SIRRFS Angio Club Ethan M Dobrow PGY4 Maine

SIR-RFS Angio. Club Ethan M. Dobrow, PGY-4 Maine Medical Center, Portland, Maine (The Freeman Hospital, Newcastle-Upon-Tyne, UK)

Presentation • 62 year old female presents with vague chest discomfort and cough. • Relevant past medical history includes 80 packyears tobacco abuse, hypertension, dyslipidemia, Et. OH. • Chest radiograph reveal enlarged aorta, and CT angiography was ordered. These findings progressed over the course of 6 months prompting vascular medicine consult.

Thoracoabdominal aortic aneurysm • Incidence of 5 per 100, 00 patient years. • High mortality if untreated, in one series rupture in 74%, nearly all fatal with a 60% 1 -year and 20% 5 -year survival. • Typically degenerative TAAA diagnosed age 5070, men more common than females. • Comorbid conditions typically included: HTN, CAD, COPD, PAD, CHF, prior CVA • Worse outcomes with increased age, COPD, large diameter abdominal aortic component, pain. Fann, JI. Descending thoracic and throacoabdominal aortic aneurysms. Coron Artery Dis. 2002 Apr; 13(2): 93 -102.

Fig 1 TAAA Classification I. Below L SCA to above renal arteries. II. Below L SCA and including infrarenal aorta to the bifurcation. (most common, as is seen in our patient) III. 6 th intercostal space to bifurcation. IV. 12 th intercostal space to bifurcation. V. 6 th intercostal space to above renal arteries. Source: The Annals of Thoracic Surgery 1998; 66: 1204 -1208 (DOI: 10. 1016/S 0003 -4975(98)00781 -4 ) Copyright © 1998 The Society of Thoracic Surgeons Terms and Conditions

TAAA treatment options • Open repair: high morbidity and mortality. – Recent meta-analysis showed average 30 -day mortality at 19% with high associated morbidity. • Endovascular treatment in a combined series shown to have a 3 -6% 30 -day and 11 -13% 1 -year mortality. Uncomplicated case with hospital stay <5 days. 1. 2. Piazza M, Ricotta JJ. Open Surgical Repair of Thoracoabdominal Aortic Aneurysms. Ann Vasc Surg. 2012; 26: 600605. Greenberg RK, Lytle B. Endovascular Repair of Thoracoabdominal Aneurysms, Circulation, 2008; 117: 2288 -2296.

Endovascular techniques • Hybrid: uses extra-anatomic bypass (i. e. renal to external iliac) prior to endograft placement. Allows for off-the-shelf endografts. • Fenestrated/Branched: Allows placement of endografts through the aorta containing visceral branches. Custom grafts preferred. There is at least a 6 week minimum from time of imaging to manufacture. • Complications: most feared complication is paraplegia from spinal ischemia (stage procedure), visceral injury related to malpositioned branch/fenstration graft.

Spinal drains • Spinal drains are thought to decrease CSF pressure and increase spinal cord perfusion. • Preoperative placement of spinal drains for open procedures including long segment repair and reintervention is shown to decrease rates of spinal cord ischemia (SCI). • Endovascular repair is overall associated with lower rates of SCI. • No conclusive evidence that CSF drainage is beneficial for endovascular treatment. • It has been shown that postoperative place of spinal drain does not reverse SCI. Hanna JM, et al. Results With Selective Preoperative Lumbar Drain Placement for Thoraccic Endovascular Aortic Repair. Ann Thorac Surg. 2013; 95(6): 1968 -74.

Technique • Initially the left subclavian was bypassed and plugged. • Two Cook TX 2 TAA endografts were placed, the first covering the occluded left SCA. • Segment three was a Cook Zenith endograft with branches for the celiac, SMA, and left renal artery. • Segment four was a customized fenestrated bifurcated endograft. • The IMA was chronically occluded. • Atrium stent for the fenestrated component and self expandable stents for branched segments. • Procedure was staged to prevent spinal cord ischemia, the SMA branch was sealed 2 weeks after initial endovascular procedure.

Conclusion: • Endovascular treatment for TAAA has decreased morbidity and mortality compared to open repair based on a small number of series. • No randomized prospective trials. • Customization allows treatment of aneurysms involving visceral branches. – Long manufacturing times limits treatment to elective cases, limiting utility for treatment for acute rupture unless the interventionalist has experience with modification. • Spinal drains remain controversial for endovascular technique. Staged procedures have been advocated.

Qustions/Discussion • Special thanks to Dr. Rob Williams of the Freeman Hospital, Newcastle-upon-Tyne Hospitals, National Heath Trust.