Surgical correction of failed thoracic endovascular aortic repair.
OBJECTIVE
The number of thoracic aortic endovascular procedures is increasing rapidly, and the clinical outcome largely depends on the underlying aortic pathology. When primary stent grafting is unsuccessful, secondary endovascular solutions are most often feasible. However, in recurrent endovascular failure without further minimally invasive options, conservative treatments or conversion to open surgery are the only remaining therapeutic strategies.


METHODS
In our experience, 106 patients received thoracic aortic endovascular treatment. Five of these patients and three from other centers underwent conversion to open repair because of 4 type Ia endoleaks (3 thoracic aortic aneurysms, 1 traumatic rupture), 2 retrograde type A dissections, 1 type Ib endoleak with contained rupture, and 1 secondary false aneurysm rupture due to stent graft migration. The latter four were surgical emergencies; the other four were urgent or elective procedures. Three patients underwent supracoronary arch replacement through sternotomy. One patient had arch and proximal descending aortic replacement, three had hemiarch and descending aortic replacement, and one had descending aortic replacement through left thoracotomy. Five stent grafts were totally removed, and three endografts were left in situ. All conversions were performed according to a protocol including total extracorporeal circulation (n = 7) or left heart bypass (n = 1), cerebrospinal fluid drainage and monitoring motor-evoked potentials, transcranial Doppler, and electroencephalography.


RESULTS
All patients survived the surgical procedure. Six patients had an uneventful postoperative course, whereas necrotic cholecystitis developed in one patient who required cholecystectomy and prolonged intensive care stay. One polytrauma patient died from secondary rupture due to prosthesis infection 24 days after stent graft explantation. No stroke, paraplegia, renal failure, or other major complication occurred. With a mean follow-up of 14 months (range, 4-71 months), seven patients are alive without any sign of recurrent aortic problems.


CONCLUSIONS
Failure of thoracic endovascular aortic repair comprises a new aortic pathology. Secondary endovascular treatment is feasible in most patients; however, some patients will require open surgery to repair failures of thoracic endovascular aortic treatment. These procedures constitute a large surgical trauma and require an extensive protocol, including extracorporeal circulation, neuromonitoring, and adjunctive modalities to provide organ protection. We recommend that these procedures be performed in centers with experience and the infrastructure to offer these protective measures.
Langer
Stephan
S
European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, University Hospital Aachen, Aachen, Germany.
Mommertz
Gottfried
G
Koeppel
Thomas A
TA
Schurink
Geert W H
GW
Autschbach
Rüdiger
R
Jacobs
Michael J
MJ
D000328:Adult; D000784:Aortic Dissection / Q000000981:diagnostic imaging / Q000601:surgery*; D017541:Aneurysm, False / Q000000981:diagnostic imaging / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000601:surgery*; D001019:Aortic Rupture / Q000000981:diagnostic imaging / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D003250:Constriction; D020878:Device Removal; D005112:Extracorporeal Circulation; D005260:Female; D005500:Follow-Up Studies; D005858:Germany; D006324:Heart Arrest, Induced; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D009426:Netherlands; D011474:Prosthesis Design; D011475:Prosthesis Failure; D012086:Reoperation; D015607:Stents; D013249:Sternum / Q000601:surgery; D013908:Thoracotomy; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D017211:Treatment Failure