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Simultaneous Thoracic and Aortic Stent Graft Placement for Synchronous Aortic Disease
Salvatore T. Scali, M.D.1, David H. Stone, M.D.2, Philip P. Goodney, M.D.2, Catherine K. Chang, M.D.1, Robert J. Feezor, M.D.1, Peter R. Nelson, M.D.,M.S.1, Scott A. Berceli, M.D.,Ph.D.1, Thomas S. Huber, M.D.,Ph.D.1, Adam W. Beck, M.D.1.
1University of Florida-Gainesville, Gainesville, FL, USA, 2Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.

OBJECTIVES: Simultaneous treatment of multi-level aortic disease(MLAD) is controversial due to the theoretical increase in morbidity. The purpose of this study was to define the outcomes in patients treated electively with simultaneous thoracic(TEVAR) and abdominal aortic(EVAR) endografting for synchronous aortic pathology. The results of the combined procedures were compared to TEVAR alone(TA) to determine the safety of performing both procedures together.
METHODS: Patients treated with simultaneous TEVAR-EVAR (T&E) at a single institution were identified and compared to those treated with TA. All cases with emergent indications were excluded, as well as those requiring chimney stents, fenestrations or visceral de-branching procedures. Demographics, operative details, and peri-procedural complications were recorded. Freedom from re-intervention was determined using survival analysis.
RESULTS: From 2000 to 2011, 595 patients underwent TEVAR, of who 435 were non-emergent. Twenty-two were identified who were treated with simultaneous T&E. There were 18 male patients (81%) with a mean age(±SD) of 66±9yrs and median follow-up time was 8.8mos(range 1-34 months). Four patients(18%) had a remote history of previous open aortic surgery prior to the index procedure. Indications included dissection-related pathology(N=11, 50%), and various combinations of degenerative etiologies(N=11, 50%)(e.g. aneurysm, penetrating ulcer, post-surgical pseudoaneurysm and atheromatous disease).
Procedural details are outlined in the attached Table. Compared with TA patients, T&E patients had significantly higher blood loss, contrast exposure, fluoroscopy and operative times. The permanent spinal cord ischemia(SCI) rate was 4% for both groups(P=0.96). The 30-day mortality for T&E was 4.6%(N=1) compared to 2.1%(N=9) for TA(P=0.45). No significant difference in renal injury(defined by a 25% increase over baseline creatinine) occurred between the two groups (P=0.14).
CONCLUSIONS: As far as we are aware, this is the largest reported series to date of patients undergoing simultaneous T&E for MLAD. Acceptable short term morbidity and mortality can be achieved when compared to TA. Not surprisingly, longer operative and fluoroscopy times, greater contrast exposure, and higher blood loss can be expected, which may lead to increased morbidity to the patient. Short-term re-intervention rates are low but longer follow up is needed to determine procedural applicability and durability.


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