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International Angiology 2003 June;22(2):125-33


language: English

Treatment of thoracoabdominal aortic aneurysms with a combined endovascular and surgical approach

Kotsis T., Scharrer-Palmer R., Kapfer X., Liewald F., Gorich J., Sunder-Plassmann L., Orend K. H.

Department of Thoracic and Vascular Surgery, University of Ulm, Ulm, Germany


Aim. The con­ven­tion­al ­approach for the ­repair of thor­a­coab­dom­i­nal aneu­rysms ­remains com­plex and demand­ing and is asso­ciat­ed with sub­stan­tial mor­bid­ity and mor­tal­ity. More­over, in cases of reop­er­a­tion the ­impact can be dra­mat­ic ­either in sur­vi­val or in qual­ity of life of the ­patients, ­albeit the use of ­adjuncts. A com­bined endo­vas­cu­lar and sur­gi­cal ­approach with ret­ro­grade per­fu­sion of vis­cer­al and renal ves­sels has been real­ized in order to min­i­mize intra­op­er­a­tive and post­op­er­a­tive com­pli­ca­tions.
Methods. With­in an expe­ri­ence of 231 aor­tic stent-­grafts ­between 1995-2000, 4 of the ­patients with thor­a­coab­dom­i­nal aneu­rysms were treat­ed with a com­bined endo­vas­cu­lar and sur­gi­cal ­approach. Three pro­ce­dures were elec­tive­ly con­duct­ed and 1 on emer­gen­cy basis. Two women, 59 and 68 years old, and 2 men, 68 and 73 years old (max­i­mum ­aneurysm’s diam­e­ter was 10, 6, 8 and 9 cm, respec­tive­ly) were oper­at­ed with the com­bined meth­od (the first 2 ­patients had a pre­vi­ous open ­repair of a thor­a­coab­dom­i­nal aneu­rysm). The sur­gi­cal ­approach was exe­cut­ed in all ­patients with­out thor­a­cot­o­my or re-do ret­ro­per­i­to­neal expo­sure. Revas­cu­lar­iza­tion of renal, super­i­or mes­en­ter­ic (and ­celiac in 2 cases) arter­ies was accom­plished via trans­per­it­o­neal bypass graft­ing. Aneu­rys­mal exclu­sion was per­formed by stent-graft deploy­ment.
­Results. The ­entire pro­ce­dure was tech­ni­cal­ly suc­cess­ful in all ­patients. The 1st ­patient was dis­charged 6 weeks after the oper­a­tion, while the postop­e­rative stud­ies ­revealed the paten­cy of the ves­sels and no evi­dence of leak or sec­on­dary rup­ture of the aneu­rysm; the ­patient died 3 ­months after the ­repair, due to rup­ture of an aneu­rysm of the ascend­ing aorta. In the 2nd ­patient, 30 ­months after the oper­a­tion, spi­ral-CT scan­ning ­revealed dis­tinct shrink­age of the aneu­rysm, no graft migra­tion or endo­leak and paten­cy of all revas­cu­lar­ized ves­sels. The 3rd ­patient died on the 6th post­op­er­a­tive day due to mul­ti­or­gan fail­ure after hav­ing devel­oped ischem­ic-relat­ed pan­crea­titis, ­albeit the suc­cess­ful com­bined ­repair. The 4th ­patient fol­lowed an unevent­ful ­course. No ­patient expe­ri­enced any tem­po­rary or per­ma­nent neu­ro­log­i­cal def­i­cit.
Conclusion. The com­bined endo­vas­cu­lar and sur­gi­cal ­approach is fea­sible, with­out cross-clamp­ing of the aorta and with min­i­mized ische­mia time for renal and vis­cer­al arter­ies, and seems the appro­pri­ate strat­e­gy for high risk and pre­vi­ous­ly oper­at­ed, with a thor­a­coab­dom­i­nal trans-dia­phrag­mat­ic ­approach, ­patients.

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