|Year : 2021 | Volume
| Issue : 4 | Page : 105-110
Viabahn Open Rebranching Technique combined with hybrid debranching technique help preventing renal artery obliteration and renal dysfunction aggravation in the treatment of thoracoabdominal aortic aneurysms
Hao Zhang1, Hua Liu2, Li-Wei Zhang3, Meng-Tao Wu4, Chao Song1, Kak Khee Yeung5, Xiang Feng6, Lei Zhang1
1 Department of Vascular Surgery, Changhai Hospital, Second (Navy) Military Medical University, Shanghai, China
2 Department of Thoracic, Cardiac, and Great Vascular Surgery, Shiyan Taihe Hospital, The Affiliated Taihe Hospital of Hubei University of Medical Sciences, Shiyan, Hubei, China
3 Department of Cardio-Thoracic Surgery, The People's Hospital of China Three Gorges University, Yichang, Hubei, China
4 Department of Peripheral Vascular, the Second Hospital of Shandong University, Ji'nan, Shandong, China
5 Department of Vascular Surgery, VU University Medical Center, Amsterdam, The Netherlands
6 Department of Urology Surgery, Changhai Hospital, Second (Navy) Military Medical University, Shanghai, China
|Date of Submission||13-May-2021|
|Date of Decision||20-Jun-2021|
|Date of Acceptance||25-Jun-2021|
|Date of Web Publication||21-Dec-2021|
Department of Vascular Surgery, Changhai Hospital, 168 Changhai Rd, Shanghai
Department of Urology Surgery, Changhai Hospital, 168 Changhai Rd, Shanghai
Source of Support: None, Conflict of Interest: None
OBJECTIVE: Hybrid debranching technique combined with conventional open surgery and endovascular repair was an effective treatment for thoracoabdominal aortic aneurysm (TAAA). We propose a new technique to reduce the time of RA anastomosis.
MATERIALS AND METHODS: The hybrid staged operation procedure was evaluated in the period of 2013 and 2017 in three academic centers. The bilateral renal artery anastomosis in the experimental group used VORTEC technique. In the control group, the bilateral renal artery reconstruction was performed by conventional artificial blood vessel anastomosis. Primary outcome was technical success, the time of renal artery anastomosis, and major complications. Long term follow-up up to 7 years was evaluated as well.
RESULTS: In total 57 patients were enrolled. Compared with the control group, there was a statistical difference in the mean time of left RA anastomosing (19.8 vs 4.6 min, p<0.001) and the right RA anastomosing (20.5 vs 4.6 min, p<0.001) in the experimental group. While the aggravation of renal dysfunction occurred in 12 patients in 1 year after the stage surgery, and there was a statistical difference between the experimental group and the control group (4 vs 8, p=0.025).
CONCLUSION: The VORTEC technique could help reducing the time of RA anastomosing and get lower complication rate and better effect during long-term follow up.
Keywords: Hybrid debranching; VORTEC technique; sutureless anastomosis; thoracoabdominal aortic aneurysm; renal dysfunction
|How to cite this article:|
Zhang H, Liu H, Zhang LW, Wu MT, Song C, Yeung KK, Feng X, Zhang L. Viabahn Open Rebranching Technique combined with hybrid debranching technique help preventing renal artery obliteration and renal dysfunction aggravation in the treatment of thoracoabdominal aortic aneurysms. Vasc Invest Ther 2021;4:105-10
|How to cite this URL:|
Zhang H, Liu H, Zhang LW, Wu MT, Song C, Yeung KK, Feng X, Zhang L. Viabahn Open Rebranching Technique combined with hybrid debranching technique help preventing renal artery obliteration and renal dysfunction aggravation in the treatment of thoracoabdominal aortic aneurysms. Vasc Invest Ther [serial online] 2021 [cited 2022 Jan 29];4:105-10. Available from: https://www.vitonline.org/text.asp?2021/4/4/105/333003
| Introduction|| |
Hybrid debranching technique combined with conventional open surgery and endovascular repair was an effective treatment for thoracoabdominal aortic aneurysm (TAAA). However, the patency rate of visceral artery and the function of target organ are always the key factors affecting the surgical effect. Among the visceral arteries, renal artery (RA) anastomosis was the most difficult compared with superior mesenteric artery (SMA) or celiac artery (CA) including splenic artery (SA) and hepatic artery. Once the anastomosis time is too long, the warm ischemic time of the kidney will be prolonged, which will seriously affect the function of the kidney and even cause kidney necrosis.
In 2008, Lachat et al. described the Viabahn Open Rebranching Technique (VORTEC) for the revascularization of renal arteries, allowing for a fast and simple procedure with better hemodynamic results at the experimental level. In this retrospective study, we aim to enhance the awareness of VORTEC technique efficacy and clinical outcomes through combining with hybrid debranching technique treating TAAA.
| Methods|| |
We enrolled all patients who were admitted and staged received endovascular debranching hybrid operation in three centers (Shanghai Changhai Hospital, The People's Hospital of China Three Gorges University in Yichang, Hubei and The Fifth People's Hospital in Chengdu, Sichuan) between May 2013 and March 2017. Treatment indications of TAAA were symptomatic or a maximum diameter over 5.5 cm. The exclusion criteria were patients receiving conventional open surgery or completely endovascular surgery. All enrolled patients were considered at high risk for conventional aortic surgery due to their age, comorbidities, and previous surgery history. High risk was defined as patient's ASA (American Society of Anesthesiologists) score ≥3, according to Boyd and Jackson's review. The bilateral renal artery anastomosis in the experimental group used VORTEC technique. In the control group, the bilateral renal artery reconstruction was performed by conventional artificial blood vessel anastomosis. Appropriate computed tomography (CT) data reconstructions were analyzed on a workstation (Leonardo; Siemens, Erlangen, Germany) to obtain pertinent endograft size (typically 15%–25% oversize). Aneurysm characteristics and individual procedural details were all collected and reviewed for each patient.
The study was performed in accordance with the Institutional Ethics Committee rules, and individual consent for this retrospective analysis was waived. All patients provided consent for intervention.
The bypass surgery of SMA, renal arteries (RA), and/or CA was performed before endovascular repair. Bilateral common iliac arteries were selected as the proximal inflow tract of vascular prosthesis.
An 8 mm × 40 cm expanded polytetrafluoroethylene (ePTFE) vascular prosthesis (Bard, Inc., Tempe, AZ, USA or W. L. Gore, Flagstaff, AZ, USA) was used for bilateral common iliac bypass, with the left side anastomosed with SMA in a “C” curve shape, and the biological external ring was removed from the corresponding position, to which a 6 mm × 40 cm ePTFE external vascular prosthesis ring was anastomosed, and it was connected with the common HA or the SA. Later, the bilateral renal arteries were exposed, and the renal artery debranching anastomosis was prepared.
The lateral edge of the vascular prosthesis was prepared to connect the left renal artery, and another 6 mm × 40 cm ePTFE ring vascular prosthesis was prepared to anastomose the right renal artery on the right side. The connection between artificial vessels and renal arteries was bridged by an 8 mm Viabahn. The Viabahn was connected to the renal artery directly [Figure 1]a or through the side puncture of the artificial vessels [Figure 1]b, [Figure 1]c, [Figure 1]d; this technique is referred as the VORTEC technique.
|Figure 1: Anastomosis with Viabahn Open Rebranching TEChnique technique. (a) The Viabahn was connected to the renal artery directly. (b) The Viabahn was connected the renal artery through the side puncture of the artificial vessels. (c) Diagrammatic drawing of Viabahn Open Rebranching TEChnique technique anastomosis with Viabahn. (d) In vitro Viabahn Open Rebranching TEChnique technique anastomosis with Viabahn|
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Taking the right renal artery as an example, first use a sterile marker to mark a position 2 cm from the tip of the Viabahn stent graft. The renal artery and Viabahn stent should have an overlap for at least 2 cm to complete VORTEC. Then block the proximal end of the right renal artery and prepared vascular prosthesis. According to the length of the Viabahn stent, puncture was performed at the junction of the stent with the vascular prosthesis and the right renal artery. Later, the Viabahn stent was introduced from the vascular prosthesis puncture site, and the distal end of the vascular prosthesis was penetrated to the right renal artery puncture site to introduce the right renal artery. The previous “2 cm” marking point is overlapped with the right renal artery puncture point, and then, the stent is released to complete the right renal artery reconstruction. The reconstruction method of the left renal artery is the same. The proximal visceral artery such as RA and SMA was ligated to prevent Type II endoleak.
The lateral edge of the vascular prosthesis was connected to the left renal artery, and another 6 mm × 40 cm ePTFE ring vascular prosthesis was anastomosed to the right renal artery on the right side. The time of each renal artery anastomosis was recorded.
After construction of the vascular prosthesis bypass, all patients were transferred to intensive care unit, and the mean arterial pressure was maintained above 90 mmHg. Endovascular thoracoabdominal aortic repair was performed 1 week later. If the diameter of the stent prosthesis was inappropriate, a restrictive bare stent from OptiMed Medizinische Instrumente GmbH (Optimed CO, Ettlingen, Germany) would be used as replacement.
Treatment during perioperative period
Anti-coagulation therapy including heparinization during surgery was administrated. Regular low-molecular-weight heparin, depending on the postoperative wound oozing, as a prophylactic anticoagulation therapy, was maintained after surgery and was transited to warfarin simultaneously for lifetime use when patients' gastrointestinal function was recovered.
Endpoints and follow up
CT angiography (CTA) was performed on the 3rd, 6th, and 12th months and annually after the last stage of surgery. The maximal diameter of TAAA was measured, and the diameter increased or decreased 5 mm or 5 mm above was defined as significant change. The primary endpoint was in-hospital or follow-up mortality and major complications, including paraplegia, acute renal failure, exacerbation of preexisting renal dysfunction (the rise of creatinine exceeded 100 μmoI/L), intestinal necrosis, and liver failure. The secondary endpoints were stenosis of the visceral artery, increased aneurysm diameter, and re-intervention or conversion to open surgery.
Analysis was performed with the SPSS software version 13.0 (SPSS, Inc., Chicago, USA). Data were presented as mean ± standard deviation; nonparametric data (e.g., follow-up time) was given as median and range. Survival analysis was performed using the Kaplan − Meier method; continuous data were evaluated by normal distribution (Kolmogorov–Smirnov Test) and homogeneity of variances (Levene's Test). For the analysis of differences between the groups, paired sample t-test was applied. Differences were considered statistically significant if two-tailed P < 0.05.
| Results|| |
From May 2013 to March 2017, a total of 236 TAAA patients were admitted for different types of treatment in these three centers. Among them, 57 (42 male and 15 female) patients who received a hybrid operation were enrolled, with a mean age of 65 years (ranging from 58 to 76 years). Of the 57 enrolled cases, 37 were in the experimental group and 20 were in the control group. The VORTEC technique was technical successful used in bilateral RA anastomosing of experimental group patients. Preoperative CTA revealed that the mean diameter of the TAAA was 68.9 ± 10.6 mm (range 56–108 mm). Symptoms, comorbidities, and other information are shown in [Table 1].
Staged surgeries were performed in all cases; stent prosthesis was applied in Stage 3.
Including 12 Valiant (Medtronic Vascular, USA) in experimental group, and 10 in control group; 10 Zenith TX2 (Cook Inc., USA) in experimental group, and 4 in control group; 8 C-TAG (Gore, USA) in experimental group, and 3 in control group; and 7 Hercules (MicroPort Medical, China) in experimental group, and 3 in control group. Each patient received bilateral renal arteries anastomosed. Compared with the control group, there was a statistical difference in the meantime of left RA anastomosing (19.8 vs. 4.6 min, P < 0.001) and the right RA anastomosing (20.5 vs. 4.6 min, P < 0.001) in the experimental group.
The mean duration of debranching was 2.7 h in the experimental group versus 3.1 h in the control group; and the mean duration of endovascular repair was 1.0 h in the experimental group versus 1.3 h in the control group. The mean intraoperative blood loss was 425 ml in the experimental group versus 477 ml in the control group. The mean amount of intraoperative medium contrast used was 70 ml in experimental group versus 76 ml in control group [Table 2].
Bilateral RA was anastomosed in each patient. 37 patients in the experimental group received 74 renal artery reconstructions using the VORTEC technique, and 0 renal artery obliteration occurred after surgery; 40 renal artery reconstructions were performed by conventional artificial blood vessel anastomosis in 20 patients in the control group. 4 cases of renal artery obliteration occurred in the control group, in which 2 cases occurred during postoperative hospitalization, 2 cases occurred 3 months after surgery.
All patients were in the follow-up for 3–7 years with a mean follow-up time of 64 months. In the control group, five patients died or lost to follow-up after the staged surgeries, the all-cause mortality is 25.0%. One patient died of DIC 3 days after surgery; two patients succumbed to multiple organ failure within 7 months and 34 months after surgery; one patient died of colon cancer liver metastasis 31 months after surgery; one patient was lost to follow-up 60 months after surgery. In the experimental group, six patients died or lost to follow-up after the staged surgeries, the all-cause mortality is 16.2%. One patient died of pulmonary infections in 5 months after surgery; one patient died of cerebral hemorrhage 19 months after surgery; one patient died of myocardial infarction within 38 months after surgery; two patients died of unknown cause in 29 and 46 months; one patient was lost to follow-up 48 months after surgery. There was no TAAA-related death during the follow-up.
Aggravation of renal dysfunction occurred in 12 patients in 1 year after the stage surgery, and there was a statistical difference between the experimental group and the control group (4 vs. 8, P = 0.025). Among them, four cases in the control group occurred during postoperative hospitalization, three cases occurred in 6 months after surgery, and 1 case occurred in 12 months after surgery; in the experimental group, 2 cases occurred in 6 months after surgery and 2 cases occurred in 12 months after surgery.
The maximal diameter of TAAA decreased to 62.3 ± 10.5 mm (two tail P = 0.008) from preoperative 68.9 ± 10.6 mm during the follow-up, and there was no statistical difference between the experimental group and the control group. Among these patients, the diameter of aneurysm significantly decreased (e5 mm) in 13 cases, 8 in the experimental group versus 4 in the control group; stabilized (increased or decreased <5 mm) in 40 cases, 27 in the experimental group and 13 in the control group; significantly increased (n5 mm) in 4 cases, 2 in the experimental group and 2 in the control group [Table 3].
One patient in the experimental group had lower limb intermittent claudication 27 months after the operation and was cured by pharmacotherapy. No such complications as paraplegia, intestinal ischemia, and graft infection occurred during the follow-up period. CTA was not performed on one patient in the control group that had hemodialysis and only ultrasound and CT scanning without contrast agent was done on this patient.
| Discussion|| |
Methods of treating treatment for thoracoabdominal aortic aneurysm
The treatment of TAAA is a clinical challenge. There are controversies over the selection of surgical modalities. Conventional and modified surgical approaches have their own advantages and disadvantages. Endovascular techniques, especially “chimney” and “fenestration” technique could cure TAAA. However, the persistently high rate of endoleak and high medical cost are two obstacles that prevent further development of the endovascular technique.
Deficiency of hybrid debranching technique
The hybrid debranching technique is a surgical modality between the conventional operation and complete endovascular therapy, which not only minimizes the time and the trauma of conventional operation but also reduces the high rate of endoleak and high medical cost arising from branch stents in endovascular therapy. However, debranching requires reconstruction of branch arteries, which increases the difficulty and time of the operation.
Difference of visceral artery reconstruction
The core of the endovascular debranching technique is the preceding bypass surgery of the visceral arteries, which is performed to ensure blood supply of these arteries before endovascular repair can be performed.,, In the process of visceral artery reconstruction, the time requirement for renal artery reconstruction is the most stringent. It is necessary to avoid excessively long renal ischemia, which may cause renal failure or even necrosis after surgery. There are many ways to reconstruct the renal artery. In our study, the shortest time-consuming VORTEC technique was selected for renal artery reconstruction, which protects the patient's renal function to the greatest extent.
Viabahn Open Rebranching technique solving the challenge of renal function deterioration
The anatomy and anastomosis of bilateral renal arteries are relatively difficult in the treatment of TAAA using the debranching technique. Distinct from intestine or liver, kidney is very sensitive for ischemia, and long-time ischemia can lead to renal insufficiency. Several studies show that the deterioration of renal function is the most common postoperative complication of hybrid debranching,,,, and patients that underwent hybrid repair had a higher rate of new permanent dialysis compared to those underwent open repair. It is more possible for renal function to aggravate when anastomosis lasts longer. Therefore, since year 2013, according to other previous studies, VORTEC has been used in our centers to make renal artery anastomosis more convenient and time-saving. VORTEC technique could be used in thin arteries like RA and lead to no stenosis of anastomotic stoma. Moreover, VORTEC could avoid intimal hyperplasia as there were no stitches in anastomotic stoma. In our study, compared with the control group, the overall time of VORTEC for RA significantly decreased. Moreover, the time of renal heat ischemia during debranching decreased. In our study, only one patient needed long-term hemodialysis and one patient got renal function deterioration, but the creatinine was still stable. The results showed that VORTEC was an effective technique for the reconstruction of RA and the protection of renal function.
CA can tolerate ischemia for a long time, and there are more anastomosis sites that can be selected in hybrid debranching operations, and the difficulty is relatively small, and the use of VORTEC technology will increase the patient's medical expenses. The emitting of SMA is an acute angle , if VORTEC technology is used, it will increase the risk of reconstructing arterial dissection and plaque shedding.
Although the effect of hybrid debranching combined with VORTEC technique seems wonderful, there are still some shortcomings. First of all, it is a retrospective study. In addition, there is a doctor's selective bias in using VORTEC technology, the sample size of the study is limited, and the follow-up time is still short. Last but not the least, VORTEC needed additional Viabahn stent, which increases the medical cost. Therefore, a large sample prospective comparative study is needed for more authoritative evidence.
| Conclusion|| |
In our study, the incidence of renal dysfunction after applying hybrid debranching combined with VORTEC technique to treat TAAA was low. The VORTEC technique could help reducing the time of RA anastomosing and get lower complication rate and better effect during long-term follow up. In summary, the debranching technique will continue to play an important role in the treatment of TAAA with continuous developing techniques, and the intermediate-and long-term therapeutic efficacy is worthy of anticipation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]