CCVS 2021｜Li Xiaoqiang: Current status and future prospects of surgical treatment of thoracic and abdominal aortic aneurysms

Thoracic-abdominal aortic aneurysm (TAAA) is less common than abdominal aortic aneurysm, and its incidence only accounts for 3% to 10% of aortic aneurysms
.

The difference from descending aortic and abdominal aortic aneurysms lies in the reconstruction of visceral arteries

Open surgery

Open surgery

So far, TAAA surgical open surgery is still the most challenging operation in cardiovascular surgery, with high difficulty and high mortality
.

Traditional surgical methods are mainly DeBakey operation and Crawford operation:

(1) In DeBakey operation, the proximal end uses an artificial blood vessel to do end-to-side anastomosis of the descending aorta, the internal hemorrhoids are anastomosed separately without blocking the descending aorta, and the distal end is anastomosed
.

The advantage of this procedure is that the corresponding visceral vascular anastomosis is performed separately without blocking the blood supply of the visceral blood vessels

(2) Crawford's modified operation method, the proximal end is first done end-to-end anastomosis, and then it is different from the DeBakey operation in that the visceral blood vessels are anastomosed with a patch, and the right renal artery, superior mesenteric artery and celiac artery are made into one large The patch is anastomosed to the artificial blood vessel
.

Make a separate anastomosis of the left renal artery

Regardless of the type of operation, surgical operation is still a combined thoracic-abdominal incision.
It is a massively invasive operation.
During the operation, one-lung ventilation is required and the thoracic aorta needs to be blocked.
Therefore, it has a high incidence of complications, including cardiopulmonary failure.
, kidney failure, stroke and spinal cord ischemia and paraplegia
.

In the early stage of surgical treatment, the mortality rate is as high as 10%, the incidence of paraplegia is as high as 14%, the stroke rate is 3%, 9% of patients with renal failure who require permanent dialysis, and respiratory complications are as high as 33%

Although surgical techniques are becoming more and more mature, the incidence of postoperative complications (spinal cord ischemia and renal failure) and high postoperative mortality are still obvious problems in open surgery for thoracic and abdominal aortic aneurysms
.

If there is no major technological innovation in open surgery in the future, its curative effect will hardly be substantially improved in the short term.

Compound surgery-debranching technique

Compound surgery-debranching technique

TAAA de-branching technology was first used by William in 1999
.

This technology combines open and intracavitary technology, first by bypassing the reconstruction of the visceral artery, and then implanting the aortic stent graft

An article in 2006 compared open surgery and compound surgery, with 84 cases of open surgery and 80 cases of compound surgery
.

The results showed that there was no difference between the hospital mortality rate and postoperative paraplegia rate of open and compound surgery.

The early stage of compound surgery is for patients who are not suitable for traditional surgery.
Its advantages are that there is no need for thoracotomy, no hypothermia surgery (less coagulation and circulation abnormalities), no need for aortic blockage (reduction of visceral ischemia, spinal cord ischemia, etc.
), and blood loss The amount is reduced, and the time of intensive care and hospitalization is shorter than that of traditional surgery
.

The disadvantage is that both surgery and interventional techniques are required at a high level, visceral artery thrombosis may occur after surgery, and the incidence of endoleaks is relatively high (10%)
.

Minimally invasive treatment technology

Minimally invasive treatment technology

Parallel stent technology (chimney, periscope, octopus technology): the technical success rate is 94% to 100%, it has not become the mainstream treatment method, there is no large report, and no long-term effect control study
.
The advantage is to use the existing bracket to complete this, without spending time customizing the bracket
.
The disadvantage is that multiple upper approaches such as the axilla and subclavian are required, which increases the risk of stroke; the incidence of endoleaks between the stents is high; the branch stents are long and the long-term patency rate is doubtful
.

Window branch bracket: This technology was first applied in 1996, and so far, both technology and equipment have been developed by leaps and bounds
.
There are currently two main stents: fenestrated and branched stent grafts
.
Window brackets can be customized or modified on the stage.
Both have higher requirements for the accuracy and alignment of the window
.
The integrated branch stent solves possible errors or problems in preoperative evaluation by adjusting the path and length of the branch
.
The literature published by Johns Hopkins Hospital in the United States in 2018 compared open and endovascular repairs (879 cases of intracavitary, 398 cases of open), and compared results and costs
.
The results showed that the mortality rate of hospitalization was significantly higher than that of intracavity, and the rate of severe complications was 2 to 3 times that of intracavity.
The cost of hospitalization was significantly higher than that of intracavity, mainly because of the higher incidence of perioperative complications.

.

The disadvantage of the full-cavity repair technology is that the current equipment customization time is long, and it is limited in the treatment of patients who are about to rupture or have ruptured and have symptoms of compression
.
Changes to the stand on the stage may face compliance issues
.
The occurrence of complications: due to the need for repeated imaging for positioning during the operation, the dose of contrast medium is large, and the incidence of kidney disease is high; the sealing of the long intercostal and lumbar arteries in the treatment of long lesions may put the patient at risk of paraplegia; the incidence of endoleaks High cost and more secondary operations; this technique has strict requirements on the shape of the aorta, branch position and course, arterial calcification, etc.
, complex cases may not be suitable for intraluminal; the final cost is high, and there is a lack of long-term efficacy reports
.

The development time of whole cavity treatment is relatively short, but it develops rapidly
.
The literature confirms that the early and mid-term follow-up results are good, and the mortality and complication rate are better than those of traditional open surgery
.
There is a tendency to gradually replace open surgery and may become the standard treatment
.
However, attention needs to be paid to the design of interventional techniques and materials, the selection of suitable people, and the long-term effects and patient benefits
.

Summarize

Summarize

Traditional open, compound, and full endovascular repair are all options for thoracoabdominal aortic aneurysms
.
Each treatment method has certain advantages and limitations.
The choice of the method should be decided according to the patient's specific disease and economic situation, and a reasonable treatment plan is formulated for each patient
.
Open surgery has huge trauma, high complications and high mortality, and must be performed in a large hospital with rich experience and very good conditions
.
The mortality and complication rate of minimally invasive techniques are better than those of traditional surgery, and it requires long-term follow-up data support, which may partially replace open surgery, which is the future development direction of TAAA treatment
.

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