Is open repair still an option for treating of thoracoabdominal aneurysms in endovascular era?

• Lazar Davidovic
• Kostic Ognjen

Abstract

Besides new advanced thoracic stent graft and devices, as well as an improvement of surgical skill, open repair of thoracoabdominal aortic aneurysms is still very important. The main indications for it include patients with unfavorable aneurysm anatomy, patients with connective tissue disorders, good-risk patients with life expectancy of at the least 10 years regardless of anatomic suitability and genetic, then patients with mycotic thoracoabdominal aortic aneurysms and finally patients with same long-term complications after previous TEVAR.

Open repair of thoracoabdominal aortic aneurysms can be only performed in high volume centers, while younger generation of vascular surgeons should be educated in both endovascular and open aortic surgery.

Keywords:  thoracoabdominal aortic aneurysm; stent graft; TEVAR; endovascular surgery; open surgery

Introduction

Regardless of the treatment option, a repair of thoracoabdominal aortic aneurysms (ThAAs) is the most challenging vascular procedure for patients, for surgeons and for anesthesiologists. Main reasons include the risk of the spinal cord and visceral ischemia (Fig. 1). We will try to explain that open repair (OR) of ThAA is still very important in endovascular era (Fig. 2, 3).

Discussion

Let us begin with unfavourable anatomy of the ThAA. Because of short distal lending zone, severe angulation of the thoracic aorta, an occlusion of infrarenal aorta, visceral artery stenosis, as well as significant tortuosity and small diameter of iliac arteries, 20 to 40% of ThAAs are unsuitable for total endovascular repair [2–4]. Due to this OR should be considered as a first treatment option of ThAAs with unfavorable anatomy.

Endovascular repair is not recommended in patients with connective tissue disorders. The first reason is generalized disease of the entire aorta. Then the friability of the aortic wall in these patients seems to be incompatible with the radial forces that are important for stent graft fixation. Because of previous reasons, type 1 endoleak and graft migration may occur [4]. Due to this a TEVAR is recommended only during emergency procedures including the treatment of aneurysm rupture or severe mal perfusion, but as a bridge to open surgery [6, 7]. TEVAR can be also considered in patients with significant comorbidity [8]. In majority of patients with connective tissue disorders OR is the method of choice for treatment of ThAAs [9].

According to some of the most recently published reports there is no significant differences regarding the early outcome (perioperative mortality and paraplegia rates) compared open and total endovascular repair of ThAAs [10, 11]. At the same time OR is followed with a lower rate of required re-interventions [12]. European guidelines recommends OR of ThAAs in fit patients who are unsuitable for endovascular repair [7]. We are not totally agreeing with this recommendation. We recommend OR of ThAAs in low-risk patients with life expectancy longer than 10 years, regardless of anatomic suitability and genetic.

Endovascular treatment of mycotic ThAAs provides an early survival benefit, but it is associated with a very high reinfection rate [13]. Due to this TEVAR can be also used in such cases only as a bridge to OR which is still gold standard for definitive treatment of all mycotic aneurysms.

Finally, same long term complications after previous TEVAR require OR or so called “late open surgical conversion” (LOSC). Those are: endoleak type I, stent graft collapse, migration and infection, then distal aneurysm formation, as well as secondary aorta esophageal and pulmonary fistulas [14–18]. The incidence of LOSC after previous TEVAR is higher than previously thought including very experienced endovascular centers [19].

Conclusion

OR of ThAAs shouldn’t be forgotten in endovascular era. It can be only performed in high volume centers. On the other hand, the development of endovascular surgery during the past three decades has significantly reduced the number of hospitals and surgeons that can perform OR of complex aortic pathology. Due to this, younger generation of vascular surgeons should be educated in both endovascular and open aortic surgery. However, an education in open aortic surgery is a great problem in many hospitals. Not in our. Namely during the past 23 years 406 patients with ThAA in our Clinic, were underwent to OR with satisfied results.

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