651
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Zhang L, Tian W, Feng R, Song C, Zhao Z, Bao J, Liu A, Su D, Zhou J, Jing Z. Prognostic Impact of Blood Pressure Variability on Aortic Dissection Patients After Endovascular Therapy. Medicine (Baltimore) 2015; 94:e1591. [PMID: 26402822 PMCID: PMC4635762 DOI: 10.1097/md.0000000000001591] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Hypertension has been deemed as a pivotal risk factor for the development of aortic dissection; however, the importance and prognostic significance of blood pressure variability (BPV) in aortic dissection are always ignored. A total of 173 acute type B aortic dissection patients were enrolled in and retrospectively reviewed between January 2009 and November 2013. There were 74 patients with high BPV and 99 with low BPV stratified by preoperative mean BPV. Technical success was achieved in all patients. The proportions of hypertension and general anesthesia were significantly higher in the high BPV group (70.3% vs 55.6% and 77% vs 62.6%, P = 0.049 and 0.043, respectively). The risk of aorta-related death in the high BPV group was apparently higher than the low BPV group (28.4% vs 9.1%, P = 0.001). By performing multivariable logistic regression, we found history of hypertension was likely to be a risk factor of BPV (95% confidence interval [CI]: 1.010-3.911), and high BPV was an independent predictor of aorta-related death (95% CI: 1.671-9.587). The difference of aorta-related mortality was pronounced between high and low BPV subgroups regardless of the refractory hypertension (41.4% vs 14.3% and 20.0% vs 7.0%, P = 0.023 and 0.037, respectively). The thrombosis ratio of false lumen was significantly higher in the low BPV group at 3-month (72.4 ± 17.5% vs 51.8 ± 11.6%, P < 0.001) and 6-month (86.4 ± 9.1% vs 69.7 ± 7.9%, P < 0.001). High BPV is an independent risk factor for the prognosis of aortic dissection. Further studies on BPV might provide new preventive and therapeutic strategies for aortic dissection.
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Affiliation(s)
- Lei Zhang
- From the Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China (LZ, WT, RF, CS, ZZ, JB, ZJ); Department of Pharmacology, Second Military Medical University, Shanghai, China (AL, DS); and Department of Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China (JZ)
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652
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Conrad MF, Carvalho S, Ergul E, Kwolek CJ, Lancaster RT, Patel VI, Cambria RP. Late aortic remodeling persists in the stented segment after endovascular repair of acute complicated type B aortic dissection. J Vasc Surg 2015; 62:600-5. [DOI: 10.1016/j.jvs.2015.03.064] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 03/20/2015] [Indexed: 11/29/2022]
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653
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Pacini D. Re: Repair of complicated type B dissection with an isolated left vertebral artery using the stented elephant trunk technique. Eur J Cardiothorac Surg 2015; 49:782-3. [PMID: 26269511 DOI: 10.1093/ejcts/ezv286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Davide Pacini
- Department of Cardiac Surgery, S Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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654
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Nagpal P, Khandelwal A, Saboo SS, Bathla G, Steigner ML, Rybicki FJ. Modern imaging techniques: applications in the management of acute aortic pathologies. Postgrad Med J 2015; 91:449-62. [DOI: 10.1136/postgradmedj-2014-133178] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 07/07/2015] [Indexed: 12/21/2022]
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655
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Cambria RP, Conrad MF, Matsumoto AH, Fillinger M, Pochettino A, Carvalho S, Patel V, Matsumura J. Multicenter clinical trial of the conformable stent graft for the treatment of acute, complicated type B dissection. J Vasc Surg 2015. [DOI: 10.1016/j.jvs.2015.03.026] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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656
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Iranmanesh S, Ricotta JJ. Current management of acute type B aortic dissection. World J Surg Proced 2015; 5:208-216. [DOI: 10.5412/wjsp.v5.i2.208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 02/23/2015] [Accepted: 04/02/2015] [Indexed: 02/06/2023] Open
Abstract
Acute type B aortic dissection (TBAD) occurs as a result of an intimal tear within the proximal thoracic aorta. Patients are typically managed acutely with aggressive antihypertensive therapy. Surgical repair is reserved for those who develop complications such as rupture or malperfusion. The surgical management of acute TBAD has changed considerably in the last decade secondary to the advent of thoracic stent grafting. Thoracic endovascular aortic repair (TEVAR) has improved early mortality and morbidity rates for patients presenting with complicated TBAD. The role of TEVAR in patients presenting with acute and subacute uncomplicated TBAD is less clear. TEVAR has been associated with increased late survival and better aortic remodeling, with low perioperative morbidity in selected patients. Recent literature suggests certain radiographic criteria may be used to predict patients developing late aortic events who would benefit from early TEVAR. The purpose of this article is to review the contemporary management of acute TBAD, discuss controversies in management and evaluate the latest research findings.
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657
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Lavingia KS, Larion S, Larion S, Ahanchi SS, Ammar CP, Bhasin M, Mirza AK, Dexter DJ, Panneton JM. Volumetric analysis of the initial index computed tomography scan can predict the natural history of acute uncomplicated type B dissections. J Vasc Surg 2015. [PMID: 26210490 DOI: 10.1016/j.jvs.2015.04.449] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Our objective was to characterize the predictive impact of computed tomography (CT) scan volumetric analysis on the natural history of acute uncomplicated type B aortic dissections (ADs). METHODS We conducted a retrospective review of patients with acute type B ADs from 2009 to 2014. On an iNtuition workstation (TeraRecon, Foster City, Calif), volume measurements were obtained using the true lumen volume (TLV), false lumen volume (FLV), and total aortic volume from the left subclavian artery to the celiac artery. Growth rate was calculated as the change in maximal diameter between first and last available CT scans during the time interval. The primary outcome of the study was delayed aortic intervention. P < .05 was considered statistically significant. RESULTS During a 5-year period, 164 patients had CT scan evidence of acute type B ADs; 11 patients were excluded for lack of subsequent follow-up imaging; 36 patients who underwent urgent repair (<14 days from presentation) were also excluded. We evaluated a total of 117 patients: 85 patients who did not require intervention and 32 who underwent delayed (>14 days) thoracic endovascular aneurysm repair (29) or open repair (3). Mean age was 66 ± 12 years. Mean TLV/FLV ratio on initial CT scan was significantly higher in patients who did not eventually require an operation (1.55 vs 0.82; P = .02). The mean growth rate was higher in those eventually requiring operation (2.47 vs 0.42 mm/mo; P = .003). Patients were divided into three subgroups on the basis of their initial imaging TLV/FLV ratios (<0.8, 0.8-1.6, and >1.6). There was a significant difference in the growth rates between these three groups (4.6 vs 2.4 vs 0.8 mm/mo; P < .025). Area under the receiver operating characteristic curve analysis revealed that a TLV/FLV ratio <0.8 was highly predictive for requiring an intervention (area = 0.8; sensitivity, 69%; specificity, 84%: positive predictive value, 71%; negative predictive value, 81%), with an odds ratio of 12.2 (confidence interval, 5-26; P < .001). Conversely, a TLV/FLV ratio of >1.6 was highly predictive for freedom from delayed operation (sensitivity, 91%; specificity, 42%; positive predictive value, 61%; negative predictive value, 86%). After Kaplan-Meier analysis, 1-year and 2-year survival free of aortic interventions was 60% and 42% with a TLV/FLV ratio <0.8 and 92% and 82% with a ratio >1.6 (P = .001). CONCLUSIONS Initial CT scan volumetric analysis in patients presenting with uncomplicated acute type B ADs is a useful tool to predict growth and need for future intervention.
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Affiliation(s)
- Kedar S Lavingia
- Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, Va
| | | | - Sebastion Larion
- Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, Va
| | - Sadaf S Ahanchi
- Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, Va
| | - Chad P Ammar
- Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, Va
| | - Mohit Bhasin
- Division of Cardiology, Eastern Virginia Medical School, Norfolk, Va
| | - Aleem K Mirza
- Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, Va
| | - David J Dexter
- Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, Va
| | - Jean M Panneton
- Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, Va.
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658
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Szeberin Z, Dósa E, Fehérvári M, Csobay-Novák C, Pintér N, Entz L. Early and Long-term Outcome after Open Surgical Suprarenal Aortic Fenestration in Patients with Complicated Acute Type B Aortic Dissection. Eur J Vasc Endovasc Surg 2015; 50:44-50. [DOI: 10.1016/j.ejvs.2014.12.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 12/22/2014] [Indexed: 12/14/2022]
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659
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Meyersohn NM, Ghemigian K, Shapiro MD, Shah SV, Ghoshhajra BB, Ferencik M. Role of Computed Tomography in Assessment of the Thoracic Aorta. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:395. [DOI: 10.1007/s11936-015-0395-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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660
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Maeda K, Kanaoka Y, Ohki T, Sumi M, Toya N, Fujita T. Better Clinical Practice Could Overcome Patient-Related Risk Factors of Vascular Surgical Site Infections. J Endovasc Ther 2015; 22:640-6. [DOI: 10.1177/1526602815591553] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Purpose: To clarify the current status of surgical site infection (SSI) during endovascular aortic repair and to define risk factors for SSI among the patients who underwent thoracic or abdominal stent-graft repair through a groin incision. Methods: Between 2006 and 2013, data were collected from 1604 patients (mean age 75.2±9.5 years; 1282 men) with 2799 groin incisions for transfemoral access during aortic stent-graft procedures. SSIs were classified as superficial or deep (both occurring within 30 days) or organ/space infections (occurring within 1 year after surgery) according to the Centers for Disease Control and Prevention guidelines. Strategies in place for minimizing SSIs were (1) employing oblique groin incisions, (2) covering the incision with saline-soaked gauze, (3) irrigating the incision thoroughly with saline per layer, and (4) using absorbable sutures. Results: Overall incidence of SSI was 0.4% (6 patients). The majority of SSIs were late-onset prosthetic graft infections (5, 0.3%). Five of the 6 were successfully treated with conservative therapy; one patient died of sepsis. Univariate analysis showed additional therapy (eg, coil embolization) with a stent-graft procedure was a risk factor for SSI. Conclusion: Appropriate antibiotic administration, oblique groin incision, meticulous operative technique, protection against airborne infection during the operation, and closed dressings may avert vascular wound SSIs.
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Affiliation(s)
- Koji Maeda
- Division of Vascular Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Yuji Kanaoka
- Division of Vascular Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Makoto Sumi
- Division of Vascular Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Naoki Toya
- Division of Vascular Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Tetsuji Fujita
- Division of Vascular Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
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661
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Huang C, Zhou M, Liu Z, Huang D, Ran F, Wang W, Zhang M, Liu C, Liu C, Qiao T, Liu C. Computed tomography-based study exploring the feasibility of endovascular treatment of type A aortic dissection in the Chinese population. J Endovasc Ther 2015; 21:707-13. [PMID: 25290800 DOI: 10.1583/14-4733mr.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE To characterize type A aortic dissection (TAAD) in the Chinese population using high-resolution computed tomography (CT) and explore potential candidacy for endovascular repair of TAAD. METHODS The imaging studies and medical records of all 302 patients presenting with TAAD at two Chinese hospitals from 2010 to 2013 were reviewed. Of these, 221 patients were excluded because of missing/inadequate preoperative CT scans. The remaining 91 patients (64 men; mean age 51.1±7.5 years) had CT data adequate to assess anatomical suitability for endovascular treatment. Entry tears were identified using multiplanar reconstructions, while morphological measurements were based on a centerline of flow (CLF) technique. Suitability for endovascular treatment was based on a proximal landing zone ≥20 mm long, a true lumen aortic diameter ≤38 mm, and a total aortic diameter ≤46 mm; no coronary bypass grafts originating from the ascending aorta; no malfunctioning aortic valve; and good cerebral and cardiac perfusion. RESULTS In the 91 patients, the precise location of the primary proximal entry tear could be identified in only 34 (37.4%) patients; in these patients, the identifiable intimal tears were located 36.4±41.0 mm distal to the closest coronary artery. The CLF was successfully generated in the CT scans of all patients; the mean lumen and total aortic lumen diameters at the entry tear level were 37.6±6.3 and 44.3±13.3 mm, respectively. Based on the CT measurements, stent-graft repair would have been anatomically feasible in 35 (38.5%) patients. No proximal landing zone (n=23), large aortic diameter (n=15), abnormal aortic valve (n=10), previous coronary bypass graft surgery (n=5), and poor cerebral and cardiac perfusion (n=3) were obstacles that affected the suitability for this treatment. CONCLUSION Based on high-resolution CT scans, our pilot study suggested that 38% of Chinese patients with TAAD could potentially be treated by stent-grafting based on the anatomical characteristics of the proximal dissection.
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Affiliation(s)
- Chen Huang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing, People's Republic of China
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662
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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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663
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Benson RA, Patterson BO, Loftus IM. Diagnosis and management of thoracic aortic dissection: An update. World J Hypertens 2015; 5:79-84. [DOI: 10.5494/wjh.v5.i2.79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 11/11/2014] [Accepted: 02/09/2015] [Indexed: 02/06/2023] Open
Abstract
Acute thoracic aortic dissection is part of the acute aortic syndrome triad. Caused by an intimal tear in the lumen of the aorta, it leads to the creation and propagation of a false lumen. In the acute setting this can lead to malignant hypertension, pain and end organ malperfusion. In the chronic setting it can lead to aneurysm formation and rupture. It remains the most common aortic emergency, affecting up to 4 per 100000 people per year in the United Kingdom and United States. Despite advances in treatment and centralisation of vascular services, it continues to be associated with a high pre-admission and in-hospital mortality. Dissection is classified in several ways according to anatomical extent, timing and underlying pathology, all of which guides clinical management. Traditionally, medical management has been the mainstay of treatment in patients with uncomplicated disease. Surgery has been used in symptomatic patients. With published information now available from several prospective international registries, we are beginning to see the advantages of newer surgical treatment options such as endovascular repair, in the acute setting. This review provides an update on diagnosis and management of aortic dissection, including new information that has become available in recent years.
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664
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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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665
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Bastos Gonçalves F, Verhagen JMH. Commentary on 'Early and Long-term Outcome after Open Surgical Suprarenal Aortic Fenestration in Patients with Complicated Acute Type B Aortic Dissection'. Eur J Vasc Endovasc Surg 2015; 50:51-2. [PMID: 25958810 DOI: 10.1016/j.ejvs.2015.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 04/07/2015] [Indexed: 11/29/2022]
Affiliation(s)
- F Bastos Gonçalves
- Erasmus University Medical Centre, Rotterdam, The Netherlands; Hospital de Santa Marta, CHLC - NOVA University, Lisbon, Portugal.
| | - J M H Verhagen
- Erasmus University Medical Centre, Rotterdam, The Netherlands
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666
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Mani K. Aortic remodeling after TEVAR for type B dissection: time for consensus definition. J Endovasc Ther 2015; 21:526-8. [PMID: 25101580 DOI: 10.1583/13-4646c.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital, Uppsala, Sweden
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667
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The natural history of medically managed acute type B aortic dissection. J Vasc Surg 2015; 61:1192-8. [DOI: 10.1016/j.jvs.2014.12.038] [Citation(s) in RCA: 123] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 12/08/2014] [Indexed: 11/20/2022]
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668
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Wolfschmidt F, Hassold N, Goltz JP, Leyh R, Bley TA, Kickuth R. Aortic Dissection: Accurate Subintimal Flap Fenestration by Using a Reentry Catheter with Fluoroscopic Guidance-Initial Single-Institution Experience. Radiology 2015; 276:862-72. [PMID: 25902186 DOI: 10.1148/radiol.2015140520] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To evaluate the feasibility, effectiveness, and safety of using a commercially available reentry catheter with fluoroscopic guidance to gain controlled target lumen reentry for fenestration in patients with aortic dissection. MATERIALS AND METHODS This retrospective study was approved by the local institutional review board; informed consent was waived. Between April 2009 and December 2013, 13 consecutive patients (10 men and three women; mean age, 51.2 years; range, 30.0-77.0 years; mean age of women, 47.0 years; range, 30.0-69.0 years; mean age of men, 52.4 years; range, 35.0-77.0 years) with aortic dissection and spinal (n = 4), renal (n = 7), mesenteric (n = 2), and/or iliofemoral (n = 9) malperfusion syndrome were included. All patients received target lumen reentry by means of balloon fenestration of the aortic dissection flap. A reentry catheter was used for fluoroscopically guided puncture of the target lumen. Technical success, clinical outcome, Stanford type of dissection, procedure time, number of fenestrations of the intimal flap per patient, necessity of additional aortic stent-graft implantation and/or placement of a bare metal stent, complications, and follow-up images were evaluated. Pre- and postinterventional systolic blood pressure gradients between the true lumen and the false lumen were compared (Wilcoxon signed-rank test). Safety of the reentry catheter maneuver was estimated with the Clopper-Pearson method. RESULTS Use of the reentry catheter was technically successful in all 13 (100%) patients and clinically successful in 10 of 13 (77%) patients. Four patients had type A and nine had type B dissection. The mean clinical follow-up period was 14.2 months. Median procedure time was 71 minutes. In four patients, fenestration of the intimal flap was performed twice. Three patients underwent additional aortic stent grafting, four patients underwent placement of an iliofemoral stent, and one patient underwent placement of a carotid artery stent. Blood pressure gradients between the true lumen and the false lumen were significantly reduced (P = .0313). One patient who had a combination of syndromes died of multiorgan failure. CONCLUSION The applied commercially available reentry catheter seems to be a reliable and safe tool that may be useful for gaining target lumen reentry with reasonably good clinical outcomes.
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Affiliation(s)
- Franziska Wolfschmidt
- From the Department of Diagnostic and Interventional Radiology (F.W., N.H., T.A.B., R.K.) and Department of Cardiothoracic and Thoracic Vascular Surgery (R.L.), University Hospital of Wuerzburg, Oberduerrbacherstr 6, D-97070 Wuerzburg, Germany; and Clinic for Radiology and Nuclear Medicine, Luebeck, Germany (J.P.G.)
| | - Nicole Hassold
- From the Department of Diagnostic and Interventional Radiology (F.W., N.H., T.A.B., R.K.) and Department of Cardiothoracic and Thoracic Vascular Surgery (R.L.), University Hospital of Wuerzburg, Oberduerrbacherstr 6, D-97070 Wuerzburg, Germany; and Clinic for Radiology and Nuclear Medicine, Luebeck, Germany (J.P.G.)
| | - Jan Peter Goltz
- From the Department of Diagnostic and Interventional Radiology (F.W., N.H., T.A.B., R.K.) and Department of Cardiothoracic and Thoracic Vascular Surgery (R.L.), University Hospital of Wuerzburg, Oberduerrbacherstr 6, D-97070 Wuerzburg, Germany; and Clinic for Radiology and Nuclear Medicine, Luebeck, Germany (J.P.G.)
| | - Rainer Leyh
- From the Department of Diagnostic and Interventional Radiology (F.W., N.H., T.A.B., R.K.) and Department of Cardiothoracic and Thoracic Vascular Surgery (R.L.), University Hospital of Wuerzburg, Oberduerrbacherstr 6, D-97070 Wuerzburg, Germany; and Clinic for Radiology and Nuclear Medicine, Luebeck, Germany (J.P.G.)
| | - Thorsten Alexander Bley
- From the Department of Diagnostic and Interventional Radiology (F.W., N.H., T.A.B., R.K.) and Department of Cardiothoracic and Thoracic Vascular Surgery (R.L.), University Hospital of Wuerzburg, Oberduerrbacherstr 6, D-97070 Wuerzburg, Germany; and Clinic for Radiology and Nuclear Medicine, Luebeck, Germany (J.P.G.)
| | - Ralph Kickuth
- From the Department of Diagnostic and Interventional Radiology (F.W., N.H., T.A.B., R.K.) and Department of Cardiothoracic and Thoracic Vascular Surgery (R.L.), University Hospital of Wuerzburg, Oberduerrbacherstr 6, D-97070 Wuerzburg, Germany; and Clinic for Radiology and Nuclear Medicine, Luebeck, Germany (J.P.G.)
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669
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Management of aortic dissection: medical therapy and intervention. Is there a growing role for endovascular techniques? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:386. [PMID: 25895739 DOI: 10.1007/s11936-015-0386-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OPINION STATEMENT Historically, type B aortic dissection was managed as a medical condition with limited surgical intervention unless aortic rupture occurred. Today, however, evidence is building that highlights the importance of strict medical management, timely surveillance, and windows of opportunity for surgical intervention to address both early and late aortic-based morbidities.
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670
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Duarte JJ. Is clinical treatment the gold standard in the treatment of acute type B aortic dissections? Braz J Cardiovasc Surg 2015; 30:127-8. [PMID: 25859877 PMCID: PMC4389515 DOI: 10.5935/1678-9741.20150002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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671
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The Role of Branch Vessels in Aortic Type B Dissection: An in vitro Study. Eur J Vasc Endovasc Surg 2015; 49:375-81. [DOI: 10.1016/j.ejvs.2014.12.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Accepted: 12/15/2014] [Indexed: 11/22/2022]
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672
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Shrestha M, Bachet J, Bavaria J, Carrel TP, De Paulis R, Di Bartolomeo R, Etz CD, Grabenwöger M, Grimm M, Haverich A, Jakob H, Martens A, Mestres CA, Pacini D, Resch T, Schepens M, Urbanski PP, Czerny M. Current status and recommendations for use of the frozen elephant trunk technique: a position paper by the Vascular Domain of EACTS. Eur J Cardiothorac Surg 2015; 47:759-69. [DOI: 10.1093/ejcts/ezv085] [Citation(s) in RCA: 211] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 02/02/2015] [Indexed: 01/05/2023] Open
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673
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Estrera AL, Sandhu HK, Leake SS, Charlton-Ouw KM, Afifi RO, Miller CC, Safi HJ. Reprint of: Early and late outcomes of acute type A aortic dissection with intramural hematoma. J Thorac Cardiovasc Surg 2015; 149:S110-5. [PMID: 25726071 DOI: 10.1016/j.jtcvs.2014.12.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 09/18/2014] [Accepted: 10/05/2014] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Controversy remains regarding management of acute type A dissection with intramural hematoma (IMH). Our purpose was to analyze our experience and report outcomes after repair of acute type A aortic dissection with IMH. METHODS We analyzed all patients from a single center who underwent open repair for acute type A aortic dissection with IMH. RESULTS Between 2000 and 2013, we performed 418 repairs for acute type A aortic dissection. These were divided into 2 groups of patients: 64 patients (15%) with type A IMH and 354 patients (85%) with typical dissection. Those with IMH were older (62.4 ± 13.9 years vs 56.7 ± 14.7 years; P < .0046) and presented with reduced renal function (ie, glomerular filtration rate) (P < .0341), less frequently with distal malperfusion, and less frequently with rupture (P < .0116). With IMH, the time from presentation to repair was, by strategy, longer (median, 67 vs 6 hours; P < .0001), but no mortality occurred within 3 days of presentation. Mortality with IMH did not differ from typical dissection: 7 out of 64 patients (10.9%) versus 52 out of 354 patients (14.7%; P = .4276). A lower incidence of postoperative dialysis in the IMH group approached significance: 6 out of 63 patients (9.5%) versus 64 out of 347 patients (18.4%; P = .0820). When adjusted for age and renal function, late survival was improved with IMH (P < .0343). CONCLUSIONS Repair of acute type A aortic dissection with IMH is associated with significant early morbidity and mortality, differing minimally from typical aortic dissection. Although expectant repair within 3 days may be applied, the purposeful delay imparted little advantage. Improved late outcomes may be seen with IMH, but continued long-term surveillance is required for verification.
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Affiliation(s)
- Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, Clinical Science Program, The University of Texas Medical School at Houston, and Memorial Hermann Hospital, Houston, Tex.
| | - Harleen K Sandhu
- Department of Cardiothoracic and Vascular Surgery, Clinical Science Program, The University of Texas Medical School at Houston, and Memorial Hermann Hospital, Houston, Tex
| | - Samuel S Leake
- Department of Cardiothoracic and Vascular Surgery, Clinical Science Program, The University of Texas Medical School at Houston, and Memorial Hermann Hospital, Houston, Tex
| | - Kristofer M Charlton-Ouw
- Department of Cardiothoracic and Vascular Surgery, Clinical Science Program, The University of Texas Medical School at Houston, and Memorial Hermann Hospital, Houston, Tex
| | - Rana O Afifi
- Department of Cardiothoracic and Vascular Surgery, Clinical Science Program, The University of Texas Medical School at Houston, and Memorial Hermann Hospital, Houston, Tex
| | - Charles C Miller
- Department of Cardiothoracic and Vascular Surgery, Clinical Science Program, The University of Texas Medical School at Houston, and Memorial Hermann Hospital, Houston, Tex
| | - Hazim J Safi
- Department of Cardiothoracic and Vascular Surgery, Clinical Science Program, The University of Texas Medical School at Houston, and Memorial Hermann Hospital, Houston, Tex
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674
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Estrera AL, Jan A, Sandhu H, Shalhub S, Medina-Castro M, Nguyen TC, Azizzadeh A, Charlton-Ouw K, Miller CC, Safi HJ. Outcomes of Open Repair for Chronic Descending Thoracic Aortic Dissection. Ann Thorac Surg 2015; 99:786-93; discussion 794. [DOI: 10.1016/j.athoracsur.2014.08.077] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 07/23/2014] [Accepted: 08/15/2014] [Indexed: 11/30/2022]
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675
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Abstract
A new appraisal of the management of acute aortic dissection is timely because of recent developments in diagnostic strategies (including biomarkers and imaging), endograft design, and surgical treatment, which have led to a better understanding of the epidemiology, risk factors, and molecular nature of aortic dissection. Although open surgery is the main treatment for proximal aortic repair, use of endovascular management is now established for complicated distal dissection and distal arch repair, and has recently been discussed as a pre-emptive measure to avoid late complications by inducing aortic remodelling.
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Affiliation(s)
| | - Rachel E Clough
- King's College London, Cardiovascular Imaging Department, Lambeth Wing St Thomas, London, UK
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676
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Goldfinger JZ, Halperin JL, Marin ML, Stewart AS, Eagle KA, Fuster V. Thoracic aortic aneurysm and dissection. J Am Coll Cardiol 2015; 64:1725-39. [PMID: 25323262 DOI: 10.1016/j.jacc.2014.08.025] [Citation(s) in RCA: 230] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 08/26/2014] [Accepted: 08/26/2014] [Indexed: 11/27/2022]
Abstract
Aortic dissection is the most devastating complication of thoracic aortic disease. In the more than 250 years since thoracic aortic dissection was first described, much has been learned about diseases of the thoracic aorta. In this review, we describe normal thoracic aortic size; risk factors for dissection, including genetic and inflammatory conditions; the underpinnings of genetic diseases associated with aneurysm and dissection, including Marfan syndrome and the role of transforming growth factor beta signaling; data on the role for medical therapies in aneurysmal disease, including beta-blockers, angiotensin receptor blockers, and angiotensin-converting enzyme inhibitors; prophylactic surgery for aneurysm; surgical techniques for the aortic root; and surgical and endovascular management of aneurysm and dissection for different aortic segments.
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Affiliation(s)
- Judith Z Goldfinger
- Department of Medicine, Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jonathan L Halperin
- Department of Medicine, Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael L Marin
- Department of Surgery, Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Allan S Stewart
- Department of Cardiothoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kim A Eagle
- Department of Medicine, Samuel and Jean A. Frankel Cardiovascular Center, University of Michigan Health System and Medical School, Ann Arbor, Michigan
| | - Valentin Fuster
- Department of Medicine, Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York.
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677
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van Bogerijen GHW, Patel HJ, Williams DM, Yang B, Dasika NL, Eliason JL, Deeb GM. Propensity adjusted analysis of open and endovascular thoracic aortic repair for chronic type B dissection: a twenty-year evaluation. Ann Thorac Surg 2015; 99:1260-6. [PMID: 25686670 DOI: 10.1016/j.athoracsur.2014.11.037] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 11/04/2014] [Accepted: 11/17/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Optimal treatment of chronic type B aortic dissection (CBAD), whether open (open descending aortic repair, OAR) or endovascular (thoracic endovascular aortic repair, TEVAR), is controversial, suggesting a comparative analysis is warranted. METHODS One hundred twenty-two of 1,049 patients (1993 to 2013) undergoing descending aortic repair required intervention for CBAD 29.2 ± 34.9 months after the initial acute event and formed the study cohort (mean age 59.7 years). Those with degenerated residual type A dissection were excluded (n = 65). Eighty-eight had extent IIIB CBAD; 11 had intramural hematoma. Indications for surgery included aneurysmal degeneration (n = 105), rupture (n = 8), acute or chronic dissection (n = 8), and extension of dissection (n = 1). Open strategy included descending (n = 71) and thoracoabdominal repair (n = 19), with hypothermic circulatory arrest used in 70 patients. The TEVAR was performed with (n = 2) or without (n = 30) visceral debranching. A treatment strategy propensity score incorporating time since initial acute event, CBAD extent, year of intervention, age, and selected comorbidities was constructed for multivariable analysis. RESULTS Early outcome included the following: 30-day mortality 4% (n = 5); stroke 2% (n = 2); permanent paraplegia 3% (n = 4); renal failure requiring dialysis 7% (n = 8, 5 temporary and 3 permanent); and tracheostomy 3% (n = 4). Visceral aorta intervention (odds ratio [OR] 3.5, p = 0.026) and maximum aortic diameter (OR 1.1, p = 0.001) but not treatment type (p = 0.64) independently predicted an early composite outcome comprised of these variables. Ten-year survival was 56.2%. Baseline creatinine (hazard ratio [HR] 1.7, p < 0.001) and peripheral vascular disease (HR 2.5, p = 0.021), but not treatment type (p = 0.225) predicted late mortality. Ten-year freedom from aortic rupture or need for reintervention was 78.3%. Treatment efficacy was improved after OAR (3-year freedom 96.7% vs TEVAR 87.5%, p = 0.026), and this was confirmed after Cox regression (TEVAR, HR 4.6, p = 0.046). CONCLUSIONS Intervention for CBAD can be performed with excellent results, either by an open or endovascular approach. The higher rate of treatment failure after TEVAR warrants modification of current device design or endovascular approach before broad application of this treatment strategy.
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Affiliation(s)
- Guido H W van Bogerijen
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan.
| | - David M Williams
- Department of Radiology, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Bo Yang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Narasimham L Dasika
- Department of Radiology, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Jonathan L Eliason
- Department of Vascular Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - G Michael Deeb
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
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678
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679
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Desai ND, Gottret JP, Szeto WY, McCarthy F, Moeller P, Menon R, Jackson B, Vallabhajosyula P, Wang GJ, Fairman R, Bavaria JE. Impact of timing on major complications after thoracic endovascular aortic repair for acute type B aortic dissection. J Thorac Cardiovasc Surg 2015; 149:S151-6. [DOI: 10.1016/j.jtcvs.2014.10.105] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 10/22/2014] [Accepted: 10/26/2014] [Indexed: 10/24/2022]
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680
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Thoracic endovascular aortic repair versus open surgery for type-B chronic dissection. J Thorac Cardiovasc Surg 2015; 149:S163-7. [DOI: 10.1016/j.jtcvs.2014.11.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Revised: 10/29/2014] [Accepted: 11/07/2014] [Indexed: 11/15/2022]
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681
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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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682
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Cleveland JC, Reece TB. Noteworthy literature in cardiac surgery for 2014. Semin Cardiothorac Vasc Anesth 2015; 19:21-3. [PMID: 25634929 DOI: 10.1177/1089253214568531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Year 2014 has provided insight into the optimal care of surgical patients with cardiovascular disease. In mitral disease, the management of degenerative mitral regurgitation and ischemic mitral insufficiency are moving in the opposite directions. In aortic disease, the description of arch procedures is becoming more definable for comparisons across approaches, while the treatment of acute type B dissections is becoming more aggressive, yet deliberate.
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683
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Kitamura T, Torii S, Oka N, Horai T, Itatani K, Yoshii T, Nakamura Y, Shibata M, Tamura T, Araki H, Matsunaga Y, Sato H, Miyaji K. Impact of the entry site on late outcome in acute Stanford type B aortic dissection. Eur J Cardiothorac Surg 2015; 48:655-61; discussion 661-2. [DOI: 10.1093/ejcts/ezu531] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 12/05/2014] [Indexed: 11/13/2022] Open
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684
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Sakalihasan N, Nienaber CA, Hustinx R, Lovinfosse P, El Hachemi M, Cheramy-Bien JP, Seidel L, Lavigne JP, Quaniers J, Kerstenne MA, Courtois A, Ooms A, Albert A, Defraigne JO, Michel JB. (Tissue PET) Vascular metabolic imaging and peripheral plasma biomarkers in the evolution of chronic aortic dissections. ACTA ACUST UNITED AC 2015; 16:626-33. [DOI: 10.1093/ehjci/jeu283] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 11/11/2014] [Indexed: 11/14/2022]
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685
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Mousa AY, Abu-Halimah S, Gill G, Yacoub M, Stone P, Hass S, Campbell JE, AbuRahma AF. Current Treatment Strategies for Acute Type B Aortic Dissection. Vasc Endovascular Surg 2015; 49:30-6. [PMID: 25571896 DOI: 10.1177/1538574414564580] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Acute type B aortic dissection (ATBAD) is a medical emergency that is a common occurrence in patients with atherosclerotic disease. The presentation is usually severe, with tearing pain that radiates to the back, and various levels of end-organ ischemia and malperfusion, even rupture, may occur. Everyone agrees that prompt and aggressive blood pressure control with β-blockers and nitroprusside is imperative, but when to surgically intervene is still not well characterized. However, the advent of minimally invasive stent graft placement has reshaped our thoughts regarding therapeutic intervention for ATBAD. This review is an attempt to define the current surgical indications for treating ATBAD.
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Affiliation(s)
- Albeir Y. Mousa
- Department of Vascular Surgery, West Virginia University/CAMC, Charleston, WV, USA
| | - Shadi Abu-Halimah
- Department of Vascular Surgery, West Virginia University/CAMC, Charleston, WV, USA
| | - Gurpreet Gill
- Department of Vascular Surgery, West Virginia University/CAMC, Charleston, WV, USA
| | - Michael Yacoub
- Department of Vascular Surgery, West Virginia University/CAMC, Charleston, WV, USA
| | - Patrick Stone
- Department of Vascular Surgery, West Virginia University/CAMC, Charleston, WV, USA
| | - Stephen Hass
- Department of Vascular Surgery, West Virginia University/CAMC, Charleston, WV, USA
| | - John E. Campbell
- Department of Vascular Surgery, West Virginia University/CAMC, Charleston, WV, USA
| | - Ali F. AbuRahma
- Department of Surgery, R. C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA
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686
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Early and late outcomes of acute type A aortic dissection with intramural hematoma. J Thorac Cardiovasc Surg 2015; 149:137-42. [DOI: 10.1016/j.jtcvs.2014.10.028] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 09/18/2014] [Accepted: 10/05/2014] [Indexed: 11/21/2022]
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687
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Moñux Ducajú G, Serrano Hernando F. Disección de aorta tipo B no complicada: ¿debe ser todavía el tratamiento médico la mejor opción? Sí, el tratamiento conservador es la mejor opción. ANGIOLOGIA 2015. [DOI: 10.1016/j.angio.2014.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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688
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Disección de aorta tipo B: ¿debe ser todavía el tratamiento médico la mejor opción? No, el tratamiento endovascular puede ser la mejor opción. ANGIOLOGIA 2015. [DOI: 10.1016/j.angio.2014.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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689
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Patterson BO, Vidal-Diez A, Karthikesalingam A, Holt PJ, Loftus IM, Thompson MM. Comparison of Aortic Diameter and Area After Endovascular Treatment of Aortic Dissection. Ann Thorac Surg 2015; 99:95-102. [DOI: 10.1016/j.athoracsur.2014.08.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Revised: 07/30/2014] [Accepted: 08/06/2014] [Indexed: 10/24/2022]
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690
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Coil Embolization of the False Lumen in Complicated Type B Aortic Dissection. Ann Vasc Surg 2015; 29:125.e13-7. [DOI: 10.1016/j.avsg.2014.07.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 06/29/2014] [Accepted: 07/26/2014] [Indexed: 11/23/2022]
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691
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692
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Khoynezhad A. Timing in life is everything. J Thorac Cardiovasc Surg 2014; 149:S156-7. [PMID: 25483900 DOI: 10.1016/j.jtcvs.2014.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 11/04/2014] [Indexed: 11/17/2022]
Affiliation(s)
- Ali Khoynezhad
- Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif.
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693
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Luebke T, Brunkwall J. Type B Aortic Dissection: A Review of Prognostic Factors and Meta-analysis of Treatment Options. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2014; 2:265-78. [PMID: 26798745 DOI: 10.12945/j.aorta.2014.14-040] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 11/07/2014] [Indexed: 01/29/2023]
Abstract
According to international guidelines, stable patients with uncomplicated Type B aortic dissection (TBAD) should receive optimal medical treatment. Despite adequate antihypertensive therapy, the long-term prognosis of these patients is characterized by a significant aortic aneurysm formation in 25-30% within four years, and survival rates from 50 to 80% at five years and 30 to 60% at 10 years. In a prospective randomized trial, preemptive thoracic endovascular aortic repair (TEVAR) in patients with chronic uncomplicated TBAD was associated with an excess early mortality (due to periprocedural hazards), but the procedure showed its benefit in prevention of aortic-specific mortality at five years of follow-up. However, preemptive TEVAR may not be the treatment of choice in all patients with uncomplicated TBAD because of the inherent periprocedural complications like stroke, paraparesis, and death, as well as stent graft-induced complications (i.e., retrograde dissection or endoleaks). Thus, the TEVAR-related deaths and complications (especially paraplegia and stroke) raise concerns that moderate the better survival with TEVAR at five years. By timely identification of those patients prone for developing complications, early intervention, preferably in the subacute or early chronic phase, may improve the overall long-term outcome for these patients. Therefore, early detectable and reliable prognostic factors for adverse events are essential to stratify patients who can be treated medically and those who will benefit from rigorous follow-up and, in the long-term, from timely, or even prophylactic, TEVAR. Several studies have identified prognostic factors in TBAD such as aortic diameter, partial false lumen thrombosis, false lumen thickness, and location of the primary entry tear. Combining these clinical and radiological predictors may be essential to implement a patient-specific approach designed to intervene only in those patients who are at high risk of developing complications to improve the long-term outcomes of patients with uncomplicated Type B aortic dissection.
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Affiliation(s)
- Thomas Luebke
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Germany
| | - Jan Brunkwall
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Germany
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694
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van Bogerijen GHW, Auricchio F, Conti M, Lefieux A, Reali A, Veneziani A, Tolenaar JL, Moll FL, Rampoldi V, Trimarchi S. Aortic Hemodynamics After Thoracic Endovascular Aortic Repair, With Particular Attention to the Bird-Beak Configuration. J Endovasc Ther 2014; 21:791-802. [DOI: 10.1583/14-4778mr.1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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695
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Zhang L, Zhou J, Lu Q, Zhao Z, Bao J, Jing Z. Potential risk factors of re-intervention after endovascular repair for type B aortic dissections. Catheter Cardiovasc Interv 2014; 86:E1-E10. [PMID: 25382066 DOI: 10.1002/ccd.25733] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 11/02/2014] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To assess the potential risk factors of re-intervention after thoracic endovascular aortic repair (TEVAR). BACKGROUND TEVAR has been chosen as a less invasive alternative for Type B aortic dissections (TBADs); however, the potential risk factors of re-intervention remain unclear. METHODS A total of 252 TBADs patients initially treated with TEVAR between September 1998 and July 2012 were retrospectively reviewed. The indications for the initial TEVAR were 32 aorta enlargement (24 chronic), 71 malperfusion, 46 rupture (32 chronic), 67 refractory pain (54 chronic), and 44 refractory hypertension (38 chronic). The patients were stratified into single-intervention group and multi-intervention group. RESULTS The mean age was 54.1 years with 81.7% of male. We found the time from symptom onset to TEVAR was longer in multi-intervention group (17 vs. 112.5 days, P = 0.006). Higher proportions of chronic dissection and smoking occurred in multi-intervention group (53.9% vs. 79.2% and 43.9% vs. 70.8%, P = 0.018 and 0.012, respectively). The differences of oversizing, operation time, contrast medium dose, and blood loss between the groups were significant (13.8 ± 2.4% vs. 16.4 ± 2.9%, 92.5 vs. 196 minutes, 110 vs. 210 ml, 100 vs. 300 ml; P < 0.001, <0.001, =0.002, and =0.003, respectively). The mortality within 30 days was 2.4% and the rates of stoke, paraplegia and retrograde dissection were 3.6%, 5.6% and 0.8%, respectively. The most common reasons of re-intervention were endoleaks, new dissections and incomplete thrombosis of the false lumen. CONCLUSIONS we concluded that chronic phase, smoking and too big oversizing were potential risk factors of re-intervention.
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Affiliation(s)
- Lei Zhang
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jian Zhou
- Department of Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Qingsheng Lu
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhiqing Zhao
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Junmin Bao
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zaiping Jing
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
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696
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Czerny M, Reser D, Eggebrecht H, Janata K, Sodeck G, Etz C, Luehr M, Verzini F, Loschi D, Chiesa R, Melissano G, Kahlberg A, Amabile P, Harringer W, Janosi RA, Erbel R, Schmidli J, Tozzi P, Okita Y, Canaud L, Khoynezhad A, Maritati G, Cao P, Kölbel T, Trimarchi S. Aorto-bronchial and aorto-pulmonary fistulation after thoracic endovascular aortic repair: an analysis from the European Registry of Endovascular Aortic Repair Complications. Eur J Cardiothorac Surg 2014; 48:252-7. [DOI: 10.1093/ejcts/ezu443] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 10/16/2014] [Indexed: 12/11/2022] Open
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697
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Sueyoshi E, Onitsuka H, Nagayama H, Sakamoto I, Uetani M. Endovascular repair of aortic dissection and intramural hematoma: indications and serial changes. SPRINGERPLUS 2014; 3:670. [PMID: 25512883 PMCID: PMC4252497 DOI: 10.1186/2193-1801-3-670] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 10/24/2014] [Indexed: 01/22/2023]
Abstract
Thoracic aortic dissection (AD) is one of the most common aortic emergencies. It can be fatal if not promptly diagnosed and treated. Intramural hematoma (IMH) of the aorta is recognized as distinct from classic (double-barreled) AD. IMH also frequently leads to aortic emergency, which can be fatal unless rapidly diagnosed and treated. Recently, thoracic endovascular aortic repair (TEVAR) has been used for the treatment of complications caused by AD. TEVAR is also a viable option for the treatment of complicated IHM. In this article, we review the details of TEVAR as treatment options for AD and IMH, including the indications for TEVAR, imaging, and follow-up.
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Affiliation(s)
- Eijun Sueyoshi
- Department of Radiology, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki, 852-8501 Japan
| | - Hironori Onitsuka
- Department of Radiology, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki, 852-8501 Japan
| | - Hiroki Nagayama
- Department of Radiology, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki, 852-8501 Japan
| | - Ichiro Sakamoto
- Department of Radiology, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki, 852-8501 Japan
| | - Masataka Uetani
- Department of Radiology, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki, 852-8501 Japan
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698
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Duarte JJ, Pontes JCDV, Benfatti RA, Ferrachini AL, Karakhanian WK, Razuk Filho A. Indication of endovascular treatment of type B aortic dissection--literature review. Braz J Cardiovasc Surg 2014; 29:396-401. [PMID: 25372915 PMCID: PMC4412331 DOI: 10.5935/1678-9741.20140076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 05/26/2014] [Indexed: 11/20/2022] Open
Abstract
Aortic dissection is a cardiovascular event of high mortality if not early diagnosed
and properly treated. In Stanford type A aortic dissection, there is the involvement
of the ascending aorta, whereas in type B the ascending aorta is not affected. The
treatment of type A aortic dissection is mainly surgical. The hospital mortality of
type B aortic dissection surgical treatment is approximately 20%, while medical
therapy is 10%. However, half the patients who are discharged from hospital after
medical treatment, progress to aortic complications in the following years, and the
mortality in three to five years may reach 25-50%. In addition, the surgical
treatment of aortic complications after medical treatment, has also a significant
mortality. This way, the endovascular treatment comes up as an interesting
alternative of a less invasive treatment for this disease. They presented a mortality
rate lower than 10% with more than 80% success rate of occlusion and thrombosis of
the false lumen. The INSTEAD TRIAL, which randomized patients with uncomplicated type
B aortic dissection for optimal medical therapy and endovascular treatment in
addition to optimal medical therapy, showed that after three years of follow up,
patients who underwent endovascular treatment had lower mortality and aorta-related
complications. Therefore, there is a current tendency to recommend the endovascular
treatment as a standard for the treatment of type B aortic dissection
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Affiliation(s)
| | | | | | | | | | - Alvaro Razuk Filho
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brazil
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699
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Grommes J, Greiner A, Bendermacher B, Erlmeier M, Frech A, Belau P, Kennes LN, Fraedrich G, Schurink GW, Jacobs MJ, Klocker J. Risk factors for mortality and failure of conservative treatment after aortic type B dissection. J Thorac Cardiovasc Surg 2014; 148:2155-2160.e1. [DOI: 10.1016/j.jtcvs.2014.03.053] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 03/25/2014] [Accepted: 03/28/2014] [Indexed: 10/25/2022]
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700
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Schaffer JM, Lingala B, Miller DC, Woo YJ, Mitchell RS, Dake MD. Midterm survival after thoracic endovascular aortic repair in more than 10,000 Medicare patients. J Thorac Cardiovasc Surg 2014; 149:808-20; discussion 820-3. [PMID: 25541408 DOI: 10.1016/j.jtcvs.2014.10.036] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 09/10/2014] [Accepted: 10/04/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Aneurysms and dissections of the descending thoracic aorta represent a complex substrate with a variety of therapeutic options. The introduction of thoracic endovascular aortic repair (TEVAR) has revolutionized the treatment of thoracic aortic disease. However, longitudinal analyses of post-TEVAR outcomes appropriately stratified by aortic disease remain limited. METHODS A total of 11,996 patients undergoing TEVAR from 2005-2010 were identified from the Medicare/Centers for Medicare and Medicaid Services database. Patients were stratified by underlying aortic disease and the presence of Current Procedural Terminology (CPT) codes. Survival was assessed using Kaplan-Meier analysis. Cox proportional hazards analysis determined predictors of survival from TEVAR. RESULTS After TEVAR, patients had a median survival of 57.6 months (95% confidence interval, 54.9-61.3 months). Although patients without CPT codes had significantly fewer recorded comorbidities, TEVAR survival was comparable between patients with and without CPT codes (56.3 vs 59.5 months, P = .54). The early and late incidence of death varied significantly by aortic disease. Patients with aortic rupture, acute aortic dissection, and aortic trauma had the highest early incidence of death, whereas late survival was highest in patients with acute aortic dissection, aortic trauma, and isolated thoracic aortic aneurysm. Although hospital TEVAR volume was not associated with survival, an independent hospital effect (determined by using a mixed-effect Cox model) associated certain hospitals with a hazard for death 50% of what it was at other hospitals. CONCLUSIONS TEVAR has been applied to a multitude of aortic diseases in the Medicare population; early and late post-TEVAR survival varies by aortic disease. The late incidence of death remains high in TEVAR recipients, although certain aortic diagnoses such as acute aortic dissection, aortic trauma, and isolated thoracic aortic aneurysm were associated with improved late survival. An independent hospital effect, but not hospital volume, is correlated with post-TEVAR survival. Future analyses of TEVAR outcomes using the Medicare database should adjust for underlying aortic diagnoses and the presence of CPT codes.
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Affiliation(s)
- Justin M Schaffer
- Department of Cardiothoracic Surgery, Stanford Hospital and Clinics, Stanford, Calif
| | - Bharathi Lingala
- Department of Cardiothoracic Surgery, Stanford Hospital and Clinics, Stanford, Calif
| | - D Craig Miller
- Department of Cardiothoracic Surgery, Stanford Hospital and Clinics, Stanford, Calif
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford Hospital and Clinics, Stanford, Calif
| | - R Scott Mitchell
- Department of Cardiothoracic Surgery, Stanford Hospital and Clinics, Stanford, Calif
| | - Michael D Dake
- Department of Cardiothoracic Surgery, Stanford Hospital and Clinics, Stanford, Calif.
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