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Sultan S, Acharya Y, Soliman O, Parodi JC, Hynes N. TEVAR and EVAR, the unknown knowns of the cardiovascular hemodynamics; and the immediate and long-term consequences of fabric material on major adverse clinical outcome. Front Surg 2022; 9:940304. [PMID: 36111231 PMCID: PMC9468223 DOI: 10.3389/fsurg.2022.940304] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/11/2022] [Indexed: 11/29/2022] Open
Abstract
This review discusses the impact of endovascular aneurysm repair on cardiovascular (CV) hemodynamics and the role of stent-graft material, i.e., polytetrafluoroethylene (PTFE) vs. polyester in post-procedural outcomes. Endovascular aneurysm repair has been widely employed in the last decades for thoracic and abdominal aneurysm repair. However, aortic endografts are stiff and alter the native flow hemodynamics. This failure to simulate the native aorta could lead to added strain on the heart, manifesting as increased left ventricular strain, higher pulse pressure, and congestive heart failure later. This could result in adverse CV outcomes. Also, evidence is mounting to support the implication of stent-graft materials, i.e., PTFE vs. polyester, in adverse post-procedural outcomes. However, there is an absence of level one evidence. Therefore, the only way forward is to plan and perform a randomised controlled trial to demonstrate the alterations in the CV hemodynamics in the short and long run and compare the available stent-graft materials regarding procedural and clinical outcomes. We believe the best solution, for now, would be to reduce the stented length of the aorta. At the same time, in the longer term, encourage continuous improvement in stent-graft materials and design.
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Affiliation(s)
- Sherif Sultan
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland, Galway, Ireland
- Galway Clinic, Doughiska, Royal College of Surgeons in Ireland and the National University of Ireland, Galway Affiliated Hospital, Galway, Ireland
- CÚRAM-CORRIB-Vascular Group, National University of Ireland, Galway, Ireland
- Correspondence: Sherif Sultan ,
| | - Yogesh Acharya
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland, Galway, Ireland
- Galway Clinic, Doughiska, Royal College of Surgeons in Ireland and the National University of Ireland, Galway Affiliated Hospital, Galway, Ireland
| | - Osama Soliman
- CÚRAM-CORRIB-Vascular Group, National University of Ireland, Galway, Ireland
| | - Juan Carlos Parodi
- Department of Vascular Surgery and Biomedical Engineering Department, University of Buenos Aires, Buenos Aires, Argentina
| | - Niamh Hynes
- CÚRAM-CORRIB-Vascular Group, National University of Ireland, Galway, Ireland
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Hynes N, Acharya Y, Sultan S. The contemporary design of endovascular aneurysm stent-graft materials: PTFE versus polyester. Front Surg 2022; 9:984727. [PMID: 36051707 PMCID: PMC9424654 DOI: 10.3389/fsurg.2022.984727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 08/02/2022] [Indexed: 11/13/2022] Open
Abstract
Endovascular aneurysm repair of the abdominal aorta (EVAR) and of the thoracic aorta (TEVAR) have revolutionised therapeutic strategies in the management of aortic pathology, and endovascular repair is now an established and attractive alternative to open surgical repair (OSR) due to its superior short-term safety profile. However, opinions are divided regarding its long-term cost-effectiveness, which is reflected in the controversial NICE guidelines on abdominal aortic aneurysm (AAA) repair published in 2018, which advised against EVAR for elective aortic repair due to high secondary intervention rates and resultant associated costs. There is no doubt that OSR continues to have a valuable role to play in aortic repair, but it is not universally applicable, especially in older and sicker patients. Therefore, we should not dismiss EVAR and TEVAR without examining the reasons for long-term failure, and the most obvious starting point is stent graft material properties. Polytetrafluoroethylene (PTFE) and polyester are the two most common stent-graft materials; however, there has been no objective comparison of PTFE and polyester stent-graft post-procedural outcomes in EVAR and TEVAR, or even OSR. This lack of definitive data on different stent-graft materials and their configuration necessitates a comprehensive review to elucidate the post-procedural outcome in terms of endograft failure, cardiovascular events, and aortic-related mortality and morbidity.
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Affiliation(s)
- Niamh Hynes
- CURAM SFI Centre for Medical Devices, Biomedical Sciences, National University of Ireland Galway, Galway, Ireland
- Department of Vascular & Endovascular Surgery, Western Vascular Institute, Galway University Hospital, Galway, Ireland
| | - Yogesh Acharya
- Department of Vascular & Endovascular Surgery, Western Vascular Institute, Galway University Hospital, Galway, Ireland
| | - Sherif Sultan
- Department of Vascular & Endovascular Surgery, Western Vascular Institute, Galway University Hospital, Galway, Ireland
- Department of Vascular & Endovascular Surgery, Galway Clinic, Galway, Ireland
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Chatzelas DA, Pitoulias AG, Telakis ZC, Kalogirou TE, Tachtsi MD, Christopoulos DC, Pitoulias GA. Incidence and risk factors of post implantation syndrome after elective endovascular aortic aneurysm repair. INT ANGIOL 2022; 41:196-204. [PMID: 35138072 DOI: 10.23736/s0392-9590.22.04759-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Post implantation syndrome (PIS) represents an acute phase systemic inflammatory response following endovascular aortic aneurysm repair (EVAR). Our objective was to investigate the risk factors associated with the manifestation and severity of PIS with various available stent-grafts. MATERIALS AND METHODS We performed a retrospective analysis of prospectively collected data covering the period 2016 - 2020. 191 patients were included. Body temperature was recorded regularly and blood sample was obtained daily. The imaging protocol included computed tomography aortoiliac angiography before surgery and one month after. The volumes of pre-existing and new-onset mural thrombus were calculated in a semiautomated fashion. Five abdominal aortic stent-graft devices were used: Endurant™ ΙΙ, Anaconda™, Treo®, E-tegra® and AFX® 2. Subgroup analysis was performed between woven polyester and ePTFE lined devices. RESULTS The incidence of PIS was 21.5%. No significant differences were observed regarding demographics, risk factors, aneurysm anatomy or operative data. The amount of preexisting and new-onset mural thrombus were not related with PIS (p=0.117 and p=0.096). PIS incidence in the polyester subgroup was 24.2%, significantly higher compared to 8.3% in the ePTFE subgroup. In-subgroup analysis revealed that the use of Anaconda™ was associated with the higher frequency (61.1%, p=0.021). Multivariate logistic regression showed that polyester was the single factor significantly associated with PIS (hazard ratio=2.6, p=0.043), as opposed to the new onset thrombus (hazard ratio=1.29, p=0.101). CONCLUSIONS PIS is not uncommon and should be taken into consideration in patients presenting with fever after EVAR. The endograft's liner material seems to play the primordial role, with woven polyester to be attributed with significantly higher incidence.
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Affiliation(s)
- Dimitrios A Chatzelas
- Division of Vascular Surgery, G. Gennimatas, Second Department of Surgery, School of Health Sciences, Faculty of Medicine, Thessaloniki General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece - ,
| | - Apostolos G Pitoulias
- Division of Vascular Surgery, G. Gennimatas, Second Department of Surgery, School of Health Sciences, Faculty of Medicine, Thessaloniki General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Zisis C Telakis
- Division of Vascular Surgery, G. Gennimatas, Second Department of Surgery, School of Health Sciences, Faculty of Medicine, Thessaloniki General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Thomas E Kalogirou
- Division of Vascular Surgery, G. Gennimatas, Second Department of Surgery, School of Health Sciences, Faculty of Medicine, Thessaloniki General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria D Tachtsi
- Division of Vascular Surgery, G. Gennimatas, Second Department of Surgery, School of Health Sciences, Faculty of Medicine, Thessaloniki General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios C Christopoulos
- Division of Vascular Surgery, G. Gennimatas, Second Department of Surgery, School of Health Sciences, Faculty of Medicine, Thessaloniki General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios A Pitoulias
- Division of Vascular Surgery, G. Gennimatas, Second Department of Surgery, School of Health Sciences, Faculty of Medicine, Thessaloniki General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Schizas N, Salem A, Lama N, Leventi E, Argiriou M, Patris V. Delayed disseminated intravascular coagulopathy post thoracic endovascular aortic repair (TEVAR). J Card Surg 2020; 35:3610-3613. [PMID: 33032361 DOI: 10.1111/jocs.15057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 09/08/2020] [Accepted: 09/10/2020] [Indexed: 11/30/2022]
Abstract
Disseminated intravascular coagulopathy (DIC) is a very rare outcome post endovascular repair of aortic aneurysm dissections. We present a case of a 70-year-old male who presented with DIC post a thoracic endovascular aortic repair (TEVAR) procedure due to a type 1A endoleak. Initially, the patient was treated with red blood cells and blood products; however, when failing to improve, he underwent a hybrid arch replacement. In this study, we will analyze the management of DIC post TEVAR and look at its presentation more extensively, as it is currently a topic that is poorly studied.
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Affiliation(s)
- Nikolaos Schizas
- Department of Cardiothoracic and Vascular Surgery, Evangelismos General Hospital, Athens, Greece
| | - Agni Salem
- Department of Cardiovascular Surgery, Heart and Chest Surgery Hospital, Liverpool, UK
| | - Niki Lama
- Research Unit of Radiology and Medical Imaging, Kapodistrian University of Athens, Athens, Greece
| | - Eleni Leventi
- Department of Anesthesiology, Evangelismos General Hospital, Athens, Greece
| | - Michail Argiriou
- Department of Cardiothoracic and Vascular Surgery, Evangelismos General Hospital, Athens, Greece
| | - Vasilios Patris
- Department of Cardiothoracic and Vascular Surgery, Evangelismos General Hospital, Athens, Greece
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Sultan S, Barrett N, Tawfick W, Parodi JC, Hynes N. Contemporary abdominal aortic aneurysm devices, three decades of research and development with big data. Why has the best graft not been produced yet? A missed opportunity. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2019. [DOI: 10.23736/s1824-4777.19.01417-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Ito E, Toya N, Fukushima S, Nishie R, Akiba T, Ohki T. Polyester Grafts Are a Risk Factor for Postimplantation Syndrome after Abdominal Endovascular Aneurysm Repair: Retrospective Analysis for Polyester Graft, Excluder®, and Endologix Powerlink®/AFX®. Ann Vasc Dis 2018; 11:520-524. [PMID: 30637008 PMCID: PMC6326045 DOI: 10.3400/avd.oa.18-00058] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: Postimplantation syndrome (PIS) is a postoperative syndrome that occurs after endovascular aneurysm repair (EVAR), accompanied by high fever, leukocytosis, and high serum C-reactive protein (CRP). Its pathogenesis and clinical meaning are still under discussion. Here, we evaluate the relationship between postoperative fever after EVAR and graft fabric focusing on Endologix Powerlink® and AFX® (EPL/AFX). Materials and Methods: From January 2015 to July 2017, data on elective EVAR for abdominal aortic aneurysm (AAA) using mainbody were retrospectively collected. The primary endpoint was maximal postoperative fever. Results: We identified 128 patients who underwent elective EVAR for AAA (105 males, 82%; aged 57–90, median: 74 years). The median maximal postoperative fever was 37.8°C (36.6–39.7°C): polyester graft, 38.2°C (37.1–39.7°C); Excluder®, 37.8°C (36.6–39.2°C); and EPL/AFX, 37.7°C (37–38.7°C). The maximal postoperative fever with a polyester graft was significantly higher than that with an expanded polytetrafluoroethylene (ePTFE) graft (p<0.001). However, there was no difference between Excluder® and EPL/AFX (p=0.214). Conclusion: In this study, it was found that polyester grafts are significantly associated with PIS after elective EVAR for AAA. If patient anatomy is permitted, it may be better to choose the ePTFE graft, especially for patients with a poor general condition.
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Affiliation(s)
- Eisaku Ito
- Division of Vascular Surgery, The Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan
| | - Naoki Toya
- Division of Vascular Surgery, The Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan
| | - Soichiro Fukushima
- Division of Vascular Surgery, The Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan
| | - Ryosuke Nishie
- Division of Vascular Surgery, The Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan
| | - Tadashi Akiba
- Department of Surgery, The Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan
| | - Takao Ohki
- Department of Vascular Surgery, The Jikei University School of Medicine, Tokyo, Japan
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Fujii M, Watanabe H, Otsu M, Sugahara Y. Successful treatment of disseminated intravascular coagulation associated with aortic dissection. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2018; 4:268-271. [PMID: 30547143 PMCID: PMC6282448 DOI: 10.1016/j.jvscit.2018.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 07/16/2018] [Indexed: 01/16/2023]
Abstract
Disseminated intravascular coagulation (DIC) is an infrequent aortic dissection complication, and its optimal treatment remains controversial. A 55-year-old woman developed DIC associated with Stanford type B aortic dissection, which improved by administration of low-molecular-weight heparin combined with tranexamic acid, but the dissecting aneurysm of the descending aorta was dilated. After thoracic endovascular aortic repair for occlusion of entry tears detected by transesophageal echocardiography, DIC improved without anticoagulant therapy. Three months after treatment, the patient is doing well without complications. Endovascular repair is effective for DIC due to aortic dissection that requires anticoagulant therapy.
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Affiliation(s)
- Masahiko Fujii
- Division of Cardiovascular Surgery, Narita Red Cross Hospital, Chiba, Japan
| | - Hiroyuki Watanabe
- Division of Cardiovascular Surgery, Narita Red Cross Hospital, Chiba, Japan
| | - Masayoshi Otsu
- Division of Cardiovascular Surgery, Narita Red Cross Hospital, Chiba, Japan
| | - Yuta Sugahara
- Division of Cardiovascular Surgery, Narita Red Cross Hospital, Chiba, Japan
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Chou AH, Chen CC, Lin YS, Lin MS, Wu VCC, Ting PC, Chen SW. A population-based analysis of endovascular aortic stent graft therapy in patients with liver cirrhosis. J Vasc Surg 2018; 69:1395-1404.e4. [PMID: 30528408 DOI: 10.1016/j.jvs.2018.06.225] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 06/25/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endovascular aneurysm repair (EVAR) and thoracic endovascular aortic repair (TEVAR) are effective and minimally invasive treatments for high-risk surgical candidates. However, information about the management of EVAR and TEVAR in liver cirrhosis (LC) is lacking. The aim of our study was to evaluate outcomes after EVAR and TEVAR in patients with LC. METHODS Using Taiwan's National Health Insurance Research Database, we retrospectively evaluated patients who underwent EVAR and TEVAR therapy between January 1, 2006, and December 31, 2013. RESULTS A total of 146 patients with LC and 730 matched patients without LC were eligible for analysis after propensity score matching. In-hospital mortality and perioperative complications were not statistically significantly different between the two cohorts, although the LC group had an increased volume of blood transfusion and a trend toward a lower survival rate (P of stratified Cox = .092). However, patients with LC had a higher adjusted hazard ratio for death (1.66; 95% confidence interval, 1.31-2.12; P < .001) in the sensitivity analysis by traditional multivariable adjustment. The LC cohort had a higher risk of liver-related death (4.1% vs 0.7%; P = .001) and liver-related readmission (6.2% vs 0.3%; P < .001). As expected, the advanced LC group had a higher mortality rate than the early LC group (P = .022). The risk for reintervention, redo open aortic surgery (P = .859), and redo stent graft therapy (P = .179) was not statistically significantly different between the two cohorts. CONCLUSIONS Short-term results after EVAR and TEVAR are promising in patients with LC, despite poor long-term outcomes, because of the nature of LC. Innovations in endovascular therapy for aortic disease have improved surgical outcomes, even in high-risk patients with LC.
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Affiliation(s)
- An-Hsun Chou
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taipei, Taiwan; Department of Medicine, Chang Gung University, Taoyuan City, Taipei, Taiwan
| | - Ching-Chang Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taipei, Taiwan
| | - Yu-Sheng Lin
- Department of Cardiology, Chang Gung Memorial Hospital, Chiayi Branch, Chiayi City, Taiwan
| | - Ming-Shyan Lin
- Department of Cardiology, Chang Gung Memorial Hospital, Chiayi Branch, Chiayi City, Taiwan
| | - Victor Chien-Chia Wu
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taipei, Taiwan
| | - Pei-Chi Ting
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taipei, Taiwan
| | - Shao-Wei Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taipei, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan City, Taipei, Taiwan.
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Wang L, Liu F, Guo D, Xu D, Zhou X, Hou K, Zhang W, Shi Z, Tang X, Fu W. Radical treatment of primary type B aortic dissection or after thoracic endovascular aortic repair to manage disseminated intravascular coagulation. J Thorac Dis 2018; 10:3808-3813. [PMID: 30069381 DOI: 10.21037/jtd.2018.06.93] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Disseminated intravascular coagulation (DIC) secondary to type B aortic dissection is an unusual and fatal complication that has not been fully investigated. The aim of our study is to report a novel endovascular technique excluding all tears to manage DIC. From April 2017 to October 2017, we performed 2 cases of DIC complicated to type B aortic dissection using this novel radical endovascular repair technique. Clinical data of patients were collected and technical details were presented. These two cases were successfully treated with novel radical endovascular repair technique. DIC was managed and FL thrombosis was formed in these two patients. Follow-up at 6 months revealed no recurrent DIC and a stable aortic diameter with complete FL thrombosis. This endovascular repair technique that excluding all the tears is a feasible approach to prevents continuous coagulation components consumption and thus to manage DIC effectively.
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Affiliation(s)
- Lixin Wang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China.,Institute of Vascular Surgery, Fudan University, Shanghai 200032, China.,Department of Vascular Surgery in Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen 361015, China
| | - Fei Liu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China.,Institute of Vascular Surgery, Fudan University, Shanghai 200032, China
| | - Daqiao Guo
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China.,Institute of Vascular Surgery, Fudan University, Shanghai 200032, China
| | - Demin Xu
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China.,Department of Cardiac Surgery in Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen 361015, China
| | - Xiushi Zhou
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China.,Institute of Vascular Surgery, Fudan University, Shanghai 200032, China
| | - Kai Hou
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China.,Institute of Radiology, Shanghai Municipal, Shanghai 200032, China
| | - Wei Zhang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China.,Institute of Vascular Surgery, Fudan University, Shanghai 200032, China
| | - Zhenyu Shi
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China.,Institute of Vascular Surgery, Fudan University, Shanghai 200032, China
| | - Xiao Tang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China.,Institute of Vascular Surgery, Fudan University, Shanghai 200032, China
| | - Weiguo Fu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China.,Institute of Vascular Surgery, Fudan University, Shanghai 200032, China.,Department of Vascular Surgery in Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen 361015, China
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Arnaoutoglou E, Kouvelos G, Tzimas P, Laou E, Bouris V, Papadopoulos G, Matsagkas M. Relationship between normal preoperative white blood cell count and major adverse events after endovascular repair for abdominal aortic aneurysm: results of a pilot study. J Clin Anesth 2017; 36:201-205. [DOI: 10.1016/j.jclinane.2016.10.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 09/11/2016] [Accepted: 10/27/2016] [Indexed: 10/20/2022]
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Mendes BC, Oderich GS, Erben Y, Reed NR, Pruthi RK. False Lumen Embolization to Treat Disseminated Intravascular Coagulation After Thoracic Endovascular Aortic Repair of Type B Aortic Dissection. J Endovasc Ther 2015; 22:938-941. [DOI: 10.1177/1526602815607185] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Purpose: To present a rare case of disseminated intravascular coagulation (DIC) after thoracic endovascular aortic repair (TEVAR) and its novel treatment. Case Report: A 55-year-old man presented with DIC 10 months after TEVAR for chronic type B aortic dissection and descending thoracic aortic aneurysm. He had persistent retrograde flow in the false lumen with a stable aneurysm diameter. The false lumen was embolized with multiple Amplatzer plugs, which promoted false lumen thrombosis. Laboratory evaluation on postoperative day 7 demonstrated resolution of the coagulopathy. Follow-up at 18 months revealed no recurrent DIC; computed tomography angiography showed a stable aortic diameter and excluded thoracic aneurysm sac. Conclusion: This case demonstrates an unusual, potentially fatal postoperative complication of endovascular treatment of type B aortic dissections successfully treated with an innovative endovascular solution.
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Affiliation(s)
- Bernardo C. Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Gustavo S. Oderich
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Young Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Nanette R. Reed
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
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An Update on the Inflammatory Response after Endovascular Repair for Abdominal Aortic Aneurysm. Mediators Inflamm 2015; 2015:945035. [PMID: 26166953 PMCID: PMC4488540 DOI: 10.1155/2015/945035] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 06/07/2015] [Accepted: 06/11/2015] [Indexed: 12/14/2022] Open
Abstract
Postimplantation syndrome (PIS) is the clinical and biochemical expression of an inflammatory response following endovascular repair of an aortic aneurysm (EVAR). The goal of this review is to provide an update on the inflammatory response after endovascular repair of abdominal aortic aneurysm, discussing its causes and effects on the clinical outcome of the patient. PIS concerns nearly one-third of patients after EVAR. It is generally a benign condition, although in some patients it may negatively affect outcome. The different definitions and conclusions drawn from several studies reveal that PIS needs to be redefined with standardized diagnostic criteria. The type of the endograft's material seems to play a role in the inflammatory response. Future studies should focus on a better understanding of the underlying pathophysiology, predictors, and risk factors as well as determining whether effective preventive strategies are necessary.
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13
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Arnaoutoglou E, Kouvelos G, Papa N, Kallinteri A, Milionis H, Koulouras V, Matsagkas M. Prospective evaluation of post-implantation inflammatory response after EVAR for AAA: influence on patients' 30 day outcome. Eur J Vasc Endovasc Surg 2015; 49:175-83. [PMID: 25579873 DOI: 10.1016/j.ejvs.2014.12.006] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 12/03/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim was to prospectively evaluate post-implantation syndrome (PIS) after elective endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) and to investigate its association with clinical and laboratory parameters and the clinical outcome of the patients. METHODS From January 2010 till June 2013, 214 consecutive patients treated electively by EVAR for AAA were prospectively included. PIS was defined according to systemic inflammatory response syndrome criteria. Adverse events included any major adverse cardiovascular events (MACE), acute renal failure, re-admission and death from any cause. RESULTS PIS was diagnosed in 77 (34%) patients. Pre-operative white blood cell (WBC) count values (p < .001), endograft material (polyester) (p < .001), and heart failure (p = .03) were independent predictors of PIS. Mean post-operative temperature (p < .001), length of hospital (p < .001) and intensive care unit (p = .008) stay, as well as maximum post-operative WBC count (p < .001) and hs-CRP values (p < .001) were significantly higher in the PIS group. Post-operative hs-CRP (p = .001) and duration of fever (p = .02) independently predicted the occurrence of MACE. Post-operative hs-CRP (p = .004), maximum temperature (p = .03), and the presence of PIS (p = .01) were independent predictors of an adverse event during the first 30 days. A threshold of post-operative hs-CRP value of 125 mg/L was highly associated with the occurrence of MACE, with a sensitivity of 82% and specificity of 75%. CONCLUSIONS A systematic inflammatory response is observed in a significant number of patients after EVAR. The type of endograft material seems to play a significant role in this inflammatory process. The intensity of inflammation, as assessed mainly by the post-operative hs-CRP values, correlates with the presence of a cardiovascular or any other adverse event during the first 30 days after the procedure.
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Affiliation(s)
- E Arnaoutoglou
- Department of Anesthesiology, School of Medicine, University of Ioannina, Ioannina, Greece
| | - G Kouvelos
- Department of Surgery - Vascular Surgery Unit, School of Medicine, University of Ioannina, Ioannina, Greece
| | - N Papa
- Department of Surgery - Vascular Surgery Unit, School of Medicine, University of Ioannina, Ioannina, Greece
| | - A Kallinteri
- Laboratory of Immunology and Microbiology, School of Medicine, University of Ioannina, Ioannina, Greece
| | - H Milionis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - V Koulouras
- Department of Intensive Care Medicine, Medical School, University of Ioannina, Ioannina, Greece
| | - M Matsagkas
- Department of Surgery - Vascular Surgery Unit, School of Medicine, University of Ioannina, Ioannina, Greece.
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Dua A, Algodi MM, Furlough C, Ray H, Desai SS. Development of a scoring system to estimate mortality in abdominal aortic aneurysms management. Vascular 2014; 23:586-91. [PMID: 25492573 DOI: 10.1177/1708538114563825] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION This study aimed to define risk factors associated with inpatient mortality in patients undergoing elective repair for unruptured abdominal aortic aneurysm and utilize these factors to create a scoring system to estimate risk of mortality. METHODS A retrospective analysis was completed using the Nationwide Inpatient Sample from 1998 to 2011. Patients who underwent elective abdominal aortic aneurysm repair were identified using ICD-9 codes. Demographics, comorbidities, length of stay, insurance status, and mortality were recorded. Statistically significant variables were identified using a multivariate analysis, and a discriminant analysis was used to identify factors predictive of inpatient mortality. RESULTS Over a 14-year period, 28,448 patients underwent elective repair of an unruptured abdominal aortic aneurysm. Independent variables associated with inpatient mortality included: age >60, female gender, congestive heart failure, peripheral artery disease, renal failure, malnutrition, and hypercoagulability. Endovascular aneurysm repair was protective against inpatient mortality. The area under the curve for the discriminant function was 0.83 (95% CI, 0.81-0.85) and successfully classified 87.9% of patients within the Nationwide Inpatient Sample (25,006/28,448 patients). CONCLUSION Seven factors that predict an increased risk of mortality and one factor that decreased the risk of mortality were identified. Preoperative risk factor mitigation may improve mortality following elective abdominal aortic aneurysm repair.
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Affiliation(s)
- Anahita Dua
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mohammed M Algodi
- Department of Cardiology Research, Montefiore Medical Center, New York, NY, USA
| | | | - Hunter Ray
- University of Texas Medical School at Houston, Houston, TX, USA
| | - Sapan S Desai
- Department of Vascular Surgery, Southern Illinois University, Springfield, IL, USA
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Operative and nonoperative management of chronic disseminated intravascular coagulation due to persistent aortic endoleak. J Vasc Surg 2014; 59:1426-9. [DOI: 10.1016/j.jvs.2013.05.097] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 05/13/2013] [Accepted: 05/16/2013] [Indexed: 11/19/2022]
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Bischoff M, Hafner S, Able T, Peters A, Hyhlik-Dürr A, Böckler D. Inzidenz und Therapie des Postimplantationssyndroms nach endovaskulärer Ausschaltung infrarenaler Aortenaneurysmen. GEFASSCHIRURGIE 2013. [DOI: 10.1007/s00772-013-1193-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Moulakakis KG, Alepaki M, Sfyroeras GS, Antonopoulos CN, Giannakopoulos TG, Kakisis J, Karakitsos P, Liapis CD. The impact of endograft type on inflammatory response after endovascular treatment of abdominal aortic aneurysm. J Vasc Surg 2013; 57:668-77. [DOI: 10.1016/j.jvs.2012.09.034] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2012] [Revised: 08/31/2012] [Accepted: 09/05/2012] [Indexed: 11/26/2022]
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Changes in thrombin generation, fibrinolysis, platelet and endothelial cell activity, and inflammation following endovascular abdominal aortic aneurysm repair. J Vasc Surg 2012; 55:41-6. [DOI: 10.1016/j.jvs.2011.07.094] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 07/26/2011] [Accepted: 07/28/2011] [Indexed: 11/18/2022]
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Marrocco-Trischitta MM, Kahlberg A, Astore D, Tshiombo G, Mascia D, Chiesa R. Outcome in cirrhotic patients after elective surgical repair of infrarenal aortic aneurysm. J Vasc Surg 2011; 53:906-11. [PMID: 21215574 DOI: 10.1016/j.jvs.2010.10.095] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Revised: 10/14/2010] [Accepted: 10/16/2010] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Abdominal surgery in patients with advanced liver disease has been reported to be associated with high morbidity and mortality rates. However, the surgical risk of infrarenal abdominal aortic aneurysm (AAA) repair in cirrhotics remains ill-defined. We reviewed our experience to investigate the predictors of the outcome in cirrhotic patients after elective AAA open repair. METHODS Between January 2001 and March 2006, 1189 patients underwent elective open repair of infrarenal AAA and 24 (2%) had a biopsy-proven cirrhosis (23 male, 1 female; mean age, 68 ± 7 years). The latter were retrospectively stratified according to the Child-Turcotte-Pugh (CTP) score and the Model for End-Stage Liver Disease (MELD) score. Operative variables, perioperative complications, and survival were recorded and compared with those of 48 concurrent noncirrhotic controls matched (2:1) by gender, age, aneurysm size, preoperative glomerular filtration rate, and type of reconstruction. The effect of CTP and MELD scores on midterm survival was investigated in cirrhotics with the Kaplan-Meier log-rank method. RESULTS No intraoperative or 30-day deaths were recorded. No significant differences in terms of major perioperative complications were observed between cirrhotic patients and controls. Operative time and intraoperative blood transfusion requirement were significantly higher in cirrhotics (162 ± 49 vs 132 ± 39 minutes; P = .007 and 273 ± 364 vs 84 ± 183 mL; P = .040, respectively). Hospital length of stay was nearly doubled in cirrhotic patients (11.0 ± 2.8 vs 5.8 ± 1.5 days; P < .0001). Twenty-two cirrhotic patients were classified as CTP A and two as CTP B. Median MELD score was 8 (range, 6-14). CTP class B was associated with higher intraoperative blood transfusion requirement (941 ± 54 vs 213 ± 314 mL; P = .029). At a mean follow-up of 30.7 ± 22.1 months, five deaths were recorded in cirrhotics, and three in controls. Actuarial survival at 2 years was 77.4% in cirrhotics and 97.8% in controls (log-rank test, P = .026). Both CTP B patients died within 6 months. CTP class B and a MELD score ≥10 were associated with reduced midterm survival rates (log-rank test, P < .0001 and P = .021, respectively). CONCLUSIONS In our experience, elective AAA open repair in relatively compensated cirrhotics was safely performed with an acceptable increase of the magnitude of the operation. However, the reduced life expectancy of cirrhotics with a MELD score ≥10 suggests that such a procedure may not be warranted in this subgroup of patients.
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Disseminated intravascular coagulation after endovascular aneurysm repair: Resolution after aortic banding. J Vasc Surg 2009; 49:1046-9. [DOI: 10.1016/j.jvs.2008.11.055] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2008] [Revised: 11/10/2008] [Accepted: 11/11/2008] [Indexed: 11/18/2022]
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Laohapensang K, Sirivanichai C. An Unusual Complication of EVAR, Spontaneous Rectus Sheath Hematoma: A Case Report. Ann Vasc Dis 2009. [DOI: 10.3400/avd.cr08035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Laohapensang K, Sirivanichai C. An Unusual Complication of EVAR, Spontaneous Rectus Sheath Hematoma: A Case Report. Ann Vasc Dis 2009; 2:122-5. [PMID: 23555371 DOI: 10.3400/avd.avdcr08035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2008] [Accepted: 11/06/2009] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To report a successful conservative management in a case of spontaneous rectus sheath hematoma (SRSH) after Endovascular Aneurysmal Repair (EVAR) of infrarenal Abdominal Aortic Aneurysm (AAA). CASE PRESENTATION An 84-year-old woman with a 6 cm in diameter infrarenal AAA underwent EVAR at our hospital. During the procedure, intravenous heparin was administered to keep the activated clotting time around 300 seconds. One hour after the procedure, the patient complained of pain on her right side abdomen. Physical examination revealed a tender mass in the right lower abdominal wall. Laboratory studies showed a fall in hemoglobin from 12.7 g/dl to 9.3 g/dl. Ultrasound (US) examination demonstrated an 8 × 5 cm hematoma within the right rectus muscle. Follow-up US examination revealed that the hematoma had enlarged and a computed tomography (CT) examination of the lower abdomen was performed. CT scan showed a smooth-shaped mass within the layers of the anterolateral abdominal wall leading to enlargement of the right rectus abdominis muscle without signs of active bleeding. A conservative management was considered. RESULT The clinical course was uneventful with a stable hemodynamic state. The patient was discharged 12 days later and was doing well at the 2 week follow-up. CONCLUSION Spontaneous rectus sheath hematoma is an unusual complication of a patient on anticoagulant therapy during EVAR. A prompt radiological investigation may prevent unnecessary surgical procedures in this unusual complication.
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Affiliation(s)
- Kamphol Laohapensang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Chiang Mai University Hospital, Chiang Mai, 50100, Thailand
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Higashiura W, Kichikawa K, Sakaguchi S, Kubota Y, Nagata T, Nishimine K, Ide K, Tabayashi N, Taniguchi S, Uchida H. Deteriorating consumptive coagulopathy with type III endoleak following endovascular repair for abdominal aortic aneurysm associated with liver cirrhosis. J Endovasc Ther 2007; 14:421-5. [PMID: 17723004 DOI: 10.1583/06-1965.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To report a case of deteriorating consumptive coagulopathy with type III endoleak following endovascular aneurysm repair (EVAR) of the abdominal aorta associated with liver cirrhosis. CASE REPORT A 72-year-old man with liver cirrhosis developed type III endoleak following EVAR. Spontaneous intramuscular hematoma developed due to deteriorating consumptive coagulopathy induced by type III endoleak and liver dysfunction. Although additional EVAR was performed at 52 months after primary EVAR, the patient died due to multiorgan failure and multifocal hematoma of the muscles and subserosa. CONCLUSION EVAR for patients with liver dysfunction and coagulopathy should be considered with great caution. We suggest that prompt and adequate treatment using an endovascular technique or surgical repair should be performed for patients with liver dysfunction, coagulopathy, and turbulent endoleak, even if the coagulopathies are worse compared to before EVAR.
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Affiliation(s)
- Wataru Higashiura
- Department of Radiology, Nara Medical University, Kashihara, Nara, Japan.
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Shimazaki T, Ishimaru S, Kawaguchi S, Yokoi Y, Watanabe Y. Blood coagulation and fibrinolytic response after endovascular stent grafting of thoracic aorta. J Vasc Surg 2003; 37:1213-8. [PMID: 12764267 DOI: 10.1016/s0741-5214(02)75323-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Thrombosis is common in aneurysms immediately after stent-grafting, because of exclusion from systemic blood flow. We studied changes in blood coagulation and the fibrinolytic system in patients with thoracic aortic aneurysm or dissection after stent-grafting to examine risk for consumption coagulopathy. METHODS Thirty-one thoracic aortic aneurysms were treated with stent-grafting (aneurysm group), and 29 aortic dissections were treated with entry closure with stent-grafting (dissection group). The stent-graft was constructed from a self-expanding Z stent and thin-walled woven polyester fabric. Platelet count, fibrinogen, antithrombin III (AT III), and thrombin-AT III complex were assayed as markers of coagulation. Plasminogen, alpha(2)-plasmin inhibitor, alpha(2)-plasmin inhibitor-plasmin complex, fibrin degradation products fragment E (FDP-E), and fibrin degradation products d-dimer were monitored as markers of fibrinolysis. Blood samples were collected before surgery and on postoperative days 1, 3, 7, and 14. RESULTS In both groups platelet count significantly decreased on postoperative days 1 and 3, and increased on postoperative day 14. AT III significantly decreased on postoperative day 1, but recovered after postoperative day 7. FDP-E significantly increased on postoperative day 1 in both groups. There was significant correlation of aneurysm diameter with alpha(2)-plasmin inhibitor-plasmin complex, fibrin degradation products, and d-dimer in the dissection group on postoperative day 1. CONCLUSIONS Activation of coagulation and fibrinolysis was observed after stent-grafting to treat thoracic aortic aneurysm and aortic dissection. However, no patients exhibited consumption coagulopathy postoperatively. Therefore we believe there is little risk for consumption coagulopathy after stent-grafting.
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Affiliation(s)
- Taro Shimazaki
- Department of Surgery II, Tokyo Medical University, Tokyo, Japan.
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