Endovascular treatment of synchronous and metachronous aneurysms of the thoracic aorta. Is there an increase in the procedural risk?

Abstract

Objective

The independent occurrence of aneurysms in the thoracic aorta (TAA) and abdominal aorta (AAA), simultaneously (synchronous aneurysms – SA) or sequentially (metachronous aneurysms – MA) occurs in 20–25%.

Endovascular or open repair (OR) of SA may be simultaneous or staged, while interventions for MA always involves two procedures.

In both cases, an increase of spinal cord ischemia (SCI) rates was reported.

The present study analyzes our experience in the management of SA and MA.

Methods

In a retrospective analysis, all the patients submitted to thoracic endovascular aneurysm repair (TEVAR) between March 2009 and February 2015, were identified. From these, those who had TEVAR + EVAR or TEVAR + OR of AAA in the same period of time (Group-1: synchronous) and those who had TEVAR and had previous repair of AAA (Group-2: metachronous) were selected.

All surgeries were performed under strict haemodynamic control, cerebrospinal fluid (CSF) drainage and pressure monitoring and the patency of the left subclavian artery was assured.

The endpoints were: incidence of SCI, stroke, acute kidney injury and mortality.

Results

TEVAR was performed in 58 patients of which 5 had SA (Group-1: 8.6%) and 6 had MA (Group-2: 10.3%).

Group-1 included 3 patients treated with EVAR + TEVAR simultaneously, one patient who had a TEVAR and OR of a type-4 thoracoabdominal aneurysm (TAAA) in the same hospitalization and, finally, a fifth patient that underwent TEVAR due to a contained rupture of a proximal TAA. This patient also presented a type-4 TAAA, whose treatment was deferred due to poor medical condition, but ruptured 1 month after.

Group-2 included 6 patients. Five had OR of AAA in the past and underwent TEVAR. The sixth patient had a previous EVAR with an abdominal debranching. One patient was submitted to a supra-aortic debranching and another to a chimney procedure of the superior mesenteric artery. The median of the initial to current intervention time was 6.5 years.

There were no reports of SCI or early mortality but 1 patient in Group-1 died due to non-procedural complications.

Conclusion

The prevalence of SA and MA in all the TEVAR cases was 18.9%.

With implementation of a surgical and anesthetic protocol, there were no cases of SCI or surgical mortality.