flow, preserves visceral perfusion and avoids many of the physiologic stresses associated with other forms of repair. The results support an expanded role for this technique in the treatment of TAAA.