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Patency and durability of presewn multiple branched graft for thoracoabdominal aortic aneurysm repair
Patency and durability of presewn multiple branched graft for thoracoabdominal aortic aneurysm repair Alexander Kulik, MD, MPH,a Catherine F. Castner, RN,b and Nicholas T. Kouchoukos, MD,b Boca Raton, Fla; and St Louis, Mo Objective: The use of an aortic patch containing the visceral and renal arteries is a well-established technique during thoracoabdominal aortic aneurysm (TAAA) repair. However, the retained aortic tissue may later become aneurysmal. We reviewed our TAAA repair experience using a presewn aortic branched graft to eliminate this risk. Methods: Between March 2003 and December 2008, 52 patients with Crawford extent II and III TAAAs had surgical repair using a presewn aortic branched graft. Postoperative computed tomography (CT) scans with intravenous contrast were available for 41 patients (mean angiographic follow-up 2.3 years). The mean age of these 41 patients was 59 ⴞ 16 years (range, 22-86), and 21 patients were female (51%). The indications for surgery were degenerative aneurysms in 30 patients (73%), type B dissections in 10 patients (24%), and visceral patch aneurysm in 1 patient (2.4%). Twenty-four patients (59%) underwent repair of a Crawford extent II TAAA and 17 patients (41%) had extent III TAAA repair. Results: Patency of the branches to the visceral and renal arteries at 1 and 5 years was 100% and 98%, respectively. Of the 148 graft branches, 2 became occluded and 4 developed stenosis (2 patients). One patient required percutaneous stenting of 3 stenosed branches, and 1 patient died after acute occlusion of 2 branches and stenosis of a third. During the follow-up period that extended to 6.3 years, there were 10 late deaths. Six patients required reoperation on the aortic graft or contiguous aorta, but no reoperations have been required on the visceral abdominal aorta or its branches. Conclusion: The use of a presewn aortic branched graft is a safe and suitable option for TAAA repair. With midterm follow-up, this technique seems to eliminate the risk of visceral patch aneurysms and results in favorable durability and patency. ( J Vasc Surg 2010;51:1367-72.)
During open repair of thoracoabdominal aortic aneurysms (TAAAs), several options are available for reattachment of the celiac, superior mesenteric, and renal arteries to the aortic graft. The inclusion technique, popularized by Crawford, involves the creation of a side-to-side anastomosis between the prosthetic graft and the aortic tissue surrounding the reimplanted vessels.1 Alternatively, using the Carrel patch technique, one or more full-thickness patches of aortic tissue containing the orifices of the arteries are sutured to the aortic graft in an end-to-side fashion.2 Although these two methods are commonly used, they result in the retention of aortic tissue that may be weakened from atherosclerotic degeneration or chronic aortic dissection. Over time, the potential exists for this tissue to become aneurysmal or separate from the graft, with the risk of subsequent rupture.2,3 Previous studies have suggested that the prevalence of visceral artery patch aneurysms after From the Division of Cardiothoracic Surgery, Lynn Heart Institute, Boca Raton Community Hospital, Boca Raton,a and the Division of Cardiovascular and Thoracic Surgery, Missouri Baptist Medical Center, St Louis.b Competition of interest: none. Reprint requests: Nicholas T. Kouchoukos, MD, Cardiac, Thoracic, and Vascular Surgery, 3009 N Ballas Road, Suite 360C, St Louis, MO 63131 (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a competition of interest. 0741-5214/$36.00 Copyright © 2010 by the Society for Vascular Surgery. doi:10.1016/j.jvs.2010.01.031
TAAA repair using the Crawford or Carrel techniques is between 4% and 8%.2,4,5 We previously applied the Carrel patch technique during TAAA repair.6,7 However, in 2003, we modified our technique to eliminate the potential for future aneurysmal degeneration of the visceral patch. We have since repaired Crawford extent II and III TAAAs using a presewn aortic branched graft that was originally designed for replacement of the aortic arch. The four branches of the graft are anastomosed to the celiac, superior mesenteric, and renal arteries in various configurations according to size and location of these vessels. Our early experience using this technique was favorable,8 but patency of the graft branches has not been formally evaluated. Novel endovascular techniques for TAAA repair have recently been described applying hybrid debranching strategies and multibranched stent grafts. Small series have confirmed the feasibility of these endovascular approaches.9-17 However, concerns have been raised regarding the durability of TAAA stent graft repair and the long-term patency of the revascularized visceral and renal arteries using these techniques.18 In this context, we reviewed our open TAAA repair experience with the presewn aortic branched graft to evaluate the durability of this method and the midterm patency of the graft branches. METHODS Patient characteristics. Between March 2003 and December 2008, 52 patients with Crawford extent II and 1367
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Table I. Preoperative patient characteristics Patient characteristic Comorbidity Marfan syndrome Hypertension History of smoking Hyperlipidemia Chronic obstructive pulmonary disease Coronary artery disease Peripheral vascular disease Creatinine ⱖ1.5 mg/dL Previous transient ischemic attack or stroke Diabetes mellitus Previous operations Coronary artery bypass graft surgery or percutaneous coronary intervention Aortic valve procedure Ascending aortic repair Aortic arch repair Descending thoracic aortic repair Thoracoabdominal aortic repair Abdominal aortic aneurysm repair Cause of aortic disease Degenerative aneurysm Chronic type B dissection Other (visceral patch aneurysm)
Number of patients (%) (n ⫽ 41) 12 (29%) 29 (71%) 18 (44%) 18 (44%) 12 (29%) 13 (32%) 12 (29%) 4 (10%) 5 (12%) 4 (10%) 10 (24%) 13 (32%) 17 (41%) 6 (15%) 2 (4.9%) 1 (2.4%) 7 (17%) 30 (73%) 10 (24%) 1 (2.4%)
III TAAAs underwent repair with cardiopulmonary bypass and hypothermic circulatory arrest. No other operative technique was utilized for repair during this interval. A collagen-impregnated woven polyester branched aortic graft (Hemashield Platinum TAAA graft; MAQUET Cardiovascular LLC, San Jose, Calif) was used in all patients to reimplant the visceral and renal arteries.8 Perioperative complications for these 52 patients included death within 30 days in 2 patients (3.8%), transient paraparesis in 1 patient (1.9%), stroke in 3 patients (5.8%), and renal failure requiring dialysis in 2 patients (3.8%). Postoperative computed tomography (CT) scans with intravenous contrast were obtained before hospital discharge when feasible and at 6- to 12-month intervals during outpatient follow-up. Eleven patients did not undergo postoperative CT surveillance with contrast because of in-hospital death (3 patients), death after hospital discharge (2 patients), refusal of postoperative CT scan surveillance (1 patient), or chronic renal dysfunction mandating CT scan surveillance without intravenous contrast (5 patients, mean postoperative creatinine 2.1 ⫾ 0.4 mg/dL). Due to the absence of graft patency data, these 11 patients were excluded from the study. Forty-one patients were available for analysis. The clinical characteristics of the 41 patients are shown in Table I. The mean age at operation was 59 ⫾ 16 years (range, 22-86), and 21 patients were female (51%). Twelve patients (29%) had clinical manifestations of Marfan syndrome. Seventeen patients (41%) had symptoms associated with their aortic disease. The remaining patients had aneurysms that were more than twice the size of adjacent normal aorta, or had evidence of progressive aortic enlargement.
Degenerative aneurysms were present in 30 patients (73%). Ten patients (24%) had chronic type B dissections with aneurysms. Twenty-four patients (59%) underwent repair of a Crawford extent II TAAA, and 17 patients (41%) had extent III TAAA repair. All patients underwent elective operation except for 1 patient who presented with a contained rupture of a visceral patch aneurysm 10 years postrepair of an extent II TAAA. The study was reviewed by the Institutional Review Board of the Missouri Baptist Medical Center and was exempted from Board approval. Operative technique. Our general technique has been previously described.6-8 With increasing experience, several modifications have been introduced. Since September 2004, cerebrospinal fluid drainage has been used routinely, if technically feasible (31 patients). A standard posterolateral thoracotomy incision is made and the diaphragm is incised circumferentially. Cardiopulmonary bypass is established utilizing either the left femoral artery or a cannula placed into a nondiseased portion of the descending thoracic aorta for arterial return. A long cannula is inserted into the left common femoral vein with the tip positioned in the right atrium for venous return. Cooling is initiated and a catheter is placed into the left inferior pulmonary vein for venting of the heart. When adequate cooling is achieved (electroencephalographic silence, nasopharyngeal temperature 22°C or lower), circulatory arrest is established. A collagen-impregnated woven polyester aortic graft (26-32 mm) containing a 10 mm side arm (Hemashield Platinum single branch graft; MAQUET Cardiovascular LLC) is sutured to the transected descending thoracic aorta or aortic arch. The side arm of the graft is then connected to a second arterial line from the pump oxygenator. After evacuation of air, a clamp is placed on the graft just distal to the side arm. Flow to the upper body is re-established at a rate of 15 to 20 mL/kg/minute and a temperature of 20°C to 22°C. Patent intercostal and lumbar arteries below the level of the sixth or seventh intercostal space are sutured to an opening in the graft when technically feasible using a full-thickness cuff of aorta. The clamp on the graft is then repositioned below the intercostals pedicle to establish antegrade flow to the implanted arteries. The distal thoracic and upper abdominal aorta are opened and the orifices of the celiac, superior mesenteric, and the left and right renal arteries are identified. If the aortic disease extends to the level of the iliac arteries, a bifurcation graft (Hemashield Platinum bifurcation graft; MAQUET Cardiovascular LLC) is implanted. Whenever possible, a clamp is placed on the infrarenal aorta (or previously placed graft) to permit hypothermic perfusion of the lower body using the femoral artery cannula. The visceral and renal arteries are detached from the aorta with a small cuff of aortic tissue. If the origin of a vessel is severely stenotic or calcified, the vessel is transected beyond the aortic wall. The body of an aortic branched graft (Hemashield Platinum TAAA graft; MAQUET Cardiovascular LLC) is positioned so that the three adjacent branches lie opposite the origins of the celiac, superior mesenteric, and right renal arteries. The distal end of the aortic branched
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Table II. Cardiopulmonary perfusion data Mean ⫾ SD Time (min) Cardiopulmonary bypass Cooling Circulatory arrest Low-flow hypothermic bypass Hypothermic ventricular fibrillation Spinal cord ischemia Left renal ischemia Right renal ischemia Celiac ischemia SMA ischemia Rewarming Temperature (°C) Lowest nasopharyngeal Lowest bladder/rectal
Range
175.8 ⫾ 36.6 105-248 31.5 ⫾ 5.8 24-50 24.1 ⫾ 10.9 9-49 68.9 ⫾ 28.2 18-160 114.0 ⫾ 39.5 45-217 55.9 ⫾ 21.4 11-107 109.4 ⫾ 31.8 50-179 90.0 ⫾ 39.3 12-200 114.9 ⫾ 36.7 40-215 102.1 ⫾ 36.5 31-230 72.1 ⫾ 12.9 53-108 15.4 ⫾ 2.0 20.7 ⫾ 2.7
12-22 14-26
SMA, Superior mesenteric artery.
graft is cut to the appropriate length and sutured to the infrarenal aorta or to the previously placed infrarenal graft. A clamp is placed on the graft below the branches, and flow to the lower body is re-established. Direct perfusion of the visceral and renal arteries is not performed. Maintaining hypothermic low flow, the anastomoses between the branches of the graft and the visceral and renal arteries are completed using 5-0 or 6-0 polypropylene sutures.8 Typically, the most distal 8 mm branch is anastomosed to the right renal artery, followed by the middle 8 mm limb to the superior mesenteric artery and the upper 10 mm limb to the celiac artery. The left renal artery is usually sewn to the fourth (perpendicular) 10 mm branch of the graft or to a separate 6 or 8 mm interposition graft that is then attached to the side of the aortic graft (20 patients). In 10 patients, it was also necessary to use a separate interposition graft for the right renal artery. In 6 patients, 15 of the visceral and renal artery anastomoses were performed to the transected arteries beyond the aortic wall because of severe ostial stenosis. After each anastomosis is completed, the distal clamp on the aortic graft is positioned more proximally to enable perfusion of each reimplanted artery. Rewarming is initiated after establishing perfusion to all of the implanted arteries. The anastomosis of the branched aortic graft to the descending thoracic aortic graft is completed, and after evacuation of air from the grafts, full antegrade flow is established from the proximal arterial line. Twenty-nine patients had all four graft branches used to attach the visceral and renal arteries. In 4 patients, the aneurysm did not extend to the level of the renal arteries, and only 2 branches were used to reimplant the celiac and superior mesenteric arteries. Due to chronic renal atrophy or previous nephrectomy, only 3 branches were needed in 8 patients. A total of 148 branches were used in the 41 patients. The mean durations of cooling, circulatory arrest, low flow hypothermic bypass, hypothermic ventricular fibrillation, rewarming, and cardiopulmonary bypass are shown in Table II. The mean duration of hypothermic circulatory arrest was 24.1 ⫾ 10.9 minutes.
Fig 1. Computed tomography angiogram demonstrating patency of branch grafts to the celiac, superior mesenteric and right renal arteries (arrows) 74 months postoperatively. A separate fourth branch to the left renal artery was also patent.
Follow-up. After hospital discharge, patients were evaluated clinically at 1 and 6 months postoperatively and subsequently at 12-month intervals. CT scans with intravenous contrast were obtained before discharge, at 6 months, and yearly thereafter, when feasible. Follow-up was 100% complete. The mean duration of clinical follow-up was 2.9 years (range, 1 month-6.3 years). The mean duration of angiographic follow-up was 2.3 years (range, 1 month-6.3 years). Eight patients had CT angiograms performed more than 4 years postoperatively, and 3 patients more than 6 years postoperatively. Patency of the visceral and renal graft branches was documented from images generated using multidetector CT angiography (Fig 1).19,20 Specifically, patency was defined as opacification of the branch lumen with contrast enhancement of the perfused organ. Stenosis was defined as ⬎50% obstruction either within the branch or native arterial lumen. Graft occlusion was defined as complete obstruction with no evidence of contrast within the branch lumen or enhancement of the perfused organ. Statistical analyses. Data were analyzed in Intercooled Stata 9.2 (Stata; College Station, Tex). Standard descriptive statistical analyses were used. Continuous data are presented as a mean ⫾ SD and categorical data are presented as proportions. Nonparametric estimates of freedom from death and graft occlusion were determined using the Kaplan-Meier method and are reported as mean ⫾ SE. RESULTS Patency. Patency of the branches to the visceral and renal arteries at 1 month, 1 year, and 5 years was 100 ⫾ 0%, 100 ⫾ 0%, and 98.0 ⫾ 1.4%, respectively (Fig 2). All interposition grafts to the renal arteries were patent at follow-up. Of the 148 branch grafts, 2 became occluded and 4 developed stenosis (2 patients). One patient had extent III repair using all four of the presewn branches. Between the time of hospital discharge and the CT angiogram performed 6 months postoperatively, she developed 50% to 70% stenoses of the branches sewn to the celiac,
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Fig 2. Patency of the visceral and renal artery branches after thoracoabdominal aortic aneurysm repair with the presewn graft.
superior mesenteric, and right renal arteries. Percutaneous angioplasty and stenting was successfully performed to all three branches. The second patient had extent II repair using three of the presewn branches and a separate interposition graft to the left renal artery. A CT scan 1.1 years after surgery found all 4 branches to be patent. Two months later, she presented to the hospital with acute intestinal ischemia. A repeat CT scan with intravenous contrast demonstrated occlusion of the celiac and superior mesenteric branches and stenosis of the right renal artery branch. Her condition quickly deteriorated and she died shortly thereafter. Follow-up. During the follow-up period that extended to 6.3 years, there were 10 late deaths. Survival at 1 month, 1 year, and 5 years was 100 ⫾ 0%, 85.4 ⫾ 5.5%, and 74.6 ⫾ 7.7%, respectively. Six patients required reoperation on the aortic graft or contiguous aorta. Indications for reoperation included late aneurysmal dilatation of the intercostal patch (3), repair of a false aneurysm at the proximal suture line (1), progressive dilatation of an iliac artery aneurysm (1), and progressive dilatation of the native aortic arch and proximal descending thoracic aorta (1). The remaining patients are free of symptoms or abnormal findings of the contiguous aorta on serial CT scan examinations from 1 month to 6.3 years postoperatively. No open reoperations have been required on the visceral portion of the abdominal aorta or its branches. One patient required a percutaneous intervention (as noted above). DISCUSSION Several methods are available to attach the celiac, superior mesenteric, and renal arteries during TAAA repair. Traditionally, either the Crawford inclusion or Carrel patch techniques have been used to re-establish their continuity with the aortic graft.1,2 To avoid retained aortic tissue and the potential for aneurysmal dilatation of the visceral artery patch,2,4,5 we modified our approach for reimplantation of these vessels in 2003. We have since repaired Crawford extent II and III TAAAs using a presewn aortic branched graft, with the four branches of the graft anastomosed to the celiac, superior mesenteric, and renal arteries.8 In this
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study, we reviewed our 6-year experience using the presewn branched graft, demonstrating favorable durability and patency with this technique. Patency of the branches was 100% and 98% at 1 and 5 years, respectively, and no open operations on the visceral segment of the abdominal aorta or its branches were required. Thus, we believe this technique represents a safe option for TAAA repair. The simplest and most expeditious technique for revascularization of the visceral and renal arteries during TAAA repair is the use of the Crawford inclusion technique. This method reduces the number of anastomoses and may limit the visceral and renal ischemic time. Whereas this technique provides reasonable durability,2 degenerated or chronically dissected aortic tissue surrounding the visceral and renal arteries is retained. With time, this diseased native aortic tissue may become aneurysmal or separate from the graft. Several cases of visceral artery patch degeneration and rupture have been documented in the literature.2,15,21,22 The risk of developing visceral artery patch aneurysms after the application of the Crawford or Carrel patch techniques has been estimated at 4% to 8%.2,4,5 Tshomba et al4 reviewed their experience within a cohort of 182 patients who underwent TAAA repair using the Crawford inclusion technique. At a mean interval of 6 years after TAAA repair, 23 patients developed visceral artery patch aneurysms with an average diameter of 5.9 cm, including 16 (12%) visceral artery patch dilatations ⬍5 cm, 6 (4%) dilatations ⬎5 cm, and 1 pseudoaneurysm. Amongst 107 patients with TAAA treated at Johns Hopkins using the Crawford inclusion technique, Dardik et al2 reported that 8 patients (7.5%) developed visceral patch aneurysm greater than 4 cm in diameter during an average follow-up of 6.5 years after repair. LeMaire et al5 reported a repair failure rate of 4% (8 patients) after TAAA repair in patients with suspected or confirmed Marfan syndrome, including the development of 6 recurrent aneurysms and 2 pseudoaneurysms at a mean of 7.2 years after the initial operation. Reoperations to treat visceral artery patch aneurysms have been associated with considerable risk. Mortality rates between 17% and 50% have been reported.2,4,15 Our experience with the presewn branched graft has demonstrated its utility for the repair of extent II and III TAAAs. Configuration of the branches of the aortic graft provides a number of options for their attachment to the renal and visceral arteries. In contrast to the use of patch techniques, our midterm follow-up suggests that separate attachment of the visceral and renal arteries eliminates recurrent aneurysmal disease by limiting the amount of native aortic tissue retained in the arterial circulation. Compared to the use of separate grafts individually sutured to the aortic graft, the presewn branched graft can reduce the ischemic interval for the kidneys and the abdominal organs. Perfusion of the kidneys and viscera can be re-established sequentially. Separate perfusion of the kidneys and abdominal viscera is not necessary because adequate protection of these organs is achieved with hypothermia. Because the presence of visceral or renal arterial occlusive disease may increase the risk of complications after traditional TAAA
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repair,23 ostial disease of the visceral and renal branches can be addressed using our technique by transecting the vessel beyond the stenosis. This avoids the need for vessel endarterectomy or the placement of visceral or renal artery stents.24 Recent developments in endovascular stent graft technology have led to the application of hybrid debranching strategies9-12,16,17 and multibranched stent grafts13,14 for TAAA repair. Claimed advantages of these techniques include a smaller incision, less postoperative pain, limited pulmonary complications, and more rapid recovery.18 However, concerns remain regarding the durability of TAAA stent graft repair.18 Using the strategy of debranching and aortic stent grafting, the patency of grafts placed to the visceral and renal arteries has been reported as low as 89%, with follow-up generally limited to less than 2 years.9-11,16,17 Complications such as endoleak requiring reintervention and the need for long-term dialysis have not been infrequent.9-12,16,17 Summarizing their experience using debranching and endovascular TAAA repair in 21 patients, Siegenthaler et al12 reported that 5 patients (24%) required early (⬍30 days) and 4 patients (19%) underwent late endovascular reinterventions for persistent endoleaks. One additional reintervention included percutaneous stenting of a superior mesenteric artery stenosis. Actual freedom from late reintervention in their series was 81% and 76% at 1-year and 3-year follow-up, respectively. Although results with multibranched stent grafts for TAAA repair seem more favorable (graft patency 99% to 100%),13,14 long-term durability and patency remain unknown. Limitations. This study is the first to report follow-up data after the implantation of a presewn aortic branched graft during TAAA repair. However, the results presented must be interpreted within the context of the study design. Observational in nature, this study involved the retrospective review of prospectively collected data in a referral-based tertiary care center. Many patients were referred to our center from afar. However, every effort was made to obtain imaging surveillance at regular intervals, even if from a distance. Due to chronic renal dysfunction or early death, patency data could not be obtained for the 11 patients who were excluded from this study. Although patency could not be confirmed, based on the clinical status of these patients, there was no reason to suspect any graft occlusions within this excluded group. CONCLUSIONS In summary, we have documented that the presewn aortic branched graft is a safe and suitable option for TAAA repair. With midterm follow-up, this technique seems to eliminate the risk of developing visceral patch aneurysms and results in favorable durability and patency. AUTHOR CONTRIBUTIONS Conception and design: AK, NK Analysis and interpretation: AK, CC, NK Data collection: AK, CC, NK Writing the article: AK, CC, NK Critical revision of the article: AK, NK
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Final approval of the article: AK, CC, NK Statistical analysis: AK, CC Obtained funding: Not applicable Overall responsibility: NK REFERENCES 1. Crawford ES. Thoraco-abdominal and abdominal aortic aneurysms involving renal, superior mesenteric, celiac arteries. Ann Surg 1974; 179:763-72. 2. Dardik A, Perler BA, Roseborough GS, Williams GM. Aneurysmal expansion of the visceral patch after thoracoabdominal aortic replacement: an argument for limiting patch size? J Vasc Surg 2001;34:405-9; discussion 410. 3. Dias RR, Coselli JS, Stolf NA, Dias AR, Mady C, Oliveira SA. Aneurysmal dilation of the reimplant segment of the visceral vessels after thoracoabdominal aneurysm correction. [Article in English, Portuguese] Arq Bras Cardiol 2003;81:273-8. 4. Tshomba Y, Melissano G, Civilini E, Setacci F, Chiesa R. Fate of the visceral aortic patch after thoracoabdominal aortic repair. Eur J Vasc Endovasc Surg 2005;29:383-9. 5. LeMaire SA, Carter SA, Volguina IV, Laux AT, Milewicz DM, Borsato GW, et al. Spectrum of aortic operations in 300 patients with confirmed or suspected Marfan syndrome. Ann Thorac Surg 2006;81:2063-78; discussion 2078. 6. Kouchoukos NT, Daily BB, Rokkas CK, Murphy SF, Bauer S, Abboud N. Hypothermic bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta. Ann Thorac Surg 1995;60:67-76; discussion 76-7. 7. Kouchoukos NT, Masetti P, Rokkas CK, Murphy SF, Blackstone EH. Safety and efficacy of hypothermic cardiopulmonary bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta. Ann Thorac Surg 2001;72:699-707; discussion 707-8. 8. Kouchoukos NT, Masetti P, Castner CF. Use of presewn multiple branched graft in thoracoabdominal aortic aneurysm repair. J Am Coll Surg 2005;201:646-9. 9. Lee WA, Brown MP, Martin TD, Seeger JM, Huber TS. Early results after staged hybrid repair of thoracoabdominal aortic aneurysms. J Am Coll Surg 2007;205:420-31. 10. Böckler D, Kotelis D, Geisbüsch P, Hyhlik-Dürr A, Klemm K, von Tengg-Kobligk H, et al. Hybrid procedures for thoracoabdominal aortic aneurysms and chronic aortic dissections - a single center experience in 28 patients. J Vasc Surg 2008;47:724-32. 11. Chiesa R, Tshomba Y, Melissano G, Marone EM, Bertoglio L, Setacci F, Calliari FM. Hybrid approach to thoracoabdominal aortic aneurysms in patients with prior aortic surgery. J Vasc Surg 2007;45:1128-35. 12. Siegenthaler MP, Weigang E, Brehm K, Euringer W, Baumann T, Uhl M, et al. Endovascular treatment for thoracoabdominal aneurysms: outcomes and results. Eur J Cardiothorac Surg 2008;34:810-9. 13. Chuter TA, Rapp JH, Hiramoto JS, Schneider DB, Howell B, Reilly LM. Endovascular treatment of thoracoabdominal aortic aneurysms. J Vasc Surg 2008;47:6-16. 14. Roselli EE, Greenberg RK, Pfaff K, Francis C, Svensson LG, Lytle BW. Endovascular treatment of thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg 2007;133:1474-82. 15. Carrel TP, Signer C. Separate revascularization of the visceral arteries in thoracoabdominal aneurysm repair. Ann Thorac Surg 1999;68:573-5. 16. Patel R, Conrad MF, Paruchuri V, Kwolek CJ, Chung TK, Cambria RP. Thoracoabdominal aneurysm repair: hybrid versus open repair. J Vasc Surg 2009;50:15-22. 17. Gawenda M, Aleksic M, Heckenkamp J, Reichert V, Gossmann A, Brunkwall J. Hybrid-procedures for the treatment of thoracoabdominal aortic aneurysms and dissections. Eur J Vasc Endovasc Surg 2007;33: 71-7. 18. Greenberg RK, Lytle B. Endovascular repair of thoracoabdominal aneurysms. Circulation 2008;117:2288-96. 19. Foley WD, Karcaaltincaba M. Computed tomography angiography: principles and clinical applications. J Comput Assist Tomogr 2003;27 Suppl 1:S23-30.
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20. Lin PH, Bechara C, Kougias P, Huynh TT, LeMaire SA, Coselli JS. Assessment of aortic pathology and peripheral arterial disease using multidetector computed tomographic angiography. Vasc Endovascular Surg 2008;42:583-98. 21. Clouse WD, Marone LK, Davison JK, Dorer DJ, Brewster DC, LaMuraglia GM, Cambria RP. Late aortic and graft-related events after thoracoabdominal aneurysm repair. J Vasc Surg 2003;37:254-61. 22. Gasparis AP, Da Silva MS, Semel L. Visceral patch rupture after repair of thoracoabdominal aortic aneurysm–a case report. Vasc Surg 2001;35: 491-4.
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23. Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Thoracoabdominal aortic aneurysms associated with celiac, superior mesenteric, and renal artery occlusive disease: methods and analysis of results in 271 patients. J Vasc Surg 1992;16:378-89; discussion 389-90. 24. LeMaire SA, Jamison AL, Carter SA, Wen S, Alankar S, Coselli JS. Deployment of balloon expandable stents during open repair of thoracoabdominal aortic aneurysms: a new strategy for managing renal and mesenteric artery lesions. Eur J Cardiothorac Surg 2004;26:599-607. Submitted Oct 6, 2009; accepted Jan 13, 2010.
During open repair of thoracoabdominal aortic aneurysms (TAAAs), several options are available for reattachment of the celiac, superior mesenteric, and renal arteries to the aortic graft. The inclusion technique, popularized by Crawford, involves the creation of a side-to-side anastomosis between the prosthetic graft and the aortic tissue surrounding the reimplanted vessels.1 Alternatively, using the Carrel patch technique, one or more full-thickness patches of aortic tissue containing the orifices of the arteries are sutured to the aortic graft in an end-to-side fashion.2 Although these two methods are commonly used, they result in the retention of aortic tissue that may be weakened from atherosclerotic degeneration or chronic aortic dissection. Over time, the potential exists for this tissue to become aneurysmal or separate from the graft, with the risk of subsequent rupture.2,3 Previous studies have suggested that the prevalence of visceral artery patch aneurysms after From the Division of Cardiothoracic Surgery, Lynn Heart Institute, Boca Raton Community Hospital, Boca Raton,a and the Division of Cardiovascular and Thoracic Surgery, Missouri Baptist Medical Center, St Louis.b Competition of interest: none. Reprint requests: Nicholas T. Kouchoukos, MD, Cardiac, Thoracic, and Vascular Surgery, 3009 N Ballas Road, Suite 360C, St Louis, MO 63131 (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a competition of interest. 0741-5214/$36.00 Copyright © 2010 by the Society for Vascular Surgery. doi:10.1016/j.jvs.2010.01.031
TAAA repair using the Crawford or Carrel techniques is between 4% and 8%.2,4,5 We previously applied the Carrel patch technique during TAAA repair.6,7 However, in 2003, we modified our technique to eliminate the potential for future aneurysmal degeneration of the visceral patch. We have since repaired Crawford extent II and III TAAAs using a presewn aortic branched graft that was originally designed for replacement of the aortic arch. The four branches of the graft are anastomosed to the celiac, superior mesenteric, and renal arteries in various configurations according to size and location of these vessels. Our early experience using this technique was favorable,8 but patency of the graft branches has not been formally evaluated. Novel endovascular techniques for TAAA repair have recently been described applying hybrid debranching strategies and multibranched stent grafts. Small series have confirmed the feasibility of these endovascular approaches.9-17 However, concerns have been raised regarding the durability of TAAA stent graft repair and the long-term patency of the revascularized visceral and renal arteries using these techniques.18 In this context, we reviewed our open TAAA repair experience with the presewn aortic branched graft to evaluate the durability of this method and the midterm patency of the graft branches. METHODS Patient characteristics. Between March 2003 and December 2008, 52 patients with Crawford extent II and 1367
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Table I. Preoperative patient characteristics Patient characteristic Comorbidity Marfan syndrome Hypertension History of smoking Hyperlipidemia Chronic obstructive pulmonary disease Coronary artery disease Peripheral vascular disease Creatinine ⱖ1.5 mg/dL Previous transient ischemic attack or stroke Diabetes mellitus Previous operations Coronary artery bypass graft surgery or percutaneous coronary intervention Aortic valve procedure Ascending aortic repair Aortic arch repair Descending thoracic aortic repair Thoracoabdominal aortic repair Abdominal aortic aneurysm repair Cause of aortic disease Degenerative aneurysm Chronic type B dissection Other (visceral patch aneurysm)
Number of patients (%) (n ⫽ 41) 12 (29%) 29 (71%) 18 (44%) 18 (44%) 12 (29%) 13 (32%) 12 (29%) 4 (10%) 5 (12%) 4 (10%) 10 (24%) 13 (32%) 17 (41%) 6 (15%) 2 (4.9%) 1 (2.4%) 7 (17%) 30 (73%) 10 (24%) 1 (2.4%)
III TAAAs underwent repair with cardiopulmonary bypass and hypothermic circulatory arrest. No other operative technique was utilized for repair during this interval. A collagen-impregnated woven polyester branched aortic graft (Hemashield Platinum TAAA graft; MAQUET Cardiovascular LLC, San Jose, Calif) was used in all patients to reimplant the visceral and renal arteries.8 Perioperative complications for these 52 patients included death within 30 days in 2 patients (3.8%), transient paraparesis in 1 patient (1.9%), stroke in 3 patients (5.8%), and renal failure requiring dialysis in 2 patients (3.8%). Postoperative computed tomography (CT) scans with intravenous contrast were obtained before hospital discharge when feasible and at 6- to 12-month intervals during outpatient follow-up. Eleven patients did not undergo postoperative CT surveillance with contrast because of in-hospital death (3 patients), death after hospital discharge (2 patients), refusal of postoperative CT scan surveillance (1 patient), or chronic renal dysfunction mandating CT scan surveillance without intravenous contrast (5 patients, mean postoperative creatinine 2.1 ⫾ 0.4 mg/dL). Due to the absence of graft patency data, these 11 patients were excluded from the study. Forty-one patients were available for analysis. The clinical characteristics of the 41 patients are shown in Table I. The mean age at operation was 59 ⫾ 16 years (range, 22-86), and 21 patients were female (51%). Twelve patients (29%) had clinical manifestations of Marfan syndrome. Seventeen patients (41%) had symptoms associated with their aortic disease. The remaining patients had aneurysms that were more than twice the size of adjacent normal aorta, or had evidence of progressive aortic enlargement.
Degenerative aneurysms were present in 30 patients (73%). Ten patients (24%) had chronic type B dissections with aneurysms. Twenty-four patients (59%) underwent repair of a Crawford extent II TAAA, and 17 patients (41%) had extent III TAAA repair. All patients underwent elective operation except for 1 patient who presented with a contained rupture of a visceral patch aneurysm 10 years postrepair of an extent II TAAA. The study was reviewed by the Institutional Review Board of the Missouri Baptist Medical Center and was exempted from Board approval. Operative technique. Our general technique has been previously described.6-8 With increasing experience, several modifications have been introduced. Since September 2004, cerebrospinal fluid drainage has been used routinely, if technically feasible (31 patients). A standard posterolateral thoracotomy incision is made and the diaphragm is incised circumferentially. Cardiopulmonary bypass is established utilizing either the left femoral artery or a cannula placed into a nondiseased portion of the descending thoracic aorta for arterial return. A long cannula is inserted into the left common femoral vein with the tip positioned in the right atrium for venous return. Cooling is initiated and a catheter is placed into the left inferior pulmonary vein for venting of the heart. When adequate cooling is achieved (electroencephalographic silence, nasopharyngeal temperature 22°C or lower), circulatory arrest is established. A collagen-impregnated woven polyester aortic graft (26-32 mm) containing a 10 mm side arm (Hemashield Platinum single branch graft; MAQUET Cardiovascular LLC) is sutured to the transected descending thoracic aorta or aortic arch. The side arm of the graft is then connected to a second arterial line from the pump oxygenator. After evacuation of air, a clamp is placed on the graft just distal to the side arm. Flow to the upper body is re-established at a rate of 15 to 20 mL/kg/minute and a temperature of 20°C to 22°C. Patent intercostal and lumbar arteries below the level of the sixth or seventh intercostal space are sutured to an opening in the graft when technically feasible using a full-thickness cuff of aorta. The clamp on the graft is then repositioned below the intercostals pedicle to establish antegrade flow to the implanted arteries. The distal thoracic and upper abdominal aorta are opened and the orifices of the celiac, superior mesenteric, and the left and right renal arteries are identified. If the aortic disease extends to the level of the iliac arteries, a bifurcation graft (Hemashield Platinum bifurcation graft; MAQUET Cardiovascular LLC) is implanted. Whenever possible, a clamp is placed on the infrarenal aorta (or previously placed graft) to permit hypothermic perfusion of the lower body using the femoral artery cannula. The visceral and renal arteries are detached from the aorta with a small cuff of aortic tissue. If the origin of a vessel is severely stenotic or calcified, the vessel is transected beyond the aortic wall. The body of an aortic branched graft (Hemashield Platinum TAAA graft; MAQUET Cardiovascular LLC) is positioned so that the three adjacent branches lie opposite the origins of the celiac, superior mesenteric, and right renal arteries. The distal end of the aortic branched
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Table II. Cardiopulmonary perfusion data Mean ⫾ SD Time (min) Cardiopulmonary bypass Cooling Circulatory arrest Low-flow hypothermic bypass Hypothermic ventricular fibrillation Spinal cord ischemia Left renal ischemia Right renal ischemia Celiac ischemia SMA ischemia Rewarming Temperature (°C) Lowest nasopharyngeal Lowest bladder/rectal
Range
175.8 ⫾ 36.6 105-248 31.5 ⫾ 5.8 24-50 24.1 ⫾ 10.9 9-49 68.9 ⫾ 28.2 18-160 114.0 ⫾ 39.5 45-217 55.9 ⫾ 21.4 11-107 109.4 ⫾ 31.8 50-179 90.0 ⫾ 39.3 12-200 114.9 ⫾ 36.7 40-215 102.1 ⫾ 36.5 31-230 72.1 ⫾ 12.9 53-108 15.4 ⫾ 2.0 20.7 ⫾ 2.7
12-22 14-26
SMA, Superior mesenteric artery.
graft is cut to the appropriate length and sutured to the infrarenal aorta or to the previously placed infrarenal graft. A clamp is placed on the graft below the branches, and flow to the lower body is re-established. Direct perfusion of the visceral and renal arteries is not performed. Maintaining hypothermic low flow, the anastomoses between the branches of the graft and the visceral and renal arteries are completed using 5-0 or 6-0 polypropylene sutures.8 Typically, the most distal 8 mm branch is anastomosed to the right renal artery, followed by the middle 8 mm limb to the superior mesenteric artery and the upper 10 mm limb to the celiac artery. The left renal artery is usually sewn to the fourth (perpendicular) 10 mm branch of the graft or to a separate 6 or 8 mm interposition graft that is then attached to the side of the aortic graft (20 patients). In 10 patients, it was also necessary to use a separate interposition graft for the right renal artery. In 6 patients, 15 of the visceral and renal artery anastomoses were performed to the transected arteries beyond the aortic wall because of severe ostial stenosis. After each anastomosis is completed, the distal clamp on the aortic graft is positioned more proximally to enable perfusion of each reimplanted artery. Rewarming is initiated after establishing perfusion to all of the implanted arteries. The anastomosis of the branched aortic graft to the descending thoracic aortic graft is completed, and after evacuation of air from the grafts, full antegrade flow is established from the proximal arterial line. Twenty-nine patients had all four graft branches used to attach the visceral and renal arteries. In 4 patients, the aneurysm did not extend to the level of the renal arteries, and only 2 branches were used to reimplant the celiac and superior mesenteric arteries. Due to chronic renal atrophy or previous nephrectomy, only 3 branches were needed in 8 patients. A total of 148 branches were used in the 41 patients. The mean durations of cooling, circulatory arrest, low flow hypothermic bypass, hypothermic ventricular fibrillation, rewarming, and cardiopulmonary bypass are shown in Table II. The mean duration of hypothermic circulatory arrest was 24.1 ⫾ 10.9 minutes.
Fig 1. Computed tomography angiogram demonstrating patency of branch grafts to the celiac, superior mesenteric and right renal arteries (arrows) 74 months postoperatively. A separate fourth branch to the left renal artery was also patent.
Follow-up. After hospital discharge, patients were evaluated clinically at 1 and 6 months postoperatively and subsequently at 12-month intervals. CT scans with intravenous contrast were obtained before discharge, at 6 months, and yearly thereafter, when feasible. Follow-up was 100% complete. The mean duration of clinical follow-up was 2.9 years (range, 1 month-6.3 years). The mean duration of angiographic follow-up was 2.3 years (range, 1 month-6.3 years). Eight patients had CT angiograms performed more than 4 years postoperatively, and 3 patients more than 6 years postoperatively. Patency of the visceral and renal graft branches was documented from images generated using multidetector CT angiography (Fig 1).19,20 Specifically, patency was defined as opacification of the branch lumen with contrast enhancement of the perfused organ. Stenosis was defined as ⬎50% obstruction either within the branch or native arterial lumen. Graft occlusion was defined as complete obstruction with no evidence of contrast within the branch lumen or enhancement of the perfused organ. Statistical analyses. Data were analyzed in Intercooled Stata 9.2 (Stata; College Station, Tex). Standard descriptive statistical analyses were used. Continuous data are presented as a mean ⫾ SD and categorical data are presented as proportions. Nonparametric estimates of freedom from death and graft occlusion were determined using the Kaplan-Meier method and are reported as mean ⫾ SE. RESULTS Patency. Patency of the branches to the visceral and renal arteries at 1 month, 1 year, and 5 years was 100 ⫾ 0%, 100 ⫾ 0%, and 98.0 ⫾ 1.4%, respectively (Fig 2). All interposition grafts to the renal arteries were patent at follow-up. Of the 148 branch grafts, 2 became occluded and 4 developed stenosis (2 patients). One patient had extent III repair using all four of the presewn branches. Between the time of hospital discharge and the CT angiogram performed 6 months postoperatively, she developed 50% to 70% stenoses of the branches sewn to the celiac,
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Fig 2. Patency of the visceral and renal artery branches after thoracoabdominal aortic aneurysm repair with the presewn graft.
superior mesenteric, and right renal arteries. Percutaneous angioplasty and stenting was successfully performed to all three branches. The second patient had extent II repair using three of the presewn branches and a separate interposition graft to the left renal artery. A CT scan 1.1 years after surgery found all 4 branches to be patent. Two months later, she presented to the hospital with acute intestinal ischemia. A repeat CT scan with intravenous contrast demonstrated occlusion of the celiac and superior mesenteric branches and stenosis of the right renal artery branch. Her condition quickly deteriorated and she died shortly thereafter. Follow-up. During the follow-up period that extended to 6.3 years, there were 10 late deaths. Survival at 1 month, 1 year, and 5 years was 100 ⫾ 0%, 85.4 ⫾ 5.5%, and 74.6 ⫾ 7.7%, respectively. Six patients required reoperation on the aortic graft or contiguous aorta. Indications for reoperation included late aneurysmal dilatation of the intercostal patch (3), repair of a false aneurysm at the proximal suture line (1), progressive dilatation of an iliac artery aneurysm (1), and progressive dilatation of the native aortic arch and proximal descending thoracic aorta (1). The remaining patients are free of symptoms or abnormal findings of the contiguous aorta on serial CT scan examinations from 1 month to 6.3 years postoperatively. No open reoperations have been required on the visceral portion of the abdominal aorta or its branches. One patient required a percutaneous intervention (as noted above). DISCUSSION Several methods are available to attach the celiac, superior mesenteric, and renal arteries during TAAA repair. Traditionally, either the Crawford inclusion or Carrel patch techniques have been used to re-establish their continuity with the aortic graft.1,2 To avoid retained aortic tissue and the potential for aneurysmal dilatation of the visceral artery patch,2,4,5 we modified our approach for reimplantation of these vessels in 2003. We have since repaired Crawford extent II and III TAAAs using a presewn aortic branched graft, with the four branches of the graft anastomosed to the celiac, superior mesenteric, and renal arteries.8 In this
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study, we reviewed our 6-year experience using the presewn branched graft, demonstrating favorable durability and patency with this technique. Patency of the branches was 100% and 98% at 1 and 5 years, respectively, and no open operations on the visceral segment of the abdominal aorta or its branches were required. Thus, we believe this technique represents a safe option for TAAA repair. The simplest and most expeditious technique for revascularization of the visceral and renal arteries during TAAA repair is the use of the Crawford inclusion technique. This method reduces the number of anastomoses and may limit the visceral and renal ischemic time. Whereas this technique provides reasonable durability,2 degenerated or chronically dissected aortic tissue surrounding the visceral and renal arteries is retained. With time, this diseased native aortic tissue may become aneurysmal or separate from the graft. Several cases of visceral artery patch degeneration and rupture have been documented in the literature.2,15,21,22 The risk of developing visceral artery patch aneurysms after the application of the Crawford or Carrel patch techniques has been estimated at 4% to 8%.2,4,5 Tshomba et al4 reviewed their experience within a cohort of 182 patients who underwent TAAA repair using the Crawford inclusion technique. At a mean interval of 6 years after TAAA repair, 23 patients developed visceral artery patch aneurysms with an average diameter of 5.9 cm, including 16 (12%) visceral artery patch dilatations ⬍5 cm, 6 (4%) dilatations ⬎5 cm, and 1 pseudoaneurysm. Amongst 107 patients with TAAA treated at Johns Hopkins using the Crawford inclusion technique, Dardik et al2 reported that 8 patients (7.5%) developed visceral patch aneurysm greater than 4 cm in diameter during an average follow-up of 6.5 years after repair. LeMaire et al5 reported a repair failure rate of 4% (8 patients) after TAAA repair in patients with suspected or confirmed Marfan syndrome, including the development of 6 recurrent aneurysms and 2 pseudoaneurysms at a mean of 7.2 years after the initial operation. Reoperations to treat visceral artery patch aneurysms have been associated with considerable risk. Mortality rates between 17% and 50% have been reported.2,4,15 Our experience with the presewn branched graft has demonstrated its utility for the repair of extent II and III TAAAs. Configuration of the branches of the aortic graft provides a number of options for their attachment to the renal and visceral arteries. In contrast to the use of patch techniques, our midterm follow-up suggests that separate attachment of the visceral and renal arteries eliminates recurrent aneurysmal disease by limiting the amount of native aortic tissue retained in the arterial circulation. Compared to the use of separate grafts individually sutured to the aortic graft, the presewn branched graft can reduce the ischemic interval for the kidneys and the abdominal organs. Perfusion of the kidneys and viscera can be re-established sequentially. Separate perfusion of the kidneys and abdominal viscera is not necessary because adequate protection of these organs is achieved with hypothermia. Because the presence of visceral or renal arterial occlusive disease may increase the risk of complications after traditional TAAA
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repair,23 ostial disease of the visceral and renal branches can be addressed using our technique by transecting the vessel beyond the stenosis. This avoids the need for vessel endarterectomy or the placement of visceral or renal artery stents.24 Recent developments in endovascular stent graft technology have led to the application of hybrid debranching strategies9-12,16,17 and multibranched stent grafts13,14 for TAAA repair. Claimed advantages of these techniques include a smaller incision, less postoperative pain, limited pulmonary complications, and more rapid recovery.18 However, concerns remain regarding the durability of TAAA stent graft repair.18 Using the strategy of debranching and aortic stent grafting, the patency of grafts placed to the visceral and renal arteries has been reported as low as 89%, with follow-up generally limited to less than 2 years.9-11,16,17 Complications such as endoleak requiring reintervention and the need for long-term dialysis have not been infrequent.9-12,16,17 Summarizing their experience using debranching and endovascular TAAA repair in 21 patients, Siegenthaler et al12 reported that 5 patients (24%) required early (⬍30 days) and 4 patients (19%) underwent late endovascular reinterventions for persistent endoleaks. One additional reintervention included percutaneous stenting of a superior mesenteric artery stenosis. Actual freedom from late reintervention in their series was 81% and 76% at 1-year and 3-year follow-up, respectively. Although results with multibranched stent grafts for TAAA repair seem more favorable (graft patency 99% to 100%),13,14 long-term durability and patency remain unknown. Limitations. This study is the first to report follow-up data after the implantation of a presewn aortic branched graft during TAAA repair. However, the results presented must be interpreted within the context of the study design. Observational in nature, this study involved the retrospective review of prospectively collected data in a referral-based tertiary care center. Many patients were referred to our center from afar. However, every effort was made to obtain imaging surveillance at regular intervals, even if from a distance. Due to chronic renal dysfunction or early death, patency data could not be obtained for the 11 patients who were excluded from this study. Although patency could not be confirmed, based on the clinical status of these patients, there was no reason to suspect any graft occlusions within this excluded group. CONCLUSIONS In summary, we have documented that the presewn aortic branched graft is a safe and suitable option for TAAA repair. With midterm follow-up, this technique seems to eliminate the risk of developing visceral patch aneurysms and results in favorable durability and patency. AUTHOR CONTRIBUTIONS Conception and design: AK, NK Analysis and interpretation: AK, CC, NK Data collection: AK, CC, NK Writing the article: AK, CC, NK Critical revision of the article: AK, NK
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Final approval of the article: AK, CC, NK Statistical analysis: AK, CC Obtained funding: Not applicable Overall responsibility: NK REFERENCES 1. Crawford ES. Thoraco-abdominal and abdominal aortic aneurysms involving renal, superior mesenteric, celiac arteries. Ann Surg 1974; 179:763-72. 2. Dardik A, Perler BA, Roseborough GS, Williams GM. Aneurysmal expansion of the visceral patch after thoracoabdominal aortic replacement: an argument for limiting patch size? J Vasc Surg 2001;34:405-9; discussion 410. 3. Dias RR, Coselli JS, Stolf NA, Dias AR, Mady C, Oliveira SA. Aneurysmal dilation of the reimplant segment of the visceral vessels after thoracoabdominal aneurysm correction. [Article in English, Portuguese] Arq Bras Cardiol 2003;81:273-8. 4. Tshomba Y, Melissano G, Civilini E, Setacci F, Chiesa R. Fate of the visceral aortic patch after thoracoabdominal aortic repair. Eur J Vasc Endovasc Surg 2005;29:383-9. 5. LeMaire SA, Carter SA, Volguina IV, Laux AT, Milewicz DM, Borsato GW, et al. Spectrum of aortic operations in 300 patients with confirmed or suspected Marfan syndrome. Ann Thorac Surg 2006;81:2063-78; discussion 2078. 6. Kouchoukos NT, Daily BB, Rokkas CK, Murphy SF, Bauer S, Abboud N. Hypothermic bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta. Ann Thorac Surg 1995;60:67-76; discussion 76-7. 7. Kouchoukos NT, Masetti P, Rokkas CK, Murphy SF, Blackstone EH. Safety and efficacy of hypothermic cardiopulmonary bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta. Ann Thorac Surg 2001;72:699-707; discussion 707-8. 8. Kouchoukos NT, Masetti P, Castner CF. Use of presewn multiple branched graft in thoracoabdominal aortic aneurysm repair. J Am Coll Surg 2005;201:646-9. 9. Lee WA, Brown MP, Martin TD, Seeger JM, Huber TS. Early results after staged hybrid repair of thoracoabdominal aortic aneurysms. J Am Coll Surg 2007;205:420-31. 10. Böckler D, Kotelis D, Geisbüsch P, Hyhlik-Dürr A, Klemm K, von Tengg-Kobligk H, et al. Hybrid procedures for thoracoabdominal aortic aneurysms and chronic aortic dissections - a single center experience in 28 patients. J Vasc Surg 2008;47:724-32. 11. Chiesa R, Tshomba Y, Melissano G, Marone EM, Bertoglio L, Setacci F, Calliari FM. Hybrid approach to thoracoabdominal aortic aneurysms in patients with prior aortic surgery. J Vasc Surg 2007;45:1128-35. 12. Siegenthaler MP, Weigang E, Brehm K, Euringer W, Baumann T, Uhl M, et al. Endovascular treatment for thoracoabdominal aneurysms: outcomes and results. Eur J Cardiothorac Surg 2008;34:810-9. 13. Chuter TA, Rapp JH, Hiramoto JS, Schneider DB, Howell B, Reilly LM. Endovascular treatment of thoracoabdominal aortic aneurysms. J Vasc Surg 2008;47:6-16. 14. Roselli EE, Greenberg RK, Pfaff K, Francis C, Svensson LG, Lytle BW. Endovascular treatment of thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg 2007;133:1474-82. 15. Carrel TP, Signer C. Separate revascularization of the visceral arteries in thoracoabdominal aneurysm repair. Ann Thorac Surg 1999;68:573-5. 16. Patel R, Conrad MF, Paruchuri V, Kwolek CJ, Chung TK, Cambria RP. Thoracoabdominal aneurysm repair: hybrid versus open repair. J Vasc Surg 2009;50:15-22. 17. Gawenda M, Aleksic M, Heckenkamp J, Reichert V, Gossmann A, Brunkwall J. Hybrid-procedures for the treatment of thoracoabdominal aortic aneurysms and dissections. Eur J Vasc Endovasc Surg 2007;33: 71-7. 18. Greenberg RK, Lytle B. Endovascular repair of thoracoabdominal aneurysms. Circulation 2008;117:2288-96. 19. Foley WD, Karcaaltincaba M. Computed tomography angiography: principles and clinical applications. J Comput Assist Tomogr 2003;27 Suppl 1:S23-30.
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20. Lin PH, Bechara C, Kougias P, Huynh TT, LeMaire SA, Coselli JS. Assessment of aortic pathology and peripheral arterial disease using multidetector computed tomographic angiography. Vasc Endovascular Surg 2008;42:583-98. 21. Clouse WD, Marone LK, Davison JK, Dorer DJ, Brewster DC, LaMuraglia GM, Cambria RP. Late aortic and graft-related events after thoracoabdominal aneurysm repair. J Vasc Surg 2003;37:254-61. 22. Gasparis AP, Da Silva MS, Semel L. Visceral patch rupture after repair of thoracoabdominal aortic aneurysm–a case report. Vasc Surg 2001;35: 491-4.
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23. Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Thoracoabdominal aortic aneurysms associated with celiac, superior mesenteric, and renal artery occlusive disease: methods and analysis of results in 271 patients. J Vasc Surg 1992;16:378-89; discussion 389-90. 24. LeMaire SA, Jamison AL, Carter SA, Wen S, Alankar S, Coselli JS. Deployment of balloon expandable stents during open repair of thoracoabdominal aortic aneurysms: a new strategy for managing renal and mesenteric artery lesions. Eur J Cardiothorac Surg 2004;26:599-607. Submitted Oct 6, 2009; accepted Jan 13, 2010.