Endovascular treatment of thoracoabdominal aortic aneurysms

Objective: This study assessed the role of multibranched stent grafts for thoracoabdominal aortic aneurysm (TAAA) repair. Metbods: Self-expanding covered stents were used to connect the caudally directed cuffs of an aortic stent graft with the visceral branches of a TAAA in 22 patients (16 men, 6 women) with a mean age of 76 +/- 7 years. All patients were unfit for open repair, and nine had undergone prior aortic surgery. Customized aortic stent grafts were inserted through surgically exposed femoral (n = 16) or iliac (n = 6) arteries. Covered stents were inserted through surgically exposed brachial arteries. Spinal catheters were used for cerebrospinal fluid pressure drainage in 22 patients and for and spinal anesthesia in 11. Results: All 22 stent grafts and all 81 branches were deployed successfully. Aortic coverage as a percentage of subclavian-to-bifurcation distance was 69% +/- 20%. Mean contrast volume was 203 mL, mean blood loss was 714 mL, and mean hospital stay was 10.9 days. Two patients (9.1%) died perioperatively: one from guidewire injury to a renal arterial branch and the other from a medication error. Serious or potentially serious complications occurred in 9 of 22 patients (41%). There was no paraplegia, renal failure, stroke, or myocardial infarction among the 20 surviving patients. Two patients (9.1%) underwent successful reintervention: one for localized intimal disruption and the other for aortic dissection, type I endoleak, and stenosis of the superior mesenteric artery. One patient has a type II endoleak. Follow-up is > 1 month in 19 patients, > 6 months in 12, and > 12 months in 8. One branch (renal artery) occluded for a 98.75% branch patency rate at I month. The other 80 branches remain patent. There are no signs of stent graft migration, component separation, or fracture. Conclusions: Multibranched stent graft implantation eliminates aneurysm flow, preserves visceral perfusion, and avoids many of the physiologic stresses associated with other forms of repair. The results support an expanded role for this technique in the treatment of TAAA.