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Lou X, Duwayri YM, Chen EP, Jordan WD, Forcillo J, Zehner CA, Leshnower BG. Predictors of Failure of Medical Management in Uncomplicated Type B Aortic Dissection. Ann Thorac Surg 2019; 107:493-498. [PMID: 30292842 PMCID: PMC6408689 DOI: 10.1016/j.athoracsur.2018.08.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 05/24/2018] [Accepted: 08/13/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Optimal medical therapy (OMT) for uncomplicated type B aortic dissection (uTBAD) provides excellent short-term outcomes but is associated with a high incidence of failure. This study identified predictors of aortic intervention and mortality in uTBAD patients undergoing OMT. METHODS A retrospective review of the Emory University School of Medicine aortic database identified 314 uTBAD patients undergoing OMT from 2000 to 2016. Two hundred sixty-three (84%) patients had imaging at presentation analyzed for maximum aortic diameters (ADs), false lumen (FL) status, and visceral vessel perfusion. Cox proportional hazards models were constructed to estimate hazards ratios (HRs) and identify predictors of OMT failure. RESULTS The mean age of patients was 58 ± 12 years, and 67% were men. FL status was patent in 59.4%, partially thrombosed in 39.8%, and completely thrombosed in 0.8% of patients. Over a median follow-up of 5.6 (interquartile range, 1.4 to 8.5) years, 44.9% of patients failed OMT and underwent intervention (n = 58 open, n = 83 endovascular). The estimated incidence of OMT failure was 46%. Multivariate analysis identified the presence of diabetes, renal failure, DeBakey 3B dissection, and a descending thoracic AD of 4.5 cm or greater (HR, 1.39; 95% confidence interval, 1.24 to 1.56; p < 0.001) to be independent predictors of failure of OMT. FL status or the distribution of visceral vessels arising from the FL did not predict OMT failure. CONCLUSIONS There is a significant incidence of OMT failure in uTBAD patients. A descending thoracic AD of 4.5 cm or greater at the time of diagnosis is an independent predictor of failure of OMT.
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Affiliation(s)
- Xiaoying Lou
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Yazan M Duwayri
- Division of Vascular and Endovascular Therapy, Emory University School of Medicine, Atlanta, Georgia
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - William D Jordan
- Division of Vascular and Endovascular Therapy, Emory University School of Medicine, Atlanta, Georgia
| | - Jessica Forcillo
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Carl A Zehner
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
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Yammine H, Briggs CS, Stanley GA, Ballast JK, Anderson WE, Nussbaum T, Madjarov J, Frederick JR, Arko FR. Retrograde type A dissection after thoracic endovascular aortic repair for type B aortic dissection. J Vasc Surg 2019; 69:24-33. [DOI: 10.1016/j.jvs.2018.04.047] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 04/07/2018] [Indexed: 11/25/2022]
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Lansman SL, Goldberg JB, Kai M, Malekan R, Spielvogel D. Extended Arch Procedures for Acute Type A Aortic Dissection: A Downstream Problem? Semin Thorac Cardiovasc Surg 2019; 31:17-20. [DOI: 10.1053/j.semtcvs.2018.07.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 07/24/2018] [Indexed: 11/11/2022]
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Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury: A Report of Three Cases in Which Surgeries Were Performed at Different Timings. Case Rep Surg 2018; 2018:7061509. [PMID: 30159195 PMCID: PMC6109575 DOI: 10.1155/2018/7061509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 07/14/2018] [Indexed: 11/24/2022] Open
Abstract
Introduction Blunt thoracic aortic injury (BTAI) is a critical condition. Thoracic endovascular aortic repair (TEVAR) is considered a surgical treatment for BTAI. Reports reveal that some patients benefit from conservative and delayed operation rather than emergency operative therapy. Here, we present three BTAI cases that were treated with TEVAR using different timings. Case Presentation Case 1 involved a 49-year-old man injured in a car accident and who went into shock. After stabilization with Advanced Trauma Life Support in the emergency room, TEVAR was performed immediately. Case 2 involved a 69-year-old man who was injured after falling. His hemodynamic status was stable and enhanced computed tomography revealed intraluminal hematoma. He underwent TEVAR 15 days after the injury occurred, following conservative therapy. Case 3 involved a 60-year-old man who was injured in a car accident and presented BTAI with subarachnoid hemorrhage and diaphragm tear. A pseudoaneurysm was observed in the distal aortic arch. After open abdominal exploration, diaphragm repair, and observation for subarachnoid hemorrhage, TEVAR was performed 8 hours after arrival. All three patients survived. Conclusions We treated BTAI successfully. We suggest that TEVAR is useful for BTAI. The timing of the operation and therapeutic option, including conservative therapy, should be decided for each patient.
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Miyairi T, Miyata H, Chiba K, Nishimaki H, Ogawa Y, Motomura N, Takamoto S. Influence of Timing After Thoracic Endovascular Aortic Repair for Acute Type B Aortic Dissection. Ann Thorac Surg 2018; 105:1392-1396. [DOI: 10.1016/j.athoracsur.2017.11.054] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 11/14/2017] [Accepted: 11/17/2017] [Indexed: 11/28/2022]
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Lou X, Leshnower BG. The impact of thoracic endovascular aortic repair on long-term survival in type B aortic dissection: response to editorial. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:72. [PMID: 29611551 DOI: 10.21037/atm.2017.11.41] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Xiaoying Lou
- Department of Cardiothoracic Surgery, Emory University, Atlanta, GA, USA
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Abstract
Stanford type B aortic dissection (TBAD) is a life-threatening disease. Current therapeutic guidelines recommend medical therapy with aggressive blood pressure lowering for patients with acute TBAD unless they have fatal complications. Although patients with uncomplicated TBAD have relatively low early mortality, aorta-related adverse events during the chronic phase worsen the long-term clinical outcome. Recent advances in thoracic endovascular aortic repair (TEVAR) can improve clinical outcomes in patients with both complicated and uncomplicated TBAD. According to present guidelines, complicated TBAD patients are recommended for TEVAR. However, the indication in uncomplicated TBAD remains controversial. Recent results of randomized trials, which compared the clinical outcome in patients treated with optimal medical therapy and those treated with TEVAR, suggest that preemptive TEVAR should be considered in uncomplicated TBAD with suitable aortic anatomy. However, these trials failed to show improvement in early mortality in patients treated with TEVAR compared with patients treated with optimal medical therapy, which suggest the importance of patient selection for TEVAR. Several clinical and imaging-related risk factors have been shown to be associated with early disease progression. Preemptive TEVAR might be beneficial and should be considered for high-risk patients with uncomplicated TBAD. However, an interdisciplinary consensus has not been established for the definition of patients at high-risk of TBAD, and it should be confirmed by experts including physicians, radiologists, interventionalists, and vascular surgeons. This review summarizes the current understanding of the therapeutic strategy in patients with TBAD based on evidence and expert consensus.
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Affiliation(s)
- Shuichiro Kaji
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
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Fleerakkers J, Schepens M. How should we manage type B aortic dissections? Gen Thorac Cardiovasc Surg 2017; 67:154-160. [PMID: 28852959 DOI: 10.1007/s11748-017-0818-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 08/17/2017] [Indexed: 12/16/2022]
Abstract
Dissection of the descending aorta is a serious and potentially lethal event. Treatment options consist of medical therapy, open surgical replacement of the affected aorta and thoracic endovascular repair. In acute cases, medical treatment is started initially. When complicated, endovascular repair is generally considered as first choice treatment, except for connective tissue disorders where open surgery remains the standard. In stable, uncomplicated patients with risk factors for future aortic growth pre-emptive endovascular repair should be considered in the sub-acute phase of the dissection. The treatment strategy in chronic dissections is somewhat debated. Long-term results and aortic remodeling of endovascular repair are disappointing and open surgery remains the standard.
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Affiliation(s)
- J Fleerakkers
- Department of Cardiac Surgery, AZ Sint-Jan, Ruddershove 10, 8000, Brugge, Belgium.
| | - M Schepens
- Department of Cardiac Surgery, AZ Sint-Jan, Ruddershove 10, 8000, Brugge, Belgium
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Zhang MH, Du X, Guo W, Liu XP, Jia X, Ge YY. Early and midterm outcomes of thoracic endovascular aortic repair (TEVAR) for acute and chronic complicated type B aortic dissection. Medicine (Baltimore) 2017; 96:e7183. [PMID: 28700467 PMCID: PMC5515739 DOI: 10.1097/md.0000000000007183] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Thoracic endovascular aortic repair (TEVAR) in the current era has been chosen as a dominant and minimally invasive treatment for complicated aorta dissection. This study aimed to assess safety and feasibility of TEVAR in acute and chronic type B aortic dissection.Between January 2011 and December 2013, 85 patients with complicated type B aortic dissection undergoing TEVAR were divided into acute aortic dissection (AAD) (n = 60) group and chronic aortic dissection (CAD) group (n = 25). Computed tomography was used to evaluate postoperative changes in maximal aortic diameter and true and false lumen diameters at 3 levels during a mean follow-up period of 26.4 ± 15.6 months.The technical success rate was 100%. In-hospital and 30-day rates of death were 3.3% in acute group and 0 in chronic group. Postdischarge rates of type I leak, type II leak, and retrograde type A dissection were 6.7%, 5.2%, and 3.4% (acute) and 0%, 4.0%, and 4.0% (chronic), respectively. The maximal aorta diameter remained stable in all the 3 levels in both acute and chronic group. The cumulative freedom from all-cause mortality at 3 years was similar in acute and chronic groups (89.5% vs 95.5%, P = .308). The cumulative freedom from aortic-related mortality was also not significantly different in the acute and chronic groups (92.8% vs 95.2%, P = .531). In the thoracic aorta, TEVAR treatment resulted in a significant increase in true lumen (TL) diameter and decrease in false lumen (FL). However, in the abdominal aorta, TEVAR did not lead to significant change in TL and FL diameters. The rates of complete thrombosis thoracic false lumens were better than that in the abdominal false lumen.TEVAR was a safe and effect therapy for complicated acute and chronic type B dissection with low early and mid-term mortality and morbidity.
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Treatment of uncomplicated type B aortic dissection. Gen Thorac Cardiovasc Surg 2016; 65:74-79. [DOI: 10.1007/s11748-016-0734-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 11/25/2016] [Indexed: 10/20/2022]
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Peterss S, Mansour AM, Ross JA, Vaitkeviciute I, Charilaou P, Dumfarth J, Fang H, Ziganshin BA, Rizzo JA, Adeniran AJ, Elefteriades JA. Changing Pathology of the Thoracic Aorta From Acute to Chronic Dissection. J Am Coll Cardiol 2016; 68:1054-65. [DOI: 10.1016/j.jacc.2016.05.091] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 04/25/2016] [Accepted: 05/24/2016] [Indexed: 01/16/2023]
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Affiliation(s)
- Vikalp Jain
- Department of Surgery, Division of Vascular Surgery, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Mark A. Farber
- Department of Surgery, Division of Vascular Surgery, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Raghuveer Vallabhaneni
- Department of Surgery, Division of Vascular Surgery, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
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Impact of age and urgency on survival after thoracic endovascular aortic repair. J Vasc Surg 2016; 64:25-32. [PMID: 27103337 DOI: 10.1016/j.jvs.2015.11.054] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 11/19/2015] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Elderly patients are often turned down from receiving treatment for descending thoracic aortic diseases (DTADs) because of the uncertain benefits, especially in acute settings. This study investigated the impact of old age and timing of thoracic endovascular aortic repair (TEVAR) on outcomes of DTAD in patients older than 75 years of age. METHODS Patients from a prospective TEVAR database were dichotomized by age (75 and 80 years of age). Older and young patients were compared in three timing scenarios: (1) elective procedures, (2) any emergency (within 15 days from onset), and (3) acute ruptures (any emergency subgroup). Primary outcome was perioperative mortality assessed at 30 and 90 days. RESULTS Between 2003 and 2015, 141 consecutive TEVARs (71.6% men) were performed. Fifty-seven patients (40.4%) were older than 75 years of age; 28 were octogenarians. Eighty-three TEVARs were performed electively and 58 emergently. Among overall emergencies, 42 TEVARs were for acute ruptures. In the elective scenario, the 30-day mortality rate was 5.0% vs 0 (odds ratio [OR], 1.1; 95% confidence interval [CI], 0.98-1.1; P = .23), and 90-day mortality was 7.5% vs 0, for patients older than 75 years of age vs those who were younger than 75, respectively (P = .11). No octogenarian died. In the emergency scenario, 30-day mortality was 41.2% vs 9.8%, for patients older than 75 years of age vs those who were younger than 75, respectively (OR, 6.5; 95% CI, 1.6-26.6; P = .01) with unchanged rates at 90 days. The mortality rate was 50% for octogenarians. In the acute rupture scenario, 30-day mortality was 40% vs 11.1% (OR, 5.3; 95% CI, 1.10-25.99; P = .05) for patients older than 75 years of age vs those younger than 75 years of age and 46% vs 10% (OR, 7.5; 95% CI, 1.47-37.46; P = .016) for octogenarians vs younger patients. Rates remained unchanged at 90 days. Patients older than age 75 survived for a mean of 53.98 ± 7.7 months after TEVAR. CONCLUSIONS In the elderly patient population with DTAD, mortality risks from TEVAR are strongly related to timing and age. When compared to younger patients, those older than 75 years of age have three to five times the risk of mortality after urgent or emergent TEVAR. However, older patients should still be considered for emergent life-saving treatment, given that the majority survives.
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65
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Wheatley GH. Through the endovascular looking glass: Total endovascular repair for combined congenital and acute aortic arch disease. J Thorac Cardiovasc Surg 2015; 150:411-2. [PMID: 25960074 DOI: 10.1016/j.jtcvs.2015.04.024] [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: 04/07/2015] [Accepted: 04/09/2015] [Indexed: 11/18/2022]
Affiliation(s)
- Grayson H Wheatley
- Division of Cardiovascular Surgery, Temple University School of Medicine, Philadelphia, Pa.
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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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