Single-stage thoracic and abdominal endovascular aneurysm repair for multilevel aortic disease

Abstract

This investigation evaluated the results of single-stage thoracic endovascular aneurysm repair (TEVAR) and endovascular aneurysm repair (EVAR) for multilevel aortic disease in a series of nine patients. The lesions repaired included thoracic and abdominal aortic aneurysms (n = 7) and subacute type B dissections with abdominal aortic aneurysms (n = 2). All procedures were successfully performed, and none of the patients experienced postoperative stroke or spinal cord ischemia. The median follow-up period for these patients was 18.9 months (range 1.7–31.4 months) and none of the patients exhibited any signs of type I endoleaks or aneurysmal diameter enlargements more than 5 mm. In conclusion, single-stage TEVAR and EVAR procedures for multilevel aortic disease were found to be safe and feasible modalities for high-risk patients.

Keywords

single-stage operation TEVAR EVAR multilevel aortic disease spinal cord ischemia

Introduction

Multilevel aortic disease (multiple aortic aneurysms or abdominal aortic aneurysms in combination with type B aortic dissections) is often encountered. In fact, several investigations have reported that 10–20% of patients with thoracic aortic aneurysms have a concomitant abdominal aortic aneurysm,^1,2 and type B aortic dissection and abdominal aortic aneurysm sometimes present together.^3,4

Historically, two-stage, open surgery has been recommended for the repair of multilevel aortic disease. The development of endovascular stent-graft technologies, however, have provided a number of advantages that allow for the now common single-stage procedures of simultaneous thoracic endovascular aneurysm repair (TEVAR) and open abdominal aortic aneurysm repair.^5–7 To date, single-stage TEVAR and endovascular aneurysm repair (EVAR) procedures are being performed only at a few institutions.^2,8,9 A review of the literature indicated that only 13 cases from three institutions have been reported. The largest case series among these reports examined eight patients,⁹ while the other two institutions reported one and four cases.^2,8 The more widespread use of these procedures appears to be limited due to the apparent risk of the development of paraplegia. Therefore, this case series is presented to report our experience with single-stage TEVAR and EVAR in patients with multilevel aortic disease.

Methods

Between December 2007 and September 2011, nine patients underwent single-stage TEVAR and EVAR for multilevel aortic disease in our hospital. Patients with thoraco-abdominal aortic aneurysms were specifically excluded. The patient population comprised eight men and one woman with a median age of 78 years (range, 57–83 years). All the patients had significant co-morbidities, including hypertension (n = 9), a history of smoking (n = 7), hypercholesterolemia (n = 6), a history of ischemic heart disease (n = 3), stroke (n = 2), chronic kidney disease (n = 3), diabetes mellitus (n = 2) and chronic obstructive pulmonary disease (n = 1). After surgery, the median follow-up period was 18.9 months (range, 1.7–31.4 months).

Seven patients were diagnosed with thoracic and abdominal aortic aneurysms. The remaining two patients were diagnosed with subacute type B dissections and abdominal aortic aneurysms; both patients also had renal dysfunction due to malperfusion of renal artery. The median diameter of the thoracic aortic aneurysms was 60 mm (range, 42–80 mm). All of the abdominal aortic aneurysms were infra-renal, with a median aneurysmal diameter of 50 mm (range, 45–68 mm; Table 1). In addition to aneurysmal diameters, the morphology of the aneurysms, the patient's condition and other complications were also considered, resulting in the single-stage procedure being chosen as the most desirable approach for the patients in this series.

Table 1

Type and diameter of thoracic and abdominal aortic lesions

		Thoracic		Abdominal
Patient	Age/sex	Type	Diameter(mm)	Type	Diameter(mm)
1	57/M	TAA (Distal arch)	80	AAA	55
2	78/M	TAA (Distal arch)	65	AAA	50
3	83/M	TAA (Prox. descend)	75	AAA	50
4	79/F	TAA (Distal arch)	60	AAA	54
5	78/M	TAA (Descend)	45 (Sac)	AAA	48
6	75/M	PAU (Distal arch)	46 (Sac)	AAA	45
7	66/M	PAU (Descend)	42 (Sac)	AAA	49
8	83/M	Subacute type B dissection (complicated)		AAA	53
9	68/M	Subacute type B dissection (complicated)		AAA	68
Median	78		60		50
(Range)	(57–83)		(42–80)		(45–68)

TAA, thoracic aortic aneurysm; Prox., proximal; AAA, abdominal aortic aneurysm; PAU, penetrating aortic ulcer; Sac, saccular aneurysm; LCIA, left common iliac artery aneurysm

A debranching bypass was necessary in two patients prior to TEVAR and EVAR, in order to create a sufficient landing zone for graft placement. Right subclavian artery bypass to the left common carotid artery and left subclavian artery bypass were performed in one patient with a distal arch aneurysm wherein the landing zone to the left common carotid artery was less than 2 cm. The left subclavian artery was preserved because of an insufficient formation of the circle of Willis, assessed by preoperative magnetic resonance imaging evaluation, thus avoiding the simultaneous occlusion of the subclavian artery and the ipsilateral internal iliac artery (Figure 1). A left common carotid to left subclavian artery bypass was also carried out to preserve the coronary artery bypass flow (left internal mammary artery to left anterior descending coronary artery) in the second patient (Figure 2).

Figure 1

Pre- and postoperative cross-sectional (a, b, e, f) and three-dimensional (c, d) computed tomograms. Right subclavian artery to left common carotid artery and left subclavian artery bypasses were performed first (d, arrow), followed by endovascular grafting to preserve left common carotid artery and left subclavian artery

Figure 2

Pre- and postoperative cross-sectional (a, b, e, f) and three-dimensional (c, d) computed tomograms. Left common carotid artery to left subclavian artery bypass was performed first (d, arrow), followed by endovascular grafting to preserve left subclavian artery (left internal thoracic artery)

Intraoperative somatosensory and motor evoked potentials were not monitored, and cerebrospinal fluid (CSF) drainage was not carried out in any of the cases.

Seven TAG (W L Gore and Associates, Flagstaff, AZ, USA), one Najuta (Kawasumi Laboratories, Tokyo, Japan) and one Zenith TX2 (Cook Medical, Bloomington, IN, USA) stent-grafts were used for TEVAR, and six Excluder (W L Gore and Associates), two Zenith (Cook Medical) and one Powerlink (Endologix, Irvine, CA, USA) stent-grafts were used for EVAR. The median number of thoracic stent-grafts was 2 (range, 1–2 grafts).

All TEVAR and EVAR procedures were carried out through the femoral artery approach. Simple coverage of the left subclavian artery was performed in two patients. The unilateral internal iliac artery was embolized with metallic coils in two patients, and the bilateral internal iliac artery was occluded in one patients. None of the patients underwent simultaneous occlusion of the left subclavian artery and the ipsilateral internal iliac artery. The Adamkiewicz artery, located between the eighth and the 12th thoracic vertebrae, was simply covered with TEVAR in three patients to obtain the adequate landing zone (Table 2).

Table 2

Devices and operative procedures

No.	Type	Graft(thoracic)	Graft(abdominal)	Debranching	LSCAocclusion	IIAocclusion	Adamkiewiczocclusion
1	TAA (Distal arch)	TAG	Excluder	RSCA-LCCA-LSCA	–	• (U/L)	–
	AAA
2	TAA (Distal arch)	Najuta	Excluder	LCCA-LSCA	–	–	–
	AAA
3	TAA (Prox. descend)	TAG	Powerlink	–	–	–	–
	AAA
4	TAA (Distal arch)	TAG	Excluder	–	•	–	–
	AAA
5	TAA (Descend)	TX2	Zenith	–	–	• (B/L)	•
	AAA
6	PAU (Distal arch)	TAG	Excluder	–	•	–	•
	AAA
7	PAU (Descend)	TAG	Excluder	–	–	• (U/L)	•
	AAA+LCIA
8	Subacute type B dissection	TAG	Excluder	–	–	–	–
	AAA
9	Subacute type B dissection	TAG	Zenith	–	–	–	–
	AAA

SCA, subclavian artery; CCA, common carotid artery; IIA, internal iliac artery; U/L, unilateral; B/L, bilateral; LCIA, left common iliac artery aneurysm; RSCA, right subclavian artery; LCCA, left common carotid artery; LSCA, left subclavian artery

Results

The technical success rate of these procedures was 100%. The median operation time was 186 minutes (range, 131–295 minutes), and the median intraoperative blood loss was 100 g (range, 0–400 g). All patients required an overnight stay in the intensive care unit, and the patients had a median postoperative hospital stay of 13 days (range, 7–21 days).

Side-effects of the procedures were noted in three patients. One patient developed renal dysfunction (peak creatinine level, 2.47 mg/dL; preoperative level, 1.55 mg/dL), but dialysis was not required. The second patient, with a chronic type B dissection, developed consumption coagulopathy (reduced platelet counts and anemia) due to the rapid thrombosis of the false lumen. The third patient developed an allergic reaction to the contrast dye after postoperative computed tomography (CT) angiography. After conservative therapy, these three patients were able to leave the hospital on postoperative days 19, 21 and 17, respectively. None of the patients experienced postoperative stroke or paraplegia.

During the follow-up period, none of the patients demonstrated type I endoleaks. Type II endoleaks from the lumbar artery were observed in only two patients. CT angiography revealed shrinkage of the thoracic aneurysms by more than 5 mm in three patients and no change in four others. Two patients demonstrated an increase in the size of their aneurysms, but this expansion was less than 5 mm. In the complicated cases involving subacute type B dissections with renal dysfunction, a false lumen was completely thrombosed, and shrinkage was seen in both cases. In addition, renal function improvement was achieved in both patients, along with a decline in serum creatinine levels from 3.20 to 1.57 mg/dL in one patient and from 2.11 to 1.88 mg/dL in the other. Among the abdominal aneurysms, aneurysmal shrinkage of more than 5 mm occurred in three patients, and no changes were seen in six patients. No aneurysmal expansion (Table 3) was seen in any of the patients, and no aneurysm-related re-interventions or subsequent deaths occurred.

Table 3

The early and mid-term results of single-phase surgery

No.	Type	Op. time(minutes)	Bloodloss (g)	Hospitalstay (day)	f/u period(months)	Endoleak		Diameter (mm)
1	TAA (Distal arch)	235	110	13	18.4	TAA	–	TAA	80→57
	AAA					AAA	–	AAA	55→39
2	TAA (Distal arch)	186	200	10	18.6	TAA	–	TAA	65→56
	AAA					AAA	–	AAA	50→39
3	TAA (Prox. Descend)	131	100	19	19.4	TAA	–	TAA	75→70
	AAA					AAA	Type II	AAA	50→46
4	TAA (Distal arch)	201	100	7	18.9	TAA	–	TAA	60→51
	AAA					AAA	Type II	AAA	54→53
5	TAA (Descend)	173	190	17	1.7	TAA	–	TAA	45→45
	AAA					AAA	–	AAA	48→48
6	PAU (Distal arch)	295	400	7	25	PAU	–	PAU	46→45
	AAA					AAA	–	AAA	45→32
7	PAU (Descend)	168	50	21	22.2	PAU	–	PAU	42→37
	AAA+LCIA					AAA	–	AAA	49→48
8	Subacute type B dissection	176	0	14	31.4	False lumen	–	False lumen	Disappeared
	AAA					AAA	–	AAA	53→58
9	Subacute type B dissection	140	50	7	3.5	False lumen	–	False lumen	Disappeared
	AAA					AAA	–	AAA	68→68
Median		186	100	13	18.9
(Range)		(131–295)	(0–400)	(7–21)	(1.7–31.4)

Op., operation; TAA, thoracic aortic aneurysm; AAA, abdominal aortic aneurysm; PAU, penetrating aortic ulcer; LCIA, left common iliac artery aneurysm

Discussion

There is no consensus on whether one- or two-stage surgery is the optimal therapeutic strategy for multilevel aortic disease. In single-stage surgery, the danger of a residual aneurysm rupture is significantly less in comparison to two-stage surgery, in which the patient must wait a considerable period prior to undergoing the second procedure. Simultaneous operations also result in a shortening of the operative time, avoidance of the need for two episodes of general anesthesia and shortening of the postoperative hospital stay. Therefore, single-stage TEVAR and EVAR may subject the patients to less intraoperative risk as compared with two-stage surgeries. However, the single-stage TEVAR and EVAR strategy may pose a risk for the development of postoperative paraplegia, in spite of several reports failing to demonstrate an association between spinal cord ischemia and single-stage TEVAR and EVAR surgeries.^2,8–10

The mechanism involved in the development of postoperative paraplegia remains unclear, although spinal cord ischemia and reperfusion injury are believed to be causative factors.¹¹ Some reports have indicated that TEVAR produces a lower risk for inducing paraplegia compared with conventional open surgery.¹² However, low blood pressure after TEVAR in cases of abdominal aortic aneurysm open repair, wide-ranging stent graft placement, internal iliac artery occlusion, subclavian artery occlusion and renal failure have been associated with an increased incidence of postoperative paraplegia.^13–15 The 2007 EUROSTAR Registry reported that the risk for paraplegia was extremely high in patients with a history of abdominal aortic aneurysm surgery (odds ratio [OR], 5.5; P = 0.0371), usage of more than three stent grafts (OR, 3.5; P = 0.0428), left subclavian artery occlusion (OR, 5.5; P = 0.0274) and renal failure (OR, 3.6; P = 0.0215).¹⁶ Single-stage TEVAR and EVAR procedures may negatively affect collateral circulation, such as the intercostal artery, lumbar artery and internal iliac artery to the spinal cord, unlike TEVAR alone.

Based on the collateral network concept proposed by Griepp and Griepp,¹⁷ the most important consideration for the prevention of spinal cord ischemia is the maintenance of high spinal reflux pressure and maintenance of collateral arterial flow. Accordingly, when carrying out single-stage TEVAR and EVAR, the simultaneous occlusion of the left subclavian artery and internal iliac arteries should be avoided due to the high probability of reducing the arterial flow to the spinal cord through the formation of a collateral network.

For cases in which the left subclavian artery and internal iliac arteries must be simultaneously occluded in order to create an appropriately sized landing zone, the left subclavian arterial flow can be maintained by using a debranching bypass or chimney technique. Furthermore, low blood pressure during the perioperative period can be avoided by strict monitoring of blood pressure until the absence of paraplegia is confirmed; we attempted to maintain a systolic blood pressure of 150 mmHg or more. Moreover, according to reports by Chiesa et al.,¹⁸ the risk for paraplegia is considered particularly high when the mean perioperative arterial pressure is <70 mmHg. Therefore, we attempted to maintain both an elevated systolic blood pressure and a mean arterial pressure above 75 mmHg. In cases involving more than three stent-grafts covering the left subclavian artery and the internal iliac artery, and in cases with preoperative renal dysfunction, the perioperative blood pressure management is the most important factor for preventing paraplegia.

Some reports have also shown the efficacy of CSF drainage to minimize paraplegia.^14,18 As a result, we planned to place CSF drains if any patient developed paraplegia; however, none of the patients in this case series developed the condition.

In cases without an anatomically sufficient landing zone, a fundamental rule requires that debranching bypasses be performed prior to carrying out TEVAR and EVAR. If the debranching bypass is performed simultaneously with TEVAR and EVAR, it is difficult to determine which procedure directly induces stroke, renal infarction or superior mesenteric artery thrombosis. However, with new devices, such as the fenestrated or branched stent grafts, TEVAR and EVAR may, in the near future, be performed without the use of either the debranching bypass or chimney technique.

Conclusion

Single-stage TEVAR and EVAR for multilevel aortic disease were found to be safe and feasible in this small series. In particular, it did not cause postoperative paraplegia. We believe that our results will encourage further investigation and lead to this procedure becoming a treatment of choice for high-risk patients.

Footnotes

Acknowledgements

Grant support: None.

Conflicts of interest: None.

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