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Appoo JJ, Herget EJ, Pozeg ZI, Ferris MC, Wong JK, Gregory AJ, Gupta AK, Merchant N, Kent WDT. Midterm results of endovascular stent grafts in the proximal aortic arch (zone 0): an imaging perspective. Can J Cardiol 2014; 31:731-7. [PMID: 25882336 DOI: 10.1016/j.cjca.2014.12.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 12/12/2014] [Accepted: 12/12/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Endovascular options to repair the arch and ascending aorta are rapidly evolving. Little is known about the durability of endovascular devices deployed at this location. This report describes a single-centre experience with the novel application of thoracic endovascular aortic repair (TEVAR) by examining clinical and radiological outcomes. METHODS A retrospective review was performed for a cohort of patients undergoing TEVAR of the arch or ascending aorta, or both, at a single centre from November 2008-July 2012. RESULTS Sixteen patients were included in the study, with mean imaging follow-up of 38 months (range, 15-72 months). Two complications at the proximal landing zone in the ascending aorta were identified: 1 endoleak and 1 infolding identified at 3 and 24 months postoperatively, respectively. Clinically, both these complications were attributed to the bird-beak configuration at the proximal landing zone site. At up to 72 months of follow-up, there were no cases of retrograde dissection of the native sinus of Valsalva. There were no cases of stent graft migration, graft fracture, open surgical reintervention for aortic pathologic conditions, or late mortality. CONCLUSIONS Early outcomes suggest that the current generation of thoracic aortic endografts can be placed in the complex anatomy of the ascending aorta and aortic arch without a high incidence of early graft fracture or migration. Future endeavors will need to focus on techniques to achieve optimal apposition with the curves of the ascending aorta. These findings are important as indications for endovascular aortic therapies expand to address proximal aortic pathologic conditions.
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Affiliation(s)
- Jehangir J Appoo
- Division of Cardiac Surgery, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada.
| | - Eric J Herget
- Department of Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Zlatko I Pozeg
- Division of Cardiac Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mollie C Ferris
- Department of Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Jason K Wong
- Department of Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Alex J Gregory
- Department of Anaesthesia, University of Calgary, Calgary, Alberta, Canada
| | - Arjun K Gupta
- Division of Cardiac Surgery, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Naeem Merchant
- Department of Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - William D T Kent
- Division of Cardiac Surgery, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
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52
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Early outcomes of extra-thoracic debranching thoracic endovascular aortic repair for distal aortic arch disease. J Artif Organs 2014; 17:236-42. [DOI: 10.1007/s10047-014-0774-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 05/19/2014] [Indexed: 10/25/2022]
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53
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Chiesa R, Bertoglio L, Rinaldi E, Tshomba Y. Hybrid repair of aortic arch pathology. Multimed Man Cardiothorac Surg 2014; 2014:mmu003. [PMID: 24876520 DOI: 10.1093/mmcts/mmu003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The objective was to evaluate a 13-year single-centre experience of arch endovascular aortic repair using the hybrid approach. Between 1999 and 2013, 491 patients were treated with endografts for thoracic aortic pathologies. The aortic arch was involved in 179 (36.5%) patients (128 men; mean age 70.2 ± 10.8 years, range 27-84). A hybrid approach was performed for all Zone 0 and 1 procedures and in nearly half of Zone 2 procedures. Early and mid-term outcomes were reviewed retrospectively. Overall primary technical success (24 h) was achieved in 162 (90.5%) of the 179 cases; 2 deaths and 15 Type 1 endoleaks were observed. Clinical success at 30 days was achieved in 161 (89.9%) of the 179 patients, with a mortality rate of 4.5% (8/179). Short-term clinical success at 6 months was achieved in 169 (94.4%) of the 179 patients; the rates for the different landing zones did not differ significantly. At a mean follow-up of 27.3 ± 15.7 months (range 1-94), the mid-term clinical success was 165 (92.2%) of the 179 patients; the rates among the different proximal zones did not differ significantly. In selected patients, early and mid-term outcomes of arch endovascular aortic repair using the hybrid approach are promising; however, mortality and morbidity are not negligible. Our results may have practical implications for the ongoing evaluation of the hybrid procedure in the aortic arch, as well as for patients fit for traditional surgery.
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Affiliation(s)
- Roberto Chiesa
- 'Vita-Salute' University, Scientific Institute H. San Raffaele, Milan, Italy
| | - Luca Bertoglio
- 'Vita-Salute' University, Scientific Institute H. San Raffaele, Milan, Italy
| | - Enrico Rinaldi
- 'Vita-Salute' University, Scientific Institute H. San Raffaele, Milan, Italy
| | - Yamume Tshomba
- 'Vita-Salute' University, Scientific Institute H. San Raffaele, Milan, Italy
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54
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Irisawa Y, Kitamura T, Taketani T, Hanayama N, Oka N, Tomoyasu T, Itatani K, Shibata M, Hayashi H, Inoue T, Miyaji K. Aortic arch rerouting and OPCAB in a patient with situs inversus totalis. Int Heart J 2014; 55:278-9. [PMID: 24814324 DOI: 10.1536/ihj.13-280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Endovascular therapy approaches for aortic aneurysm have lowered the mortality and morbidity rates even in high-risk patients; moreover, these approaches are applied in the management of aortic arch pathologies by transposition of the supra-aortic branches. We present the case of a 75-year-old female patient with situs inversus totalis on hemodialysis. The patient underwent off-pump aortic arch rerouting and thoracic endovascular aortic repair concomitant with coronary artery bypass grafting for distal aortic arch aneurysm and ischemic heart disease.
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Affiliation(s)
- Yusuke Irisawa
- Department of Cardiovascular Surgery, Kitasato University School of Medicine
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55
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Midterm Outcomes of Carotid-to-Carotid Bypass for Hybrid Treatment of Aortic Arch Disease. Ann Vasc Surg 2014; 28:860-5. [DOI: 10.1016/j.avsg.2013.10.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 10/11/2013] [Accepted: 10/24/2013] [Indexed: 11/18/2022]
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56
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Kefeng Z, Xudong P, Yongmin L, Junming Z, Lianjun H, Jian Z, Lizhong S. Hybrid Operation for Type B Aortic Dissection Involving Distal Aortic Arch. J Card Surg 2014; 29:359-63. [PMID: 24684588 DOI: 10.1111/jocs.12330] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Zhang Kefeng
- Department of Cardiovascular Surgery, Xuanwu Hospital; Capital Medical University; Xicheng District Beijing China
- Beijing Aortic Disease Center, Beijing Anzhen Hospital; Capital Medical University; Chaoyang District Beijing China
| | - Pan Xudong
- Beijing Aortic Disease Center, Beijing Anzhen Hospital; Capital Medical University; Chaoyang District Beijing China
| | - Liu Yongmin
- Beijing Aortic Disease Center, Beijing Anzhen Hospital; Capital Medical University; Chaoyang District Beijing China
| | - Zhu Junming
- Beijing Aortic Disease Center, Beijing Anzhen Hospital; Capital Medical University; Chaoyang District Beijing China
| | - Huang Lianjun
- Beijing Aortic Disease Center, Beijing Anzhen Hospital; Capital Medical University; Chaoyang District Beijing China
| | - Zhang Jian
- Department of Cardiovascular Surgery, Xuanwu Hospital; Capital Medical University; Xicheng District Beijing China
| | - Sun Lizhong
- Beijing Aortic Disease Center, Beijing Anzhen Hospital; Capital Medical University; Chaoyang District Beijing China
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De Rango P, Cao P, Ferrer C, Simonte G, Coscarella C, Cieri E, Pogany G, Verzini F. Aortic arch debranching and thoracic endovascular repair. J Vasc Surg 2014; 59:107-14. [DOI: 10.1016/j.jvs.2013.07.010] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Revised: 07/01/2013] [Accepted: 07/04/2013] [Indexed: 10/26/2022]
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Clough RE, Lotfi S, Powell J, Lee A, Taylor PR. Hybrid aortic arch repair. Ann Cardiothorac Surg 2013; 2:300-2. [PMID: 23977598 DOI: 10.3978/j.issn.2225-319x.2013.05.10] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 05/20/2013] [Indexed: 11/14/2022]
Abstract
Innovations in thoracic endovascular aortic repair techniques have enabled its incorporation in open procedures, resulting in a hybrid approach to aortic arch repair. The present study reported our experience with the hybrid technique in managing arch pathologies. Fifty-one patients underwent a hybrid repair of arch pathologies. 10 patients had urgent or emergency surgery, and 8 had previous abdominal aortic aneurysm repair; all were classified as high risk (ASA grade III or IV). Overall 30-day mortality was 9.8% (5/51). Hospital mortality was 30% (3/10) in urgent/emergent surgery and 4.90% (2/41) in elective cases. Ischemic stroke occurred in 11.8% (6/51) of patients, while 5.9% (3/51) experienced paraplegia. Endoleaks occurred in 8 patients, 6 of which were Type 1. Long-term patency rate was 96%. The hybrid technique is a safe, effective and less invasive alternative to open repair of arch pathologies, with comparable outcomes in high-risk patient groups. Patency rates and durability demonstrate the long-term potential of this technique.
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Affiliation(s)
- Rachel E Clough
- Department of Vascular Surgery, St Thomas' Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
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Moulakakis KG, Mylonas SN, Markatis F, Kotsis T, Kakisis J, Liapis CD. A systematic review and meta-analysis of hybrid aortic arch replacement. Ann Cardiothorac Surg 2013; 2:247-60. [PMID: 23977592 DOI: 10.3978/j.issn.2225-319x.2013.05.06] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 05/20/2013] [Indexed: 11/14/2022]
Abstract
BACKGROUND Evolution in the endovascular era has influenced the management of aortic arch pathologies. Several studies have described the use of a combined endovascular and open surgical approach to the treatment of arch diseases. Hybrid repair of arch pathologies has been considered as a less invasive method, and is therefore an appealing option for high-risk patients who are unsuitable for open repairs. The aim of the present meta-analysis was to assess the efficacy of hybrid techniques in patients with aortic arch pathologies. METHODS Extensive electronic literature search was undertaken to identify all articles published up to December 2012 that described hybrid aortic arch repair with intrathoracic supra-aortic branch revascularisation and subsequent stent graft deployment. Eligible studies were divided into two groups: group I included studies on the aortic arch debranching procedure and group II included studies that reported an elephant trunk technique (either "frozen" or stented). Separate meta-analyses were conducted in order to assess technical success, stroke, spinal cord ischemia (SCI), renal failure requiring dialysis, and cardiac and pulmonary complications rate, as well as 30-day/in-hospital mortality. RESULTS Forty-six studies were eligible for the present meta-analysis: 26 studies with a total of 956 patients reported aortic arch debranching procedures, and 20 studies with 1,316 patients performed either 'frozen' or stented elephant trunk technique. The pooled estimate for 30-day/in-hospital mortality was 11.9% for the arch debranching group and 9.5% for the elephant trunk group. Cerebrovascular events of any severity were found to have occurred postoperatively at a pooled rate of 7.6% and 6.2%, while irreversible spinal cord injury symptoms were present in a pooled estimate of 3.6% and 5.0% in the arch debranching and elephant trunk group, respectively. Renal failure requiring dialysis occurred at 5.7% and 3.8% in both groups, while cardiac complications rate was 6.0% in the arch debranching cohort and pulmonary complication was 19.7% in the elephant trunk cohort. CONCLUSIONS Hybrid arch techniques provide a safe alternative to open repair with acceptable short- and mid-term results. However, stroke and mortality rates remain noteworthy. Future prospective trials that compare open conventional techniques with the hybrid method or the entirely endovascular methods are needed.
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Affiliation(s)
- Konstantinos G Moulakakis
- Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece; ; The Systematic Review Unit, The Collaborative Research (CORE) Group, Sydney, Australia
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Hybrid aortic arch repair for complicated type B aortic dissection. J Vasc Surg 2013; 58:1490-6. [PMID: 23880549 DOI: 10.1016/j.jvs.2013.05.091] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 05/14/2013] [Accepted: 05/14/2013] [Indexed: 11/21/2022]
Abstract
OBJECTIVE This study analyzed the outcome of a combined endovascular and debranching procedure for hybrid aortic arch repair (HAR) in patients with complicated type B aortic dissection. METHODS Between February 2006 and August 2012, HAR was performed in 75 consecutive patients, with retrospective analysis of a subgroup of 45 patients who underwent HAR with complicated acute (n = 10), subacute (n = 7), or chronic (n = 28) type B dissection as the underlying disease. Descriptive statistics were computed for continuous and categoric variables. The interval to death or last follow-up was estimated using the Kaplan-Meier method. RESULTS The patients were a mean age of 59.9 ± 10.7 years (median, 59.2; range, 35-78 years). Complete supra-aortic debranching was performed in six (13%) in zone 0 (procedure time, 200 minutes; range, 185-365 minutes) and partial debranching in 39 (87%), comprising 16 (36%) in zone 1 (procedure time, 120 minutes; range, 75-250 minutes) and 23 (51%) in zone 2 (procedure time, 91 minutes; range, 70-210 minutes). Technical success was achieved in 86.7% (39 of 45). Thirty-day mortality was 4.4% (two of 45), with an in-hospital mortality of 11.1% (five of 45) as a result of three additional deaths after days 33, 35, and 111. Comparing HAR for type B dissection after complete debranching in six and partial debranching in 39, the overall in-hospital mortality was 67% (four of six) and 2.6% (one of 39), respectively. After a median follow-up of 20.8 months (range, 0.3-70 months), the overall mortality was 13.3% (six of 45), with Kaplan-Meier survival estimate of 85% at 1 year. Stroke rate was 8.8% (four of 45). Paraplegia developed in one patient (2.2%), with complete recovery after spinal drainage. Cardiac complications occurred in three patients (6.7%), pulmonary complications in 10 (22.2%), and renal insufficiency requiring dialysis developed in five (11%). Retrograde dissection occurred in one patient (2.2%) 14 days after complete debranching and zone 0 thoracic endovascular aortic repair, with fatal outcome. No bypass dysfunction was seen during follow-up. The overall early and late endoleak rates were 27% (12 of 44) and 43% (13 of 30), respectively. Eight patients (18%) required reintervention, with freedom of reintervention in 91% at 1 year and 81% at 2 years. CONCLUSIONS HAR in zone 1 and 2 appears a viable alternative to conventional aortic arch surgery in patients with complicated type B dissection. Stroke and endoleaks remain complications that need to be addressed. Treatment of type B aortic dissection with complete supra-aortic debranching and thoracic endovascular aortic repair in zone 0, however, is associated with high mortality, which might be reduced by improved technology using branched stent grafts.
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Andersen ND, Williams JB, Hanna JM, Shah AA, McCann RL, Hughes GC. Results with an algorithmic approach to hybrid repair of the aortic arch. J Vasc Surg 2012. [PMID: 23186868 DOI: 10.1016/j.jvs.2012.09.039] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Hybrid repair of the transverse aortic arch may allow for aortic arch repair with reduced morbidity in patients who are suboptimal candidates for conventional open surgery. We present our results with an algorithmic approach to hybrid arch repair, based on the extent of aortic disease and patient comorbidities. METHODS Between August 2005 and January 2012, 87 patients underwent hybrid arch repair by three principal procedures: zone 1 endograft coverage with extra-anatomic left carotid revascularization (zone 1; n = 19), zone 0 endograft coverage with aortic arch debranching (zone 0; n = 48), or total arch replacement with staged stented elephant trunk completion (stented elephant trunk; n = 20). RESULTS The mean patient age was 64 years, and the mean expected in-hospital mortality rate was 16.3% as calculated by the EuroSCORE II. Of operations, 22% (n = 19) were nonelective. Sternotomy, cardiopulmonary bypass, and deep hypothermic circulatory arrest were required in 78% (n = 68), 45% (n = 39), and 31% (n = 27) of patients to allow for total arch replacement, arch debranching, or other concomitant cardiac procedures, including ascending with or without hemiarch replacement in 17% (n = 8) of patients undergoing zone 0 repair. All stented elephant trunk procedures (n = 20) and 19% (n = 9) of zone 0 procedures were staged, with 41% (n = 12) of patients undergoing staged repair during a single hospitalization. The 30-day/in-hospital rates of stroke and permanent paraplegia or paraparesis were 4.6% (n = 4) and 1.2% (n = 1). Of 27 patients with native ascending aorta zone 0 proximal landing zone, three (11.1%) experienced retrograde type A dissection after endograft placement. The overall in-hospital mortality rate was 5.7% (n = 5); however, 30-day/in-hospital mortality increased to 14.9% (n = 13) owing to eight 30-day out-of-hospital deaths. Native ascending aorta zone 0 endograft placement was found to be the only univariate predictor of 30-day in-hospital mortality (odds ratio, 4.63; 95% confidence interval, 1.35-15.89; P = .02). Over a mean follow-up period of 28.5 ± 22.2 months, 13% (n = 11) of patients required reintervention for type 1A (n = 4), type 2 (n = 6), or type 3 (n = 1) endoleak. Kaplan-Meier estimates of survival at 1 year, 3 years, and 5 years were 73%, 60%, and 51%. CONCLUSIONS Hybrid aortic arch repair can be tailored to patient anatomy and comorbid status to allow complete repair of aortic pathology, frequently in a single stage, with acceptable outcomes. However, endograft placement in the native ascending aorta is associated with high rates of retrograde type A dissection and 30-day/in-hospital mortality and should be approached with caution.
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Affiliation(s)
- Nicholas D Andersen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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