Contemporary strategies for repair of complex thoracoabdominal aortic aneurysms: real-world experiences and multilayer stents as an alternative

Kolvenbach, Ralf Robert

doi:10.1590/1677-5449.011417

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Brasil

Jornal Vascular Brasileiro

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Brasil

Español English

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REVIEW ARTICLES • J. Vasc. Bras. 16 (4) • Oct-Dec 2017 • https://doi.org/10.1590/1677-5449.011417 copy

Contemporary strategies for repair of complex thoracoabdominal aortic aneurysms: real-world experiences and multilayer stents as an alternative

Estratégias contemporâneas para reparo de aneurismas da aorta toracoabdominal: experiências reais e stents multilayer como alternativa

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Thoracoabdominal aortic aneurysms (TAAA) present special challenges for repair due to their extent, their distinctive pathology, and the fact that they typically cross the ostia of one or more visceral branch vessels. Historically, the established treatment for TAAA was open surgical repair, with the first procedure reported in 1955. Endovascular repair of TAAA with fenestrated and/ or branched endografts, has been studied since the beginning of the current century as a means of mechanical aneurysm exclusion. More recently, flow modulator stents have been employed with the aim at reducing shear stress on aortic aneurysmal wall. In this review we present technical and main results of these techniques, based on literature review and personal experience.

Keywords:
aortic aneurysm; vascular surgical; endovascular procedures; stents; endoleak

Outcomes	Coselli et al. (Baylor)²⁰20 Coselli JS, LeMaire SA, Preventza O, et al. Outcomes of 3309 thoracoabdominal aortic aneurysm repairs. J Thorac Cardiovasc Surg. 2016;151(5):1323-38. PMid:26898979. http://dx.doi.org/10.1016/j.jtcvs.2015.12.050. http://dx.doi.org/10.1016/j.jtcvs.2015.1... n = 3309	Murana et al. (St. Antonius)¹⁰10 Murana G, Castrovinci S, Kloppenburg G, et al. Open thoracoabdominal aortic aneurysm repair in the modern era: results from a 20-year single-centre experience. Eur J Cardiothorac Surg. 2016;49(5):1374-81. PMid:26612715. http://dx.doi.org/10.1093/ejcts/ezv415. http://dx.doi.org/10.1093/ejcts/ezv415... n = 542
Perioperative outcomes (≤ 30 days)
Crawford type	I, 914; II, 1066; III, 660; IV, 669	I, 128; II, 285; III, 62; IV, 48; V, 19
Operative death (≤ 30 days)	249 (7.5%)	46 (8.5%)
Spinal cord ischemia	178 (5.4%)	32 (5.9%)
Renal failure necessitating dialysis	250 (7.6%)	23 (4.2%)
Stroke	98 (3.0%)	23 (4.2%)
Respiratory failure	281 (8.5%)	42 (7.7%)
Myocardial infarction	41 (1.2%)	13 (2.4%)
Long-term outcomes
Mean follow-up		6.32 years
Freedom from repair failure	5 years: 97.9%±0.3% 10 years: 95.3%±0.6% 15 years: 94.1%±0.8%
Freedom from reintervention		1 year: 96.1%±0.1% 5 years: 86.3%±1.8% 10 years: 80.7%±2.3%
Estimated survival	1 year: 83.5%±0.7% 5 years: 63.6%±0.9% 10 years: 36.8%±1.0% 15 years: 18.3%±0.9%	1 year: 85.9%±1.5% 5 years: 74.2%±2.0% 10 years: 61.6%±2.5%

Outcomes	Verhoeven et al. (Paracelsus)²⁴24 Verhoeven EL, Katsargyris A, Bekkema F, et al. Ten-year experience with endovascular repair of thoracoabdominal aortic aneurysms: results from 166 consecutive patients. Eur J Vasc Endovasc Surg. 2015;49(5):524-31. PMid:25599593. http://dx.doi.org/10.1016/j.ejvs.2014.11.018. http://dx.doi.org/10.1016/j.ejvs.2014.11... n = 166	Eagleton et al. (Cleveland Clinic)²⁶26 Eagleton MJ, Follansbee M, Wolski K, Mastracci T, Kuramochi Y. Fenestrated and branched endovascular aneurysm repair outcomes for type II and III thoracoabdominal aortic aneurysms. J Vasc Surg. 2016;63(4):930-42. PMid:26792544. http://dx.doi.org/10.1016/j.jvs.2015.10.095. http://dx.doi.org/10.1016/j.jvs.2015.10.... n = 354	Marzelle et al. (WINDOWS trial)³²32 Marzelle J, Presles E, Becquemin JP. Results and factors affecting early outcome of fenestrated and/or branched stent grafts for aortic aneurysms. Ann Surg. 2015;261(1):197-206. PMid:24670864. http://dx.doi.org/10.1097/SLA.0000000000000612. http://dx.doi.org/10.1097/SLA.0000000000... n = 268
Perioperative outcomes (≤ 30 days)
Crawford type	I, 12; II, 50; III, 53; IV, 41; V, 10	II, 128; III, 226	I, 2; II 16; III, 24; IV, 26
Target branch arteries	600	1305	1463
Technical success	157 (95%)	333 (94.1%)	230/252 (91.2%)
Operative death (≤30 days)	13 (7.8%)	17 (4.8%)	18 (6.7%)
Spinal cord ischemia	15 (9%)	31 (8.8%)	11 (4.1%)
Renal failure necessitating dialysis	9 (5.4%)	10 (2.8%)	15 (5.6%)
Stroke	2 (1.2%)	8 (2.3%)	5 (1.9%)
Respiratory failure	6 (3.6%)	32 (9.0%)	14 (5.2%)
Myocardial infarction	9 (5.4%)	10 (2.8%)	4 (1.5%)
Branch vessel occlusion	2 (1.2%)	4 (1.1%)	8/252 (3.2%)
Rupture	1 (0.6%)	1 (0.3%)	1 (0.4%)
Type I/III endoleak		10 (2.8%)	15 (5.6%)
Early reintervention	12 (7.2%)	13 (3.7%)	31 (11.6%)
Long-term outcomes
Mean follow-up	29.2±21 months	22±19 months
Estimated target branch vessel patency	1 year: 98%±0.6% 2 years: 97%±0.8% 5 years: 94.2%±1.5%	3 years: CA 96% (95%CI 0.93-0.99); SMA 98% (95%CI 0.97-1.0); RA 98% (95%CI 0.96-1.0)
Reintervention for endoleak	20 (12.0%)	67 (18.9%)
Freedom from reintervention	1 year: 88.3%±2.7% 3 years: 78.4%±4.5%	3 years: 54% (95%CI 0.47-0.61)
Estimated survival	1 year: 83%±3% 2 years: 78%±3.5% 5 years: 66.6%±6.1%	3 years: 57% (95%CI 0.50-0.63)

Outcomes	Vaislic et al. (STRATO multicenter)⁴⁰40 Vaislic CD, Fabiani JN, Chocron S, et al., and the STRATO Investigators Group. One-year outcomes following repair of thoracoabdominal aneurysms with the multilayer flow modulator: report from the STRATO trial. J Endovasc Ther. 2014;21(1):85-95. PMid:24502488. http://dx.doi.org/10.1583/13-4553R.1. http://dx.doi.org/10.1583/13-4553R.1... ^,⁴¹41 Vaislic CD, Fabiani J, Chocron S, et al., and the STRATO Investigators Group. Three-year outcomes with the Multilayer Flow Modulator for repair of thoracoabdominal aneurysms: a follow-up report from the STRATO trial. J Endovasc Ther. 2016;23(5):762-72. PMid:27280802. http://dx.doi.org/10.1177/1526602816653095. http://dx.doi.org/10.1177/15266028166530... n = 23	Benjelloun et al. (single-center Moroccan registry)⁴²42 Benjelloun A, Henry M, Taberkant M, Berrado A, Houati RE, Semlali A. Multilayer flow modulator treatment of abdominal and thoracoabdominal aortic aneurysms with side branch coverage: outcomes from a prospective single-center moroccan registry. J Endovasc Ther. 2016;23(5):773-82. PMid:27381934. http://dx.doi.org/10.1177/1526602816657087. http://dx.doi.org/10.1177/15266028166570... n = 18	Sultan et al. (initial MFM patients in 12 countries)⁴³43 Sultan S, Hynes N. One-year results of the multilayer flow modulator stent in the management of thoracoabdominal aortic aneurysms and type B dissections. J Endovasc Ther. 2013;20(3):366-77. PMid:23731310. http://dx.doi.org/10.1583/12-4077MR-R.1. http://dx.doi.org/10.1583/12-4077MR-R.1... ^,⁴⁴44 Sultan S, Sultan M, Hynes N. Early mid-term results of the first 103 cases of multilayer flow modulator stent done under indication for use in the management of thoracoabdominal aortic pathology from the independent global MFM registry. J Cardiovasc Surg. 2014;55(1):21-32. PMid:24356043. n = 103
Perioperative outcomes (≤ 30 days)
Indications	TAAA: II, 10; III, 13	TAAA: I, 4; II, 2; IV, 4; AAA: 8	TAAA: I, 11; II, 14; III, 26; IV, 24; arch aneurysms: 7; suprarenal AAA: 15; type B dissections: 6
Target branch arteries	55	61	378
Technical success	23 (100%)	18 (100%)	100 (97.1%)
Operative death (≤30 days)	0 (0%)	0 (0%)	0 (0%)
Spinal cord ischemia	0 (0%)	0 (0%)	1 (0.99%)^* * One successful deployment of a second MFM within the first 30 days, to correct for device retraction into the aneurysm sac caused by stent foreshortening; one conversion to open repair at 30 days to correct for proximal device infolding, the conversion complicated by postoperative paraplegia.
Renal failure necessitating dialysis	0 (0%)	0 (0%)	0 (0%)
Stroke	0 (0%)	0 (0%)	0 (0%)
Respiratory failure	0 (0%)	0 (0%)
Myocardial infarction	0 (0%)	0 (0%)
Branch vessel occlusion	2/55 (3.6%)	0 (0%)	0 (0%)
Rupture	0 (0%)	0 (0%)	0 (0%)
Type I/III endoleak	1 (4%)	0 (0%)
Early reintervention	1 (4%)	0 (0%)	2 (1.94%)^* * One successful deployment of a second MFM within the first 30 days, to correct for device retraction into the aneurysm sac caused by stent foreshortening; one conversion to open repair at 30 days to correct for proximal device infolding, the conversion complicated by postoperative paraplegia.
Long-term outcomes
Mean follow-up		13.4 months	11.6±3.3 months
Target branch vessel patency	1 year: 100% 2 years: 100% 3 years: 96.6% 4 years: 100%	1 year: 100%	1 year: 95.3%
Reintervention for endoleak	10 (43.5%)	1 (5.5%)
Freedom from reintervention			1 year: 89.3%
Cumulative mortality	1 year: 1 (4.3%) 2 years: 3 (13.0%) 3 years: 8 (34.8%) 4 years: 11 (47.8%)	1 year: 3 (16.7%)
Estimated survival			1 year: 86.8%

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[1] Conflicts of interest: No conflicts of interest declared concerning the publication of this article.