Off-the-Shelf Endovascular Treatment of Type III and IV Thoracoabdominal Aneurysm
Jeffrey B. Edwards, MD1, Mathew Wooster, MD2, Adam Tanious, MD1, Marcelo Giarelli, MSN, RN, CCRN1, Paul A. Armstrong, DO1, Murray L. Shames, MD1.
1University of South Florida, Tampa, FL, USA, 2Medical University of South Carolina, Charleston, SC, USA.
OBJECTIVES: Thoracoabdominal aortic aneurysms (TAAA) remain a challenge for the vascular surgeon. Though endovascular branched technologies have evolved to include custom pre-fabricated endografts, access to these devices is limited. We present our experience with an off-the-shelf technique to treat TAAA.
METHODS: All patients undergoing endovascular repair of type III and IV TAAAs using this technique were included in a prospectively maintained registry at a regional aortic referral center. The proximal bifurcated Gore C3 Excluder device is positioned in the descending thoracic aorta with the contralateral gate 2-3 cm above the celiac artery. The celiac artery was incorporated using a parallel stent graft in select cases. Via a Dacron axillary conduit or percutaneous brachial approach, renovisceral vessels were cannulated through the contralateral gate and simulateneously stented using Viabahn covered stents. All branches are simultaneously balloon dilated to minimize risk for gutter leak. The proximal bifurcated device was then extended from the ipsilateral limb using a flared iliac extension or additional bifurcated device to achieve adequate seal in the distal aorta or iliac arteries.
RESULTS: Fourteen patients (7 males, mean age 78y) have been treated using this technique since January 2015. All patients were considered high-risk for open repair and 35% (n=5) presented with symptomatic aneurysms. All underwent repair using Gore C3 device with proximal CTAG (n=2), and 2 (n=2), 3 (n=7), or 4 (n=5) renovisceral branches for a total of 45 stents. 2 renal arteries and 1 celiac artery were unable to be cannulated and 3 Celiac arteries were occluded with an Amplatzer II embolization device. Mean (median) length of stay was 11(7) days, with 8(4) days in the ICU. Six patients had endoleaks, 2 gutter leaks treated with peri-graft embolization and type III endoleak treated with iliac limb re-lining. There were 2 post-operative deaths, one due to multi-system organ failure on post-operative day 3, and one due to acute mesenteric ischemia after mesenteric artery stent thrombosis. 43/45 stents remain patent at the time of last imaging study (mean 3.5m, max 1.2y). CONCLUSIONS:
We present an endovascular technique using readily available, off-the-shelf devices for type III and IV TAAAs which is feasible and safe with good short term outcomes.
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