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Piffaretti G, Menegolo M, Kahlberg A, Mariscalco G, Rinaldi E, Castelli P, Grego F, Chiesa R, Antonello M. Hemothorax Management After Endovascular Treatment For Thoracic Aortic Rupture. Eur J Vasc Endovasc Surg 2015; 50:608-13. [DOI: 10.1016/j.ejvs.2015.07.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 07/08/2015] [Indexed: 01/19/2023]
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452
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Misskey J, Johnson S, Baxter K, Gagnon J. Using a Chimney to Make a Sandwich: Salvage of a Multibranched Thoracoabdominal Aortic Endograft with a Type IIIb Endoleak. Ann Vasc Surg 2015; 29:1660.e5-10. [DOI: 10.1016/j.avsg.2015.06.081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 06/28/2015] [Indexed: 12/20/2022]
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453
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Kotelis D, Bischoff MS, Rengier F, Ruhparwar A, Gorenflo M, Böckler D. Endovascular repair of pseudoaneurysms after open surgery for aortic coarctation. Interact Cardiovasc Thorac Surg 2015; 22:26-31. [DOI: 10.1093/icvts/ivv297] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 09/21/2015] [Indexed: 11/12/2022] Open
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He H, Yao K, Nie W, Wang Z, Liang Q, Shu C, Dardik A. Modified Petticoat Technique with Pre-placement of a Distal Bare Stent Improves Early Aortic Remodeling after Complicated Acute Stanford Type B Aortic Dissection. Eur J Vasc Endovasc Surg 2015; 50:450-9. [DOI: 10.1016/j.ejvs.2015.04.035] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Accepted: 04/21/2015] [Indexed: 10/23/2022]
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455
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Martin-Gonzalez T, Pinçon C, Maurel B, Hertault A, Sobocinski J, Spear R, Le Roux M, Azzaoui R, Mastracci T, Haulon S. Renal Outcomes Following Fenestrated and Branched Endografting. Eur J Vasc Endovasc Surg 2015; 50:420-30. [DOI: 10.1016/j.ejvs.2015.04.011] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 04/08/2015] [Indexed: 11/30/2022]
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456
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Sheath-shunt technique for avoiding lower limb ischemia during complex endovascular aneurysm repair. J Vasc Surg 2015; 62:762-6. [DOI: 10.1016/j.jvs.2015.03.072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 03/30/2015] [Indexed: 11/21/2022]
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457
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Bavaria JE, Brinkman WT, Hughes GC, Khoynezhad A, Szeto WY, Azizzadeh A, Lee WA, White RA. Outcomes of Thoracic Endovascular Aortic Repair in Acute Type B Aortic Dissection: Results From the Valiant United States Investigational Device Exemption Study∗. Ann Thorac Surg 2015. [DOI: 10.1016/j.athoracsur.2015.03.108] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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458
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Outcomes of surgeon-modified fenestrated-branched endograft repair for acute aortic pathology. J Vasc Surg 2015; 62:1148-59.e2. [PMID: 26254453 DOI: 10.1016/j.jvs.2015.06.133] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 06/03/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Open surgical repair for acute aortic pathologies involving the visceral vessels is associated with morbidity and mortality rates of 40% to 70% and 30% to 60%, respectively. Due to these poor outcomes, the application of fenestrated/branched endovascular aortic repair (F/B-EVAR) has been expanded in this setting; however, durability remains unknown. The purpose of this analysis was to describe outcomes after F/B-EVAR for acute aortic disease. METHODS A single center retrospective review of all F/B-EVARs for acute aortic disease was completed. Primary end points included mortality and reintervention-free survival. Secondary end points were patency and freedom from endoleak, as well as change in aneurysm diameter and estimated glomerular filtration rate. Life-tables were used to estimate end points, while mixed statistical models were used to determine aneurysm diameter change. RESULTS Thirty-seven patients (mean age ± standard deviation, 67 ± 10 years; 75% male) underwent F/B-EVAR for acute aortic disease, and median follow-up time was 10.3 months (range, 0.5-31.4 months). Indications included thoracoabdominal aneurysm (65%; n = 24), pararenal aneurysm (17%; n = 6), postsurgical anastomotic pseudoaneurysm (8%; n = 3), dissection (5%; n = 2), and penetrating ulcer (5%; n = 2). Mean preoperative aneurysm diameter was 7.3 ± 1.8 cm. All patients were American Society of Anesthesiologists class IV or IV-E, and 38% (n = 14) had history of aortic repair. There were 105 visceral vessels revascularized (celiac, 26; superior mesenteric artery, 29; renal, 50) and 24 (65%) patients underwent three- or four-vessel repair. Technical success was 92% (n = 34), with no intraoperative deaths and one conversion (3%). Median length of stay was 6 days (range, 2-60 days), and postoperative morbidity was 41% (n = 15; spinal cord ischemia, 14% [8% permanent]; pulmonary, 14%; renal, 14%; extremity ischemia, 8%; stroke, 5%; cardiac, 3%; bleeding, 3%) with 30-day mortality of 19% (n = 7; in-hospital, 8%; n = 3). Endoleak was detected at some point in follow-up in 27% (n = 10), and a majority were type II (n = 7). Six (16%) patients underwent reintervention, and no late conversions occurred. Postoperative imaging was available in 27 (73%), and one celiac fenestration lost patency at 12 months. One-year branch vessel patency and freedom from reintervention was 98% ± 6% and 70% ± 9%, respectively. Estimated 1- and 4-year survival were 70% ± 8% and 67% ± 8%, respectively. During follow-up, aortic diameter decreased 0.5 cm (95% confidence interval, 1.1-0.2; P = .1) while estimated glomerular filtration rate decreased by 2 mL/min/1.73 m(2). CONCLUSIONS F/B-EVAR can be performed to treat a variety of symptomatic and/or ruptured paravisceral aortic pathologies. Perioperative morbidity and mortality can be significant; however, it is less than literature-based outcomes of open repair. Short-term fenestrated/branched graft patency is excellent, but reintervention is frequent, highlighting the need for diligent follow-up. Patients surviving the initial hospitalization for F/B-EVAR of acute aortic disease can anticipate good long-term survival.
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459
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460
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Revascularization of acute mesenteric ischemia after creation of a dedicated multidisciplinary center. J Vasc Surg 2015; 62:1251-6. [PMID: 26243208 DOI: 10.1016/j.jvs.2015.06.204] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 06/04/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Arterial acute mesenteric ischemia (AAMI) is a vascular and gastroenterologic emergency, most often surgical, still associated with a poor prognosis and frequent short bowel syndrome in survivors. We report the results of revascularization in AAMI patients after the creation of an intestinal stroke center. METHODS Since July 2009, we developed a multimodal and multidisciplinary management for AMI, focusing on intestinal viability and involving gastroenterologists, vascular and abdominal surgeons, radiologists, and intensive care specialists. This management was the first step to the creation of an intestinal stroke center, based on the stroke unit model. All patients received: (1) a specific medical protocol; (2) endovascular and/or open surgical revascularization whenever possible; and/or (3) resection of non-viable small bowel. We aimed to study survival, morbidity, type of revascularization, and bowel resection in patients who benefited from arterial revascularization in our intestinal stroke center. RESULTS Eighty-three patients with AMI were prospectively enrolled in the intestinal stroke center. Among them, 29 patients with AAMI underwent revascularization. The mean age was 50.2 ± 12 years, with 41% of male gender. The mean follow-up was 22.7 ± 19 months. Overall 2-year survival was 89.2%, and 30-day operative mortality was 6.9%. Surgical revascularization included bypass grafting (65%), endarterectomy with patch angioplasty (21%) ± retrograde open mesenteric stenting of the superior mesenteric artery (7%), and endovascular revascularization as first stage procedure (38%). The 2-year primary patency rate of open revascularization was 88%. The rate and the median length of bowel resected were 24% and 43 cm (range, 36-49 cm), respectively. CONCLUSIONS In our experience, revascularization of AAMI patients as part of a multidisciplinary and multimodal management leads to encouraging results. Vascular surgeons have a central role in a dedicated intestinal stroke center.
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Results of complex aortic stent grafting of abdominal aortic aneurysms stratified according to the proximal landing zone using the Society for Vascular Surgery classification. J Vasc Surg 2015; 62:319-25.e2. [DOI: 10.1016/j.jvs.2015.03.035] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 03/16/2015] [Indexed: 11/23/2022]
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462
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Lee HC, Joo HC, Lee SH, Lee S, Chang BC, Yoo KJ, Youn YN. Endovascular Repair versus Open Repair for Isolated Descending Thoracic Aortic Aneurysm. Yonsei Med J 2015; 56:904-12. [PMID: 26069110 PMCID: PMC4479856 DOI: 10.3349/ymj.2015.56.4.904] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To compare the outcomes of thoracic endovascular aortic repair (TEVAR) with those of open repair for descending thoracic aortic aneurysms (DTAA). MATERIALS AND METHODS We compared the outcomes of 114 patients with DTAA and proximal landing zones 3 or 4 after TEVAR to those of 53 patients after conventional open repairs. Thirty-day and late mortality were the primary endpoints, and early morbidities, aneurysm-related death, and re-intervention were the secondary endpoints. RESULTS The TEVAR group was older and had more incidences of dissecting aneurysm. The mean follow-up was 36±26 months (follow-up rate, 97.8%). The 30-day mortality in the TEVAR and open repair groups were 3.5% and 9.4% (p=0.11). Perioperative stroke and paraplegia incidences were similar between the groups [5.3% vs. 7.5% (p=0.56) and 7.5% vs. 3.5% (p=0.26), respectively]. Respiratory failure occurred more in the open repair group (1.8% vs. 26.4%, p<0.01). The incidence of acute kidney injury requiring dialysis was higher in the open repair group (1.8% vs. 9.4%, p<0.01). The cumulative survival rate was higher in the TEVAR group at 2 to 5 years (79.6% vs. 58.3%, p=0.03). The free from re-intervention was lower in the TEVAR group (65.3% vs. 100%, p=0.02), and the free from aneurysm-related death in the TEVAR and open repair groups were 88.5% and 86.1% (p=0.45). CONCLUSION TEVAR is safe and effective for treating DTAAs with improved perioperative and long-term outcomes compared with open repair.
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Affiliation(s)
- Hyung Chae Lee
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Hyun-Chel Joo
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Seung Hyun Lee
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Sak Lee
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Byung-Chul Chang
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Kyung-Jong Yoo
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Young-Nam Youn
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea.
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463
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Rose MK, Pearce BJ, Matthews TC, Patterson MA, Passman MA, Jordan WD. Outcomes after celiac artery coverage during thoracic endovascular aortic aneurysm repair. J Vasc Surg 2015; 62:36-42. [DOI: 10.1016/j.jvs.2015.02.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 02/12/2015] [Indexed: 10/23/2022]
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464
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Panuccio G, Bisdas T, Berekoven B, Torsello G, Austermann M. Performance of Bridging Stent Grafts in Fenestrated and Branched Aortic Endografting. Eur J Vasc Endovasc Surg 2015; 50:60-70. [DOI: 10.1016/j.ejvs.2015.03.023] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 03/09/2015] [Indexed: 11/24/2022]
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465
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Kotelis D, Grebe G, Kraus P, Müller-Eschner M, Bischoff M, von Tengg-Kobligk H, Böckler D. Morphologic predictors of aortic expansion in chronic type B aortic dissection. Vascular 2015; 24:187-93. [DOI: 10.1177/1708538115591941] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aim To identify morphologic factors affecting aortic expansion in patients with uncomplicated type B aortic dissections. Methods Computed tomography data of 24 patients (18 male; median age: 61 years), diagnosed with acute uncomplicated type B aortic dissections between 2002 and 2013, were retrospectively reviewed. All patients had at least two computed tomography angiography scans and six months of uneventful follow-up. Computed tomography scans were assessed by two independent readers with regard to presence and number of entry tears. Thoracic and abdominal aortic diameters were derived using image processing software. Results Twenty-two of 24 patients showed aortic expansion over a median computed tomography angiographic follow-up of 33.2 months. Annual rates showed an increase of 1.7 mm for total aortic diameter, 2.1 mm for the false and a decrease of −0.4 mm for the true lumen. In three patients (12.5%), aortic diameter exceeded 60 mm during follow-up, and all three patients underwent thoracic endovascular aortic repair. Patients with a maximum aortic diameter <4 cm at baseline showed a significantly higher expansion rate compared to cases with an initial maximum aortic diameter of ≥4 cm ( p=0.0471). A median of two entries (range: 1–5) was recognized per patient. Presence of more than two entry tears ( n = 13) was associated with faster overall diameter expansion (mean annual rates: 2.18 mm vs. 1.16 mm; p = 0.4556), and decrease of the cross-sectional surface of the true lumen over time (annual rate for > 2 entries vs. ≤2 entries: −7.8 mm2 vs. +37.5 mm2; p = 0.0369). Median size of entry tears was 12 mm (range: 2–53 mm). Conclusions The results presented herein suggest that uncomplicated type B aortic dissection patients with more than two entry tears and/or an initial maximum aortic diameter of<4 cm are at risk for aortic dilatation and, therefore, may require stricter follow-up including the possible need for early intervention.
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Affiliation(s)
- D Kotelis
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Germany
| | - G Grebe
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Germany
| | - P Kraus
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Germany
| | - M Müller-Eschner
- Department of Radiodiagnostics and Interventional Radiology, University Hospital Heidelberg, Germany
| | - M Bischoff
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Germany
| | - H von Tengg-Kobligk
- Department of Radiodiagnostics and Interventional Radiology, University Hospital Heidelberg, Germany
- Institute for Diagnostic, Interventional and Pediatric Radiology, Inselspital, University Hospital Bern, Switzerland
| | - D Böckler
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Germany
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Bosanquet DC, Twine CP, Tang TY, Boyle JR, Bell RE, Bicknell CD, Jenkins MP, Loftus IM, Modarai B, Vallabhaneni SR. Pragmatic Minimum Reporting Standards for Thoracic Endovascular Aortic Repair. J Endovasc Ther 2015; 22:356-67. [DOI: 10.1177/1526602815584925] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- David C. Bosanquet
- South East Wales Regional Vascular Network, Royal Gwent Hospital, Newport, Wales, UK
| | - Christopher P. Twine
- South East Wales Regional Vascular Network, Royal Gwent Hospital, Newport, Wales, UK
| | - Tjun Y. Tang
- Department of General Surgery, Changi General Hospital, Singapore
| | - Jonathan R. Boyle
- Regional Vascular Unit, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
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Iafrancesco M, Ranasinghe AM, Dronavalli V, Adam DJ, Claridge MW, Riley P, McCafferty I, Mascaro JG. Open aortic arch replacement in high-risk patients: the gold standard. Eur J Cardiothorac Surg 2015; 49:646-51; discussion 651. [DOI: 10.1093/ejcts/ezv149] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 02/19/2015] [Indexed: 11/12/2022] Open
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468
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Dias N, Sonesson B, Kristmundsson T, Holm H, Resch T. Short-term Outcome of Spinal Cord Ischemia after Endovascular Repair of Thoracoabdominal Aortic Aneurysms. Eur J Vasc Endovasc Surg 2015; 49:403-9. [DOI: 10.1016/j.ejvs.2014.12.034] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 12/26/2014] [Indexed: 10/24/2022]
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O'Callaghan A, Greenberg RK, Eagleton MJ, Bena J, Mastracci TM. Type Ia endoleaks after fenestrated and branched endografts may lead to component instability and increased aortic mortality. J Vasc Surg 2015; 61:908-14. [DOI: 10.1016/j.jvs.2014.10.085] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 10/22/2014] [Indexed: 10/24/2022]
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470
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Bin Jabr A, Lindblad B, Dias N, Resch T, Malina M. Efficacy and durability of the chimney graft technique in urgent and complex thoracic endovascular aortic repair. J Vasc Surg 2015; 61:886-94.e1. [DOI: 10.1016/j.jvs.2014.11.078] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 11/16/2014] [Indexed: 11/16/2022]
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471
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Outcomes of Thoracic Endovascular Aortic Repair and Subclavian Revascularization Techniques. J Am Coll Surg 2015; 221:93-100. [PMID: 25872688 DOI: 10.1016/j.jamcollsurg.2015.02.028] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Revised: 02/14/2015] [Accepted: 02/16/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Practice guidelines for management of the left subclavian artery (LSA) during thoracic endovascular aortic repair (TEVAR) are based on low-quality evidence, and there is limited literature that addresses optimal revascularization techniques. The purpose of this study was to compare outcomes of LSA coverage during TEVAR and revascularization techniques. STUDY DESIGN We performed a single-center retrospective cohort study from 2001 to 2013. Patients were categorized by LSA revascularization and by revascularization technique, carotid-subclavian bypass (CSB), or subclavian-carotid transposition (SCT). Thirty-day and mid-term stroke, spinal cord ischemia, vocal cord paralysis, upper extremity ischemia, primary patency of revascularization, and mortality were compared. RESULTS Eighty patients underwent TEVAR with LSA coverage, 25% (n = 20) were unrevascularized and the remaining patients underwent CSB (n = 22 [27.5%]) or SCT (n = 38 [47.5%]). Mean follow-up time was 24.9 months. Comparisons between unrevascularized and revascularized patients were significant for a higher rate of 30-day stroke (25% vs 2%; p = 0.003) and upper extremity ischemia (15% vs 0%; p = 0.014). However, there was no difference in 30-day or mid-term rates of spinal cord ischemia, vocal cord paralysis, or mortality. There were no statistically significant differences in 30-day or midterm outcomes for CSB vs SCT. Primary patency of revascularizations was 100%. Survival analysis comparing unrevascularized vs revascularized LSA was statistically significant for freedom from stroke and upper extremity ischemia (p = 0.02 and p = 0.003, respectively). After adjustment for advanced age, urgency, and coronary artery disease, LSA revascularization was associated with lower rates of perioperative adverse events (odds ratio = 0.23; p = 0.034). CONCLUSIONS During TEVAR, LSA coverage without revascularization is associated with an increased risk of stroke and upper extremity ischemia. When LSA coverage is required during TEVAR, CSB and SCT are equally acceptable options.
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472
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Cohort comparison of thoracic endovascular aortic repair with open thoracic aortic repair using modern end-organ preservation strategies. Ann Vasc Surg 2015; 29:882-90. [PMID: 25757992 DOI: 10.1016/j.avsg.2015.01.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Revised: 12/31/2014] [Accepted: 01/01/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Pivotal trials showed that thoracic endovascular aortic repair (TEVAR) has improved outcomes compared with open surgery for treating descending thoracic aortic aneurysms. However, those trials included historical open controls in which modern end-organ preservation strategies were not routinely employed. To create a more level assessment, we compared our outcomes of elective TEVAR with modern open thoracic aortic repair (OTAR) controls. METHODS A retrospective review of thoracic aortic aneurysm patients undergoing TEVAR was compared with a contemporaneous cohort of OTAR patients. Partial bypass or hypothermic circulatory arrest was used in all OTAR patients. Cerebrospinal fluid drain placement was attempted in all patients. Preoperative characteristics, operative variables, and outcomes were recorded, and the Kaplan-Meier method was used for survival estimates. RESULTS The main outcome was mortality. Secondary outcomes included postoperative spinal cord ischemia (SCI) or stroke, and any persistent neurologic deficit 30 days following the operation. During the study period, 62 patients underwent TEVAR and 56 underwent OTAR with median follow-up of 23.7 months and 36.4 months, respectively. No difference existed between the TEVAR and OTAR with respect to overall neurologic complications (8.1% vs. 12.5%, P = 0.55) as well as any residual neurologic deficit at 30 days (0% vs. 5.4%, P = 0.10). TEVAR patients had fewer complications including pneumonia (P = 0.02), rebleeding (P = 0.02), and acute kidney injury (P = 0.001). There was no difference in 30-day mortality (1.6% vs. 8.9%, P = 0.10), 1-year mortality (12.2% vs. 14%, P = 0.80), or 5-year mortality (53.9% vs. 44%, P = 0.48) between TEVAR and OTAR, respectively. CONCLUSIONS TEVAR continues to show improved perioperative outcomes with a trend toward decreased 30-day mortality and fewer major adverse events compared with OTAR. However, with the routine use of end-organ preservation strategies during OTAR, neurologic deficits, particularly SCI, can be safely reduced to comparable levels with those of TEVAR and 1-year all-cause mortality rates are similar between the groups. These OTAR results may serve as a benchmark as TEVAR is increasingly applied for other aortic pathologies, such as chronic dissection, wherein long-term efficacy is not proven.
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473
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Lee SH, Won JY, Lee DY, Kim IJ, Lee SJ, Kim MD, Park SI, Lee KH, Ko YG, Choi DH, Kim EK. Mid-term clinical outcomes and morphological changes after endovascular aneurysm repair of inflammatory abdominal aortic aneurysms: a single-center experience. Acta Radiol 2015; 56:304-11. [PMID: 24609870 DOI: 10.1177/0284185114526591] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Endovascular aneurysm repair (EVAR) has been suggested as treatment for inflammatory abdominal aortic aneurysms (IAAA), but the actual clinical and radiological outcomes need to be evaluated. PURPOSE To report morphological changes in EVAR of IAAAs. MATERIAL AND METHODS Ten male patients (mean age, 67 years; range, 54-78 years) with IAAA were treated with EVAR using endovascular stent-grafts between March 2001 and January 2012. We retrospectively compared computed tomography angiography (CTA) images taken immediately (30 days after the EVAR), short-term (up to 1 year), and mid-term (beyond 1 year) to CTA images taken before the EVAR. Clinical success was defined as successful deployment of the stent-graft without a type I or III endoleak. Morphologic responses of IAAA to EVAR were reviewed by measuring the changes in aneurysm sac maximum diameter (mm), periaortic fibrosis (PAF) thickness (mm), and PAF enhancement (Hounsfield units [HU] on delayed CTA) on serial images. RESULTS Ten IAAA patients treated with EVAR were followed for a mean of 42 months (range, 7-129 months). No aneurysm-related deaths were observed during the follow-up of 10 patients. Primary clinical success was achieved in seven patients, assisted primary clinical success in one patient, and secondary clinical success in two patients. Aneurysm sac maximum diameter decreased in all patients (mean percentage reduction of 7.6%, 8.5%, and 17.3% in immediate, short-term, and mid-term follow-up CTA, respectively). PAF thickness decreased in eight patients (10.4%, 16.8%, and 27.2% regression upon follow-up). PAF enhancement decreased in nine patients and increased in one patient (mean percentage decrease of 13.0%, 27.3%, and 40.8% upon follow-up). CONCLUSION Treatment of IAAA with EVAR was effective and reduced aneurysmal sac diameter and the extent of PAF with acceptable morbidity.
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Affiliation(s)
- Seung Hyun Lee
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University, College of Medicine, Seoul, Republic of Korea
| | - Jong Yun Won
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University, College of Medicine, Seoul, Republic of Korea
| | - Do Yun Lee
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University, College of Medicine, Seoul, Republic of Korea
| | - Il Jung Kim
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University, College of Medicine, Seoul, Republic of Korea
| | - Shin Jae Lee
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University, College of Medicine, Seoul, Republic of Korea
| | - Man Deuk Kim
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University, College of Medicine, Seoul, Republic of Korea
| | - Sung Il Park
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University, College of Medicine, Seoul, Republic of Korea
| | - Kwang Hun Lee
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University, College of Medicine, Seoul, Republic of Korea
| | - Young Guk Ko
- Cardiology Division, Yonsei Cardiovascular Center, Research Institute, Yonsei University, College of Medicine, Seoul, Republic of Korea
| | - Dong-Hoon Choi
- Cardiology Division, Yonsei Cardiovascular Center, Research Institute, Yonsei University, College of Medicine, Seoul, Republic of Korea
| | - Eun-Kyung Kim
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University, College of Medicine, Seoul, Republic of Korea
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474
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Dufour C, Gamondes D, Mansuy A, Robin J, Boussel L, Douek P. Pathology-specific late outcome after endovascular repair of thoracic aorta: a single-centre experience. Eur J Cardiothorac Surg 2015; 48:923-30. [PMID: 25721821 DOI: 10.1093/ejcts/ezv054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 12/29/2014] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Endovascular treatment of thoracic aortic lesions appears to be advantageous. However, long-term outcomes remain poorly reported. This retrospective study reported 6-year outcomes of thoracic endovascular aortic repair. METHODS A total of 74 patients underwent endovascular thoracic aorta treatments between 1999 and 2007; 13 had thoracic aortic dissections, 19 had traumatic aortic injuries, 35 had aneurysms, 6 had pseudoaneurysms and 1 had a penetrating ulcer. The mean follow-up was 66 months after 30 perioperative days. Yearly follow-ups included computed tomography angiography or magnetic resonance angiography. Patient demographics, mortality, complications and reinterventions were analysed. RESULTS The early 30-day mortality and the overall late mortality were 9.5 (7/74) and 37.8% (28/74), respectively. Late mortality was higher in patients with aneurysms than in the other groups (20/35; 57% vs 8/39; 20.5%; P = 0.002). Aortic-related mortality occurred in 5/35 (14%) patients with aneurysms, but not in other groups (P = 0.02). No relationships among late complications were found for traumatic aortic injuries. The most common complication was an endoleak (21/74, 28.4%), which occurred more frequently with aneurysms than other disorders (18/35, 51.4% vs 3/39, 7.7%; P < 0.001). Endoleaks also occurred most frequently in aortic-related deaths (16/69 vs 5/5; P = 0.001). Type 1 endoleaks occurred significantly more often with aneurysms (13/35) than with other disorders (P = 0.004). Reintervention was required in 9 patients (12%); 8 with atherosclerotic aneurysms (8/35; 23%). A false lumen was thrombosed in 54% of dissections (7/13), and shrank in 39% (5/13). CONCLUSIONS Long-term outcomes depended on aortic pathology. Aortic aneurysms were the most complicated and caused the highest mortality, probably due to atherosclerotic disease evolution. Patients with traumatic aortic injuries appeared to have the best long-term outcomes.
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Affiliation(s)
- Clémence Dufour
- Department of Interventional Radiology and Cardio-vascular and Thoracic Diagnostic Imaging, Louis Pradel University Hospital, Bron, France
| | - Delphine Gamondes
- Department of Interventional Radiology and Cardio-vascular and Thoracic Diagnostic Imaging, Louis Pradel University Hospital, Bron, France
| | - Adeline Mansuy
- Department of Interventional Radiology and Cardio-vascular and Thoracic Diagnostic Imaging, Louis Pradel University Hospital, Bron, France
| | - Jacques Robin
- Department of Cardio-vascular Surgery, Louis Pradel University Hospital, Bron, France
| | - Loïc Boussel
- Department of Interventional Radiology and Cardio-vascular and Thoracic Diagnostic Imaging, Louis Pradel University Hospital, Bron, France
| | - Philippe Douek
- Department of Interventional Radiology and Cardio-vascular and Thoracic Diagnostic Imaging, Louis Pradel University Hospital, Bron, France
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475
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Dohle DS, Tsagakis K, Janosi RA, Benedik J, Kühl H, Penkova L, Stebner F, Wendt D, Jakob H. Aortic remodelling in aortic dissection after frozen elephant trunk. Eur J Cardiothorac Surg 2015; 49:111-7. [DOI: 10.1093/ejcts/ezv045] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 01/19/2015] [Indexed: 11/14/2022] Open
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476
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Kotelis D, Brenke C, Wörz S, Rengier F, Rohr K, Kauczor HU, Böckler D, von Tengg-Kobligk H. Aortic morphometry at endograft position as assessed by 3D image analysis affects risk of type I endoleak formation after TEVAR. Langenbecks Arch Surg 2015; 400:523-9. [PMID: 25702140 DOI: 10.1007/s00423-015-1291-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 02/12/2015] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this study was to identify morphologic factors affecting type I endoleak formation and bird-beak configuration after thoracic endovascular aortic repair (TEVAR). METHODS Computed tomography (CT) data of 57 patients (40 males; median age, 66 years) undergoing TEVAR for thoracic aortic aneurysm (34 TAA, 19 TAAA) or penetrating aortic ulcer (n = 4) between 2001 and 2010 were retrospectively reviewed. In 28 patients, the Gore TAG® stent-graft was used, followed by the Medtronic Valiant® in 16 cases, the Medtronic Talent® in 8, and the Cook Zenith® in 5 cases. Proximal landing zone (PLZ) was in zone 1 in 13, zone 2 in 13, zone 3 in 23, and zone 4 in 8 patients. In 14 patients (25%), the procedure was urgent or emergent. In each case, pre- and postoperative CT angiography was analyzed using a dedicated image processing workstation and complimentary in-house developed software based on a 3D cylindrical intensity model to calculate aortic arch angulation and conicity of the landing zones (LZ). RESULTS Primary type Ia endoleak rate was 12% (7/57) and subsequent re-intervention rate was 86% (6/7). Left subclavian artery (LSA) coverage (p = 0.036) and conicity of the PLZ (5.9 vs. 2.6 mm; p = 0.016) were significantly associated with an increased type Ia endoleak rate. Bird-beak configuration was observed in 16 patients (28%) and was associated with a smaller radius of the aortic arch curvature (42 vs. 65 mm; p = 0.049). Type Ia endoleak was not associated with a bird-beak configuration (p = 0.388). Primary type Ib endoleak rate was 7% (4/57) and subsequent re-intervention rate was 100%. Conicity of the distal LZ was associated with an increased type Ib endoleak rate (8.3 vs. 2.6 mm; p = 0.038). CONCLUSIONS CT-based 3D aortic morphometry helps to identify risk factors of type I endoleak formation and bird-beak configuration during TEVAR. These factors were LSA coverage and conicity within the landing zones for type I endoleak formation and steep aortic angulation for bird-beak configuration.
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Affiliation(s)
- Drosos Kotelis
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany,
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477
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Twelve-year results of fenestrated endografts for juxtarenal and group IV thoracoabdominal aneurysms. J Vasc Surg 2015; 61:355-64. [DOI: 10.1016/j.jvs.2014.09.068] [Citation(s) in RCA: 176] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 09/29/2014] [Indexed: 11/22/2022]
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478
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Boufi M, Aouini F, Guivier-Curien C, Dona B, Loundou AD, Deplano V, Alimi YS. Examination of factors in type I endoleak development after thoracic endovascular repair. J Vasc Surg 2015; 61:317-23. [DOI: 10.1016/j.jvs.2014.08.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 08/05/2014] [Indexed: 11/16/2022]
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479
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Outcomes and Morphologic Changes of Immediate Type Ia Endoleak following Endovascular Repair of Acute Type B Aortic Dissection. Ann Vasc Surg 2015; 29:174-82. [DOI: 10.1016/j.avsg.2014.10.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 10/02/2014] [Accepted: 10/06/2014] [Indexed: 11/17/2022]
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480
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Verhoeven ELG, Katsargyris A, Bekkema F, Oikonomou K, Zeebregts CJAM, Ritter W, Tielliu IFJ. Editor's Choice - Ten-year Experience with Endovascular Repair of Thoracoabdominal Aortic Aneurysms: Results from 166 Consecutive Patients. Eur J Vasc Endovasc Surg 2015; 49:524-31. [PMID: 25599593 DOI: 10.1016/j.ejvs.2014.11.018] [Citation(s) in RCA: 259] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 11/28/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To present a 10 year experience with endovascular thoracoabdominal aortic aneurysm (TAAA) repair using fenestrated and branched stent grafts. MATERIALS AND METHODS Consecutive patients with TAAA treated with fenestrated and branched stent grafts within the period January 2004-December 2013. Data were collected prospectively. RESULTS 166 patients (125 male, 41 female, mean age 68.8 ± 7.6 years) were treated. The mean TAAA diameter was 71 ± 9.3 mm. Types of TAAA were: type I, n = 12 (7.2%), type II, n = 50 (30.1%), type III, n = 53 (31.9%), type IV, n = 41 (24.8%), and type V, n = 10 (6%). Fifteen (9%) patients had an acute TAAA (11 contained rupture, 4 symptomatic). One hundred and eight (65%) patients were refused for open surgery earlier. Seventy eight (47%) patients had previously undergone one or more open/endovascular aortic procedures. Technical success was 95% (157/166). Thirty day operative mortality was 7.8% (13/166), with an in hospital mortality of 9% (15/166). Peri-operative spinal cord ischemia (SCI) was observed in 15 patients (9%), including permanent paraplegia in two (1.2%). Mean follow up was 29.2 ± 21 months. During follow up 40 patients died, two of them probably from aneurysm related cause. Re-intervention, mostly by endovascular means, was needed in 40 (24%) patients. Estimated survival at 1, 2, and 5 years was 83% ± 3%, 78% ± 3.5%, and 66.6% ± 6.1%, respectively. Estimated target vessel stent patency at 1, 2, and 5 years was 98% ± 0.6%, 97% ± 0.8%, and 94.2% ± 1.5%, respectively. Estimated freedom from re-intervention at 1 and 3 years was 88.3% ± 2.7%, and 78.4% ± 4.5%, respectively. CONCLUSIONS Endovascular repair of TAAA with fenestrated and branched stent grafts in high volume centers appears safe and effective in the mid-term in a high risk patient cohort. A considerable reintervention rate should be acknowledged, however.
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Affiliation(s)
- E L G Verhoeven
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nürnberg, Germany.
| | - A Katsargyris
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nürnberg, Germany
| | - F Bekkema
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, The Netherlands
| | - K Oikonomou
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nürnberg, Germany
| | - C J A M Zeebregts
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, The Netherlands
| | - W Ritter
- Department of Radiology, Paracelsus Medical University, Nürnberg, Germany
| | - I F J Tielliu
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, The Netherlands
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481
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The impact of early pelvic and lower limb reperfusion and attentive peri-operative management on the incidence of spinal cord ischemia during thoracoabdominal aortic aneurysm endovascular repair. Eur J Vasc Endovasc Surg 2015; 49:248-54. [PMID: 25575833 DOI: 10.1016/j.ejvs.2014.11.017] [Citation(s) in RCA: 138] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Accepted: 11/25/2014] [Indexed: 01/18/2023]
Abstract
OBJECTIVE/BACKGROUND Spinal cord ischemia (SCI) is a devastating complication following endovascular thoracoabdominal aortic aneurysm (TAAA) repair. In an attempt to reduce its incidence two peri-procedural changes were implemented by the authors in January 2010: (i) all large sheaths are withdrawn from the iliac arteries immediately after deploying the central device and before cannulation and branch extension to the visceral vessels; (ii) the peri-operative protocol has been modified in an attempt to optimize oxygen delivery to the sensitive cells of the cord (aggressive blood and platelet transfusion, median arterial pressure monitoring >85 mmHg, and systematic cerebrospinal fluid drainage). METHODS Between October 2004 and December 2013, 204 endovascular TAAA repairs were performed using custom made devices manufactured with branches and fenestrations to maintain visceral vessel perfusion. Data from all of these procedures were prospectively collected in an electronic database. Early post-operative results in patients treated before (group 1, n = 43) and after (group 2, n = 161 patients) implementation of the modified implantation and peri-operative protocols were compared. RESULTS Patients in groups 1 and 2 had similar comorbidities (median age at repair 70.9 years [range 65.2-77.0 years]), aneurysm characteristics (median diameter 58.5 mm [range 53-65 mm]), and length of procedure (median 190 minutes [range 150-240 minutes]). The 30 day mortality rate was 11.6% in group 1 versus 5.6% in group 2 (p = .09). The SCI rate was 14.0% versus 1.2% (p < .01). If type IV TAAAs were excluded from this analysis, the SCI rate was 25.0% (6/24 patients) in group 1 versus 2.1% (2/95 patients) in group 2 (p < .01). CONCLUSION The early restoration of arterial flow to the pelvis and lower limbs, and aggressive peri-operative management significantly reduces SCI following type I-III TAAA endovascular repair. With the use of these modified protocols, extensive TAAA endovascular repairs are associated with low rates of SCI.
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482
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Results and Factors Affecting Early Outcome of Fenestrated and/or Branched Stent Grafts for Aortic Aneurysms. Ann Surg 2015; 261:197-206. [DOI: 10.1097/sla.0000000000000612] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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483
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Preoperative prediction of spinal cord ischemia after thoracic endovascular aortic repair. J Vasc Surg 2014; 60:1481-90.e1. [PMID: 25282701 DOI: 10.1016/j.jvs.2014.08.103] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 08/25/2014] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Spinal cord ischemia (SCI) is a devastating but potentially preventable complication of thoracic endovascular aortic repair (TEVAR). The purpose of this analysis was to determine what factors predict SCI after TEVAR. METHODS All TEVAR procedures at a single institution were reviewed for patient characteristics, prior aortic repair history, aortic centerline of flow analysis, and procedural characteristics. SCI was defined as any lower extremity neurologic deficit that was not attributable to an intracranial process or peripheral neuropathy. Forty-three patient and procedural variables were evaluated individually for association with SCI. Those with the strongest relationships to SCI (P < .1) were included in a multivariable logistic regression model, and a stepwise variable elimination algorithm was bootstrapped to derive a best subset of predictors from this model. RESULTS From 2002 to 2013, 741 patients underwent TEVAR for various indications, and 68 (9.2%) developed SCI (permanent: n = 38; 5.1%). Because of the lack of adequate imaging for centerline analysis, 586 patients (any SCI, n = 43; 7.4%) were subsequently analyzed. Patients experiencing SCI after TEVAR were older (SCI, 72 ± 11 years; no SCI, 65 ± 15 years; P < .0001) and had significantly higher rates of multiple cardiovascular risk factors. The stepwise selection procedure identified five variables as the most important predictors of SCI: age (odds ratio [OR] multiplies by 1.3 per 10 years; 95% confidence interval [CI], 0.9-1.8, P = .06), aortic coverage length (OR multiplies by 1.3 per 5 cm; CI, 1.1-1.6; P = .002), chronic obstructive pulmonary disease (OR, 1.9; CI, 0.9-4.1; P = .1), chronic renal insufficiency (creatinine concentration ≥ 1.6 mg/dL; OR, 1.9; CI, 0.8-4.2; P = .1), and hypertension (defined as chart history or medication; OR, 6.4; CI, 2.6-18; P < .0001). A logistic regression model with just these five covariates had excellent discrimination (area under the receiver operating characteristic curve = .83) and calibration (χ(2) = 9.8; P = .28). CONCLUSIONS This analysis generated a simple model that reliably predicts SCI after TEVAR. This clinical tool can assist decision-making about when to proceed with TEVAR, guide discussions about intervention risk, and help determine when maneuvers to mitigate SCI risk should be implemented.
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484
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Chen CK, Liang IP, Chang HT, Chen WY, Chen IM, Wu MH, Sheu MH, Shih CC. Impact on outcomes by measuring tortuosity with reporting standards for thoracic endovascular aortic repair. J Vasc Surg 2014; 60:937-44. [DOI: 10.1016/j.jvs.2014.04.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 04/02/2014] [Indexed: 10/25/2022]
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485
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Global experience with an inner branched arch endograft. J Thorac Cardiovasc Surg 2014; 148:1709-16. [DOI: 10.1016/j.jtcvs.2014.02.072] [Citation(s) in RCA: 198] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 02/17/2014] [Accepted: 02/20/2014] [Indexed: 11/20/2022]
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486
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Multidetector CT findings of complications of surgical and endovascular treatment of aortic aneurysms. Radiol Clin North Am 2014; 52:961-89. [PMID: 25173654 DOI: 10.1016/j.rcl.2014.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Aortic aneurysms remain a significant problem in the population, and there is a concerted effort to identify, define, image, and treat these conditions to ultimately improve outcomes. The rapid development of diagnostic modalities, operative strategies, and endovascular techniques within the realm of this aortic disease has transformed the field and broadened the spectrum of patients that can be treated with minimally invasive techniques. This investigation has a broad spectrum of normal expected findings that must be differentiated from early or late complications in which intervention is required. In this article, normal and abnormal postoperative and post-TEVAR/EVAR MDCT findings are described.
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487
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Watanabe Y, Shimamura K, Yoshida T, Daimon T, Shirakawa Y, Torikai K, Sakamoto T, Shijo T, Toda K, Kuratani T, Sawa Y. Aortic Remodeling as a Prognostic Factor for Late Aortic Events After Thoracic Endovascular Aortic Repair in Type B Aortic Dissection With Patent False Lumen. J Endovasc Ther 2014; 21:517-25. [DOI: 10.1583/13-4646r.1] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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488
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Schwierz E, Kolvenbach RR, Yoshida R, Yoshida W, Alpaslan A, Karmeli R. Experience with the sandwich technique in endovascular thoracoabdominal aortic aneurysm repair. J Vasc Surg 2014; 59:1562-9. [DOI: 10.1016/j.jvs.2013.12.044] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 12/19/2013] [Accepted: 12/20/2013] [Indexed: 11/29/2022]
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489
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Zakko J, Scali S, Beck AW, Klodell CT, Beaver TM, Martin TD, Huber TS, Feezor RJ. Percutaneous thoracic endovascular aortic repair is not contraindicated in obese patients. J Vasc Surg 2014; 60:921-8. [PMID: 24845111 DOI: 10.1016/j.jvs.2014.04.051] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 04/15/2014] [Indexed: 12/17/2022]
Abstract
OBJECTIVE There are limited data describing the preclose technique with the Perclose ProGlide device (Abbott Vascular, Redwood City, Calif) in percutaneous thoracic endovascular aortic repair (P-TEVAR), particularly in obese patients, in whom use of this technique is thought to be relatively contraindicated. The purpose of this analysis was to describe our experience with P-TEVAR and to compare outcomes in patients with or without obesity. METHODS All TEVAR procedures at a single institution from 2005 to 2011 were reviewed, and P-TEVAR patients were stratified by body mass index (obesity ≥ 30 kg/m2). Preoperative computed tomography scans were analyzed for access vessel depth, calcification, and morphology. Technical success was defined as the ability to achieve hemostasis and to maintain limb perfusion without the need for common femoral artery exposure or obligate surgical repair of the vessel within a 30-day postoperative period. Generalized estimating equations and stepwise logistic regression were used to develop prediction models of preclose failure. RESULTS The review identified 536 patients, in whom 355 (66%) P-TEVAR procedures were completed (366 arteries; n = 40 [11%] bilateral). Compared with nonobese patients (n = 264), obese patients (n = 91) were typically younger (59 ± 16 years vs. 66 ± 16 years; P = .0004) and more likely to have renal insufficiency (28% vs. 17%; P = .05) or diabetes mellitus (19% vs. 9%; P = .02). The number of Perclose deployments was similar between groups (P = NS). Mean sheath size (25.4F vs 25.0F; P = .04), access vessel inner diameters (8.5 ± 1.9 mm vs. 7.9 ± 2.0 mm; P = .02), and vessel depth (50 ± 20 mm vs. 30 ± 13 mm; P < .0001) were greater in obese patients. Adjunctive iliac stents were used in 7% of cases (10 [11%] in obese patients vs 16 [6%] in nonobese patients; P = .2). Overall technical success was 92% (92% for nonobese patients vs 93% for obese patients; P = .7). Three patients required subsequent operations for access complications, two obese patients (2%) and one nonobese patient (0.4%) (P = .3). Independent predictors of failure were adjunctive iliac stent (odds ratio [OR], 9.5; 95% confidence interval [CI], 3.3-27.8; P < .0001), more than two Perclose devices (OR, 7.0; 95% CI, 2.3-21; P = .0005), and smaller access vessel diameter to sheath size ratio (OR multiplies by 1.1 for each .01 decrease in ratio; 95% CI, 1.02-1.2; P = .007) (area under the receiver operating characteristic curve = .75). CONCLUSIONS Obesity is not a contraindication to P-TEVAR. P-TEVAR can be performed safely, despite the need for larger diameter sheaths. However, patients predicted to need adjunctive stenting or possessing smaller access vessel diameter to sheath size ratios are at highest risk of preclose failure with the Perclose ProGlide device, and selective use of this technique is recommended.
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Affiliation(s)
- Jason Zakko
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Salvatore Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Charles T Klodell
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Tomas D Martin
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Robert J Feezor
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
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490
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Scali ST, Beck AW, Butler K, Feezor RJ, Martin TD, Hess PJ, Huber TS, Chang CK. Pathology-specific secondary aortic interventions after thoracic endovascular aortic repair. J Vasc Surg 2014; 59:599-607. [PMID: 24571937 DOI: 10.1016/j.jvs.2013.09.050] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 08/24/2013] [Accepted: 09/23/2013] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Despite improved short-term outcomes, concerns remain regarding durability of thoracic endovascular aortic repair (TEVAR). The purpose of this analysis was to evaluate the pathology-specific incidence of secondary aortic interventions (SAI) after TEVAR and their impact on survival. METHODS Retrospective review was performed of all TEVAR procedures and SAI at one institution from 2004-2011. Kaplan-Meier analysis was used to estimate survival. RESULTS Of 585 patients, 72 (12%) required SAI at a median of 5.6 months (interquartile range, 1.4-14.2) with 22 (3.7%) requiring multiple SAI. SAI incidence differed significantly by pathology (P = .002) [acute dissection (21.3%), postsurgical (20.0%), chronic dissection (16.7%), degenerative aneurysm (10.8%), traumatic transection (8.1%), penetrating ulcer (1.5%), and other etiologies (14.8%)]. Most common indications after dissection were persistent false lumen flow and proximal/distal extension of disease. For degenerative aneurysms, SAI was performed primarily to treat type I/III endoleaks. SAI patients had a greater mean number of comorbidities (P < .0005), stents placed (P = .0002), and postoperative complications after the index TEVAR (P < .0005) compared with those without SAI. Freedom from SAI at 1 and 5 years (95% confidence interval) was estimated to be 86% (82%-90%) and 68% (57%-76%), respectively. There were no differences in survival (95% confidence interval) between patients requiring SAI and those who did not [SAI 1-year, 88% (77%-93%); 5-year, 51% (37%-63%); and no SAI 1-year, 82% (79%-85%); 5-year, 67% (62%-71%) (log-rank, P = .2)]. CONCLUSIONS SAI after TEVAR is not uncommon, particularly in patients with dissection, but does not affect long-term survival. Aortic pathology is the most important variable impacting survival and dictated need, timing, and mode of SAI. The varying incidence of SAI by indication underscores the need for diligent surveillance protocols that should be pathology-specific.
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Affiliation(s)
- Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Khayree Butler
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Robert J Feezor
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Tomas D Martin
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Philip J Hess
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Catherine K Chang
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
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491
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Wojciechowski J, Znaniecki L, Bury K, Rogowski J. Thoracic endovascular aortic repair with left subclavian artery coverage without prophylactic revascularisation-early and midterm results. Langenbecks Arch Surg 2014; 399:619-27. [PMID: 24770837 PMCID: PMC4050290 DOI: 10.1007/s00423-014-1186-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Accepted: 03/23/2014] [Indexed: 12/02/2022]
Abstract
Background The management of the left subclavian artery when coverage is necessary during thoracic aorta endografting remains a matter of debate. Materials and methods A retrospective analysis of a single-centre experience with thoracic endovascular aorta repair (TEVAR) was performed. Between April 2004 and October 2012, 125 cases of TEVAR were performed. The analysis focused on patients who required coverage of the left subclavian artery (LSA). We analysed mortality and morbidity with special attention to the rates of cerebrovascular accidents (CVAs) and spinal cord ischaemia (SCI) in the early and midterm. Results Of the 125 patients, 53 (42 %, group A) required an intentional coverage of the LSA to obtain an adequate proximal seal for the endograft; the remaining patients constituted group B. None of the patients in group A had protective LSA revascularisation prior to TEVAR. The primary technical success rate was 79.2 vs. 90.3 % (group A vs. group B, p = 0.08), and the primary clinical success rate was 77.4 vs. 82 % (group A vs. group B, p = 0.53). The 30-day mortality rate was 11.3 vs. 11.1 % (group A vs. group B, p = 0.97). The 30-day morbidity was 7.5 vs. 13.9 % (group A vs. group B, p = 0.4). CVA occurred in 1.9 % of group A patients, compared to 1.4 % of patients from group B (p = 0.82). The SCI incidence rate was 0 vs. 1.4 % (p = 0.39). The mean follow-up of group A was 24.1 months (range 2–64.6 months, SD = 19). Additionally, the 1-year estimated survival was 85.5 %, and the 3-year estimated survival was 78 %. There were no midterm CVAs; one event of SCI occurred in the seventh post-operative month in group A. Conclusion Our analysis, although retrospective and based on one institution experience, shows a realistic population of TEVAR patients. We prove that TEVAR with coverage of LSA origin can be accomplished with minimal neurological morbidity in this patient population. The study shows that LSA revascularisation is not mandatory before endograft deployment, especially in emergency settings. We also prove that although zone 2 TEVAR extends the proximal landing zone, it does not prevent type IA endoleaks from appearing. A multicentre randomised control trial with higher number of patients is necessary for proper, robust conclusion to be established.
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Affiliation(s)
- J. Wojciechowski
- Department of Cardiac and Vascular Surgery, Medical University of Gdansk, ul. Debinki 7, 80-211 Gdansk, Poland
| | - L. Znaniecki
- Department of Cardiac and Vascular Surgery, Medical University of Gdansk, ul. Debinki 7, 80-211 Gdansk, Poland
| | - K. Bury
- Department of Cardiac and Vascular Surgery, Medical University of Gdansk, ul. Debinki 7, 80-211 Gdansk, Poland
| | - J. Rogowski
- Department of Cardiac and Vascular Surgery, Medical University of Gdansk, ul. Debinki 7, 80-211 Gdansk, Poland
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492
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Iafrancesco M, Ranasinghe AM, Claridge MW, Mascaro JG, Adam DJ. Current results of endovascular repair of thoraco-abdominal aneurysms†. Eur J Cardiothorac Surg 2014; 46:981-4; discussion 984. [PMID: 24652813 DOI: 10.1093/ejcts/ezu090] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Fenestrated and branch endografts represent a totally endovascular solution for high-risk patients with atherosclerotic thoraco-abdominal aortic aneurysms (TAAAs). This study reports the early outcome of endovascular TAAA repair. METHODS Interrogation of a prospective database of consecutive patients who underwent endovascular repair (EVAR) for TAAA between June 2007 and October 2012. RESULTS Sixty-two high-risk patients (55 men; median age 72, range 54-84 years) underwent fenestrated (n = 39) or branch (n = 23) EVAR for non-ruptured TAAA [extent I-III (n = 26) and IV (n = 36)]. Twenty patients had undergone 22 previous aortic procedures. A total of 221 target vessels (coeliac 50, superior mesenteric 61, renal 106, left subclavian 1 and hypogastric 3) were preserved with scallops (n = 17), fenestrations (n = 140) or branches (n = 62) and 201 of these vessels were stent-grafted (coeliac 34, superior mesenteric 58, renal 105, left subclavian 1 and hypogastric 3). The 30-day mortality was 1.6% (n = 1) and one further patient died on postoperative day 62 from respiratory complications. Spinal cord injury (SCI) developed in 5 (8%) patients (3 women and 2 men). Two patients required temporary renal replacement therapy and a further two commenced planned postoperative dialysis. CONCLUSIONS In high-risk patients with TAAA, fenestrated and branch EVAR is associated with low early mortality and requirement for renal support, but the risk of SCI is not insignificant despite the use of cerebrospinal fluid drainage and blood pressure manipulation. Our current practice is to stage the repair of extent I-III aneurysms and this has significantly reduced the incidence of SCI.
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Affiliation(s)
- Mauro Iafrancesco
- Department of Cardiothoracic Surgery/Thoracic Aortic Multidisciplinary Team, Queen Elizabeth University Hospital NHS Foundation Trust, Birmingham, UK Vascular Surgery Department/Thoracic Aortic Multidisciplinary Team, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Aaron M Ranasinghe
- Department of Cardiothoracic Surgery/Thoracic Aortic Multidisciplinary Team, Queen Elizabeth University Hospital NHS Foundation Trust, Birmingham, UK
| | - Martin W Claridge
- Department of Cardiothoracic Surgery/Thoracic Aortic Multidisciplinary Team, Queen Elizabeth University Hospital NHS Foundation Trust, Birmingham, UK Vascular Surgery Department/Thoracic Aortic Multidisciplinary Team, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Jorge G Mascaro
- Department of Cardiothoracic Surgery/Thoracic Aortic Multidisciplinary Team, Queen Elizabeth University Hospital NHS Foundation Trust, Birmingham, UK
| | - Donald J Adam
- Department of Cardiothoracic Surgery/Thoracic Aortic Multidisciplinary Team, Queen Elizabeth University Hospital NHS Foundation Trust, Birmingham, UK Vascular Surgery Department/Thoracic Aortic Multidisciplinary Team, Heart of England NHS Foundation Trust, Birmingham, UK
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493
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Sultan S, Hynes N, Sultan M. When Not to Implant the Multilayer Flow Modulator: Lessons Learned From Application Outside the Indications for Use in Patients With Thoracoabdominal Pathologies. J Endovasc Ther 2014; 21:96-112. [DOI: 10.1583/13-4514mr.1] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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494
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Late rescue of proximal endograft failure using fenestrated and branched devices. J Vasc Surg 2014; 59:1479-87. [PMID: 24486036 DOI: 10.1016/j.jvs.2013.12.028] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 12/10/2013] [Accepted: 12/10/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Endovascular aneurysm repair (EVAR) will fail over time in a percentage of patients. Mechanical failure of the device, progression of aortic disease, or interface complications between the device and the native vasculature may contribute. Our aim was to evaluate the role of fenestrated and branched endografts as treatment options for failed devices. METHODS Between January 2001 and June 2013, 970 patients were enrolled into a physician-sponsored investigational device exemption (PSIDE) study and treated with a fenestrated/branched endograft. All patients treated for nonurgent proximal neck failure of an infrarenal endoprosthesis previously implanted during EVAR comprised the study group. Patients treated for a primary aneurysm within the PSIDE were evaluated as a comparison group to identify preoperative risk factors for failure. A retrospective review was undertaken to determine the details of the initial EVAR, whereas the prospective PSIDE database was used to assess outcomes of secondary treatment. Three-dimensional imaging techniques were used to define all morphologic measurements. Statistical analysis included comparisons between categoric variables with the χ(2) test and between continuous variables with the Wilcoxon rank sum test between patients with late failures and those with native aortic repair. Kaplan-Meier curves were used to analyze overall survival. RESULTS Of 970 patients enrolled in the PSIDE, 54 (5.6%) had late failure of a prior endograft. Fenestrated/branched devices were used to address the failure in each patient. The etiology of failure was related to a proximal neck issue in all patients: type Ia endoleak in 38, stent migration in 18, neck degeneration in 28, or some combination of these factors. The endovascular rescue procedure took place a mean of 61 months after the primary procedure. The mean aneurysm diameter at reintervention was 67 mm. Patients requiring a secondary fenestrated procedure were younger at the time of their primary intervention (P = .039) and were more likely to have a history of chronic renal insufficiency (P = .05) compared with other patients in the PSIDE. Technical success rate in the study group was 85% (44 of 52). Successful stenting was achieved in 71 of 77 (92%) target vessels. Thirty-day mortality was 3.8% (two of 52). Fluoroscopy dose and operating time were longer in the rescue group (P = .07) than in the control group (P = .008). Secondary interventions were required in 36.5% (19 of 52) of patients. CONCLUSIONS Our series demonstrates the risk for late failure after EVAR is greater in patients who are younger and have chronic renal impairment at the time of implantation. Branched and fenestrated repair after failed EVAR is more complex than repair in the native aorta. More research is needed to identify patients at higher risk of failure after EVAR to prevent the need for rescue in the future.
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495
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Hsu HL, Chen CK, Chen PL, Chen IM, Hsu CP, Chen CW, Shih CC. The impact of bird-beak configuration on aortic remodeling of distal arch pathology after thoracic endovascular aortic repair with the Zenith Pro-Form TX2 thoracic endograft. J Vasc Surg 2014; 59:80-8. [DOI: 10.1016/j.jvs.2013.07.098] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 07/16/2013] [Accepted: 07/17/2013] [Indexed: 10/26/2022]
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496
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Inter-observer Variability in Sizing Fenestrated and/or Branched Aortic Stent-grafts. Eur J Vasc Endovasc Surg 2014; 47:45-52. [DOI: 10.1016/j.ejvs.2013.10.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 10/07/2013] [Indexed: 11/20/2022]
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497
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Eagleton MJ, Shah S, Petkosevek D, Mastracci TM, Greenberg RK. Hypogastric and subclavian artery patency affects onset and recovery of spinal cord ischemia associated with aortic endografting. J Vasc Surg 2014; 59:89-94. [DOI: 10.1016/j.jvs.2013.07.007] [Citation(s) in RCA: 131] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Revised: 07/09/2013] [Accepted: 07/10/2013] [Indexed: 11/28/2022]
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498
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Faure EM, Canaud L, Agostini C, Shaub R, Böge G, Marty-ané C, Alric P. Reintervention after thoracic endovascular aortic repair of complicated aortic dissection. J Vasc Surg 2013; 59:327-33. [PMID: 24135620 DOI: 10.1016/j.jvs.2013.08.089] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 08/27/2013] [Accepted: 08/28/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVE This study assessed predictive factors for reintervention after thoracic endovascular aortic repair (TEVAR) for complicated aortic dissection (C-AD). METHODS An institutional review of consecutive TEVAR for C-AD was performed. RESULTS Between 2000 and 2011, 41 patients underwent TEVAR for a C-AD involving the descending thoracic aorta. Primary indications included aneurysm >55 mm in 24, rapid aneurysmal enlargement or impending rupture in 6, saccular aneurysm >20 mm in 1, malperfusion in 1, intractable chest pain in 3, and rupture in 6. Technical success was achieved in 100%. The 30-day mortality rate was 5% (n = 2). Fourteen secondary procedures were performed in 13 patients (32%) for indications of device migration in 2, proximal type I endoleak in 5, distal type I endoleak in 2, type II endoleak in 1, aneurysmal evolution of the descending thoracic aorta in 2, aneurysmal expansion of the dissected abdominal aorta in 1, and retrograde dissection in 1. Multivariate analysis demonstrated that oversizing ≥20% (odds ratio [OR], 16; P = .011), bare-spring stent in the proximal landing zone of the stent graft (OR, 12; P = .032), and anticoagulant therapy (OR, 78; P = .03) were significant factors for reintervention. On univariate analysis, large aneurysm was a risk factor for reintervention (P = .002), whereas complete false lumen thrombosis at the stent graft level was protective (P < .05). CONCLUSIONS This study confirms the feasibility of TEVAR for C-AD, although the rate of reintervention is high. Excessive oversizing, a bare-spring stent graft in the proximal landing zone, large aortic dilatation, and anticoagulant therapy were factors associated with reintervention. Complete false lumen thrombosis at the stent graft level was protective.
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Affiliation(s)
- Elsa M Faure
- Department of Thoracic and Vascular Surgery, University Hospital, Montpellier, France; U1046, Institut National de la Santé et de la Recherche Médicale, Université Montpellier 1, Montpellier, France.
| | - Ludovic Canaud
- Department of Thoracic and Vascular Surgery, University Hospital, Montpellier, France; U1046, Institut National de la Santé et de la Recherche Médicale, Université Montpellier 1, Montpellier, France
| | - Camille Agostini
- Clinical Research and Epidemiology Department, University Hospital, Montpellier, France
| | - Roxane Shaub
- Clinical Research and Epidemiology Department, University Hospital, Montpellier, France
| | - Gudrun Böge
- Department of Thoracic and Vascular Surgery, University Hospital, Montpellier, France
| | - Charles Marty-ané
- Department of Thoracic and Vascular Surgery, University Hospital, Montpellier, France
| | - Pierre Alric
- Department of Thoracic and Vascular Surgery, University Hospital, Montpellier, France; U1046, Institut National de la Santé et de la Recherche Médicale, Université Montpellier 1, Montpellier, France
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499
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Hanna JM, Andersen ND, Ganapathi AM, McCann RL, Hughes GC. Five-year results for endovascular repair of acute complicated type B aortic dissection. J Vasc Surg 2013; 59:96-106. [PMID: 24094903 DOI: 10.1016/j.jvs.2013.07.001] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 07/08/2013] [Accepted: 07/10/2013] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Despite a current lack of U.S. Food and Drug Administration approval for the indication, thoracic endovascular aortic repair (TEVAR) has replaced open surgical management for acute complicated type B aortic dissection due to promising short- and midterm data. However, long-term results, with a view toward durability and need for secondary procedures, are limited. As such, the objective of the present study is to report long-term outcomes of TEVAR for acute (≤ 2 weeks from symptom onset) complicated type B dissection. METHODS Between July 2005 and September 2012, 50 consecutive patients underwent TEVAR for management of acute complicated type B dissection at a single referral institution. Patient records were retrospectively reviewed from a prospectively maintained clinical database. RESULTS Indications for intervention included rupture in 10 (20%), malperfusion in 24 (48%), and/or refractory pain/impending rupture in 17 (34%). One patient (2%) had both rupture and malperfusion indications. Ten (20%) patients required one or more adjunctive procedures, in addition to TEVAR, to treat malperfusion syndromes. In-hospital and 30-day rates of death were both 0%; 30-day/in-hospital rates of stroke, permanent paraplegia/paraparesis, and new-onset dialysis were 2% (n = 1), 2% (n = 1), and 4% (n = 2), respectively. Median follow-up was 33.8 months [interquartile range, 12.3-56.6 months]. Overall survival at 5 and 7 years was 84%, with no deaths attributable to aortic pathology. Thirteen (26%) patients required a total of 17 reinterventions over the study period for type I endoleak (n = 5), metachronous aortic pathology (n = 5), persistent false lumen pressurization via distal fenestrations (n = 4), type II endoleak (n = 2), or retrograde acute type A aortic dissection (n = 1). Median time to first reintervention was 4.5 months (range, 0 days-40.3 months). Of the 17 total reinterventions, six (35%) were performed using open techniques and 11 (65%) with endovascular or hybrid methods; there was no difference in survival between patients who did or did not require reintervention. CONCLUSIONS This study confirms the excellent short-term outcomes of TEVAR for acute complicated type B dissection and demonstrates the results to be durable and sustained over long-term follow-up. Although aortic reinterventions were required in one-quarter of patients, no aortic-related deaths were observed. These data support the use of TEVAR for acute complicated type B aortic dissection but also highlight the importance of life-long aortic surveillance by an experienced aortic referral center in order to identify and treat complications of the underlying disease process and treatment, as well as new aortic pathologies, as they arise.
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Affiliation(s)
- Jennifer M Hanna
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Nicholas D Andersen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Asvin M Ganapathi
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Richard L McCann
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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500
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Brechtel K, Kalender G, Stock UA, Wildhirt SM. Hybrid debranching and TEVAR of the aortic arch off-pump, in re-do patients with complicated chronic type-A aortic dissections: a critical report. J Cardiothorac Surg 2013; 8:188. [PMID: 24007462 PMCID: PMC3846913 DOI: 10.1186/1749-8090-8-188] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 08/27/2013] [Indexed: 11/16/2022] Open
Abstract
Background Patients suffering from acute type A aortic dissection undergo replacement of the ascending aorta, the proximal hemiarch or complete aortic arch, depending on the extent of the individual pathology. In a subset of these treated patients, secondary pathologies of the distal anastomosis or the remaining distal part of the aorta occur. The treatment of these pathologies is challenging, requiring major surgical re-do procedures with aortic arch replacement under extracorporeal circulation and hypothermic circulatory arrest. Methods We report our experience of five patients with complex aortic pathologies after previous aortic surgery treated with a single stage re-do hybrid procedure, consisting of bypass grafting of the supraaortic branches off-pump, stent graft placement for endovascular aortic repair (TEVAR) and surgical debranching of the aortic arch. Results In all patients the surgical vascular grafts and stent grafts were deployed successfully, there were no intraoperative deaths. Four out of five patients were discharged from hospital in good clinical condition. One patient died postoperatively due to cardiac tamponade. In one patient a type I endoleak persisted leading to occlusion of a bypass branch requiring surgical revision at one year after debranching. Conclusion We discuss the prerequisites, all steps and potential pitfalls of this hybrid aortic arch replacement. The current procedure avoids cardiopulmonary bypass and circulatory arrest, which may benefit early patient outcome; however, patient and device selection plays a key role for immediate success and midterm outcomes. In addition, precise procedural planning and development of customized stents may help to develop this procedure into a true alternative for conventional aortic arch replacement.
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