Endovascular Repair of 100 Urgent and Emergent Free or Contained Thoracoabdominal Aortic Aneurysms Ruptures. An International Multicenter Trans-Atlantic Experience

Abstract

Objective: To analyze the outcomes of urgent/emergent endovascular aortic repair of patients with free/contained ruptured thoracoabdominal aortic aneurysms (rTAAA).

Background: Endovascular repair of rTAAA has been scarcely described in emergent setting.

Methods: An international multicenter retrospective observational study (ClinicalTrials.govID:NCT05956873) from January 2015 to January 2023 in 6 European and 1 US Vascular Surgery Centers. Primary end points were technical success, 30-day and/or in-hospital mortality, and follow-up survival.

Results: A total of 100 rTAAA patients were included (75 male; mean age 73 years). All patients (86 contained and 14 free ruptures) were symptomatic and treated within 24 hours from diagnosis: multibranched off-the-shelf devices (Zenith t-branch, Cook Medical Inc., Bjaeverskov, Denmark) in 88 patients, physician-modified endografts in 8, patient-specific device or parallel grafts in 2 patients each. Primary technical success was achieved in 89 patients, and 30-day and/or in-hospital mortality was 24%. Major adverse events occurred in 34% of patients (permanent dialysis and paraplegia in 4 and 8 patients, respectively). No statistical differences were detected in mortality rates between free and contained ruptured patients (43% vs 21%; P =0.075). Multivariate analysis revealed contained rupture favoring technical success [odds ratio (OR): 10.1; 95% CI: 3.0-33.6; P <0.001]. Major adverse events (OR: 9.4; 95% CI: 2.8-30.5; P <0.001) and pulmonary complications (OR: 11.3; 95% CI: 3.0-41.5; P <0.001) were independent risk factors for 30-day and/or in-hospital mortality. The median follow-up time was 13 months (interquartile range 5-24); 1-year survival rate was 65%. Aneurysm diameter >80 mm (hazard ratio: 2.0; 95% CI: 1.0-30.5; P =0.037), technical failure (hazard ratio: 2.6; 95% CI: 1.1-6.5; P =0.045) and pulmonary complications (hazard ratio: 3.0; 95% CI: 1.2-7.9; P =0.021) were independent risk factors for follow-up mortality.

Conclusions: Endovascular repair of rTAAA shows high technical success; the presence of free rupture alone appear not to correlate with early mortality. Effective prevention/management of postoperative complications is crucial for survival.

FIGURE 1

Radiological differences between free and contained rupture. A, Free rupture at the level of the thoracic aorta, with evidence of bleeding outside the aortic wall and in this specific case with left haemothorax and complete lung atelectasis. B, Contained rupture at the level of the renal and mesenteric arteries in a IV type rTAAA, with total loss of the integrity of the suprarenal right aortic wall, without clear evidence of bleeding but with periaortic structures hematoma.

FIGURE 2

Examples of preoperative computed tomography angiography (CTA), preoperative 3-dimensional volume rendering (3D VR) and postoperative 3D VR of ruptured thoracoabdominal aortic aneurysms (rTAAA) cases repaired using off-the-shelf (A), custom-made (B), and physician-modified endograft (C) techniques. A, Case of contained rupture type II rTAAA treated with 2 proximal thoracic endografts [thoracic endovascular repair (TEVAR)], and with the use of an off-the-shelf multibranched Cook t-branch and a bifurcated abdominal graft. B, Case of a double contained rupture at the level of the sura-visceral and visceral aorta and infrarenal aorta, treated with the use of a proximal TEVAR, a custom-made device of a dead patient with two proximal branches for celiac trunk and superior mesenteric artery and 2 fenestrations for renal arteries. The patient was on 3 times week dialysis and the 2 fenestrations were occluded with an aortic cuff. The cases was completed with a distal bifurcated graft. C, Case of a free aortic rupture of a postdissection TAAA below a previous implanted TEVAR and previous distal endovascular abdominal repair (EVAR), treated with the use of a thoracic stent-graft with 4 physician-modified fenestrations for celiac trunk, superior mesenteric artery, and renal arteries.