Abstract

Center of Mini-invasive endovascular Aortic Repair

Endovascular repair was first proposed by Parodi and Volodos in the early 1990s. It is a less invasive alternative to conventional open surgery. The initial results of endovascular repair were promising and encouraging. Two major recent studies (the Dutch Randomised Endovascular Aneurysm Management (DREAM) trial and the Endovascular Aneurysm Repair Trial-1 (EVAR-1)) have demonstrated impressive improvements in 30 day mortality in patients (4.6-4.7 % drop to 1.2-1.7%) undergoing endovascular repair when compared with traditional open repair.1-4 Although the initial advantage only seemed to last for a short period (months) around the time of the operation, but did benefit to high-risk patients with these less traumatic endovascular techniques.
Back to our institute history, we had implanted the first endograft for abdominal aortic repair in Taiwan with Vanguard II device on Aug. 2, 1999 and followed by another consecutive 6 patients for clinical trial with ZenithO AAA Endovascular Graft in 2001. 5,6 But until July 2005, EVAR finally became “legal” procedure for AAA treatment and until Oct. 2006 for TAA treatment, and we restart EVAR for treating AAA 3 months later. After that, EVAR became our OR routine and surgeon-independent procedure. Until then, there were 167 patients, who received endovascular repair of abdominal aortic aneurysm (AAA) and 152 patients, who received endovascular repair of thoracic aortic aneurysm (TAA) in Taipei VGH. The preliminary results were summarized as the following. All the patients received three-Piece Modular Design of ZenithO AAA Endovascular Graft. During this year, almost 71% of the abdominal aortic aneurysm were anatomically suitable and treated with aortic endograf. The procedure success rate was 100% with no surgical mortality for endograft-only implantation.
Taiwan has been entered the new era of endovascular treatment of thoracic aneurysm (TEVAR) since Oct. 25, 2006 and Only ZenithR TX2? Thoracic Endoprostheses which is two components design has been obtained medical license. Until Nov. 2008, total 152 patients received endovascular repair of TAA in our institute of Taipei. Veterans General Hospital. Most of them are chronic type B DAA , then descending arotic true aneurysm then followed by arch aneurysm. Among them, there are 59% of patients considered for extended stent-graft applications because of less than 2 cm of proximal or distal aortic neck.7,8 Eightteen patients required debranching of the aortic arch and relocation of the supra-aortic branches and four required visceral debranching. Four patients deployed the endograft with antegrade deployment technique. (3 combined with open arch repair, and one with arch branch relocation to the ascending aorta without circulatory support). 22 patients underwent emergent repair due to the ruptured and unstable condition.
The procedure success rate is near 100 % except for one emergent ruptured type A residual dissecting aneurysm. No mortaility and morbility for the simple application of TAA endograft was revealed for Zone 3 and 4. No surgical mortality for the debranching of the aortic arch and relocation of the supra-aortic branches or patients required visceral debranching. In this preliminary result, endovascular repair is associated with lower in-hospital mortality, fewer postoperative complications and a shorter length of stay. Although, long-term follow-up is needed for further evaluation, new era of more less invasive treatment of aortic aneurysm is coming.

Group	Mini-invasive Procedure
I	Simple (without bypass)
II	Hybrid with cervical reconstruction
III	Hybrid with sternotomy reconstruction without H-L machine support
IV	Hybrid with sternotomy reconstruction with H-L machine support
V	Hybrid with sternotomy Laparotomy for visceral debranching