44 Repair of Type IV Thoracoabdominal Aneurysm with a Combined Endovascular and Surgical Approach скачать в хорошем качестве

44 Repair of Type IV Thoracoabdominal Aneurysm with a Combined Endovascular and Surgical Approach

#VascularSurgery #ThoracoabdominalAneurysm #AorticAneurysm #HybridSurgery #EndovascularRepair #OpenSurgery #AneurysmRepair #MedicalLandmark #JournalOfVascularSurgery #ComplexAorticSurgery #AneurysmTreatment #SurgicalInnovation #LongTermOutcomes This video deep dive examines a landmark 1999 paper from the Journal of Vascular Surgery titled "Repair of Type V Thoracoabdominal Aneurysm with a Combined Endovascular and Surgical Approach". The study focused on an incredibly complex case of a patient with a Type IV thoracoabdominal aneurysm involving the origins of the celiac, superior mesenteric (SMA), and both renal arteries. Adding to the challenge, the patient also had aneurysms in these visceral arteries themselves and a history of two prior ruptured abdominal aortic aneurysm repairs and a popliteal aneurysm repair, indicating widespread vascular weakness. Given this complexity and surgical history, standard open repair was deemed too risky. The innovative solution was a Combined Endovascular and Surgical Approach (SISA). The strategy involved performing open surgical bypasses from the iliac arteries to the celiac, SMA, and both renal arteries first to secure organ blood flow. This was followed by deploying a Corvita endograft inside the aorta to seal off the main aneurysm sac. This approach avoided major open chest surgery and a high-risk repeat retroperitoneal operation, also reducing organ ischemia time. Technical challenges included using the early, relatively stiff Corvita graft and navigating the patient's highly tortuous aorta, requiring access from both the arm (axillary) and leg (iliac) arteries. The initial outcome was a remarkable success, with the patient handling the major combined surgery well and discharged in just one week. Follow-up CT scans confirmed the aneurysm was excluded and the new bypasses were open. Crucially, the patient was tracked for an incredible 23 years. While the earlier open repairs remained durable, the endovascular part required late interventions. The patient developed a Type 1a endo-leak at 13 years, fixed endovascularly, and a Type 3 endo-leak at 22 years, also fixed endovascularly. These late issues underscore the critical lesson that endovascular repairs, especially complex ones using early technology, often require lifelong surveillance and potential reintervention. Despite the need for later fixes, the overall outcome was profoundly positive: the patient lived 23 more years with a stable aneurysm sac. This landmark case validated the hybrid approach for seemingly inoperable complex aortic problems and serves as a foundational lesson that modern vascular surgeons must be adept in both open and endovascular techniques, knowing when and how to blend them for individualized patient care.