Trans-abdominal stent repair of thoraco-abdominal aneurysms

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Dr Nick Cheshire, St Mary’s Hospital, London, UK, presented a paper at the SVS annual meeting regarding a new trans-abdominal stent repair of thoraco-abdominal aneurysms with surgical revisualisation of the visceral and renal arteries.

A research team performed a prospective review of 25 patients between January 2002 and January 2005. There were 20 elective patients, three urgent and two emergency, with an average age of 74 (range 37-81). Patients presented with Crawford Type I (three), Type II (14), Type III (7) and Type IV (one). Previous aortic surgery had been performed in 48% of patients (12/25) and included: aortic valve and root replacement (two), Type I repair (one), Type IV repair (one), Type B dissection (two), infrarenal aneurysm (five) and R common iliac aneurysm (one).

Significant preoperative co-morbidity was present in 80% of patients (20/25): chronic renal impairment (four), severe COPD (six), Myocardial disease (10), NYHA grade II (five), grade III (five), and five had Marfan’s syndrome. A total of 22 patients (88%) had a completed procedure, whilst myocardial instability prevented completion of the procedure despite extensive preoperative cardiac assessment in three patients.

Exclusion of the full Thoraco abdominal aorta was achieved in all 22 completed procedures, and extended to include the iliac arteries in four patients, with revascularisation of coeliac (22), SMA (22), L renal (17), R renal (18).

The researchers reported no paraplegia within 30 days or during inpatient admission and elective mortality was 17.6% (3/17). Major complications included: prolonged respiratory support (>5 days) (nine), inotropic support (four), renal impairment requiring temporary support (two) and not requiring support (two); prolonged ileus (two); resolving left hemispheric stroke (one) and resection of ischaemic left colon (one). Average blood loss was 3.9L (range 1.2 – 13) and average ischaemia time for SMA & coeliac was 15 minutes (range 13-27) and 15 minutes for the renals. The average length of hospital stay was 27 days (range 16-84). The average follow-up is eight months (range 2-28) with 77/ 80 grafts patent.

A total of six patients were found to have a Type I endoleak. In four patients this was a proximal leak and stent extension and was reduced in three patients, but did not cure the endoleak. Two patients with distal Type I endoleak are awaiting further intervention. A single Type II endoleak was resolved and a single Type III endoleak was found.

Early results of visceral hybrid stent-grafts for thoraco-abdominal aneurysms are encouraging with reduced mortality and no paraplegia in this particularly high-risk group of patients. The researchers said that the results have encouraged them to perform the new procedure in preference to open surgery, in Crawford Type I, II and III thoraco-abdominal aortic aneurysms.

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