101
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Ullery BW, Cheung AT, Fairman RM, Jackson BM, Woo EY, Bavaria J, Pochettino A, Wang GJ. Risk factors, outcomes, and clinical manifestations of spinal cord ischemia following thoracic endovascular aortic repair. J Vasc Surg 2011; 54:677-84. [PMID: 21571494 DOI: 10.1016/j.jvs.2011.03.259] [Citation(s) in RCA: 144] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 03/14/2011] [Accepted: 03/15/2011] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the incidence, risk factors, and clinical manifestations of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR). METHODS A retrospective review of a prospectively collected database was performed for all patients undergoing TEVAR at a single academic institution between July 2002 and June 2010. Preoperative demographics, procedure-related variables, and clinical details related to SCI were examined. Logistic regression analysis was performed to identify risk factors for the development of SCI. RESULTS Of the 424 patients who underwent TEVAR during the study period, 12 patients (2.8%) developed SCI. Mean age of this cohort with SCI was 69.6 years (range, 44-84 years), and 7 were women. One-half of these patients had prior open or endovascular aortic repair. Indication for surgery was either degenerative aneurysm (n = 8) or dissection (n = 4). Six TEVARs were performed electively, with the remaining done either urgently or emergently due to contained rupture (n = 2), dissection with malperfusion (n = 2), or severe back pain (n = 2). All 12 patients underwent extent C endovascular coverage. Multivariate regression analysis demonstrated chronic renal insufficiency to be independently associated with SCI (odds ratio [OR], 4.39; 95% confidence interval [CI], 1.2-16.6; P = .029). Onset of SCI occurred at a median of 10.6 hours (range, 0-229 hours) postprocedure and was delayed in 83% (n = 10) of patients. Clinical manifestations of SCI included lower extremity paraparesis in 9 patients and paraplegia in 3 patients. At SCI onset, average mean arterial pressure (MAP) and lumbar cerebrospinal fluid (CSF) pressure was 77 mm Hg and 10 mm Hg, respectively. Therapeutic interventions increased blood pressure to a significantly higher average MAP of 99 mm Hg (P = .001) and decreased lumbar CSF pressure to a mean of 7 mm Hg (P = .30) at the time of neurologic recovery. Thirty-day mortality was 8% (1 of 12 patients). The single patient who expired, never recovered any lower extremity neurologic function. All patients surviving to discharge experienced either complete (n = 9) or incomplete (n = 2) neurologic recovery. At mean follow-up of 49 months, 7 of 9 patients currently alive continued to exhibit complete, sustained neurologic recovery. CONCLUSION Spinal cord ischemia after TEVAR is an uncommon, but important complication. Preoperative renal insufficiency was identified as a risk factor for the development of SCI. Early detection and treatment of SCI with blood pressure augmentation alone or in combination with CSF drainage was effective in most patients, with the majority achieving complete, long-term neurologic recovery.
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Affiliation(s)
- Brant W Ullery
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of University of Pennsylvania, Philadelphia, PA 19104, USA
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102
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Fernández Carmona A, Díaz Redondo A, Olivencia Peña L, Frías Pareja J, Rayo Bonor A. Rotura de aorta torácica descendente. Tratamiento endoprotésico. Med Intensiva 2011; 35:256-8. [DOI: 10.1016/j.medin.2010.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2010] [Revised: 06/12/2010] [Accepted: 07/10/2010] [Indexed: 10/18/2022]
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103
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Eriksson MO, Nyman R. The value of intravascular phased-array imaging in endovascular treatment of thoracic aortic pathology. Acta Radiol 2011; 52:285-90. [PMID: 21498364 DOI: 10.1258/ar.2010.100040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Careful pre-, intra- and postoperative diagnostics in endovascular treatment of thoracic aortic pathology is crucial for a favourable outcome. Computer tomography (CT) and digitally subtracted angiography (DSA) do not always provide sufficient diagnostic information. PURPOSE To report our primary experiences of using intraluminal phased-array imaging (IPAI) as an additive tool for diagnostics and endovascular treatment of thoracic aortic pathology. MATERIAL AND METHODS Eleven patients, nine men and two women (mean age 60, range 45) were examined intraoperatively with IPAI in stentgraft procedures of thoracic aortic pathology. RESULTS IPAI could detect and visualize the entries and re-entries in the intima. Aortic branch vessels could be visualized for patency both during and immediately after stentgraft deployment. It was also possible to detect ceased blood flow in the false lumen or aneurysmal sac after stentgraft deployment. CONCLUSION IPAI is a helpful tool for diagnostics and for guiding stentgraft placing in the treatment of thoracic aortic pathology.
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Affiliation(s)
- Mats-Ola Eriksson
- Department of Oncology, Radiology and Clinical Immunology, University Hospital of Uppsala, Sweden
| | - R Nyman
- Department of Oncology, Radiology and Clinical Immunology, University Hospital of Uppsala, Sweden
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104
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Current strategies for spinal cord protection during thoracic and thoracoabdominal aortic aneurysm repair. Gen Thorac Cardiovasc Surg 2011; 59:155-63. [DOI: 10.1007/s11748-010-0705-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Accepted: 08/30/2010] [Indexed: 11/26/2022]
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105
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David N, Roux N, Clavier E, Godier S, Brossard F, Bessou JP, Plissonnier D. Open repair of extensive thoracoabdominal and thoracic aneurysm: a preliminary single-center experience with femorofemoral distal aortic perfusion with oxygenator and without cerebrospinal fluid drainage. Ann Vasc Surg 2011; 25:583-9. [PMID: 21420828 DOI: 10.1016/j.avsg.2010.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Revised: 12/23/2010] [Accepted: 12/27/2010] [Indexed: 11/29/2022]
Abstract
Thoracoabdominal aortic aneurysms (TAAA) and extensive thoracic descending aortic aneurysms (TDA) are not accessible through standard endovascular treatment. Fenestrated and branched endograft technology was developed rapidly without widespread application. The aim of this study was to review our open repair (OR) experience of TAAA and TDA. A total of 28 patients who underwent elective OR of TAAA or TDA between January 2001 and January 2009 were analyzed retrospectively. The mean age of the patients was 65.5 years (three women). The anatomic locations of the aneurysms were as follows: six in thoracic descending aorta and 22 in thoracoabdominal aorta (14 TAAA I, two TAAA II, six TAAA III). TDA (40 patients) available for ordinary endovascular treatment and TAAA IV (35 patients) were excluded from this study. To focus on spinal cord vascularization, 25 patients were submitted for angiography. Three patients suffering from back pain required quick treatment and were excluded from angiographic investigations. Angiography procedures were contributive in 23 patients (92%). Surgical repairs were driven through left thoraco-phreno-laparotomy, with the adjunct of distal aortic perfusion (femorofemoral bypass) including the use of an oxygenator and sequential aortic cross-clamping. Cerebrospinal fluid drainage was not used in this experience. The 30-day mortality rate was 14.3% (four of 28 patients): one multiorgan failure and three pulmonary sepsis. An immediate postoperative paraplegia occurred, affecting a patient with TDA who was previously submitted for infrarenal aorta replacement, despite angiographic identification and revascularization of intercostal artery destined to spinal artery. The 1-year survival rate was 82.1% (23 of 28 patients). In the preliminary experience of this study, OR of extensive TAAA and TDA with distal aortic perfusion and an oxygenator without use of cerebrospinal fluid drainage was associated with a significant perioperative mortality rate (14.2%), a reasonable rate of paraplegia (3%), and 1-year survival rate of 82.1%.
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Affiliation(s)
- Nathalie David
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France.
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106
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Tholpady A, Hendricks DE, Bozlar U, Turba UC, Sabri SS, Angle JF, Arslan B, Cherry KJ, Dake MD, Matsumoto AH, Saad WEA, Park AW, Bonatti H, Hagspiel KD. Percutaneous occlusion of the left subclavian and celiac arteries before or during endograft repair of thoracic and thoracoabdominal aortic aneurysms with detachable nitinol vascular plugs. J Vasc Interv Radiol 2011; 21:1501-7. [PMID: 20801685 DOI: 10.1016/j.jvir.2010.05.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Revised: 05/14/2010] [Accepted: 05/19/2010] [Indexed: 10/19/2022] Open
Abstract
PURPOSE To review an experience with the Amplatzer vascular plug (AVP) for prevention of type II endoleaks during endovascular aneurysm repair (EVAR) of thoracic and thoracoabdominal aneurysms. MATERIALS AND METHODS Retrospective review was undertaken of 14 patients undergoing transcatheter occlusion of the left subclavian (n = 12) or celiac artery (n = 2) with the AVP as part of EVAR of thoracic and thoracoabdominal aneurysms at a single institution. Procedural criteria evaluated were success at target vessel occlusion, the number of AVPs used, use of adjunctive embolization devices, and embolization-related ischemic end-organ events. Follow-up imaging criteria included evaluation of persistent target vessel occlusion, evidence of device migration, and the presence and characterization of endoleak secondary to AVP failure. RESULTS Complete target vessel occlusion was documented for all cases. In six cases, more than one AVP was placed, with an average of 1.5 devices per patient. In two cases, adjunctive coils were placed. Computed tomographic or magnetic resonance angiography follow-up was available for all patients (mean follow-up, 419 days; range 28-930 d). No case showed evidence of device migration or type II endoleak resulting from AVP failure. There was a single instance of left subclavian artery recanalization without type II endoleak. There were no embolization-related ischemic end-organ events. CONCLUSIONS Transcatheter arterial occlusion of the subclavian and celiac arteries with the AVP is a valuable adjunct to endografting in cases in which side branch embolization is necessary to extend the landing zone.
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Affiliation(s)
- Ashok Tholpady
- Department of Radiology, University of Virginia Health System, Box 800170, Lee Street, Charlottesville, VA 22908, USA
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Carmona P, Mateo E, Otero M, Marqués JI, Peña JJ, Llagunes J, Aguar F, De Andrés J. [Spinal cord protection during open and endovascular surgery in thoracic and thoracoabdominal aorta diseases]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2011; 58:110-118. [PMID: 21427827 DOI: 10.1016/s0034-9356(11)70009-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
In recent decades great advances have been made in surgical procedures for treating thoracic and thoracoabdominal aorta defects. Associated mortality and morbidity rates have dropped considerably, mainly in major reference centers, but nonetheless continue to be significant. The need for new strategies to reduce mortality and morbidity has made endovascular approaches an attractive alternative for high-risk surgical patients. The most feared complications of these procedures include paraparesis and paraplegia, which have devastating consequences on patients' quality of life. We provide an updated review of the pathophysiology of spinal cord ischemia in open and endovascular surgery, as well as perioperative measures designed to protect the spinal cord in both types of procedure.
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Affiliation(s)
- P Carmona
- Consorcio Hospital General Universitario de Valencia.
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108
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Davidovic L, Koncar I, Markovic D, Sindjelic R, Colic M. Injuries of the thoracic aorta and its branches. VOJNOSANIT PREGL 2011; 68:257-65. [DOI: 10.2298/vsp1103257d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Lazar Davidovic
- Klinički centar Srbije, Klinika za vaskularnu hirurgiju i endovaskularnu hirurgiju, Beograd + Medicinski fakultet, Beograd
| | - Igor Koncar
- Klinički centar Srbije, Klinika za vaskularnu hirurgiju i endovaskularnu hirurgiju, Beograd + Medicinski fakultet, Beograd
| | - Dejan Markovic
- Klinički centar Srbije, Klinika za vaskularnu hirurgiju i endovaskularnu hirurgiju, Beograd + Medicinski fakultet, Beograd
| | - Radomir Sindjelic
- Klinički centar Srbije, Klinika za vaskularnu hirurgiju i endovaskularnu hirurgiju, Beograd + Medicinski fakultet, Beograd
| | - Momcilo Colic
- Klinički centar Srbije, Klinika za vaskularnu hirurgiju i endovaskularnu hirurgiju, Beograd + Medicinski fakultet, Beograd
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109
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Carrel T, Schmidli J. Management of vascular graft and endoprosthetic infection of the thoracic and thoraco-abdominal aorta. Multimed Man Cardiothorac Surg 2011; 2011:mmcts.2010.004705. [PMID: 24413747 DOI: 10.1510/mmcts.2010.004705] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Infection of a vascular prosthesis or endovascular stent-graft is probably the most serious complication that may occur after implantation and dramatically affects the patient's outcome. Surgical treatment is almost always required but even after surgery, morbidity can be significant. Several approaches have been described with some advantages and/or some limitations. Complete resection of the infected foreign material with debridement of the surrounding tissue gives most probably the better results. Orthotopic reconstruction is the best option for all thoracic and thoraco-abdominal pathologies and the use of coated prostheses, homografts or self-made vascular tubes from xenopericardial tissue has to be discussed from case to case. In some exceptional situations, endovascular stent-graft can be performed as bridging to a more complete treatment if general condition of the patient has to be stabilized.
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Affiliation(s)
- Thierry Carrel
- Clinic for Cardiovascular Surgery, University Hospital Berne, Berne, Switzerland
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110
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Pisimisis GT, Khoynezhad A, Bashir K, Kruse MJ, Donayre CE, White RA. Incidence and risk factors of renal dysfunction after thoracic endovascular aortic repair. J Thorac Cardiovasc Surg 2010; 140:S161-7. [DOI: 10.1016/j.jtcvs.2010.10.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Revised: 08/17/2010] [Accepted: 10/15/2010] [Indexed: 02/06/2023]
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111
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Walker KL, Shuster JJ, Martin TD, Hess PJ, Klodell CT, Feezor RJ, Beck AW, Beaver TM. Practice patterns for thoracic aneurysms in the stent graft era: health care system implications. Ann Thorac Surg 2010; 90:1833-9. [PMID: 21095320 PMCID: PMC3976178 DOI: 10.1016/j.athoracsur.2010.08.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Revised: 08/03/2010] [Accepted: 08/06/2010] [Indexed: 12/20/2022]
Abstract
BACKGROUND The US Food and Drug Administration approved the first thoracic aneurysm endograft in 2005. However, because the United States lacks a thoracic aneurysm endovascular repair registry, implications of Food and Drug Administration endograft approval on surgical management of thoracic aneurysms in clinical practice are unknown. METHODS Retrospective review of thoracic aneurysm repair rates for 2000 to 2007 and analysis of patient characteristics and complications for 2006 and 2007 cohorts uses the National Inpatient Sample. International Classification of Diseases, 9th Revision codes were used to identify unruptured descending thoracic aneurysm cases undergoing either thoracic endovascular aortic repair (39.73) or open repair (38.45). RESULTS Thoracic aneurysm open repair averaged 3.3 per million from 2000 to 2002 and increased to 5.6 per million in 2003 with introduction of 16 slice computed tomographic scanners. In 2005 endovascular repair was 1.2 repairs per million, which increased dramatically to 6.1 repairs per million in 2006. In 2007, endovascular repair decreased to 4.8 repairs per million while the open repair rate was 3.1 repairs per million. The 2006 and 2007 open repair cohorts had more favorable baseline characteristics compared with the endovascular cohort. Open repair mortality was significantly greater than endovascular mortality in 2006 (estimated relative risk, 8.48; 95% confidence interval 3.03 to 23.75), but not in 2007 (estimated relative risk, 0.71; 95% confidence interval 0.12 to 4.24). Length of stay was greater for open repair in 2006 and 2007. CONCLUSIONS Thoracic endovascular aortic repair has been rapidly adopted in the United States resulting in increased treatment of thoracic aortic aneurysms. Despite older age and comorbidities, endovascular repair had better outcomes and shorter hospital stays.
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Affiliation(s)
- Karen L Walker
- Division of Thoracic and Cardiovascular Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Jonathan J Shuster
- Division of Biostatistics Department of Epidemiology and Health Policy Research, University of Florida College of Medicine, Gainesville, FL
| | - Tomas D Martin
- Division of Thoracic and Cardiovascular Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Philip J Hess
- Division of Thoracic and Cardiovascular Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Charles T Klodell
- Division of Thoracic and Cardiovascular Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Robert J Feezor
- Division of Vascular and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL
| | - Adam W Beck
- Division of Vascular and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida College of Medicine, Gainesville, FL
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112
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Karthikesalingam A, Hinchliffe RJ, Loftus IM, Thompson MM, Holt PJ. Volume-outcome relationships in vascular surgery: the current status. J Endovasc Ther 2010; 17:356-65. [PMID: 20557176 DOI: 10.1583/10-3035.1] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Vascular surgery has been widely practiced in hospitals within a general surgical service, although the consequent workload of individual vascular units has been small. There is an increasing body of evidence in favor of a positive relationship between hospital and surgeon volumes and the outcome of arterial surgery. These relationships suggest that vascular surgical procedures might be best placed within a centralized model of care to increase volume and thereby attain best outcomes. This systematic review appraises the current evidence for volume-outcome relationships in vascular surgery from a number of healthcare systems to examine the basis for centralization of vascular surgical services. The index procedures addressed in this review are open or endovascular repair of abdominal aortic aneurysm (AAA), ruptured AAA, descending thoracic aortic aneurysm, and thoracoabdominal aortic aneurysm, along with carotid endarterectomy and lower extremity arterial bypass.
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Affiliation(s)
- Alan Karthikesalingam
- Department of Outcomes Research, St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK
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113
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Arnaoutakis GJ, Hundt JA, Shah AS, Cameron DE, Black JH. Comparative analysis of hospital costs of open and endovascular thoracic aortic repair. Vasc Endovascular Surg 2010; 45:39-45. [PMID: 20829240 DOI: 10.1177/1538574410380471] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Endovascular technologies represent major advancements in treating descending thoracic aortic aneurysms (DTAA). We compared hospital charges of open thoracic aortic replacement (OTAR) with endovascular repair of thoracic aortic aneurysms (TEVAR). METHODS Retrospective analysis of hospital charges related to repair of DTAA (2000-2009). Charges were inflation adjusted for dollars in 2009. RESULTS There were 50 OTAR and 50 TEVAR patients. Open thoracic aortic replacement charges were $64 531 (interquartile range [IQR]: 49 000-108 515) versus $61 909 (IQR: 41 307-92 109) for TEVAR(P = .4). A total of 10 patients (10%) died before discharge, with 0 TEVAR deaths (P < .05). For OTAR, supply charges ($9167) accounted for 13% of total charges versus 56% for TEVAR ($40 468), P < .01. Open thoracic aortic replacement length of stay (LOS) was 12 days (6 days intensive care unit [ICU] stay); bed charges comprised 40% of the total charges. Thoracic endovascular aneurysm repair had lower LOS (5days with 2 days ICU stay, P < .001). CONCLUSIONS Descending thoracic aortic aneurysm repair remains a formidable operation with significant resource utilization. Thoracic endovascular aneurysm repair does not significantly reduce overall hospital charges due to device costs but demonstrates improved mortality, ICU, and total LOS.
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Affiliation(s)
- George J Arnaoutakis
- Division of Vascular and Endovascular Surgery, John Hopkins Hospital, Baltimore, MD, USA
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114
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Kang WC, Shin EK, Ahn TH, Lee KH, Moon CI, Han SH, Park CH, Park KY, Kang JM, Kim JH. Combined open and endovascular repair for aortic arch pathology. Korean Circ J 2010; 40:399-404. [PMID: 20830254 PMCID: PMC2933465 DOI: 10.4070/kcj.2010.40.8.399] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2010] [Accepted: 04/01/2010] [Indexed: 11/22/2022] Open
Abstract
Background and Objectives We describe our experience with combined open and endovascular repair in patients who have aortic arch pathology. Subjects and Methods This study is a retrospective analysis of 7 patients who underwent combined open and endovascular repair for aortic arch pathology. Medical records and radiographic information were reviewed. Results A total of 7 consecutive patients (5 men, 71.4%) underwent thoracic stent graft implantation. The mean age was 59.9±16.7 years. The indication for endovascular repair was aneurysmal degeneration in 5 patients, and rupture or impending rupture in 2 patients. In all 7 cases, supra-aortic transposition of the great vessels was performed successfully. Stent graft implantation was achieved in all cases. Surgical exposure of the access vessel was necessary in 2 patients. A total of 9 stent grafts were implanted (3 stent grafts in one patient). The Seal thoracic and the Valiant endovascular stent graft were implanted in 6 patients and 1 patient, respectively. There were no post-procedure deaths or neurologic complications. In 2 patients, bleeding and injury of access vessel were noted after the procedure. Postoperative endoleak was noted in 1 patient. One patient died at 10 months after the procedure due to a newly developed ascending aortic dissection. No patients required secondary intervention during the follow-up period. The aortic diameter decreased in 4 patients. In 3 patients, including 1 patient with endoleak, there was no change in aortic diameter. Conclusion Our experience suggests that combined open and endovascular repair for aortic arch pathology is safe and effective, with few complications.
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Affiliation(s)
- Woong Chol Kang
- Department of Cardiology, Gil Medical Center, Gachon University of Medicine and Science, Incheon, Korea
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115
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Kuratani T, Sawa Y. Current strategy of endovascular aortic repair for thoracic aortic aneurysms. Gen Thorac Cardiovasc Surg 2010; 58:393-8. [PMID: 20703859 DOI: 10.1007/s11748-009-0578-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Indexed: 12/01/2022]
Abstract
Thoracic aortic aneurysms are extremely burdensome to treat owing to their surgical complexity. In particular, major postoperative complications lower significantly patients' quality of life. Surgical treatment has recently shifted to thoracic endovascular aortic repair (TEVAR) to respect the patients' needs and improve postoperative quality of life. This procedure is radical and innovated for thoracic aortic pathology, but the devices and the delivery systems are immature because only a little over a decade and a half has passed since starting to use them. Ready-made stent-grafts were originally indicated only for degenerated aortic aneurysms, but aortic dissection and traumatic aortic transection will become the next targets for TEVAR. This review addresses the history and changes in TEVAR as well as the current TEVAR strategy. Finally, we describe a new trial of TEVAR for aortic dissections, traumatic aortic transections, and aortic arch aneurysms.
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Affiliation(s)
- Toru Kuratani
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-9871, Japan.
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116
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Hughes GC, Lee SM, Daneshmand MA, Bhattacharya SD, Williams JB, Tucker SW, McCann RL. Endovascular repair of descending thoracic aneurysms: results with "on-label" application in the post Food and Drug Administration approval era. Ann Thorac Surg 2010; 90:83-9. [PMID: 20609753 DOI: 10.1016/j.athoracsur.2010.03.052] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Revised: 03/16/2010] [Accepted: 03/19/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Most studies of thoracic endovascular aortic repair (TEVAR) published since the technology gained US Food and Drug Administration (FDA) approval in March 2005 have included multiple applications including dissection, trauma, and "hybrid" approaches, all of which are currently "off-label." However, little post-approval data exist for the only FDA-approved application, namely descending thoracic aneurysm (DTA). The purpose of this study was to examine our experience with TEVAR for aneurysms limited to the descending thoracic aorta. METHODS Between March 23, 2005 (date of initial FDA approval) and April 6, 2009, 210 TEVAR procedures were performed at our institution. Of these, 79 (38%) were for saccular (n = 31) or fusiform (n = 48) DTA and form the basis of this report. Patients requiring "hybrid" approaches other than carotid-subclavian bypass were excluded. Devices utilized were Gore TAG (W. L. Gore Associates, Flagstaff, AZ) (n = 67; 85%), Zenith TX2 (Cook Medical Incorporated, Bloomington, IN) (n = 10; 13%), and Medtronic Talent (Medtronic, Inc, Santa Rosa, CA) (n = 5; 6%); 3 (4%) patients received more than one type of device. RESULTS Median patient age was 73 +/- 4 years; 35 (44%) were female. Mean aortic diameter was 5.8 +/- 1.8 cm. Twenty-four (30%) procedures were urgent-emergent. Thirty-day in-hospital rates of death, stroke, and permanent paraplegia-paresis were 5.1% (n = 4; 1.9% elective mortality), 2.5% (n = 2), and 1.3% (n = 1), respectively. The median postoperative length of stay was 3.0 days (25th and 75th percentiles = 2 and 6, respectively). At a mean follow-up of 23 +/- 17 months (range, 6 to 55), there were 2 (2.5%) late aortic deaths from graft infection (n = 1) and aneurysm rupture (n = 1). Overall actuarial midterm survival is 73% at 55 months, with an aorta-specific actuarial survival of 86% during this same time interval. Five patients (6.3%) required late (>30 days) secondary endovascular re-intervention for type I (n = 4) or type II (n = 1) endoleak; re-intervention was successful in 4 of 5. CONCLUSIONS Despite the advanced age, comorbid conditions, and significant incidence of urgent-emergent status of patients presenting with DTA, on-label application of TEVAR yields excellent 30-day and midterm outcomes, especially when compared with historic rates of morbidity and mortality with open repair. However, "on-label" applications represent a minority of current TEVAR use, likely due to the relative scarcity of DTA. These data appear to support the increasing utilization of TEVAR as a treatment strategy for this pathology.
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Affiliation(s)
- G Chad Hughes
- Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA.
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117
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Koullias GJ, Wheatley GH. State-of-the-Art of Hybrid Procedures for the Aortic Arch: A Meta-Analysis. Ann Thorac Surg 2010; 90:689-97. [DOI: 10.1016/j.athoracsur.2009.12.016] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2009] [Revised: 12/06/2009] [Accepted: 12/09/2009] [Indexed: 10/19/2022]
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Coady MA, Ikonomidis JS, Cheung AT, Matsumoto AH, Dake MD, Chaikof EL, Cambria RP, Mora-Mangano CT, Sundt TM, Sellke FW. Surgical Management of Descending Thoracic Aortic Disease: Open and Endovascular Approaches. Circulation 2010; 121:2780-804. [PMID: 20530003 DOI: 10.1161/cir.0b013e3181e4d033] [Citation(s) in RCA: 138] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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119
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Kang J, Albadawi H, Casey PJ, Abbruzzese TA, Patel VI, Yoo HJ, Cambria RP, Watkins MT. The effects of systemic hypothermia on a murine model of thoracic aortic ischemia reperfusion. J Vasc Surg 2010; 52:435-43. [PMID: 20541344 DOI: 10.1016/j.jvs.2010.03.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2009] [Revised: 03/08/2010] [Accepted: 03/10/2010] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Hypothermia is widely used to mediate ischemia-reperfusion injury associated with repair of the thoracoabdominal aorta. Experiments were designed in a murine model of thoracic aortic ischemia-reperfusion (TAR) to evaluate the effect of moderate systemic hypothermia on neurologic function, spinal cord morphology, and indices of inflammation in critical organs. METHODS C57BL/6 mice were subjected to TAR under hypothermic (34 degrees C) or normothermic (38 degrees C) conditions, followed by 24 or 48 hours of normothermic reperfusion. Neurologic functions were assessed during reperfusion. Spinal cords were examined at 24 and 48 hours after reperfusion, and the degree of injury qualified by counting the number of viable motor neurons within the anterior horns. Keratinocyte chemokine, interleukin-6, and myeloperoxidase levels were measured from lung, liver, and kidney at 24 and 48 hours. RESULTS Normothermic TAR resulted in a dense neurologic deficit in all mice throughout the reperfusion period. Mice subjected to TAR under hypothermic conditions had transient, mild neurologic deficit during the initial periods of reperfusion. Between 24 and 48 hours, delayed paralysis developed in half of these mice, whereas the other half remained neurologically intact. Spinal cord histology showed a graded degree of injury that correlated with neurologic function. There was no correlation between markers of inflammation in various organs and neurologic outcomes following TAR. CONCLUSION Systemic moderate hypothermia was protective against immediate paralysis after TAR in all cases and was associated with delayed paralysis in 50% of mice. This study suggests that delayed-onset paralysis may be the result of a local insult, rather than a systemic inflammatory event, precipitating spinal cord injury.
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Affiliation(s)
- Jeanwan Kang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Mass, USA
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120
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Holt PJ, Johnson C, Hinchliffe RJ, Morgan R, Jahingiri M, Loftus IM, Thompson MM. Outcomes of the endovascular management of aortic arch aneurysm: Implications for management of the left subclavian artery. J Vasc Surg 2010; 51:1329-38. [DOI: 10.1016/j.jvs.2009.10.131] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2009] [Revised: 10/20/2009] [Accepted: 10/21/2009] [Indexed: 10/19/2022]
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121
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Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA, Kouchoukos NT, Lytle BW, Milewicz DM, Reich DL, Sen S, Shinn JA, Svensson LG, Williams DM. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology,American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons,and Society for Vascular Medicine. J Am Coll Cardiol 2010; 55:e27-e129. [PMID: 20359588 DOI: 10.1016/j.jacc.2010.02.015] [Citation(s) in RCA: 1002] [Impact Index Per Article: 71.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Development of a simplified spinal cord ischemia model in mice. J Neurosci Methods 2010; 189:246-51. [PMID: 20394775 DOI: 10.1016/j.jneumeth.2010.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2010] [Revised: 04/04/2010] [Accepted: 04/05/2010] [Indexed: 11/24/2022]
Abstract
Use of genetically manipulated mice facilitates understanding pathological mechanisms in many diseases and contributes to therapy development. However, there is no practical and clinically relevant mouse model available for spinal cord ischemia. This report introduces a simplified long-term outcome mouse model of spinal cord ischemia. Male C57Bl/6J mice were anesthetized with isoflurane and endotracheally intubated. The middle segment of the thoracic aorta was clamped for 0, 8, 10 or 12 min via left lateral thoracotomy. Rectal temperature was maintained at 37.0+/-0.5 degrees C. A laser Doppler probe was used to measure lumbar spinal cord blood flow during thoracic aorta cross-clamping. Open field locomotor function and rotarod performance were evaluated at 1h and 1, 3, 5, and 7 days post-injury. Surviving neurons in the lumbar ventral horn were counted at 7 days post-injury. Cross-clamping the middle segment of the thoracic aorta resulted in approximately 90% blood flow reduction in the lumbar spinal cord. Neurological deficit and neuronal cell death were associated with ischemia duration. Another set of mice were subjected to 10 min aortic clamping or sham surgery and neurological function was examined at 1h and 1, 3, 5, 7, 14, and 28 days. Four of 5 mice (80%) in the injured group survived 28 days and had significant neurological deficit. This study indicates that cross-clamping of the aorta via left thoracotomy is a simple and reliable method to induce spinal cord ischemia in mice allowing definition of long-term outcome.
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Torsello GB, Torsello GF, Osada N, Teebken OE, Ratusinski CM, Nienaber CA. Midterm Results From the TRAVIATA Registry: Treatment of Thoracic Aortic Disease With the Valiant Stent Graft. J Endovasc Ther 2010; 17:137-50. [PMID: 20426628 DOI: 10.1583/09-2905.1] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Murphy EH, Davis CM, Modrall JG, Clagett GP, Arko FR. Effects of ethnicity and insurance status on outcomes after thoracic endoluminal aortic aneurysm repair (TEVAR). J Vasc Surg 2010; 51:14S-20S. [DOI: 10.1016/j.jvs.2009.11.079] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Revised: 11/19/2009] [Accepted: 11/24/2009] [Indexed: 10/19/2022]
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125
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Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease a systematic review and meta-analysis of comparative studies. J Am Coll Cardiol 2010; 55:986-1001. [PMID: 20137879 DOI: 10.1016/j.jacc.2009.11.047] [Citation(s) in RCA: 285] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Revised: 11/12/2009] [Accepted: 11/19/2009] [Indexed: 01/28/2023]
Abstract
OBJECTIVES The purpose of this study was to determine whether thoracic endovascular aortic repair (TEVAR) reduces death and morbidity compared with open surgical repair for descending thoracic aortic disease. BACKGROUND The role of TEVAR versus open surgery remains unclear. Metaregression can be used to maximally inform adoption of new technologies by utilizing evidence from existing trials. METHODS Data from comparative studies of TEVAR versus open repair of the descending aorta were combined through meta-analysis. Metaregression was performed to account for baseline risk factor imbalances, study design, and thoracic pathology. Due to significant heterogeneity, registry data were analyzed separately from comparative studies. RESULTS Forty-two nonrandomized studies involving 5,888 patients were included (38 comparative studies, 4 registries). Patient characteristics were balanced except for age, as TEVAR patients were usually older than open surgery patients (p = 0.001). Registry data suggested overall perioperative complications were reduced. In comparative studies, all-cause mortality at 30 days (odds ratio [OR]: 0.44, 95% confidence interval [CI]: 0.33 to 0.59) and paraplegia (OR: 0.42, 95% CI: 0.28 to 0.63) were reduced for TEVAR versus open surgery. In addition, cardiac complications, transfusions, reoperation for bleeding, renal dysfunction, pneumonia, and length of stay were reduced. There was no significant difference in stroke, myocardial infarction, aortic reintervention, and mortality beyond 1 year. Metaregression to adjust for age imbalance, study design, and pathology did not materially change the results. CONCLUSIONS Current data from nonrandomized studies suggest that TEVAR may reduce early death, paraplegia, renal insufficiency, transfusions, reoperation for bleeding, cardiac complications, pneumonia, and length of stay compared with open surgery. Sustained benefits on survival have not been proven.
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126
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Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA, Kouchoukos NT, Lytle BW, Milewicz DM, Reich DL, Sen S, Shinn JA, Svensson LG, Williams DM. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010; 121:e266-369. [PMID: 20233780 DOI: 10.1161/cir.0b013e3181d4739e] [Citation(s) in RCA: 1179] [Impact Index Per Article: 84.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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127
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Vascular injury in thoracolumbar spinal surgeries and role of angiography in early diagnosis and management. JOURNAL OF SPINAL DISORDERS & TECHNIQUES 2010; 23:418-24. [PMID: 20124921 DOI: 10.1097/bsd.0b013e3181b63f33] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN A retrospective outcomes study. OBJECTIVE To stress on the importance of early diagnosis with the help of angiography and proper treatment of vascular injuries occurring during thoracolumbar surgeries and to report our results. SUMMARY OF BACKGROUND DATA Vascular injury is a rare but dangerous complication that can develop during thoracolumbar surgeries and if not treated properly then it can lead to severe complications including the death of the patient. METHODS The patients included in this study were the ones who were suspected to have a possible vascular injury after a thoracolumbar surgery. Contrast enhanced computed tomography was performed for patients having clinical signs suggesting vascular injury. Among these patients, who were suspected to have active bleeding and major vessel injury on computed tomography were further subjected to angiography. RESULTS Of the 10 cases included in the study, vascular injury was identified to be arterial in origin in 8 cases and venous in 3 cases. Among the 8 cases of identified arterial injury, angiography was performed in 4 cases, of which 3 were found to have active bleeding and were subjected to immediate intervention. Of the 4 cases in which angiography was not performed, 3 of them expired at variable postoperative periods. Complications developed in total 5 cases including 3 cases of mortality, 1 case of infection, and 1 case of cauda equina syndrome. CONCLUSIONS The vascular injuries during thoracolumbar spinal surgeries need immediate and aggressive treatment. In arterial injuries, we can prevent serious consequences by subjecting the patient to an angiography as early as possible followed by a therapeutic embolization. In contrast, for venous injuries if hemostasis has been confirmed, then an immediate intervention may not be always required.
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128
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Replacement of the descending thoracic aorta: Contemporary outcomes using hypothermic circulatory arrest. J Thorac Cardiovasc Surg 2010; 139:249-55. [DOI: 10.1016/j.jtcvs.2009.08.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2009] [Revised: 07/07/2009] [Accepted: 08/07/2009] [Indexed: 11/19/2022]
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129
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Hughes GC, Daneshmand MA, Balsara KR, Achneck HA, Sileshi B, Lee SM, McCann RL. "Hybrid" repair of aneurysms of the transverse aortic arch: midterm results. Ann Thorac Surg 2010; 88:1882-7; discussion 1887-8. [PMID: 19932255 DOI: 10.1016/j.athoracsur.2009.07.027] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2008] [Revised: 07/03/2009] [Accepted: 07/10/2009] [Indexed: 11/15/2022]
Abstract
BACKGROUND Aneurysms of the transverse aortic arch, especially those involving the mid to distal arch, are technically challenging to repair with conventional open techniques. We present our results with a combined open/endovascular approach ("hybrid repair") in such patients. METHODS From August 11, 2005, to September 18, 2008, 28 patients underwent hybrid arch repair. For patients (n = 9) with distal arch aneurysms but 2 cm or more of proximal landing zone (PLZ) distal to the innominate artery, right to left carotid-carotid bypass was performed to create a PLZ by covering the left carotid origin. For patients (n = 12) with mid arch aneurysms but 2 cm or more of PLZ in the ascending aorta, proximal ascending aorta-based arch debranching was performed. For patients (n = 7) with arch aneurysms with no adequate PLZ ("mega aorta") but adequate distal landing zone, a stage 1 elephant trunk procedure was performed to create a PLZ. For the first two groups, endovascular aneurysm exclusion and debranching were performed concomitantly, whereas the procedures were staged for the group undergoing an initial elephant trunk procedure. RESULTS Mean patient age was 64 +/- 13 years. Primary technical success rate was 100%. Thirty-day/in-hospital rates of death, stroke, and permanent paraplegia/paresis were 0%, 0%, and 3.6% (n = 1), respectively. At a mean follow-up of 14 +/- 11 months, there have been no late aortic-related events. Two patients (7%) required secondary endovascular reintervention for a type 1 endovascular leak. No patient has a type 1 or 3 endovascular leak at latest follow-up. CONCLUSIONS Hybrid repair of transverse aortic arch aneurysms appears safe and effective at midterm follow-up and may represent a technical advance in the treatment of this pathology.
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Affiliation(s)
- G Chad Hughes
- Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA.
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130
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Matsumura JS, Lee WA, Mitchell RS, Farber MA, Murad MH, Lumsden AB, Greenberg RK, Safi HJ, Fairman RM. The Society for Vascular Surgery Practice Guidelines: Management of the left subclavian artery with thoracic endovascular aortic repair. J Vasc Surg 2009; 50:1155-8. [DOI: 10.1016/j.jvs.2009.08.090] [Citation(s) in RCA: 292] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Revised: 08/19/2009] [Accepted: 08/19/2009] [Indexed: 11/17/2022]
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131
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Endovascular grafts for treatment of traumatic injury to the aortic arch and great vessels. ACTA ACUST UNITED AC 2009; 67:660-71. [PMID: 19741416 DOI: 10.1097/ta.0b013e3181b2894c] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Treatment of traumatic vascular injury using endovascular techniques has evolved as endovascular capabilities have advanced over the past several decades. Several endovascular techniques have been employed to address the challenges of traumatic arterial injury, including coil embolization and the use of stents, which may be either bare metal or covered with graft material. Compared with traditional surgical repair, endovascular stent grafting for the repair of traumatic arterial injury offers the advantage of decreased morbidity because a remote access site may be used, avoiding surgical dissection and lengthy operating times. METHODS A Medline (1995-2007) search was performed to find all studies discussing the use of endovascular means to treat supradiaphragmatic arterial trauma. RESULTS In this review of 195 studies published between January 1995 and December 2007, the overall technical success rate of endovascular treatment of supradiaphragmatic arterial injury was 96.7%, and the complication rate was 6.4%. CONCLUSION The results of this review suggest a potential morbidity and mortality benefit over traditional open repair; however, long-term data are lacking. Long-term follow-up for stent durability is of particular concern in the trauma population, which tends to comprise younger patients with minimal atherosclerotic disease. The success of endovascular techniques is also limited by the availability of skilled interventionalists, properly outfitted angiography suites, and suitable stent graft devices. Despite these challenges, the potential advantages of endovascular stenting make it a welcome addition to the armamentarium of the vascular interventionalist who treats arterial traumatic injuries.
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132
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Velázquez C, Velázquez J, Rodríguez E, Gutiérrez MA, Miranda N, García M, Araji O, Pérez E, Barquero JM, Infantes C. Tratamiento endovascular de los aneurismas ateroscleróticos de aorta torácica descendente. CIRUGIA CARDIOVASCULAR 2009. [DOI: 10.1016/s1134-0096(09)70135-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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133
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Thoracoabdominal aneurysm repair: Hybrid versus open repair. J Vasc Surg 2009; 50:15-22. [DOI: 10.1016/j.jvs.2008.12.051] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2008] [Revised: 12/04/2008] [Accepted: 12/21/2008] [Indexed: 11/20/2022]
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134
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Bicknell C, Riga C, Wolfe J. Prevention of Paraplegia during Thoracoabdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2009; 37:654-60. [DOI: 10.1016/j.ejvs.2009.02.008] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Accepted: 02/21/2009] [Indexed: 10/20/2022]
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135
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Cooper DG, Walsh SR, Sadat U, Noorani A, Hayes PD, Boyle JR. Neurological complications after left subclavian artery coverage during thoracic endovascular aortic repair: A systematic review and meta-analysis. J Vasc Surg 2009; 49:1594-601. [DOI: 10.1016/j.jvs.2008.12.075] [Citation(s) in RCA: 149] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2008] [Revised: 11/14/2008] [Accepted: 12/30/2008] [Indexed: 11/30/2022]
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136
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Girn HRS, McPherson S, Nicholson T, Mavor AID, Homer-Vanniasinkam S, Gough MJ. Short series of emergency stent-graft repair of symptomatic penetrating thoracic aortic ulcers (PTAU). Vasc Med 2009; 14:123-8. [DOI: 10.1177/1358863x08098951] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Abstract Acute penetrating thoracic aortic ulcers (PTAU) are associated with vessel rupture, particularly when intramural haematoma (IMH) is present. Although surgical repair is the treatment of choice for PTAU in the aortic arch, definitive treatment of PTAU in other locations of the thoracic aorta remains controversial, particularly in this frail cohort of patients. Recent series of elective and semi-elective endovascular stent-graft repair of PTAU of the descending thoracic aorta show comparable results with the previously advocated best medical management. We report our results from a retrospective, observational study of acute stent-graft repair of symptomatic PTAU. Between 2000 and 2005, 11 patients (seven male, four female; median age 71 years) presented with acute PTAU. CT scans demonstrated an associated IMH in six, a contained leak in three or rupture in four unstable patients. All were covered by a single endovascular stent [Gore (5), Talent (5), Zenith (1); 10 inserted via the groin and one via iliac conduit within 1 week of presentation (five < 24 h). Technical success was 90.90% (10/11) and 3/11 (27%) died within 30 days (two ARDS, one a persistent leak and rupture at 48 h). One patient developed transient paraplegia; three haemothoraces required chest drains, one of which subsequently required empyema drainage. In survivors, CT scans were satisfactory, with no further intervention required at 32.5 (6–66) months of median follow-up. In conclusion, endovascular management of acute PTAU appears effective and durable with mortality rates that are likely to be better than for open surgery. However, haemodynamic compromise at presentation remains a robust denominator of over-all survival.
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Affiliation(s)
- HRS Girn
- Leeds Vascular Institute, Leeds General Infirmary
| | - S McPherson
- Department of Interventional Radiology, Leeds General Infirmary
| | - T Nicholson
- Department of Interventional Radiology, Leeds General Infirmary
| | - AID Mavor
- Leeds Vascular Institute, Leeds General Infirmary
| | | | - MJ Gough
- Leeds Vascular Institute, Leeds General Infirmary
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137
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McDonnell CO, Haider SN, Colgan MP, Shanik GD, Moore DJ, Madhavan P. Endovascular management of thoracic aortic pathology. Surgeon 2009; 7:24-30. [PMID: 19241982 DOI: 10.1016/s1479-666x(09)80063-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Endovascular technology has revolutionised the management of abdominal aortic aneurysmal disease but the less frequent occurrence of pathology in the thoracic aorta has meant that evidence demonstrating the primacy of endovascular treatment strategies in this portion of the vessel is less convincing. Herein we summarise the best available evidence to date. METHODS A comprehensive search of the surgical and radiological literature using the search term 'endovascular thoracic aorta' was conducted. FINDINGS AND CONCLUSIONS The vast majority of patients treated by thoracic aortic stent grafting have had their treatment outside the context of a randomised trial. While it would seem that endovascular repair is the treatment of choice for the thoracic aorta, the present evidence is based on single centre case series and is anecdotal at best.
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Affiliation(s)
- C O McDonnell
- Department ofVascular Surgery, Mater Misericordiae University Hospital, Dublin, Ireland.
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138
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Fehrenbacher JW, McCready RA. Erosion of elephant trunk Dacron graft limb by thoracic endograft causing acute aneurysm expansion. J Vasc Surg 2009; 49:491-3. [PMID: 19216967 DOI: 10.1016/j.jvs.2008.08.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2008] [Revised: 08/28/2008] [Accepted: 08/31/2008] [Indexed: 11/28/2022]
Abstract
We recently treated a patient in whom a Gore TAG thoracic endograft (W.L. Gore and Assoc, Flagstaff, Arix) had been used to repair a descending thoracic aneurysm as the second stage of a hybrid procedure. This patient had previously undergone repair of ascending and aortic arch aneurysms, with an elephant trunk graft limb placed in the descending thoracic aorta for subsequent repair of the descending thoracic aneurysm. Eight months after placement of the thoracic endograft, the patient presented with an acutely expanding and symptomatic thoracic aneurysm. The patient was operated on urgently. The proximal portion of the endograft had eroded into the previously placed Dacron elephant trunk limb. The proximal portion of the endograft was removed and was replaced with a Dacron graft. The management of this patient forms the basis of this report.
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Affiliation(s)
- John W Fehrenbacher
- Department of Cardiovascular Surgery, Methodist Hospital, Clarian Health Partners, Indianapolis, Indiana, USA.
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139
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Martin DJ, Martin TD, Hess PJ, Daniels MJ, Feezor RJ, Lee WA. Spinal cord ischemia after TEVAR in patients with abdominal aortic aneurysms. J Vasc Surg 2009; 49:302-6; discussion 306-7. [DOI: 10.1016/j.jvs.2008.08.119] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2008] [Revised: 08/25/2008] [Accepted: 08/29/2008] [Indexed: 11/27/2022]
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140
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Day C, Buckenham T. Endovascular Repair of the Thoracic Aorta: Predictors of 30-Day Mortality in Patients on the New Zealand Thoracic Aortic Stent Database (NZ TAS). Eur J Vasc Endovasc Surg 2009; 37:160-5. [DOI: 10.1016/j.ejvs.2008.09.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Accepted: 09/22/2008] [Indexed: 11/15/2022]
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141
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Neurologic outcomes from high risk descending thoracic and thoracoabdominal aortic operations in the era of endovascular repair. Neurocrit Care 2009; 9:344-51. [PMID: 18483880 DOI: 10.1007/s12028-008-9104-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Spinal cord ischemia and stroke are recognized complications of descending thoracic (DTA) and thoracoabdominal aortic (TAA) operations. However, there are limited data available on outcomes since the advent of thoracic endovascular aortic repair (TEVAR). METHODS We reviewed charts from consecutive patients who underwent open DTA and TAA operations, excluding type IV repair, from January, 2000 through April, 2005. RESULTS A total of 224 open DTA and TAA operations were included in the analysis. During this period 108 additional patients received TEVAR, accounting for 66% of all DTA repairs. Among the 224 patients who underwent open surgery, 63 patients (28%) developed spinal ischemia postprocedure, 13 (6%) had a stroke, and 9 (4%) had both. The 30 day in-hospital mortality was 18%. Neurologic complications were strongly associated with mortality: 64% of patients with stroke died compared to 17% without (P < 0.001) and 39% of patients with spinal ischemia died compared to 14% without (P < 0.001). At discharge, 29% had a poor outcome from surgery, defined as death or moderate-to-severe neurologic disability. A multivariable logistic regression incorporating characteristics known prior to surgery resulted in a score to stratify risk of poor outcome by giving one point each for age > or =60, history of cerebrovascular disease, Crawford extent II or III repair, and acute rupture. Patients with score > or =3 had an estimated 60% risk for poor outcome, while those with score < or =1 had an estimated risk of 7-11%. CONCLUSIONS Ischemic neurologic complications were frequent and strongly associated with poor outcomes after open DTA and TAA repair among patients not eligible for TEVAR. Risk of death or neurologic disability can be estimated based on factors known prior to surgery.
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142
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Thompson JL, Suri RM, McKellar SH, Schaff HV. Laparoscopic Transdiaphragmatic Access to the Apex of the Left Ventricle of the Heart. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2009. [DOI: 10.1177/155698450900400106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Rakesh M. Suri
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
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143
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Laparoscopic transdiaphragmatic access to the apex of the left ventricle of the heart. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2009; 4:27-31. [PMID: 22436900 DOI: 10.1097/imi.0b013e318198779a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE : Delivery of a collapsable aortic valve prosthesis via the left ventricular (LV) apex has proven problematic clinically. We describe our experience with a novel technique for a laparoscopic transdiaphragmatic approach to the LV outflow tract (LVOT). METHODS : Laparoscopic transabdominal access to the left ventricle was achieved in four live swine and one human cadaver using three abdominal laparoscopic trocars. Pericardioscopy and cardioscopy were performed. A hemostatic purse-string suture was placed laparoscopically at the apex of the left ventricle in one pig, and an instrument passed through the purse-string and into the LVOT. After the procedure, a thoracotomy was performed and the heart explanted for gross examination. RESULTS : Transdiaphragmatic exposure of the LV apex was accomplished at a mean of 23 minutes. Hemodynamic stability was maintained in all animals and the pleural cavities were not violated. Pericardioscopy allowed visualization of both right and left pulmonary veins along with the left atrial appendage. In situ cardioscopy confirmed that access to the LVOT and the aortic annulus was possible from the LV apex entry site. CONCLUSIONS : Laparoscopic transdiaphragmatic approach to the LVOT is a possible route for minimally invasive beating heart aortic valve implantation. This strategy permits a straight transapical line of access to the aortic valve; avoiding the potential for cardiac torsion via a thoracotomy.
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Parsa CJ, Hughes GC. Surgical Options to Contend with Thoracic Aortic Pathology. Semin Roentgenol 2009; 44:29-51. [PMID: 19064070 DOI: 10.1053/j.ro.2008.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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145
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Ting AC, Cheng SW, Ho P, Chan YC, Poon JT, Cheung GC. Endovascular Repair for Thoracic Aortic Pathologies—Early and Midterm Results. Asian J Surg 2009; 32:39-46. [DOI: 10.1016/s1015-9584(09)60007-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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146
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Abstract
In 2005, the findings of the multicenter Gore Tag study led to United States Food and Drug Administration approval for endovascular repair of thoracic aortic aneurysms (TEVAR). TEVAR provides a therapeutic option for patients who have thoracic aortic aneurysm and for the treatment of type B aortic dissection with malperfusion. Spinal cord ischemia and stroke are recognized neurologic complications of TEVAR. Identification of high-risk patients combined with targeted anesthetic and perioperative management may decrease the risk of neurologic complications after TEVAR.
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147
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Predictors of mortality after endovascular repair of the thoracic descending aorta--the preliminary New Zealand experience. Eur J Vasc Endovasc Surg 2008; 37:166-7. [PMID: 19081274 DOI: 10.1016/j.ejvs.2008.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Accepted: 11/12/2008] [Indexed: 11/21/2022]
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148
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Hoang JK, Martinez S, Hurwitz LM. Imaging of the postoperative thoracic aorta: the spectrum of normal and abnormal findings. Semin Roentgenol 2008; 44:52-62. [PMID: 19064071 DOI: 10.1053/j.ro.2008.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jenny K Hoang
- Department of Radiology, Division of Cardiothoracic Imaging, Duke University Medical Center, Durham, NC 27710, USA.
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Hughes GC, Sulzer CF, McCann RL, Swaminathan M. Endovascular Approaches to Complex Thoracic Aortic Disease. Semin Cardiothorac Vasc Anesth 2008; 12:298-319. [DOI: 10.1177/1089253208328667] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Diseases of the thoracic aorta remain among the most lethal and difficult to treat conditions. In 2005, the US Food and Drug Administration approved the first endoprosthesis for the treatment of aneurysms of the descending thoracic aorta; at present, there are 3 thoracic devices approved by the US Food and Drug Administration. Although approved only for the treatment of descending aneurysms, thoracic endografting has other potential off-label applications, including acute and chronic aortic dissection and traumatic aortic transection. Endovascular repair of thoracic aortic pathology is emerging as the preferred treatment strategy in certain patients, as increasing data suggest that endovascular repair may be performed with lower peri-operative morbidity and mortality rates and similar midterm survival, when compared with standard open repair. However, because of anatomic constraints related to required endograft seal zones, a significant number of patients are excluded from standard endovascular repair. Hybrid techniques, including open aortic arch and thoracoabdominal debranching procedures, have been described to allow creation of proximal and/or distal landing zones for the stent graft seal. This review describes the surgical and anesthetic considerations relevant to thoracic endografting, with an emphasis on hybrid procedures used to treat more complex thoracic aortic pathology. Hybrid techniques may be performed with lower rates of morbidity and mortality than conventional open repair, and they appear to be a safe alternative to open repair for thoracoabdominal and aortic arch aneurysms in properly selected patients with significant comorbidity or prior open aortic surgery.
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Affiliation(s)
- G. Chad Hughes
- Division of Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina,
| | - Christopher F. Sulzer
- Service d'Anesthesiologie, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Richard L. McCann
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Madhav Swaminathan
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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Xenos ES, Abedi NN, Davenport DL, Minion DJ, Hamdallah O, Sorial EE, Endean ED. Meta-analysis of endovascular vs open repair for traumatic descending thoracic aortic rupture. J Vasc Surg 2008; 48:1343-51. [DOI: 10.1016/j.jvs.2008.04.060] [Citation(s) in RCA: 178] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Revised: 03/25/2008] [Accepted: 04/25/2008] [Indexed: 10/21/2022]
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