Aortic Endograft

Indications

Abdominal Aorta

Repair of Abdominal Aortic Aneurysm (AAA) (see Abdominal Aortic Aneurysm, [[Abdominal Aortic Aneurysm]])

  • Indications
    • Repair of Aortic Aneurysm in Setting Where Anticoagulation/Extracorporeal Support (i.e. Cardiopulmonary Bypass) is Contraindicated

Thoracic Aorta

Repair of Thoracic Aortic Intramural Hematoma/Penetrating Aortic Ulcer

  • xxx

Repair of Thoracic Aortic Dissection (see Aortic Dissection, [[Aortic Dissection]])

  • xxxx

Repair of Blunt Thoracic Aortic Injury (see Blunt Aortic Injury, [[Blunt Aortic Injury]])

  • xxx

Repair of Thoracic Aortic Aneurysm (TAA) (see Thoracic Aortic Aneurysm, [[Thoracic Aortic Aneurysm]])

  • xxxx

Repair of Thoracic Aortoesophageal Fistula

  • xxx

Physiology

  • xxx

Technique

Types of Devices

  • Gore cTAG device
  • Cook TX2 endograft
  • Medtronic Valiant endograft
  • Bolton Relay endograft

XXXX

  • xxxx

Adverse Effects/Complications

Cardiovascular Adverse Effects/Complications

  • Endograft Collapse
    • Epidemiology
      • More Frequently Occurs in Young Patients with Pliable Aortas and an Endograft Which Does Not Fully Appose the Inner Curve of the Aorta
        • Force of Cardiac Contraction Can Collapse the Endograft, Leading to an Acute Aortic Coarctation
      • Has Been Described with the Gore TAG Device After Removal of the Longitudinal Spine: this removal results in a less rigid endograft
      • Endograft Collapse May Occur within 24 hrs-3 mo After Aortic Endograft Placement
    • Physiology
      • Aortic Occlusion Resulting in Spinal Cord Ischemia-Infarction/Distal Hypoperfusion
    • Clinical
      • Acute Kidney Injury (AKI) (see Acute Kidney Injury, [[Acute Kidney Injury]]): due to renal hypoperfusion
      • Chest Pain (see Chest Pain, [[Chest Pain]])
      • Lower Extremity Weakness (see Weakness, [[Weakness]]): due to spinal cord ischemia/infarction
    • Treatment
      • Insertion of Another Endograft within the Current Graft
      • Palmaz Stenting within the Endograft
      • Open Surgical Endograft Removal
  • Endograft Device Migration
    • Epidemiology: may occur
  • Endograft Limb Kinking/Occlusion
  • Endoleak
    • Epidemiology: occurs in 3.9-15.3% of thoracic endograft cases
    • Physiology: due to persistent blood flow within the aneurysmal sac
    • Diagnosis: detected by CT scan
    • Clinical
      • Usually Asymptomatic
      • Back Pain/Flank Pain (see Back Pain, [[Back Pain]] and Flank Pain, [[Flank Pain]])
      • Symptoms Related to Aortic Rupture
    • Clinical Classification:
      • Type I
      • Type II
      • Type III
      • Type IV
      • Type V
  • Separation of Endograft Components

Gastrointestinal Adverse Effects/Complications

  • Colonic Ischemia (see Colonic Ischemia, [[Colonic Ischemia]])
    • Epidemiology
    • Physiology: colonic ischemia
  • Intestinal Ischemia (see Acute Mesenteric Ischemia, [[Acute Mesenteric Ischemia]])
    • Epidemiology
    • Physiology: small intestinal ischemia
  • Pelvic Ischemia
    • Physiology

Infectious Adverse Effects/Complications

  • Endograft Infection
    • Epidemiology: occurs in 0.4-3% of cases
    • Prognosis: 25%

Neurologic Adverse Effects/Complications

  • Cerebrovascular Ischemia
    • Epidemiology
      • XXX
    • Clinical
      • XXX
  • Spinal Cord Infarction (see Spinal Cord Infarction, [[Spinal Cord Infarction]])
    • Epidemiology
      • Incidence: 3-11% of cases (comparable to the rate of open surgery)
      • Risk Factors
        • Extent of Thoracic Aortic Coverage: greatest risk factor
        • Perioperative Hypotension
        • Long Procedure Duration
        • Visceral Artery Reimplantation
        • Renal Insufficiency
    • Physiology: occlusion of spinal intercostal arteries

Renal Adverse Effects/Complications

  • Acute Kidney Injury (AKI) (see Acute Kidney Injury, [[Acute Kidney Injury]])
    • Physiologic Mechanisms
      • Cholesterol Emboli Syndrome (see Cholesterol Emboli Syndrome, [[Cholesterol Emboli Syndrome]]): see below
      • Contrast Nephropathy (see xxxx, [[xxxx]])
      • Renal Ischemia: see below
  • Renal Ischemia
    • Physiology
      • Impingement of Endograft on Renal Artery Origin
      • Renal Artery Dissection
      • Renal Artery Embolism
      • Renal Artery Thrombosis

Rheumatologic/Orthopedic Adverse Effects/Complications

  • Acute Limb Ischemia (see Acute Limb Ischemia, [[Acute Limb Ischemia]])
    • Epidemiology: xxxx
    • Physiology: lower extremity ischemia is usually due to endograft limb occlusion

Other Adverse Effects/Complications

  • Cholesterol Emboli Syndrome (see Cholesterol Emboli Syndrome, [[Cholesterol Emboli Syndrome]])
  • Postimplantation Syndrome
    • Epidemiology
      • May Occur During the Early Postoperative Period
    • Physiology
      • Endothelial Activation by the Endograft
      • Increased IL-6 and TNFα
    • Clinical
      • Elevated C-Reactive Protein (see xxxx, [[xxxx]])
      • Fever (see xxxx, [[xxxx]])
      • Leukocytosis (see xxxx, [[xxxx]])
      • Reactive Unilateral/Bilateral Pleural Effusion(s) (see xxxx, [[xxxx]]): occurs frequently with thoracic endografts (occurs in 37-73% of cases)

References

  • Endovascular treatment of thoracic aortic aneurysms: results of the phase II multi-center trial of the Gore TAG thoracic endoprosthesis. J Vasc Surg 2005;41:1–9
  • Endovascular repair of thoracic aortic tears. Ann Thorac Surg 2006;82: 873– 8
  • Endovascular management of traumatic ruptures of the thoracic aorta: a retrospective multi-center analysis of 28 cases in the Netherlands. J Vasc Surg 2006;43:1096–102
  • Endovascular repair of proximal endograft collapse after treatment for thoracic aortic disease. J Vasc Surg 2006;43:609–12
  • Anatomic factors associated with acute endograft collapse after Gore TAG treatment of thoracic aortic dissection or traumatic rupture. J Vasc Surg 2007;45:655–61
  • Operative strategy for open surgery after failed thoracic aortic stent grafting. J Thorac Cardiovasc Surg 2007;134:1044 – 6
  • Endograft collapse after thoracic stent-graft repair for traumatic rupture. Ann Thorac Surg. 2009;87(5):1582-1583 [MEDLINE]
  • Great vessel and cardiac trauma. Surg Clin North Am. 2009 Aug;89(4):797-820, viii. doi: 10.1016/j.suc.2009.05.002 [MEDLINE]