Elective Multistaged Endovascular Repair of Thoraco-abdominal Aneurysms with Fenestrated and Branched Endografts to Mitigate Spinal Cord Ischaemia

Luca Bertoglio; Maria Katsarou; Diletta Loschi; Enrico Rinaldi; Daniele Mascia; Andrea Kahlberg; Rosalba Lembo; Germano Melissano; Roberto Chiesa

doi:10.1016/j.ejvs.2019.10.003

Elective Multistaged Endovascular Repair of Thoraco-abdominal Aneurysms with Fenestrated and Branched Endografts to Mitigate Spinal Cord Ischaemia

Eur J Vasc Endovasc Surg. 2020 Apr;59(4):565-576. doi: 10.1016/j.ejvs.2019.10.003. Epub 2019 Dec 20.

Authors

Luca Bertoglio¹, Maria Katsarou², Diletta Loschi², Enrico Rinaldi², Daniele Mascia², Andrea Kahlberg², Rosalba Lembo², Germano Melissano², Roberto Chiesa²

Affiliations

¹ Division of Vascular Surgery, "Vita - Salute" University, Scientific Institute H. San Raffaele, Milan, Italy. Electronic address: bertoglio.luca@hsr.it.
² Division of Vascular Surgery, "Vita - Salute" University, Scientific Institute H. San Raffaele, Milan, Italy.

PMID: 31870689
DOI: 10.1016/j.ejvs.2019.10.003

Abstract

Objective: To evaluate the safety and effectiveness of a multistaged approach for elective thoraco-abdominal aneurysm (TAAAs) repair by means of endovascular fenestrated and/or branched (F/B-EVAR) grafts.

Methods: Between 2013 and 2018, 80 high risk surgical patients received elective F/B-EVAR for TAAAs with a protocolled multistaged approach (thoracic, visceral, and limb steps) and were enrolled in an ambispective single centre study called STEAR (STaged Endovascular Aortic Repair - NCT03342755). Data regarding all study participants, single step mortality and morbidity (systemic complications) rates were recorded and the overall results were considered for statistical analysis.

Results: Previous aortic interventions (61/80 cases, 76.3%) combined with the TAAA extents resulted in different staging strategies: 58 patients (73%) had a thoracic step and 33 (41%) a limb step. The median TAAA treatment time was 77 days (50-107). The overall mortality was six cases (8%) and 30 day clinical success rate 64 cases (80%). The overall rate of grade 2 or 3 (including death) systemic complications was 19 cases (24%) and 20 patients (25%) experienced grade 1 complications. Three patients with type II or III TAAAs (4%) had permanent and fatal spinal cord (SC) impairment. On multivariable analysis, SC ischaemia was associated with an aortic coverage ≥350 mm (OR: 9.15, p = .03, 95% CI: 1.3-66.4) and bovine arch (OR: 10.6, p = .01, 95% CI: 1.6-68.6). The overall short term (six month) clinical success was 72 cases (90%) and none experienced SC ischaemia after late endoleak resolution or treatment. At mid term (mean follow up: 13.3 ± 15.4 months), the overall freedom from conversions, re-interventions, late rupture, or type I and III endoleaks was 57 of 72 survivors (79%).

Conclusion: A multistaged approach with a third limb step in case of TAAAs is safe and technically feasible, with an acceptable rate of permanent spinal cord ischaemia. Different staging methods and protocols have been proposed and standardisation is required, especially for type I-II-III aneurysms.

Keywords: Branched; Endovascular; Fenestrated; Paraplegia; Prevention; Spinal cord; Staged; Thoraco-abdominal aneurysms.

MeSH terms

Aged
Aged, 80 and over
Aneurysm / surgery*
Aortic Aneurysm, Thoracic / surgery*
Blood Vessel Prosthesis / adverse effects
Blood Vessel Prosthesis Implantation / adverse effects
Elective Surgical Procedures / adverse effects
Endoleak / etiology
Endovascular Procedures* / adverse effects
Female
Humans
Male
Middle Aged
Spinal Cord Ischemia / surgery*
Stents / adverse effects