CX Aortic Vienna: Presenters advocate for patient-tailored approach in thoracoabdominal procedures

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Day three of CX Aortic Vienna Digital Edition (24–26 October) gave airtime to risk prediction and management for thoracoabdominal aortic aneurysm (TAAA) procedures. Presentations focused specifically on the “shaggy” aorta and spinal cord ischaemia post-thoracic endovascular aortic repair (TEVAR), among other clinical scenarios. The speakers recommended careful choice of procedure and prevention strategies tailored to the patient—one of the session’s main take-home messages.

Luca Bertoglio (Milan, Italy), who also moderated the session, centred his presentation around the use of “different strategies according to the distal pathology extension” when undertaking distal aortic repair after frozen elephant trunk (FET). In the case of descending thoracic distal extension, he noted, “the aim [is] to fix the entire thoracic aorta”. This involves “[prolonging] the FET” and thus “[addressing] the thoracoabdominal type I or the thoracoabdominal descending aneurysm with a simple TEVAR”.

Left to right: Roger Greenhalgh, Heinz Jakob, Luca Bertoglio

However, if there is a post-dissection aneurysm, Bertoglio relayed that it is key to proceed quickly which can be “easily” achieved with an endovascular approach. Also important to remember, the presenter added, is that “if the patient is fit for open surgery, you can address any aetiology this way”.

In instances of elective endovascular repair, Bertoglio advocates for a “staged approach”, comprising “progressive thrombosis of intercostal and lumbar arteries to reduce the risk of spinal cord ischaemia [SCI]”.

A study carried out at Bertoglio’s centre, Ospedale San Raffaele, yielded results this year, of which a takeaway was that “endovascular and open repair of the downstream aorta after the FET procedure show similarly good midterm clinical success and survival rates”. With this in mind, the presenter concluded that “FET is an optimal solution when any kind of distal thoracic procedures are planned”. Additionally, Bertoglio asserted that one should “tailor the approach to different morbidities”, meaning that “a multidisciplinary approach is key to improving results and planning tailored solutions,” reminding delegates that “different distal open and endovascular solutions are available.”

Anchor Roger Greenhalgh (London, United Kingdom) probed Bertoglio on the feasibility of offering both endovascular and open procedures at a given centre. The presenter delivered his verdict that “an endovascular solution can be given in all centres”, and is more of a “one-man show” during the operation itself. Open surgery, however, is best left to high-volume centres, as it is a more complex, “team approach”.

Bijan Modarai (London, United Kingdom) also addressed the risk of SCI in his presentation, which, when occurring post-TEVAR can cause paraplegia. “This can have a profound effect on the patient’s quality of life and often leads to premature death,” Modarai elaborated, underlining why prevention should be a priority.

The presenter took the time to share a predictor of SCI post-TEVAR—endograft coverage >20cm of the descending thoracic aorta—adding that there is evidence pointing to the artery of Adamkiewicz being present in one in eight SCI cases. Yet, greater aortic coverage has been shown to reduce rates of distal reintervention.

Modarai proceeded to acknowledge that paraplegia rates are lower with bare stents compared to covered thoracic endografts only, but that this does not preclude the importance of “judicious use of different stent design to minimise coverage in the descending thoracic aorta”.

To conclude, Modarai stated that while evidence suggests “that SCI rates are decreasing, scrutiny of anatomy and the repair strategy is important.” Cerebral spinal fluid drainage as a means of reducing likelihood of SCI is “of questionable value”, he clarified, adding during subsequent discussion that he is using drainage less and less, due to complications risk. Nevertheless, “failure to rescue” via this method where necessary may “lead to paraplegia”, and so it is key to undertake this intervention in “high-risk” situations.

Tailoring the approach to the specific patient and anatomy was a message that Germano Melissano (Milan, Italy) also homed in on in his presentation on how “shagginess” of the aorta is associated with adverse events post-TAAA surgery. This can occur in the peripheral, renal and visceral arteries, as well as those in the brain, and the spinal cord.

Above L to R: Roger Greenhalgh, Heinz Jakob, Luca Bertoglio; Below: Bijan Modarai, Germano Melissano, Ali Azizzadeh

The presenter then referenced a study in which 55.2% of patients with shaggy aorta (n=114) experienced liver, kidney or spleen infarction after an endovascular TAAA procedure. He noted that it is “still not accepted”, however, that “shagginess is as important” following open TAAA surgery.

There are a “number of prevention strategies” for the risks associated with both endovascular and open TAAA procedures, Melissano shared, underlining that deciding which to employ depends on the specific case. For example, filters may be used during endovascular procedures, whereas for open surgery, “clamping the visceral arteries before the aorta is clamped” is an option.

Melissano then advised the audience on the statement that embolisation affects earlier and longer-term outcomes and that “despite different prevention strategies”, embolisation rate should still be borne in mind during open repair too. “Better strategies and cautious patient selection is needed”, was the presenter’s parting remark. Modarai concurred, questioning the availability of stabilising treatments for the clots associated with the shaggy aorta, accentuating the high-risk nature of this anatomical irregularity.

Tilo Kölbel (Hamburg, Germany) also covered TAAA, presenting an edited case of branched repair using transfemoral access with the use of the electrified wire technique in a 76-year-old male. Kölbel talked the audience through his access of false lumen for the right renal artery branch, before opining that transfemoral access for branched TAAA repair offers “a high technical success rate, faster procedure time, and a lower stroke and access-related complications rate.”

Bertoglio ventured, in response to Kölbel’s presentation, that there might be a need for “dedicated stents because not all stents can be used in this configuration”.

TEVAR featured further in the session, with Ali Azizzadeh (Los Angeles, United States) presenting on the global registry for endovascular aortic treatment (GREAT). Designed to examine whether there is a “significant difference in long-term survival after TEVAR” for type B aortic dissection patients versus those with aneurysm, Azizzadeh pointed to some of the key findings.

A the 755-strong cohort, 59% had aneurysm, 23% acute dissection, and 18% chronic dissection. The aneurysm group was “significantly older” with a “higher proportion of women” and “more baseline disease”, including cancer and diabetes, Azizzadeh elucidated.

However, despite this the primary endpoints of stroke and SCI occurred at comparable rates across the three groups. The differences were observed, the presenter went on, when it came to five-year survival, which was 75.2% for chronic dissection, 67.7% for acute dissection and 54.7% for aneurysm.

Azizzadeh left delegates with the following summary of the registry’s findings: “Despite markedly higher rates of comorbidities among aneurysms compared to dissections, short-term complication rates are low and do not differ among pathologies. Long term, patients with aneurysm have higher mortality than those with dissection, even after accounting for major morbidity.”


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