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Aneurysmal expansion of the visceral patch after thoracoabdominal aortic replacement: an argument for limiting patch
A Dardik1, B A Perler, G S Roseborough
1Division of Vascular Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287-8611, USA.
Insights
Aneurysmal expansion of visceral patches after thoracoabdominal aortic replacement occurs in 7.5% of patients. Yearly surveillance is recommended, with smaller patch sizes and separate renal artery implantation for high-risk individuals.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Aortic Aneurysm Research
Background:
- Thoracoabdominal aortic replacement often involves visceral vessel revascularization using techniques like Crawford's inclusion or Carrel patches.
- Retained native aorta segments, particularly visceral patches, are susceptible to recurrent aneurysmal disease.
- This study reviews outcomes for patients experiencing aneurysmal expansion of these visceral patches.
Purpose of the Study:
- To evaluate the incidence and characteristics of aneurysmal expansion in visceral patches used during thoracoabdominal aortic replacement.
- To identify risk factors and outcomes associated with visceral patch aneurysms.
- To inform surveillance strategies and surgical recommendations for preventing recurrent aneurysms.
Main Methods:
- A retrospective review of 107 patients who underwent thoracoabdominal aortic replacement with visceral patches between 1992 and 2000.
- Inclusion criteria involved types II, III, or IV aneurysms requiring visceral patch creation.
- Aneurysmal expansion was defined as a patch diameter of 4.0 cm or greater.
Main Results:
- Aneurysmal expansion of visceral patches was detected in 7.5% of patients (mean diameter 5.4 cm).
- Women (mean age 36) with connective tissue disorders and men (mean age 73) with atherosclerotic disease represented distinct risk groups.
- Mean time to detection was 6.5 years; successful revision occurred in three patients, while two died intraoperatively.
Conclusions:
- Crawford's inclusion method is durable, but yearly surveillance for visceral patch aneurysms is crucial after thoracoabdominal aortic replacement.
- Limiting visceral patch size by excluding the left renal artery orifice during initial surgery is recommended.
- High-risk patients, especially those with connective tissue disorders, benefit from smaller patches and separate renal artery implantation.
Introduction:
Thoracoabdominal aortic replacement requires visceral vessel revascularization and is usually performed with Crawford's inclusion technique or a large Carrel patch. This segment of retained native aorta may be prone to recurrent aneurysmal disease. We reviewed our experience with patients in whom aneurysmal expansion of the visceral patch was detected.
Methods:
The records of 107 patients undergoing thoracoabdominal aortic replacement operations performed or followed up at the Johns Hopkins Hospital between 1992 and 2000 were reviewed. All patients had visceral patches created for type II, III, or IV aneurysms. Visceral patches were considered aneurysmal if the maximal diameter of the aortic prosthesis and patch was 4.0 cm or more.
Results:
Patch aneurysmal expansion (mean, 5.4 cm) was detected in eight patients (7.5%). All three women had connective tissue disorders (mean age, 36 years), and all five men had atherosclerotic disease (mean age, 73 years). Five patients were symptom free with their aneurysms detected by surveillance computed tomography scans; two patients had back pain prompting computed tomography scans; and one patient presented with an emergency patch rupture. Aneurysmal patches were successfully revised in three patients. Two patients died in the operating room, and three patch aneurysms (< 5 cm) are still being observed. The mean time to the detection of aneurysmal expansion was 6.5 years after the original operation. Therapy consisted of replacement of a segment of the thoracoabdominal aortic graft and refashioning a smaller patch, including only the visceral artery orifices with separate attachment of the left and possibly right renal artery.
Conclusions:
Although Crawford's inclusion method of visceral patch construction is generally durable, patients undergoing thoracoabdominal aortic replacement require yearly surveillance for the detection of aneurysmal expansion of the visceral patch. We recommend limiting visceral patch size at the original operation by routinely excluding the orifice of the left renal artery. Patients at high risk for recurrent aneurysmal expansion, such as those with connective tissue disorders, will benefit from creating small visceral patches and possibly implanting both renal arteries separately during the original operation.