Branched endovascular aortic repair of chronic post-dissection thoracoabdominal aortic aneurysms: an institutional experience on preoperative planning, intraoperative execution, and pitfalls.

BACKGROUND

The purpose of this study was to evaluate the outcomes of branched endovascular aortic repair (BEVAR) in post-dissection thoracoabdominal aortic aneurysms (PD TAAAs), as well as define preoperative planning and intraoperative execution.

METHODS

Patients who underwent BEVAR in PD TAAAs from 2019 to 2024 were identified using a prospectively maintained electronic database at a single, tertiary-care hospital. Patient demographics, comorbidities, indication for the procedure, anatomic and procedural details, and outcomes were retrospectively recorded.

RESULTS

Thirty-four patients (74% male, median age 62 years) underwent BEVAR for PD TAAA. There was a high incidence of hypertension (79%) and stage III-V chronic kidney disease (41%). Prior aortic surgery was prevalent in the majority (62%) of patients, with an open (53%) and/or endovascular (35%) approach. BEVAR was commonly performed for asymptomatic PD-TAAA without rupture (71%). Target vessels (TV) arising from the false lumen (FL) and dissected TVs occurred in 32% and 11%, respectively. The majority underwent staged repair by an open (15%) and/or endovascular (47%) approach, most commonly zone 2 (24%) or 3 (15%) thoracic endovascular aortic repair (TEVAR). The off-the-shelf t-Branch (Cook Medical) was used in 24 (70%) patients. The proximal and distal landing zones were in prior/staged TEVAR (71%) and in native infrarenal aorta (65%), respectively. The bridging stent-graft was most commonly balloon-expandable (70%), including hybrid stenting with self-expandable stent-grafts. Adjunctive FL management and prophylactic embolization of type II endoleaks were performed in 56% and 79%, respectively. Technical success was 94%. Postoperative complications were most commonly self-limited acute kidney injury (9%); there was no episodes of spinal cord ischemia. There was a 30-day mortality of 6%. Thirty-day reinterventions were 3% (N.=4, 130 target vessels) for TV-related instability and 6% (N.=2, 34 patients) for FL perfusion. Based on a median follow-up of 18 months, primary and primary-assisted patency of the TV were 94% and 99%, respectively. Midterm reinterventions were 6% for TV-related instability and 35% for FL perfusion. There were no surgical conversions.

CONCLUSIONS

BEVAR can be performed with high technical success in PD TAAAs. However, secondary interventions for TV instability and continued FL perfusion are frequent; thus, close follow-up is mandatory.