Rutherford's 081: Aortic Stent Graft and Endovascular Treatment of Thoracoabdominal & Arch Aneurysms

#TAAA #AorticArchAneurysm #EndovascularRepair #VascularSurgery #FBVAR #HybridRepair #AorticStentGraft #Neuroprotection #Rutherfords #AneurysmTreatment This video delves into the complex endovascular treatment of Thoracoabdominal Aortic Aneurysms (TAAAs) and Aortic Arch aneurysms, conditions where the body's main artery abnormally dilates. While open surgery was traditional, less invasive catheter-based techniques are increasingly used, driven by substantial risks associated with open repair. TAAAs, involving the aorta extending into the abdomen, and Arch aneurysms, affecting the critical curve near the heart, present unique challenges. For TAAAs, the primary endovascular approach is Fenestrated and/or Branched Endovascular Aortic Repair (FBVAR). The goal is to prevent rupture while maintaining blood flow to crucial visceral and renal arteries. This is achieved by using endografts with customized openings (fenestrations) or pre-attached tubes (branches) that align with these vital vessels, connected by bridging stents. FBVAR has shown lower complications and mortality compared to open surgery, but is technically demanding and requires long-term follow-up. Devices include physician-modified (P-MEGs), custom-made (CMDs), and off-the-shelf options. Chronic dissection adds complexity due to the true and false lumens. Aortic Arch repair is especially challenging due to the critical branch vessels supplying the brain (innominate, carotid, subclavian) and the high risk of stroke. Indications for repair, often based on diameter (~55mm for the arch in low-risk patients), are balanced against significant risks. Anatomical factors like tortuosity, vessel disease, and plaque burden heavily influence feasibility. Strategies include traditional open surgery, hybrid repair (surgical debranching of supra-aortic vessels followed by a standard T-VAR), and total endovascular repair using specialized fenestrated or branched arch grafts. Hybrid aims to avoid complex open arch clamping but still carries risks like stroke. Total endovascular approaches use custom-designed grafts or investigational off-the-shelf devices, requiring meticulous planning and posing a non-trivial stroke risk, though outcomes improve with experience. Alternative endovascular techniques like Chimney grafts (parallel stents) and in-situ fenestration (creating holes during the procedure) are also employed. Spinal cord protection (critical for TAAAs and extensive Arch repairs) involves maintaining high blood pressure and utilizing cerebrospinal fluid drainage. Brain protection (paramount for Arch repairs) involves careful patient selection to avoid high-plaque aortas and employing various intraoperative monitoring techniques like TCD to detect emboli. Outcomes for complex repairs remain substantial, but endovascular approaches often show improved early survival compared to open surgery, though reintervention rates can be higher, necessitating lifelong surveillance. Advanced imaging, like fusion imaging and emerging non-ionizing techniques, is crucial for planning and execution. Successful outcomes rely on complex anatomical assessment, careful patient and device selection, skilled execution, and multidisciplinary team expertise.