Longitudinal Outcomes of Thoracic Endovascular Aortic Repair for Ruptured Thoracic Aortic Aneurysms.

OBJECTIVES: Limited data exist on long-term mortality and reintervention rates of emergent thoracic endovascular aortic repair (TEVAR) for ruptured thoracic aortic aneurysm (rTAA). This study aimed to characterize the long-term outcomes of emergent TEVAR for rTAA. METHODS: This study reviewed all TEVARs for emergent rTAA and elective intact thoracic aortic aneurysms (iTAA) from August 2005 to March 2022 at a large academic medical center. Outcomes, including overall survival and reinterventions, were considered over eight years. RESULTS: Of 321 patients, 65 received TEVAR for rTAA (34 hemodynamically stable) and 256 for iTAA. Respective mean (SD) ages were 74.4 (11.9) and 74.7 (9.1) years. Median follow-up was 5.1 years. rTAA patients had lower 30-day survival (69.2% vs 96.9%, P < .001) and higher rates of stroke, pneumonia, and prolonged ventilation (all P ≤ .01). Survival was significantly worse for rTAA at 1 year (46% vs 86%), 5 years (27% vs 48%), and 8 years (20% vs 32%; all P < .001). For patients surviving at least 90 days, the long-term survival difference narrowed to statistical insignificance. Ruptured aneurysms required more reinterventions within 30 days, but comparable long-term reintervention rates. Indications for reintervention were similar, with type I endoleak as the leading cause. Long-term survival for hemodynamically stable rTAA patients did not differ significantly from iTAA patients (49% vs 48% at 5 years). CONCLUSIONS: Short-to-medium-term outcomes are worse for ruptured aneurysms. However, long-term survival of hemodynamically stable rTAA patients and rTAA patients who survive the first 90 days are comparable to iTAA patients.

Sandwich thoracic branch endoprosthesis technique for endovascular repair of thoracic aortic aneurysm with aberrant right subclavian artery.

Subclavian artery coverage is frequently required to achieve an adequate proximal seal during thoracic endovascular aortic repair. The thoracic branch endoprosthesis (TBE; W.L. Gore & Associates) is the first U.S. Food and Drug Administration-approved branched device for thoracic endovascular aortic repair, designed for left subclavian artery incorporation. However, anatomic suitability of the TBE has been shown to be limited. In the present report, we describe a novel technique using the TBE in a sandwich periscope configuration to allow for emergent repair of a ruptured thoracic aortic aneurysm with a highly angulated proximal seal zone and aberrant right subclavian artery.

A fatal masquerade in pneumonia: Ruptured thoracic aortic aneurysm.

We described an 87-year-old man who presented with fever and hemoptysis. Nosocomial pneumonia was initially suspected. However, the patient had worsening hemoptysis despite defervescence. Chest computed tomography disclosed ruptured thoracic aortic aneurysm. Emergent surgery was then commenced for adequate treatment.

Single-stage hybrid procedure for ruptured calcified thoracic aortic aneurysm caused by Takayasu's arteritis.

A 68-year-old woman was referred to our hospital because of ruptured severely calcified thoracic aortic aneurysm on chest computed tomography. She was diagnosed with Takayasu's arteritis ~ 30 years ago and was treated with oral steroids daily. We performed total arch repair using uncalcified ascending aorta with open stent-grafting technique, and additional thoracic endovascular aortic repair immediately after open surgery to avoid type Ib endoleak. Continuous hemodiafiltration was needed owing to postoperative transient acute renal failure, following which the patient recovered. She was referred to another hospital 50 days after surgery. A single-stage hybrid procedure for ruptured severe calcified thoracic aortic aneurysm caused by Takayasu's arteritis was required in this case.

Trends in management and outcomes of vascular emergencies in the nationwide inpatient sample.

Background: To evaluate trends in frequency, mortality and treatment for non-traumatic vascular emergencies (VE) in the US. Methods: VE in the Nationwide Inpatient Sample (2005-2014) were identified. ICD-9 CM diagnosis and procedures codes captured six common VE. Results: 228,210,504 emergency admissions with 317,396 procedures for VE were estimated. Mean age was 67.8 years and were primarily men (56.1 %; p < 0.0001). The commonest VE was Acute Limb Ischemia (ALI) (82.4 %) followed by ruptured AAA (10.8 %) and Acute Mesenteric Ischemia (4.71 %). VE increased from 132.8 per 100,000 admissions in 2005 to 153.6 in 2014 (p < 0.001), with mortality decrease for all VE (13.8 % vs. 9.1 %; p < 0.0001). Length of stay decreased (median 8 vs. 7 days; p < 0.0001) but cost of care increased (median $ 25,443 vs. $ 29,353; p < 0.0001). Endovascular treatment increased overall for VE from 23.7 % in 2005 to 37.2 % in 2014 (p < 0.0001). Hospital mortality for VE decreased overall, except ruptured thoracoabdominal aortic aneurysm with mortality decrease with endovascular treatment (34.3 vs. 11.1; p = 0.04) and mortality increase with open treatment (44.7 vs. 47.6; p = 0.06). ALI overall mortality decreased from 8.1 % to 5.7 % (p < 0.0001) due to reduced open surgical mortality from 9.6 % to 7.4 % (p < 0.0001); endovascular mortality did not improve over time (4.0 % vs. 3.4 %; p = 0.45). Hospital mortality also increased for endovascular treatment of ruptured thoracic aortic aneurysm (rTAA) from 14.9 % to 27.4 % (p = 0.0003) during this period. Conclusions: VE frequency increased with a decrease in overall mortality over time. Overall hospital stay has decreased but with an increase in the cost of care. Open surgical mortality for VE has also decreased overall, suggesting perioperative care improvements, with the exception of ruptured thoracoabdominal aortic aneurysm. Endovascular utilization for VE has significantly increased; associated with lower mortality for most VE, although an increase in hospital mortality after endovascular repair of rTAA was seen. This may be due to an increased implementation of endovascular repair for patients not previously eligible for surgery due to high risk. We recommend careful selection of patients for rTAA treatment as mortality has increased despite endovascular therapy and at an increased cost of care.

A Case of Urgent Thoracic Endovascular Aortic Repair with the Double-Chimney Graft Technique for a Ruptured Thoracic Aortic Aneurysm / 日本心臓血管外科学会雑誌

A 73-year-old woman suffered from ruptured aortic arch aneurysm into mediastinum. The patient was treated by thoracic endovascular aortic repair with the double-chimney graft technique. Three days later, computed tomography (CT) revealed type 1a endoleak (EL) between the chimney grafts. Ten days later, the patient was treated by coil embolization of the aneurysm from the left subclavian artery. The patient recovered, and was without aortic aneurysm events during six months of follow up.

Successful Repair of Critical Anastomotic Bleeding after Surgery for Ruptured Infected Thoracic Aortic Aneurysm / 日本心臓血管外科学会雑誌

Infected aortic aneurysm is very difficult to treat and is associated with a high mortality rate. A 78-year-old man had been scheduled to undergo selective endovascular repair for distal aortic arch aneurysm. While standby, however, he was admitted to our emergency room because of hemoptysis. Rapid dilatation of the aneurysm shown on serial CT and elevated of inflammatory reactions yielded a diagnosis of infected aortic aneurysm. Because the aneurysm had ruptured into the left lung, emergency surgery was performed. Six days after the first operation, critical bleeding due to anastomotic disruption of the distal aorta caused by infection and subsequent cardiac arrest occurred. We immediately started open chest massage and controlled the bleeding manually in the ICU, while an operating room was prepared. In the redo operation, anastomotic disruption was repaired using the visceral pleura under deep hypothermic circulatory arrest. Anastomotic bleeding is a potentially life-threatening condition, therefore extremely prompt measures are vital. Appropriate management based on the assumption of anastomotic bleeding was very important in the postoperative course of this case of infectious aortic aneurysm.

A Case of Ruptured Thoracic Aortic Aneurysm Requiring Two-Stage Sternal Closure due to Posterior Mediastinal Hematoma / 日本心臓血管外科学会雑誌

A 70-year-old man with severe chest pain was transferred to our hospital by ambulance. Computed tomography revealed a ruptured thoracic aortic aneurysm and massive bleeding into the posterior mediastinum. Emergency total aortic arch replacement was performed through median sternotomy. However sternal closure induced severe hypotension because the heart was elevated anteriorly by the posterior mediastinal hematoma. The hematoma could not be eliminated fully so the sternum was kept open at the first operation followed by delayed sternal closure 3 days after the operation. After that, the postoperative course was uneventful and the patient was discharged on postoperative day 43.