151
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Marcheix B, Rousseau H, Bongard V, Heijmen RH, Nienaber CA, Ehrlich M, Amabile P, Beregi JP, Fattori R. Stent Grafting of Dissected Descending Aorta in Patients With Marfan's Syndrome. JACC Cardiovasc Interv 2008; 1:673-80. [DOI: 10.1016/j.jcin.2008.10.005] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Revised: 10/06/2008] [Accepted: 10/17/2008] [Indexed: 11/26/2022]
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152
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Gutsche JT, Cheung AT. Reply. Ann Thorac Surg 2008. [DOI: 10.1016/j.athoracsur.2008.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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153
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Gottardi R, Funovics M, Eggers N, Hirner A, Dorfmeister M, Holfeld J, Zimpfer D, Schoder M, Donas K, Weigang E, Lammer J, Grimm M, Czerny M. Supra-aortic Transposition for Combined Vascular and Endovascular Repair of Aortic Arch Pathology. Ann Thorac Surg 2008; 86:1524-9. [PMID: 19049743 DOI: 10.1016/j.athoracsur.2008.06.075] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Revised: 06/13/2008] [Accepted: 06/13/2008] [Indexed: 02/08/2023]
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154
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Peterson MD, Wheatley GH, Kpodonu J, Williams JP, Ramaiah VG, Rodriguez-Lopez JA, Diethrich EB. Treatment of type II endoleaks associated with left subclavian artery coverage during thoracic aortic stent grafting. J Thorac Cardiovasc Surg 2008; 136:1193-9. [PMID: 19026802 DOI: 10.1016/j.jtcvs.2008.05.036] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2007] [Revised: 03/27/2008] [Accepted: 05/04/2008] [Indexed: 11/29/2022]
Affiliation(s)
- Mark D Peterson
- Division of Cardiovascular Surgery, Arizona Heart Institute, Phoenix, Ariz 85006, USA
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155
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Sayer D, Bratby M, Brooks M, Loftus I, Morgan R, Thompson M. Aortic Morphology Following Endovascular Repair of Acute and Chronic Type B Aortic Dissection: Implications for Management. Eur J Vasc Endovasc Surg 2008; 36:522-9. [DOI: 10.1016/j.ejvs.2008.06.023] [Citation(s) in RCA: 152] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2008] [Accepted: 06/25/2008] [Indexed: 11/28/2022]
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156
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Kische S, Akin I, Ince H, Rehders TC, Schneider H, Ortak J, Nienaber CA. Reparación mediante implantación de stents en enfermedades agudas y crónicas de la aorta torácica. Rev Esp Cardiol 2008. [DOI: 10.1157/13126047] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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157
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Lin PH, Huynh TT, Kougias P, Huh J, LeMaire SA, Coselli JS. Descending Thoracic Aortic Dissection: Evaluation and Management in the Era of Endovascular Technology. Vasc Endovascular Surg 2008; 43:5-24. [DOI: 10.1177/1538574408318475] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute aortic dissection is a relatively uncommon but highly lethal condition. Without proper treatment, devastating consequences can occur due to aortic rupture, cardiac tamponade, or irreversible ischemia involving the spinal cord or the visceral organs. The treatment strategy of this condition is in part influenced by the location and the severity of aortic dissection as immediate surgical intervention is necessary in acute ascending aortic dissection, whereas medical therapy is the initial treatment approach in uncomplicated descending aortic dissection. Recent advances of endovascular technology have broadened the potential application of this catheter-based therapy in aortic pathologies, including descending thoracic aortic dissection. In this article, the etiology, pathogenesis, and classification of this condition are discussed. The diagnostic benefits of various imaging modalities for descending aortic dissection are also discussed. Current treatment strategies, including medical, surgical, and catheter-based interventions, are reviewed. Lastly, clinical experiences of endovascular treatment for descending aortic dissection and various endovascular devices potentially applicable for this condition are discussed.
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Affiliation(s)
- Peter H. Lin
- Michael E. DeBakey Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, and Michael E. DeBakey VA Medical Center,
| | - Tam T. Huynh
- Michael E. DeBakey Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, and Michael E. DeBakey VA Medical Center
| | - Panagiotis Kougias
- Michael E. DeBakey Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, and Michael E. DeBakey VA Medical Center
| | - Joseph Huh
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, and Texas Heart Institute at St. Luke's Episcopal Hospital Houston, Texas
| | - Scott A. LeMaire
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, and Texas Heart Institute at St. Luke's Episcopal Hospital Houston, Texas
| | - Joseph S. Coselli
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, and Texas Heart Institute at St. Luke's Episcopal Hospital Houston, Texas
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158
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Akin I, Kische S, Rehders TC, Chatterjee T, Schneider H, Körber T, Nienaber CA, Ince H. Current role of endovascular therapy in Marfan patients with previous aortic surgery. Vasc Health Risk Manag 2008; 4:59-66. [PMID: 18629349 PMCID: PMC2464744 DOI: 10.2147/vhrm.2008.04.01.59] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The Marfan syndrome is a heritable disorder of the connective tissue which affects the cardiovascular, ocular, and skeletal system. The cardiovascular manifestation with aortic root dilatation, aortic valve regurgitation, and aortic dissection has a prevalence of 60% to 90% and determines the premature death of these patients. Thirty-four percent of the patients with Marfan syndrome will have serious cardiovascular complications requiring surgery in the first 10 years after diagnosis. Before aortic surgery became available, the majority of the patients died by the age of 32 years. Introduction in the aortic surgery techniques caused an increase of the 10 year survival rate up to 97%. The purpose of this article is to give an overview about the feasibility and outcome of stent-graft placement in the descending thoracic aorta in Marfan patients with previous aortic surgery.
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Affiliation(s)
- Ibrahim Akin
- Department of Medicine, Division of Cardiology at the University Hospital Rostock, Rostock School of Medicine, Ernst-Heydemann-Str. 6, 18057 Rostock, Germany
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159
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Fairman RM, Criado F, Farber M, Kwolek C, Mehta M, White R, Lee A, Tuchek JM. Pivotal results of the Medtronic Vascular Talent Thoracic Stent Graft System: The VALOR Trial. J Vasc Surg 2008; 48:546-54. [DOI: 10.1016/j.jvs.2008.03.061] [Citation(s) in RCA: 239] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Revised: 03/25/2008] [Accepted: 03/29/2008] [Indexed: 11/26/2022]
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160
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Woo EY, Carpenter JP, Jackson BM, Pochettino A, Bavaria JE, Szeto WY, Fairman RM. Left subclavian artery coverage during thoracic endovascular aortic repair: A single-center experience. J Vasc Surg 2008; 48:555-60. [DOI: 10.1016/j.jvs.2008.03.060] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2008] [Revised: 03/28/2008] [Accepted: 03/31/2008] [Indexed: 10/21/2022]
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161
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Girdauskas E, Falk V, Kuntze T, Borger MA, Schmidt A, Scheinert D, Mohr FW. Secondary surgical procedures after endovascular stent grafting of the thoracic aorta: successful approaches to a challenging clinical problem. J Thorac Cardiovasc Surg 2008; 136:1289-94. [PMID: 19026818 DOI: 10.1016/j.jtcvs.2008.05.053] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2008] [Revised: 04/07/2008] [Accepted: 05/19/2008] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To evaluate the results of open surgical repair for complications after endovascular thoracic aorta stenting. METHODS A total of 14 patients (8 male, mean age 59.8 +/- 14.8 years) underwent conventional surgical therapy at our institution over a 5-year period after previous thoracic aortic stent implantation. The indications for surgery, intraoperative strategy, and perioperative and follow-up results were analyzed. RESULTS The indication for stent implantation was type B aortic dissection in 10 patients, expanding degenerative thoracic aneurysm in 3 patients, and pseudoaneurysm in 1 patient. The median interval to conventional surgery after stent implantation was 4.5 months (range 0.1-49 months). The indication for surgery was persistent type I endoleak with progressive aneurysm enlargement in 7 patients, aortoesophageal fistula in 2 patients, retrograde type A dissection in 2 patients, infection of the endoprosthesis in 2 patients, and aortic valve insufficiency caused by perforation of noncoronary and right coronary cusps in 1 patient. The endograft had to be removed in 9 (64%) patients, and 5 (36%) patients required replacement of the thoracoabdominal aorta. In-hospital mortality was 7% (1 patient). No patients had a postoperative stroke or paraparesis. Eleven (79%) patients are alive after a mean follow-up of 13.5 +/- 10.1 months (range 1-36 months). CONCLUSIONS Secondary surgical procedures after stenting of the thoracic aorta can be performed with very good results, despite the challenging clinical scenarios. Identification of successful surgical strategies for this difficult clinical problem is important in the era of increasing endovascular therapy.
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162
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Why are we still talking about open repair of descending aneurysms? J Thorac Cardiovasc Surg 2008; 136:278-9. [PMID: 18692627 DOI: 10.1016/j.jtcvs.2008.05.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Accepted: 05/31/2008] [Indexed: 11/21/2022]
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163
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Minatoya K, Ogino H, Matsuda H, Sasaki H, Yagihara T, Kitamura S. Replacement of the descending aorta: Recent outcomes of open surgery performed with partial cardiopulmonary bypass. J Thorac Cardiovasc Surg 2008; 136:431-5. [DOI: 10.1016/j.jtcvs.2008.03.034] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2006] [Revised: 02/10/2008] [Accepted: 03/30/2008] [Indexed: 11/25/2022]
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164
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Hoffer EK, Forauer AR, Silas AM, Gemery JM. Endovascular Stent-Graft or Open Surgical Repair for Blunt Thoracic Aortic Trauma: Systematic Review. J Vasc Interv Radiol 2008; 19:1153-64. [DOI: 10.1016/j.jvir.2008.05.012] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Revised: 05/10/2008] [Accepted: 05/18/2008] [Indexed: 10/21/2022] Open
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165
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Fattori R, Tsai TT, Myrmel T, Evangelista A, Cooper JV, Trimarchi S, Li J, Lovato L, Kische S, Eagle KA, Isselbacher EM, Nienaber CA. Complicated Acute Type B Dissection: Is Surgery Still the Best Option? JACC Cardiovasc Interv 2008; 1:395-402. [PMID: 19463336 DOI: 10.1016/j.jcin.2008.04.009] [Citation(s) in RCA: 291] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Revised: 03/31/2008] [Accepted: 04/30/2008] [Indexed: 12/01/2022]
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166
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Mohan I, Hitos K, White G, Harris J, Stephen M, May J, Swinnen J, Fletcher J. Improved Outcomes with Endovascular Stent Grafts for Thoracic Aorta Transections. Eur J Vasc Endovasc Surg 2008; 36:152-157. [DOI: 10.1016/j.ejvs.2008.03.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Accepted: 03/28/2008] [Indexed: 11/30/2022]
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167
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Melissano G, Bertoglio L, Kahlberg A, Baccellieri D, Marrocco-Trischitta MM, Calliari F, Chiesa R. Evaluation of a new disease-specific endovascular device for type B aortic dissection. J Thorac Cardiovasc Surg 2008; 136:1012-8. [PMID: 18954644 DOI: 10.1016/j.jtcvs.2008.06.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2008] [Revised: 04/30/2008] [Accepted: 06/11/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The study objective was to evaluate the feasibility, safety, and early technical and clinical success rate of a new endovascular device specifically designed for aortic dissection that has recently become available in Europe. METHODS From June of 2005 to the present, the Zenith Dissection Endovascular System (William Cook Europe, Bjaerverskov, Denmark) was used in 11 selected patients (all male, with a median age of 58 years [range, 45-76 years]) with type B chronic aortic dissection with a compression or collapse of the true lumen. All procedures were performed under general anesthesia with preoperative cerebrospinal fluid drainage in 4 patients. One-step open surgical supra-aortic vessels re-routing was performed in 6 patients to obtain an adequate proximal landing zone: Left carotid-subclavian artery bypass was performed in 5 patients, and right-to-left common carotid artery bypass and left subclavian to common carotid artery transposition was performed in 1 patient. Clinical follow-up visits and computed tomography scans were obtained at 1, 6, and 12 months, and yearly thereafter. RESULTS A secondary technical success was obtained in all patients (100%), and 30-day clinical success was achieved in 10 patients (91%). A type IA entry flow was observed in 1 patient. No mortality was recorded. Occlusion of visceral/renal arteries, retrograde dissections, and device-induced tears in the intimal lamellae were not observed. Periprocedural morbidity included temporary renal failure in 1 patient and postimplantation syndrome with fever and leukocytosis for 23 days in 1 patient. No cases of paraplegia were recorded. At a median follow-up of 12 months (range, 2-30 months), we observed a clinical success rate of 91%. No migration of the device was observed. No late occlusion of the visceral or renal arteries was recorded at follow-up. CONCLUSION The perioperative and short-term follow-up results showed that the Zenith Dissection Endovascular System for the treatment of aortic dissection can be safely used without affecting the patency of the branches covered by the bare stent. However, these results need to be validated in a larger group of patients with a mid-term follow-up.
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Affiliation(s)
- Germano Melissano
- Vita-Salute University, Scientific Institute H San Raffaele, Milan, Italy.
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168
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Morales JP, Greenberg RK, Morales CA, Cury M, Hernandez AV, Lyden SP, Clair D. Thoracic aortic lesions treated with the Zenith TX1 and TX2 thoracic devices: Intermediate- and long-term outcomes. J Vasc Surg 2008; 48:54-63. [DOI: 10.1016/j.jvs.2008.02.028] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2007] [Revised: 02/15/2008] [Accepted: 02/15/2008] [Indexed: 11/28/2022]
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169
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Flecher E, Cluzel P, Bonnet N, Aubert S, Gaubert A, Pavie A, Jault F, Leprince P. Endovascular treatment of descending aortic dissection (type B): short- and medium-term results. Arch Cardiovasc Dis 2008; 101:94-9. [PMID: 18398393 DOI: 10.1016/s1875-2136(08)70265-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Optimal treatment of type B dissections is open to debate. The use of endoprostheses is an option that requires evaluation. AIM To report our experience with endoprostheses in type B aortic dissections. METHODS We report our short- and medium-term results with covered prostheses for the treatment of acute (n=7) and chronic (n=28) type B aortic dissections. The criteria used to indicate treatment were the same as those usually used for surgery: acute complications or dilated aneurysm. Cover of the main intimal tear was obtained in all cases with an improvement in symptoms in patients with acute dissections. RESULTS Early mortality was 14.3% (five patients), linked in three cases to the occurrence of a retrograde dissection of the ascending aorta. No neurological complications were observed. Four patients required an additional endovascular and/or surgical procedure. On early control scans, complete thrombosis of the false lumen at the thoracic level was observed in 40% of cases, partial thrombosis in 42.8% and an absence of thrombosis in 11.4%. After a mean follow-up of 20.8 months, one patient died of a pneumopathy. No secondary aneurysm expansion was noted at the thoracic stage whereas three patients presented with dilation of the abdominal aorta. CONCLUSION The results of treatment of type B dissections with covered endoprostheses are encouraging. However, the morbimortality associated with treatment and the uncertainty of long-term results do not allow the use of this therapeutic option outside the criteria usually recognized to indicate surgery.
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Affiliation(s)
- E Flecher
- Université Pierre-et-Marie-Curie Paris VI, AP-HP, Service de chirurgie cardiovasculaire et thoracique (Pr I. Gandjbakhch), Groupe hospitalier Pitié-Salpêtrière, Paris
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170
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Short-term conversion to open surgery after endovascular stent-grafting of the thoracic aorta: The Talent thoracic registry. J Thorac Cardiovasc Surg 2008; 135:1322-6. [DOI: 10.1016/j.jtcvs.2007.09.036] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2007] [Revised: 09/02/2007] [Accepted: 09/12/2007] [Indexed: 11/16/2022]
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171
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Chiesa R, Melissano G, Tshomba Y, Civilini E, Marone EM, Bertoglio L, Calliari FM, Di Bernardo B. Endovascular treatment of aortic arch aneurysms. J Vasc Bras 2008. [DOI: 10.1590/s1677-54492008000200002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND: Endovascular approach to the aortic arch is an appealing solution for selected patients. OBJECTIVE: To compare the technical and clinical success recorded in the different anatomical settings of endografting for aortic arch disease. METHODS: Between June 1999 and October 2006, among 178 patients treated at our institution for thoracic aorta disease with a stent-graft, the aortic arch was involved in 64 cases. According to the classification proposed by Ishimaru, aortic zone 0 was involved in 14 cases, zone 1 in 12 cases and zone 2 in 38 cases. A hybrid surgical procedure of supra-aortic debranching and revascularization was performed in 37 cases. RESULTS: Zone 0. Proximal neck length: 44±6 mm. Initial clinical success was 78.6%: two deaths (stroke), one type Ia endoleak. At a mean follow-up of 16.4±11 months the midterm clinical success was 85.7%. Zone 1. Proximal neck length: 28±5 mm. Initial clinical success was 66.7%: 0 deaths, four type Ia endoleaks. At a mean follow-up of 16.9±17.2 months the midterm clinical success was 75.0%. Zone 2. Proximal neck length: 30±5 mm. Initial clinical success was 84.2%: two deaths (one cardiac arrest, one multiorgan embolization), three type Ia endoleaks, one case of open conversion. Two cases of delayed transitory paraparesis/paraplegia were observed. At a mean follow-up of 28.0±17.2 months the midterm clinical success was 89.5%. CONCLUSIONS: This study and a literature review demonstrated that hybrid procedure for aortic arch pathology is feasible in selected patients at high risk for conventional surgery. Our experience is still limited by the relatively small sample size. We propose to reserve zone 1 for patients unfit for sternotomy or in cases with aortic neck length > 30 mm following left common carotid artery debranching. We recommend to perform complete aortic rerouting of the aortic arch in cases with lesser comorbidities and shorter aortic neck.
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172
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Surgical correction of failed thoracic endovascular aortic repair. J Vasc Surg 2008; 47:1195-202. [DOI: 10.1016/j.jvs.2008.01.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2007] [Revised: 12/12/2007] [Accepted: 01/02/2008] [Indexed: 11/21/2022]
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173
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Boufi M, Hartung O, Dona B, Di Pasquale F, Hakam Z, Marani I, Alimi YS. [Is endovascular treatment of acute thoracic aortic disease possible in centers where extracorporal circulation is not available?]. ACTA ACUST UNITED AC 2008; 33:72-8. [PMID: 18434054 DOI: 10.1016/j.jmv.2008.01.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2007] [Accepted: 01/23/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To determine whether access to extra-corporal circulation (ECC) is necessary to treat acute descending thoracic aorta disease. METHOD From January 2004 to May 2006, 16 patients underwent endovascular stent-graft repair of the descending thoracic aorta, among them 13 (81%) were treated in an emergency setting (nine men, mean age: 75.4 years, range 30-94 years). The indication was traumatic aortic rupture (n=3, 23%), complicated acute type B dissection (n=4; 31%), symptomatic or ruptured thoracic aortic aneurysm (n=4; 31%), aorto-esophageal fistula (n=1; 7,5%) and aortic intramural haematoma (n=1; 7,5%). Computed tomography showed hemomediastin and/or hemothorax in five patients (38%). Transesophageal echocardiography and angiography were performed in two (15%) and one patients respectively. Cerebrospinal fluid drainage was performed for two patients (15%). RESULTS Endovascular repair was successfully completed in 92.3% of cases. The 30-day mortality was 7.5% (n=1). There was one case (7.5%) of delayed paraplegia. Follow-up ranged between two and 24 months (mean 10.2), no rupture occurred. Three type I endoleaks were detected and only two were treated. Two none related additional mortalities were observed. None of these patients has needed ECC. CONCLUSION The unavailability of ECC does not seem to be a compromising factor in the management of thoracic aorta disease, however a good experience in endovascular techniques is required.
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Affiliation(s)
- M Boufi
- Service de chirurgie vasculaire, hôpital Nord, chemin des Bourrelly, 13915 Marseille cedex 20, France
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174
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[Management of thoracic aorta traumatism in 5 multiple traumatized patients]. Med Intensiva 2008; 32:194-7. [PMID: 18413125 DOI: 10.1016/s0210-5691(08)70937-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Thoracic aorta traumatism is a lesion associated to high morbidity-mortality at the site of the accident. In the 90's, treatment by placement of an endovascular stent was generalized with good results. In this work, we present a series of 5 clinical cases of patients admitted to the Intensive Care Unit of our hospital during the year 2006. Out of a total of 619 patients admitted in the same period, 121 (19.5%) were traumatic and 5 (4.13%) had thoracic aorta traumatisms. All of the patients were diagnosed by thoracic helical computed tomography on admission. Four patients had a pseudoaneurism of the aorta and underwent an operation. Three received endovascular treatment within the first 36 hours and the fourth on day 28 of admission. The fifth patient had a lesion of the intima and was not operated on. Posterior evolution was good in all the cases.
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175
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Noor N, Sadat U, Hayes PD, Thompson MM, Boyle JR. Management of the Left Subclavian Artery During Endovascular Repair of the Thoracic Aorta. J Endovasc Ther 2008; 15:168-76. [DOI: 10.1583/08-2406.1] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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176
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Brown KE, Eskandari MK, Matsumura JS, Rodriguez H, Morasch MD. Short and midterm results with minimally invasive endovascular repair of acute and chronic thoracic aortic pathology. J Vasc Surg 2008; 47:714-22; Discussion 722-3. [DOI: 10.1016/j.jvs.2007.12.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2007] [Revised: 11/27/2007] [Accepted: 12/01/2007] [Indexed: 10/22/2022]
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177
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Botta L, Buttazzi K, Russo V, Parlapiano M, Gostoli V, Di Bartolomeo R, Fattori R. Endovascular repair for penetrating atherosclerotic ulcers of the descending thoracic aorta: early and mid-term results. Ann Thorac Surg 2008; 85:987-92. [PMID: 18291184 DOI: 10.1016/j.athoracsur.2007.10.079] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2007] [Revised: 10/23/2007] [Accepted: 10/24/2007] [Indexed: 12/22/2022]
Abstract
BACKGROUND Penetrating atherosclerotic ulcer is an acute aortic syndrome with a high incidence of complications and rupture. Until now, no generally accepted therapeutic regimen has been established because the natural history of penetrating atherosclerotic ulcers is extremely variable. We investigated the technical feasibility and the early and mid-term results of endovascular stent graft treatment in a consecutive series of patients who had penetrating ulcers. METHODS From July 1997 to December 2006, 19 patients (14 men and 5 women) with a mean age of 71.8 +/- 7.2 years were treated for penetrating ulcers. Seven patients presented with an acute and symptomatic penetrating atherosclerotic ulcer, and in 12 patients, the ulcerative process was chronic. Clinical and imaging follow-up was performed in all patients using computed tomography or magnetic resonance imaging. RESULTS Technical success (insertion and deployment of the stent graft) was achieved in 18 of 19 cases. Neither paraplegia nor other perioperative complications occurred. Two patients treated under emergency conditions in whom the aortic syndrome was recognized after the acute onset died in the hospital (11.1%) of multiorgan failure. Follow-up has been completed in all patients, with a median time of 22 months (range, 3 to 108 months). Endoleaks occurred in 3 patients: 1 had surgical repair (5.6%), 1 leak sealed spontaneously, and 1 sealed after a second endovascular procedure. Late death occurred in 4 patients from non-aortic causes. CONCLUSIONS Endovascular stent graft repair is a low-invasive, attractive, and rational treatment option in aortic ulcers that provides satisfactory perioperative and mid-term results.
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Affiliation(s)
- Luca Botta
- Cardiac Surgery, Cardiothoracovascular Department, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
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Hybrid Laparorobotic Debranching and Endovascular Repair of Thoracoabdominal Aortic Aneurysm. Ann Vasc Surg 2008; 22:285-9. [DOI: 10.1016/j.avsg.2007.09.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2007] [Revised: 09/11/2007] [Accepted: 09/14/2007] [Indexed: 11/18/2022]
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Abstract
PURPOSE OF REVIEW The aim of this article is to review the recent relevant literature on endovascular repair of thoracic aortic aneurismal disease. RECENT FINDINGS The introduction of endovascular stent graft technology has ushered in a new era in therapy for diseases of the aortic arch and descending thoracic aorta. The technical challenges of stent graft deployment in the descending thoracic aorta, such as proximity to the great vessels and arch tortuosity, have been and remain a device engineering focus. More recently, repair of aortic arch aneurysms has been accomplished using both 'hybrid' (open and endovascular) and totally endovascular techniques. SUMMARY Endovascular stent grafting of aneurismal disease processes of the thoracic aorta is feasible and relatively safe. Exquisite judgment is essential for good results. These results generally rest on a broad knowledge base of thoracic aortic disease processes and experience in both open and endovascular surgery. Careful attention to patient anatomy and device specifications must be maintained. The key to the successful implementation of this technology lies in careful preoperative planning, intraoperative execution with safe device delivery, and prevention of central nervous system injury. Routine follow-up imaging is imperative to better understand the long-term results and indications for these new procedures.
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180
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Svensson LG, Kouchoukos NT, Miller DC, Bavaria JE, Coselli JS, Curi MA, Eggebrecht H, Elefteriades JA, Erbel R, Gleason TG, Lytle BW, Mitchell RS, Nienaber CA, Roselli EE, Safi HJ, Shemin RJ, Sicard GA, Sundt TM, Szeto WY, Wheatley GH. Expert Consensus Document on the Treatment of Descending Thoracic Aortic Disease Using Endovascular Stent-Grafts⁎⁎Expert Consensus Document on the Treatment of Descending Thoracic Aortic Disease Using Endovascular Stent-Grafts has been supported by Unrestricted Educational Grants from Cook, Inc and Medtronic, Inc. Ann Thorac Surg 2008; 85:S1-41. [PMID: 18083364 DOI: 10.1016/j.athoracsur.2007.10.099] [Citation(s) in RCA: 553] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2007] [Revised: 10/17/2007] [Accepted: 10/18/2007] [Indexed: 01/15/2023]
Affiliation(s)
- Lars G Svensson
- Center for Aortic Surgery and Marfan Syndrome Clinic, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio 44195, USA.
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Shennib H, Turina M, Ramaiah VG, Rodriguez-Lopez J, Wheatley G, Kpodonu J, Diethrich E. Endovascular grafts for thoracic aortic pathologies. Multimed Man Cardiothorac Surg 2008; 2008:mmcts.2007.003095. [PMID: 24415547 DOI: 10.1510/mmcts.2007.003095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Endovascular aortic repair (EVAR) is rapidly being adopted to capture a substantial proportion of surgical candidates with aneurysmal disease of the descending thoracic aorta. This new technique requires both special equipment (hybrid operating room, full range of catheterization tools) and additional technical skills, which an average cardiothoracic surgeon usually lacks, not being exposed to this particular training during his formative years. Presently, EVAR is applied to high-risk surgical candidates, its main advantages being the avoidance of cardiopulmonary bypass, minimal invasiveness (no large incisions) and often the ability to perform the procedure under local anesthesia. Early mortality in the author's (H.S.) institution is comparable to the best surgical results published, which is remarkable with respect to the high-risk patients. The techniques are rapidly being developed, with treatment of the aortic arch aneurysm employing transposition of supra-aortic arteries, and of the thoraco-abdominal aneurysms with branched grafts.
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182
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Neurologic complications associated with endovascular repair of thoracic aortic pathology: Incidence and risk factors. A study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) Registry. J Vasc Surg 2007; 46:1103-1110; discussion 1110-1. [DOI: 10.1016/j.jvs.2007.08.020] [Citation(s) in RCA: 470] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2007] [Revised: 08/10/2007] [Accepted: 08/10/2007] [Indexed: 11/22/2022]
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183
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Karmy-Jones R, Simeone A, Meissner M, Granvall B, Nicholls S. Descending thoracic aortic dissections. Surg Clin North Am 2007; 87:1047-86, viii-ix. [PMID: 17936475 DOI: 10.1016/j.suc.2007.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Type B dissection has traditionally been managed medically if uncomplicated and surgically if associated with complications. This practice has resulted in most centers reporting significant morbidity and mortality if open repair is required. In the setting of malperfusion, operative repair has been conjoined with fenestration or visceral stenting to improve outcomes. Endovascular stent grafts seem to offer an attractive alternative in the acute complicated type B dissection, with reduced mortality and morbidity, particularly paralysis, compared with open repair. It is reasonable to consider endovascular stent grafts as another tool in managing dissection, but to recognize that open surgical repair still plays an important role, and that the data that define indications and outcomes are still emerging.
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Affiliation(s)
- Riyad Karmy-Jones
- Division of Thoracic Surgery, Heart and Vascular Institute, Southwest Washington Medical Center, P.O. Box 1600 Vancouver, WA 98668, USA.
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184
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Akowuah E, Baumbach A, Wilde P, Angelini G, Bryan AJ. Emergency repair of traumatic aortic rupture: Endovascular versus conventional open repair. J Thorac Cardiovasc Surg 2007; 134:897-901. [PMID: 17903503 DOI: 10.1016/j.jtcvs.2007.06.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2007] [Revised: 06/05/2007] [Accepted: 06/15/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Our objective was to compare early results of endovascular stenting for traumatic aortic rupture with conventional open repair. METHODS We conducted a retrospective review of consecutive cases of traumatic aortic rupture in a single institution from July 2000 to July 2006. RESULTS Fifteen cases were identified. The mean injury severity score was 43 +/- 10. Fourteen patients had the procedure within 24 hours of admission to the hospital. Seven patients underwent endovascular stenting and 8 underwent open repair. For endovascular stenting, there were no failed procedures, no periprocedural complications, and no periprocedural deaths. In 6 patients, there was no evidence of endoleak, stent migration, or late pseudoaneurysm formation. One patient required a second stent 2 years later to treat a stenosis in the original stent. For open repair, cardiopulmonary bypass was used in 7 of the 8 patients. Lower limb paraplegia developed postoperatively in 1 patient and another patient died of head injuries. There was a significant reduction in the mean duration of the procedure (2.2 +/- 0.90 vs 5 +/- 3.2 hours; P = 0.04), the mean intraoperative blood loss (311 +/- 20 vs 953 +/- 20 mL; P = .02), the mean number of units of blood and blood products used (0.43 +/- 1.1 vs 3 +/- 3 units; P = .026), and the mean dose of heparin required (5000 +/- 1700 vs 24,000 +/- 7500 IU; P = .001) in the endovascular stenting group. There was no difference in duration of ventilation, intensive treatment unit, or hospital stay. CONCLUSIONS Endovascular stenting is technically feasible and applicable to a range of cardiac patients. It takes less time than open repair, requires less heparin and blood products, and therefore simplifies management of other injuries. In hemodynamically stable patients, endovascular stenting is the treatment of choice for traumatic aortic rupture.
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Affiliation(s)
- Enoch Akowuah
- Department of Cardiothoracic Surgery, Bristol Heart Institute at the Bristol Royal Infirmary, Bristol, United Kingdom
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185
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Monaco M, Stassano P, Di Tommaso L, Iannelli G. Response of plasma matrix metalloproteinases and tissue inhibitor of metalloproteinases to stent-graft surgery for descending thoracic aortic aneurysms. J Thorac Cardiovasc Surg 2007; 134:925-31. [PMID: 17903509 DOI: 10.1016/j.jtcvs.2007.05.044] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2007] [Revised: 04/19/2007] [Accepted: 05/11/2007] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The role of matrix metalloproteinases and their tissue endogenous inhibitors has been documented in abdominal aortic aneurysms, but few articles have investigated their role after thoracic aortic aneurysm treatment. Our report investigates matrix metalloproteinases and tissue endogenous inhibitor-1 plasmatic changes in patients who have undergone endovascular aneurysm repair for descending thoracic aortic aneurysms and assesses their clinical significance. METHODS Thirty-two patients with thoracic aortic aneurysms who underwent endovascular aneurysm repair were compared with 25 healthy volunteers. Plasma matrix metalloproteinase-3/matrix metalloproteinase-9 and tissue endogenous inhibitor-1 values were determined by an enzyme-linked immunosorbent assay method at a predetermined time interval. RESULTS The preoperative levels of matrix metalloproteinases in the endovascular aneurysm repair group were 3-fold and 2-fold higher than those in the control group (P < .001 and .02, respectively). Matrix metalloproteinase values normalized after endovascular aneurysm repair, whereas patients experiencing endoleaks had higher matrix metalloproteinase values and matrix metalloproteinase-9/tissue endogenous inhibitor-1 ratio compared with the control group (P = .003, < .001, and = .02, respectively, at 1-month follow-up). These values normalized with the resolution of the endoleak. CONCLUSIONS Plasma matrix metalloproteinase values are increased in patients with thoracic aortic aneurysms, along with reduced tissue endogenous inhibitor-1 expression. Successful endovascular aneurysm repair results in values normalization, whereas high levels persist in patients with endoleaks. The enzyme-linked immunosorbent assay test is a simple and reliable technique that is useful to assess the efficacy of endovascular aneurysm repair and to detect endoleaks.
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Affiliation(s)
- Mario Monaco
- Department of Cardiac Surgery, University of Naples Federico II, Naples, Italy.
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186
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Gutsche JT, Cheung AT, McGarvey ML, Moser WG, Szeto W, Carpenter JP, Fairman RM, Pochettino A, Bavaria JE. Risk factors for perioperative stroke after thoracic endovascular aortic repair. Ann Thorac Surg 2007; 84:1195-200; discussion 1200. [PMID: 17888969 DOI: 10.1016/j.athoracsur.2007.04.128] [Citation(s) in RCA: 137] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Revised: 04/23/2007] [Accepted: 04/24/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Stroke has emerged as an important complication of thoracic endovascular aortic repair (TEVAR). Identifying risk factors for stroke is important to define the risks of this procedure. METHODS All neurologic complications were analyzed in a prospective database of patients in thoracic aortic stent graft trials from 1999 to 2006. Serial neurological examination was performed. Stroke was defined as any new onset focal neurologic deficit. RESULTS The TEVAR was performed on 171 patients; 52 had lesions requiring coverage of the proximal descending thoracic aorta (extent A), 50 requiring coverage of the distal descending aorta (extent B), and 69 requiring coverage of the entire descending thoracic aorta (extent C). The incidence of stroke was 5.8%. Eighty-nine percent (8 of 9) of strokes occurred within 24 hours of operation. Stroke was associated with a 33% in-hospital mortality rate. Risk factors identified for stroke included prior stroke (odds ratio [OR] 9.4, confidence interval [CI] 2.3 to 38.1, p = 0.002) and extent A or C coverage (OR 5.5, CI 1.7-12.5, p = 0.001). The stroke rate in patients with both prior stroke and extent A or C coverage was 27.7%. Severe atheromatous disease involving the aortic arch by computed tomographic scan was strongly associated with perioperative stroke (OR = 14.8, CI 1.7 to 675.6, p = 0.0016). Transesophageal echocardiography demonstrated mobile atheroma in two patients with stroke. CONCLUSIONS Stroke after TEVAR was associated with a high mortality. The TEVAR of the proximal descending aorta (extent A or C) in patients with a history of stroke had the highest perioperative stroke rate. These risk factors, together with high grade aortic atheroma of the aortic arch, predicted a high probability for cerebral embolization and can be used to identify patients at high risk for stroke as a consequence of TEVAR.
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Affiliation(s)
- Jacob T Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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187
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Thompson M, Ivaz S, Cheshire N, Fattori R, Rousseau H, Heijmen R, Beregi JP, Thony F, Horne G, Morgan R, Loftus I. Early Results of Endovascular Treatment of the Thoracic Aorta Using the Valiant Endograft. Cardiovasc Intervent Radiol 2007; 30:1130-8. [PMID: 17710474 DOI: 10.1007/s00270-007-9147-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2007] [Revised: 07/09/2007] [Accepted: 07/14/2007] [Indexed: 10/22/2022]
Abstract
Endovascular repair of the thoracic aorta has been adopted as the first-line therapy for much pathology. Initial results from the early-generation endografts have highlighted the potential of this technique. Newer-generation endografts have now been introduced into clinical practice and careful assessment of their performance should be mandatory. This study describes the initial experience with the Valiant endograft and makes comparisons with similar series documenting previous-generation endografts. Data were retrospectively collected on 180 patients treated with the Valiant endograft at seven European centers between March 2005 and October 2006. The patient cohort consisted of 66 patients with thoracic aneurysms, 22 with thoracoabdominal aneurysms, 19 with an acute aortic syndrome, 52 with aneurysmal degeneration of a chronic dissection, and 21 patients with traumatic aortic transection. The overall 30-day mortality for the series was 7.2%, with a stroke rate of 3.8% and a paraplegia rate of 3.3%. Subgroup analysis demonstrated that mortality differed significantly between different indications; thoracic aneurysms (6.1%), thoracoabdominal aneurysms (27.3%), acute aortic syndrome (10.5%), chronic dissections (1.9%), and acute transections (0%). Adjunctive surgical procedures were required in 63 patients, and 51% of patients had grafts deployed proximal to the left subclavian artery. Comparison with a series of earlier-generation grafts demonstrated a significant increase in complexity of procedure as assessed by graft implantation site, number of grafts and patient comorbidity. The data demonstrate acceptable results for a new-generation endograft in series of patients with diverse thoracic aortic pathology. Comparison of clinical outcomes between different endografts poses considerable challenges due to differing case complexity.
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Affiliation(s)
- Matt Thompson
- St George's Vascular Institute, 4th Floor St James Wing, St George's Hospital NHS Trust, Blackshaw Road, London SW17 0QT, UK.
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188
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Ince H, Nienaber CA. Etiology, pathogenesis and management of thoracic aortic aneurysm. ACTA ACUST UNITED AC 2007; 4:418-27. [PMID: 17653114 DOI: 10.1038/ncpcardio0937] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2006] [Accepted: 04/12/2007] [Indexed: 01/15/2023]
Abstract
Given the growing proportion of elderly people in Western societies and the increasing prevalence of chronic hypertension, the management of aneurysmal aortic disease is an ever growing challenge. Although degenerative changes in the aortic wall are common to thoracic aortic aneurysm (TAA) and to various types of dissection in general, TAA can result from specific heritable disorders of connective tissues. Today, increased awareness of vascular diseases and access to tomographic imaging equipment facilitate the diagnosis of TAA, even when asymptomatic. While most TAA cases with ascending aortic involvement are treated with surgical repair (primarily valve-preserving techniques), aneurysms of the distal arch and descending thoracic aorta are amenable to alternatives to classic open repair such as the emerging endovascular treatment techniques. In this Review, we provide a comprehensive overview of the etiology, pathophysiology and clinical management of patients with TAA, and discuss the most recent literature on the condition.
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Affiliation(s)
- Hüseyin Ince
- Division of Cardiology, University Hospital Rostock, Rostock School of Medicine, Rostock, Germany
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189
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Kische S, Rehders TC, Akin I, Ince H, Nienaber CA. Role of interventional repair in the thoracic aorta. Future Cardiol 2007; 3:399-412. [PMID: 19804231 DOI: 10.2217/14796678.3.4.399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Endovascular treatment of chronic aneurysmatic diseases of the descending thoracic aorta has demonstrated encouraging peri-interventional mortality and morbidity and is accepted as a preferred strategy in experienced centers. The emergence of endovascular strategies for acute thoracic aortic pathologies is an even more exciting new territory for nonsurgical interventions considering the sobering results of open surgery. Although it is apparent that patients at high risk for open surgery will benefit from endovascular strategies, the exact role of stent-graft placement remains to be defined, as the community awaits solid long-term data and as devices and techniques continue to improve. While some indications and scenarios, such as acute type B dissection with associated malperfusion syndrome or imminent aortic rupture, have been shown to benefit from stent-graft treatment, others are less settled. The current paper discusses both the established and emerging indications, as well as technical and anatomical aspects of this fascinating therapeutic option.
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Affiliation(s)
- Stephan Kische
- Rostock School of Medicine, Division of Cardiology at the University Hospital Rostock, Ernst-Heydemann-Str. 6, 18057 Rostock, Germany.
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190
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Heider P, Wolf O, Reeps C, Hanke M, Zimmermann A, Berger H, Eckstein HH. Aneurysmen und Dissektionen der thorakalen und abdominellen Aorta. Chirurg 2007; 78:600, 602-6, 608-10. [PMID: 17594068 DOI: 10.1007/s00104-007-1370-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
One to four per cent of all deaths in patients over 65 are caused by aneurysmatic diseases of the abdominal or thoracic aorta. For elective surgery in abdominal aneurysms, open surgery and endovascular treatment both demonstrate brilliant overall results. In the thoracic aorta, new endovascular procedures have led to considerable reductions of postoperative morbidity and mortality. Nevertheless, in view of the endovascular procedure's high cost and the still unclear long-term behaviour of the stent device, a second opinion from a specialised centre is an absolute necessity.
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Affiliation(s)
- P Heider
- Abteilung für Gefässchirurgie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Strasse 22, 81675, München, Deutschland.
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191
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Fattori R, Russo V. Endovascular treatment of atherosclerotic and other thoracic aortic aneurysms. Semin Intervent Radiol 2007; 24:197-205. [PMID: 21326796 DOI: 10.1055/s-2007-980043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The incidence of thoracic aortic aneurysms (TAAs) is increasing with the present rate of occurrence at 10.9 cases per 100,000 people per year. The estimated 5-year risk of rupture of a TAA with a diameter between 4 and 5.9 cm is 16%, but it rises to 31% for aneurysms ≥ 6 cm. Despite increasing awareness of the importance of early diagnosis and treatment options, there are no clear guidelines available at the time of writing. Nor is there any clear evidence for specific pharmacological treatment able to resolve or delay the disease progression. Endovascular treatment (EVT), proposed as an alternative to surgery, has been considered a therapeutic innovation, especially because it is minimally invasive, which allows treatment even in high surgical risk patients. Vascular imaging is crucial for patient selection, endoprosthesis choice, and planning of the treatment because not all aneurysms are suitable. Early and midterm results are encouraging, but long-term results are necessary to definitively assess reliability of stent-graft materials and improvement in patient survival. In the choice between surgical or endovascular repair of TAAs, many factors must be considered, including the clinical situation, comorbidities, anatomy, choice of equipment, and last, but not less important, experience of the clinical team.
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Affiliation(s)
- Rossella Fattori
- Cardiothoracovascular Department, Cardiovascular Radiology Unit, University Hospital S. Orsola, Bologna, Italy
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192
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193
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Melissano G, Civilini E, Bertoglio L, Calliari F, Setacci F, Calori G, Chiesa R. Results of Endografting of the Aortic Arch in Different Landing Zones. Eur J Vasc Endovasc Surg 2007; 33:561-6. [PMID: 17207648 DOI: 10.1016/j.ejvs.2006.11.019] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2006] [Accepted: 11/08/2006] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Endovascular approach to the aortic arch is an appealing solution for selected patients. Aim of this study is to compare the technical and clinical success recorded in the different anatomical settings of endografting for aortic arch disease. METHODS Between June 1999 and October 2006, among 178 patients treated at our Institution for thoracic aorta disease with a stent-graft, the aortic arch was involved in 64 cases. According to the classification proposed by Ishimaru, aortic "zone 0" was involved in 14 cases, "zone 1" in 12 cases and "zone 2" in 38 cases. A hybrid surgical procedure of supraortic debranching and revascularization was performed in 37 cases to obtain an adequate proximal aortic landing zone. RESULTS "Zone 0" (14 cases). Proximal neck length: 44+/-6mm. Initial clinical success 78.6%: 2 deaths (stroke), 1 type Ia endoleak. At a mean follow-up of 16.4+/-11 months the midterm clinical success was 85.7%. "Zone 1" (12 cases). Proximal neck length: 28+/-5mm. Initial clinical success 66.7%: 0 deaths, 4 type Ia endoleaks. At a mean follow-up of 16.9+/-17.2 months the midterm clinical success was 75.0%. "Zone 2" (38 cases) Proximal neck length: 30+/-5mm. Initial clinical success 84.2%: 2 deaths (1 cardiac arrest, 1 multiorgan embolization), 3 type Ia endoleaks, 1 case of open conversion. Two cases of delayed transitory paraparesis/paraplegia were observed. At a mean follow-up of 28.0+/-17.2 months the midterm clinical success was 89.5%. CONCLUSIONS Total debranching of the arch for "zone 0" aneurysms allowed to obtain a longer proximal aortic landing zone with lower incidence of endoleak, however a higher risk of cerebrovascular accident was observed. The relatively high incidence of adverse events in "zone 1" could be associated to a shorter proximal neck, therefore this landing zone is reserved for patients unfit for sternotomy. In case of endoleak, discovered after a satisfactorily positioned endograft in the arch, the rate of spontaneous resolution within the first 6 months is high.
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Affiliation(s)
- G Melissano
- Department of Vascular Surgery, Vita - Salute University, Scientific Institute H. San Raffaele, Milan, Italy.
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194
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Abstract
Endovascular repair of the traumatically injured thoracic aorta has emerged as an exceptionally promising modality that is typically quicker than open repair, with a reduced risk of paralysis. There are a specific set of anatomic criteria that need to be applied, which can be rapidly assessed by the CT angiogram. The enthusiasm for endovascular repair must be tempered by recognition of the complications and lack of long-term follow-up, particularly in younger patients. Surgeons who are skilled in open aortic repair must not only be involved, but should take on a leadership role during the planning, deployment, and follow-up of these patients. Familiarity with all of the available devices expands treatment options. As more specific devices become available, and more follow-up is accrued, the role of endovascular stents will continue to grow.
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Affiliation(s)
- Riyad Karmy-Jones
- Heart and Vascular Center, Divisions of Cardiac, Vascular and Thoracic Surgery, Southwest Washington Medical Center, SWMC Physicians Pavilion, Suite 300, 200 N.E. Mother Joseph Place, Vancouver, WA 98664, USA.
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195
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Abstract
Traumatic injury to the aorta and the brachiocephalic branches are potentially lethal injuries. Specialized preoperative imaging and medical management can lead to better outcomes in this group of patients. In addition, improved surgical techniques for spinal cord protection have led to decreased morbidity in surgical candidates. TEVAR remains a promising technique; however, long-term data currently are not available.
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Affiliation(s)
- William T Brinkman
- Division of Cardiovascular Surgery. Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein, Philadelphia, PA 19104, USA
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196
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Nienaber CA, Kische S, Zeller T, Rehders TC, Schneider H, Lorenzen B, Bünger C, Ince H. Provisional extension to induce complete attachment after stent-graft placement in type B aortic dissection: the PETTICOAT concept. J Endovasc Ther 2007; 13:738-46. [PMID: 17154712 DOI: 10.1583/06-1923.1] [Citation(s) in RCA: 144] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To report the use of a technique (PETTICOAT: provisional extension to induce complete attachment) to obliterate sustained abdominal false lumen flow and pressurization despite successful stent-graft sealing of the thoracic entry tear in patients with complicated type B aortic dissection. METHODS Of 100 initial patients subjected to stent-graft repair for complex type B aortic dissection with thoracoabdominal extension, 12 patients (10 men; mean age 58.7 years, range 44-76) demonstrated distal true lumen collapse and a perfused abdominal false lumen despite successful sealing of the proximal tears. As an adjunctive or staged procedure, a scaffolding stent was placed for distal extension of the previously implanted stent-graft. In each case, a Sinus aortic stent, Fortress stent, or a Z-stent system was customized with maximum 2-mm oversizing versus the original stent-graft diameter. Magnetic resonance or computed tomographic angiography was performed at discharge, at 3 months, and then annually to determine false channel thrombosis, true and false lumen dimensions, and re-entry flow. RESULTS Delivery was successful in all cases (100%). The compressed distal true lumen (mean 4+/-3 mm) was reconstructed to a mean width of 21+/-3 mm, and malperfusion was abolished without any obstruction of the abdominal side branches. At up to 1-year follow-up, there were no signs of expansion or distal progression of the scaffolded dissected aorta. All patients with complete thoracic thrombosis showed evidence of improved aortic remodeling; 1 patient with no false lumen thrombosis died at 11 months from thoracoabdominal aortic rupture. CONCLUSION The PETTICOAT technique may offer a safe and promising adjunctive endovascular maneuver for patients with distal malapposition of the dissecting membrane and false lumen flow. The technique can both abolish distal true lumen collapse and enhance the remodeling process of the entire dissected aorta.
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MESH Headings
- Adult
- Aged
- Aortic Dissection/classification
- Aortic Dissection/diagnostic imaging
- Aortic Dissection/mortality
- Aortic Dissection/therapy
- Angioplasty, Balloon/adverse effects
- Angioplasty, Balloon/methods
- Aortic Aneurysm, Abdominal/classification
- Aortic Aneurysm, Abdominal/diagnostic imaging
- Aortic Aneurysm, Abdominal/mortality
- Aortic Aneurysm, Abdominal/therapy
- Aortic Aneurysm, Thoracic/classification
- Aortic Aneurysm, Thoracic/diagnostic imaging
- Aortic Aneurysm, Thoracic/mortality
- Aortic Aneurysm, Thoracic/therapy
- Blood Vessel Prosthesis Implantation/adverse effects
- Blood Vessel Prosthesis Implantation/methods
- Comorbidity
- Female
- Humans
- Magnetic Resonance Angiography
- Male
- Middle Aged
- Prosthesis Design
- Retrospective Studies
- Severity of Illness Index
- Stents/adverse effects
- Survival Analysis
- Thrombosis/etiology
- Thrombosis/prevention & control
- Tomography, X-Ray Computed
- Treatment Outcome
- Vascular Patency
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Affiliation(s)
- Christoph A Nienaber
- Department of Cardiology, University Hospital Rostock, Rostock School of Medicine, Ernst-Heydemann-Strasse 6, 18057 Rostock, Germany.
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Fattori R, Russo V. Degenerative aneurysm of the descending aorta. Endovascular treatment. Multimed Man Cardiothorac Surg 2007; 2007:mmcts.2007.002824. [PMID: 24415213 DOI: 10.1510/mmcts.2007.002824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The incidence of thoracic aortic aneurysms has a rate of occurrence of 10.9 cases per 100,000 person/year, with an estimated 5-year risk of rupture ranging from 16% (diameter between 4 and 5.9 cm) to 31% (6 cm or more). Despite increasing awareness of the important role of early diagnosis in treatment options, guidelines about therapeutic strategies are actually lacking, as well as definite evidence of pharmacological treatment able to resolve or delay the disease progression. Endovascular treatment proposed as alternative to surgery has been considered a therapeutic innovation, especially because of low invasiveness, which allows to treat even high surgical risk patients. The procedure is performed under general anesthesia, mechanical ventilation and blood pressure invasive monitoring (right radial artery cannulation). The common femoral artery or external iliac artery are used for access after surgical exposure. After exposition of the artery, a 6F sheath is inserted and 5000 UI of heparin administered. Angiography is then performed to identify the lesion, landing zones and its relation to side branches. Endovascular stent-graft is thus loaded on an extra-stiff guidewire and delivered, with induced hypotension, under fluoroscopic and transesophageal echo control. Post procedural angiography and echocardiography control are performed to reveal the final result.
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Affiliation(s)
- Rossella Fattori
- Cardiothoracovascular Department, Cardiovascular Radiology Unit, University Hospital S. Orsola, Padiglione 21-Via Massarenti 9, 40138 Bologna, Italy
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