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Rizza A, Trimarchi G, Di Sibio S, Bastiani L, Murzi M, Palmieri C, Foffa I, Berti S. Preliminary Outcomes of Zone 2 Thoracic Endovascular Aortic Repair Using Castor Single-Branched Stent Grafts: A Single-Center Experience. J Clin Med 2023; 12:7593. [PMID: 38137662 PMCID: PMC10743804 DOI: 10.3390/jcm12247593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/26/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
In the context of thoracic endovascular aortic repair (TEVAR), the reconstruction of the left subclavian artery (LSA) has emerged as a crucial component in establishing a sufficient proximal landing zone. However, the technical difficulty of these procedures raises the possibility of endoleaks and neurological consequences. Single-branched stent grafts offer good anchoring and LSA flow for these patients. This study evaluates the feasibility of utilizing novel single-branched stent grafts in the treatment of distal aortic arch disease, identifying good results in the short and medium term. From September 2019 to March 2023, TEVAR and revascularized LSA were performed on ten patients at the Ospedale del Cuore-FTGM in Massa, Italy, using Castor single-branched thoracic aortic stent grafts (Microport Medical, Shanghai, China). The authors' first findings demonstrated that, after an average follow-up of one year, the Castor branching aortic stent graft system was safe and achieving an appropriate proximal landing zone and maintaining sufficient LSA perfusion was possible. With regard to the endovascular treatment of distal aortic arch diseases, this product offers a compelling substitute for surgery. For the purpose of assessing the long-term effectiveness of this approach, the follow-up period should be extended.
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Affiliation(s)
- Antonio Rizza
- Fondazione Toscana Gabriele Monasterio, 54100 Massa, Italy; (S.D.S.); (L.B.); (M.M.); (C.P.); (I.F.); (S.B.)
| | - Giancarlo Trimarchi
- Department of Clinical and Experimental Medicine, University Hospital of Messina, 98121 Messina, Italy;
| | - Silvia Di Sibio
- Fondazione Toscana Gabriele Monasterio, 54100 Massa, Italy; (S.D.S.); (L.B.); (M.M.); (C.P.); (I.F.); (S.B.)
| | - Luca Bastiani
- Fondazione Toscana Gabriele Monasterio, 54100 Massa, Italy; (S.D.S.); (L.B.); (M.M.); (C.P.); (I.F.); (S.B.)
- Institute of Clinical Physiology, National Research Council, 54100 Massa, Italy
| | - Michele Murzi
- Fondazione Toscana Gabriele Monasterio, 54100 Massa, Italy; (S.D.S.); (L.B.); (M.M.); (C.P.); (I.F.); (S.B.)
| | - Cataldo Palmieri
- Fondazione Toscana Gabriele Monasterio, 54100 Massa, Italy; (S.D.S.); (L.B.); (M.M.); (C.P.); (I.F.); (S.B.)
| | - Ilenia Foffa
- Fondazione Toscana Gabriele Monasterio, 54100 Massa, Italy; (S.D.S.); (L.B.); (M.M.); (C.P.); (I.F.); (S.B.)
- Institute of Clinical Physiology, National Research Council, 54100 Massa, Italy
| | - Sergio Berti
- Fondazione Toscana Gabriele Monasterio, 54100 Massa, Italy; (S.D.S.); (L.B.); (M.M.); (C.P.); (I.F.); (S.B.)
- Institute of Clinical Physiology, National Research Council, 54100 Massa, Italy
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Luo ZR, Zhang JX, Huang ZY, Chen LW. Endovascular repair of aortic pathologies involving the aortic arch using castor stent-graft combined with in-vitro fenestration technology. BMC Cardiovasc Disord 2023; 23:107. [PMID: 36829125 PMCID: PMC9960472 DOI: 10.1186/s12872-023-03138-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/21/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Aortic arch pathologies are concerning clinical conditions with poor prognoses. The use of thoracic endovascular aortic repair (TEVAR) has been investigated to treat aortic arch pathologies. Nonetheless, cerebral blood flow regulation during endovascular aortic arch repair therapy remains challenging. Castor, a unique single-branched stent graft, has been proven effective for retaining the left subclavian artery (LSA). This study aimed to determine whether endovascular therapy for pathologies involving the aortic arch using Castor in combination with the in-vitro fenestration technique is promising, effective, and safe. METHODS Eligible patients were enrolled between June 2018 and December 2021. All patients underwent TEVAR with an evaluated proximal landing zone for "Castor" located in Ishimaru zones 0-1. Moreover, the supra-aortic branches (SABs) were reconstructed using the Castor in combination with the in-vitro fenestration technique. RESULTS Herein, 57 patients with aortic arch lesions were treated with Castor in combination with the in-vitro fenestration technique. Innominate artery and the left carotid artery (LCA) were reconstructed in 5 patients, LCA and left subclavian artery (LSA) were reconstructed in 22 patients, and the total SABs were effectively reconstructed in 30 patients (including a hybrid arch repair case). Among them (excluding a hybrid arch repair case) were in-vitro fenestration methodologies for LCA in 32 of 34 cases (2 switched to in-situ fenestration) and LSA in 51 of 56 cases (3 switched to in-situ fenestration and 2 converted to spring coil caulking); furthermore, LCA and LSA in-vitro fenestration were simultaneously successfully performed in 27 of 34 cases. There were no surgical-related neurological complications, and early mortality was estimated at 5.26%. At a mean follow-up of 3.75 months, computed tomography (CTA) images confirmed that each branch stent remained patent. There were no signs of endoleaks, migrative manifestations, or the need for secondary endovascular intervention or conversion to open surgical procedures. CONCLUSION Castor, in combination with in-vitro fenestration, reflects a feasible, efficient procedure for re-developing SABs.
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Affiliation(s)
- Zeng-Rong Luo
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, People's Republic of China.,Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian Province, People's Republic of China
| | - Jia-Xin Zhang
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, People's Republic of China.,Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian Province, People's Republic of China
| | - Zhong-Yao Huang
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, People's Republic of China.,Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian Province, People's Republic of China
| | - Liang-Wan Chen
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, People's Republic of China. .,Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian Province, People's Republic of China.
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Eranki A, Merakis M, Williams ML, Flynn CD, Villanueva C, Wilson-Smith A, Lee Y, Mejia R. Outcomes of surgery for acute type A dissection in octogenarians versus non-octogenarians: a systematic review and meta analysis. J Cardiothorac Surg 2022; 17:222. [PMID: 36050776 PMCID: PMC9434858 DOI: 10.1186/s13019-022-01980-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 08/26/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Acute Type A Aortic Dissection (ATAAD) is a cardiothoracic emergency that requires urgent intervention. Elderly status, particularly age over 80, is an independent risk factor for mortality and morbidity. The mid-term outcomes of this age group are also unknown. This systematic review and meta-analysis of observational studies was therefore performed to analyse short- and mid-term mortality and morbidity in octogenarians following surgery for ATAAD. METHODS A systematic review was conducted for studies published since January 2000. The primary endpoint was short-term mortality, either reported as 30-day mortality or in-hospital mortality and medium-term (five year) survival. Secondary endpoints were rates of postoperative complications, namely stroke, acute renal failure (ARF), re-exploration and intensive care unit (ICU) length of stay (LOS). RESULTS A total of 16 retrospective studies, with a total of 16, 641 patients were included in the systematic review and meta-analysis. Pooled analysis demonstrated that octogenarian cohorts are at significantly higher risk of short-term mortality than non-octogenarians (OR 1.93; 95% CI 1.33-2.81; P < 0.001). Actuarial survival was significantly lower in the octogenarian cohort, with a five-year survival in the octogenarian cohort of 54% compared to 76% in the non-octogenarian cohort (P < 0.001). There were no significant differences between the cohorts in terms of secondary outcomes: stroke, ARF, re-exploration or ICU LOS. CONCLUSION Octogenarians are twice as likely to die in the short-term following surgery for ATAAD and demonstrate a significantly lower five-year actuarial survival. Patients and family members should be well informed of the risks of surgery and suitable octogenarians selected for surgery.
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Affiliation(s)
- Aditya Eranki
- Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, Australia.
| | - Michael Merakis
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Michael L Williams
- Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Campbell D Flynn
- Department of Cardiothoracic Surgery, St George Hospital, Sydney, Australia.,The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Claudia Villanueva
- Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, Australia
| | - Ashley Wilson-Smith
- Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, Australia.,The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Yangsin Lee
- Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, Australia
| | - Ross Mejia
- Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, Australia
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Wang JX, Xue YX, Zhu XY, Chong HS, Chen Z, Zhou Q, Qu JZ, Wang DJ. The impact of age in acute type A aortic dissection: a retrospective study. J Cardiothorac Surg 2022; 17:40. [PMID: 35305695 PMCID: PMC8933992 DOI: 10.1186/s13019-022-01785-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 03/13/2022] [Indexed: 11/16/2022] Open
Abstract
Background Acute type A aortic dissection (aTAAD) is a lethal disease and age is an important risk factor for outcomes. This retrospective study was to analyze the impact of age stratification in aTAAD, and to provide clues for surgeons when they make choices of therapy strategies.
Methods From January 2011 to December 2019, 1092 aTAAD patients from Nanjing Drum Tower Hospital received surgical therapy. Patients were divided into 7 groups according to every ten-year interval (20–80 s). The differences between the groups were analyzed in terms of the baseline preoperative conditions, surgical methods and postoperative outcomes of patients of different age groups. During a median follow-up term of 17 months, the survival rates were compared among 7 groups through Kaplan–Meier analysis.
Results The median age was 52.0 years old in whole cohort. The multiple comorbidities were more common in old age groups (60 s, 70 s, 80 s), while the 20 s group patients had the highest proportion of Marfan syndrome (28.1%). Preoperative hypotension was highest in 80 s (16.7%, P = 0.038). Young age groups (20–60 s) had a higher rate of root replacement and total arch replacement, which led to a longer duration of operation and hypothermic circulation arrest. The overall mortality was 14.1%, the tendency of mortality was increased with age except 20 s group (33.3% in 80 s, P = 0.016). The postoperative morbidity of gastrointestinal bleeding and bowel ischemia were 16.7% and 11.1% in 80 s group. Conclusions Age is a major impact factor for aTAAD surgery. Old patients presented more comorbidities before surgery, the mortality and complications rate were significantly higher even with less invasive and conservative surgical therapy. But the favorable long-term survival indicated that the simple or less extensive arch repair is the preferred surgery for patients over 70 years old. Supplementary Information The online version contains supplementary material available at 10.1186/s13019-022-01785-y.
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Abe N, Okada K, Tanaka H, Okita Y. Valve-sparing aortic root replacement after type A aortic dissection repairs. Asian Cardiovasc Thorac Ann 2020; 29:381-387. [PMID: 33249852 DOI: 10.1177/0218492320977981] [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: 11/17/2022]
Abstract
OBJECTIVE Aortic root reoperation after aortic dissection repair sometimes requires aortic root replacement. A valve-preserving technique should be applied when the aortic cusp is normal. Valve-sparing aortic root reconstruction using the reimplantation technique resolves aortic valve regurgitation, root dilatation, and pseudoaneurysm in the proximal anastomosis. Our experience in aortic root reoperation is presented. METHODS From January 2000 to March 2019, 26 patients underwent reoperative valve-sparing aortic root reconstruction using the reimplantation technique. The time from the initial operation to reoperation was 69.3 ± 51.6 months. Aortic root reoperation was required for a fragile wall at the previous proximal anastomosis or aortic root dilatation. We aimed to stabilize the aortic root without valve regurgitation. The native aortic cusp was aggressively preserved when nearly normal. Indications included root dilatation (n = 13), pseudoaneurysm of the previous proximal anastomosis (n = 11), and aortic valve regurgitation (n = 4). RESULTS There was no early postoperative mortality. Follow-up was 49 ± 47 months (range 4-161 months). The 3, 5, and 10-year survival was 88.9% ± 7.4%, 88.9% ± 7.4%, and 77.8% ± 12.2%, respectively. Freedom from recurrence of a greater than moderate degree of aortic valve regurgitation at 3, 5, and 10 years was 86.5% ± 8.9%, 86.5% ± 8.9%, and 86.5% ± 8.9%, respectively. One patient underwent aortic valve replacement for recurrent aortic valve regurgitation 15 months after the valve-sparing reoperation. CONCLUSIONS Midterm outcomes of reoperative valve-sparing aortic root reconstruction using the reimplantation technique and postoperative aortic valve performance were satisfactory.
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Affiliation(s)
- Noriyuki Abe
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kenji Okada
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Tanaka
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yutaka Okita
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Arakawa M, Okamura H, Miyagawa A, Kitada Y, Adachi H. Clinical outcome of acute thoracic aortic syndrome in nonagenarians. Asian Cardiovasc Thorac Ann 2020; 28:577-582. [PMID: 32819152 DOI: 10.1177/0218492320952654] [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] [Indexed: 01/16/2023]
Abstract
BACKGROUND Decision-making regarding the operability of thoracic aortic disease in nonagenarian patients remains controversial because outcomes of open surgical repair of the thoracic aorta are unclear. We investigated the surgical and nonsurgical outcomes of acute thoracic aortic syndrome treatment in nonagenarians. METHODS After evaluating data in our institute from April 2016 to March 2020, we included 10 nonagenarians who needed surgical intervention on the thoracic aorta via a median sternotomy for acute thoracic aortic syndrome. The mean age of the cohort was 91.9 ± 2.1 years. Five patients underwent open surgical repair of the thoracic aorta (surgical group), and 5 refused surgery (nonsurgical group). All patients in the surgical group performed activities of daily living independently, with a mean clinical frailty scale of 3.2 ± 0.4. The surgical group included 4 patients with type A aortic dissection and one with a ruptured thoracic aortic aneurysm. Hemiarch replacement was performed in 3 patients and total arch replacement in 2. The mean follow-up period was 17.8 ± 5.1 months. RESULTS Hospital mortality rates were 0% in the surgical and 80% in the nonsurgical group. The mean length of hospitalization was 28.4 ± 6.7 days in the surgical group. The 1-year survival rates were 100% in the surgical group and 20% in the nonsurgical group. CONCLUSION Open surgical repair for acute thoracic aortic syndrome via median sternotomy is a reasonable treatment option even in nonagenarians. Involvement of family members is important for decision-making to devise the optimal treatment strategy (surgical vs. medical).
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Affiliation(s)
- Mamoru Arakawa
- Department of Cardiovascular Surgery, 83943Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Homare Okamura
- Department of Cardiovascular Surgery, 83943Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Atsushi Miyagawa
- Department of Cardiovascular Surgery, 83943Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Yuichiro Kitada
- Department of Cardiovascular Surgery, 83943Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Hideo Adachi
- Department of Cardiovascular Surgery, 83943Nerima Hikarigaoka Hospital, Tokyo, Japan
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Igarashi T, Sato Y, Satokawa H, Takase S, Wakamatsu H, Seto Y, Iwai-Takano M, Fujimiya T, Shinjo H, Yokoyama H. The results of an entry-oriented strategy for acute type A aortic dissection in octogenarians: an 18-year experience. Eur J Cardiothorac Surg 2020; 58:949-956. [DOI: 10.1093/ejcts/ezaa195] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 04/20/2020] [Accepted: 04/23/2020] [Indexed: 01/01/2023] Open
Abstract
Abstract
OBJECTIVES
The aim of this study was to evaluate the 18-year results of emergency operations for acute type A aortic dissection, especially in octogenarians.
METHODS
We reviewed 199 patients who underwent surgical aortic repair of an acute type A aortic dissection from January 2001 to December 2018. If the primary entry existed in the ascending aorta, we limited the extent of the replacement to within the ascending aorta. We analysed the early and late outcomes and identified the predictive factors for in-hospital death and difficulty of direct discharge to home.
RESULTS
The hospital mortality was 16%. The causes of death were postoperative bleeding (n = 8, 4%), intestinal ischaemia (n = 6, 3%), respiratory failure (n = 5, 3%), systemic inflammatory response syndrome (n = 4, 2%), low output syndrome (n = 3, 2%), sudden death (n = 3, 2%), myonephrotic metabolic syndrome (n = 2, 1%) and stroke (n = 1, 1%). Multivariable analysis revealed that an estimated glomerular filtration rate <30 (P = 0.006), malperfusion (P = 0.001), rupture (P < 0.001) and cross-clamping time (P = 0.003) were independent predictive factors of in-hospital death. Age was not a significant factor for predicting in-hospital death. Ascending aorta replacement (P = 0.013), advanced age (P = 0.002) and prolonged extracorporeal circulation time (P = 0.009) were independent predictive factors of difficulty in direct discharge to home. In the late follow-up period, the 5-year survival and aortic event-free rates were 62.2% and 88.9% in octogenarians, respectively.
CONCLUSIONS
From the perspective of saving lives, the results of emergency surgery for octogenarians were acceptable. Avoiding the postoperative decline in activities of daily living in octogenarians is a consideration going forward.
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Affiliation(s)
- Takashi Igarashi
- Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan
| | - Yoichi Sato
- Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan
| | - Hirono Satokawa
- Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan
| | - Shinya Takase
- Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan
| | - Hiroki Wakamatsu
- Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan
| | - Yuki Seto
- Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan
| | - Masumi Iwai-Takano
- Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan
| | - Tsuyoshi Fujimiya
- Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan
| | - Hiroharu Shinjo
- Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan
| | - Hitoshi Yokoyama
- Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan
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Harky A, Singh VP, Khan D, Sajid MM, Kermali M, Othman A. Factors Affecting Outcomes in Acute Type A Aortic Dissection: A Systematic Review. Heart Lung Circ 2020; 29:1668-1681. [PMID: 32798049 DOI: 10.1016/j.hlc.2020.05.113] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 05/10/2020] [Accepted: 05/18/2020] [Indexed: 11/17/2022]
Abstract
Acute type A aortic dissection is a clinical emergency and is associated with significant morbidity and mortality rates if not managed promptly in specialised and high-volume centres. The mortality rate is increased by 1% for each hour delay in management; however, with advancement in clinical practice, diagnostic imaging and clinician awareness, this has been dramatically reduced to below 30% in most international centres. Not only timing of recognition of the pathology, but also other factors can significantly affect outcomes of such critical pathology. This includes, but is not limited to, age, extent of the pathology, existence of connective tissue disorders, hypertension, diabetes mellitus and surgeon experience. This narrative review will focus on current clinical practice and the evidence behind optimising each factor to minimise adverse outcomes in such high-risk cohort.
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Affiliation(s)
- Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK; School of Medicine, University of Liverpool, Liverpool, UK.
| | | | - Darab Khan
- School of Medicine, University of Liverpool, Liverpool, UK
| | | | - Muhammed Kermali
- Faculty of Medicine, St. George's, University of London, London, UK
| | - Ahmed Othman
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
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Masubuchi T, Yoshitani K, Minami K, Yokoyama C, Tsukinaga A, Goto T, Ohnishi Y. Transfusion characteristics and hemostatic conditions in octogenarians undergoing emergency surgery for acute aortic dissection: a retrospective study. JA Clin Rep 2020; 6:52. [PMID: 32648135 PMCID: PMC7347724 DOI: 10.1186/s40981-020-00358-z] [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: 05/26/2020] [Accepted: 07/03/2020] [Indexed: 12/03/2022] Open
Abstract
Background The number of elderly patients undergoing elective as well as emergent cardiac surgery is increasing. Octogenarian and older patients undergoing surgery for acute type A aortic dissection (AAD) have a significantly higher risk of postoperative mortality than younger patients. Hemostasis is difficult in octogenarians with AAD. However, few studies have investigated perioperative blood transfusion volumes and hemostatic conditions in patients undergoing AAD surgery. We retrospectively investigated whether these factors differed between octogenarians and younger patients with AAD. Methods The records of 207 patients who underwent emergency surgery for AAD were reviewed between 2008 and 2014. We compared the total volumes of transfused blood components (red blood cell concentrate, fresh frozen plasma, platelets concentrate, and cryoprecipitate), perioperative blood coagulation test results (prothrombin time-international normalized ratio, activated partial thrombin time, and activated coagulation time), and intensive care unit and hospital stay durations between octogenarians (n = 33) and patients < 80 years old (n = 170). Results A significantly greater volume of red blood cell concentrates was transfused in octogenarians than in patients < 80 years old. Isolated prolonged activated partial thromboplastin time was observed in octogenarian patients. Duration of hospital stays was significantly longer in octogenarians than in patients < 80 years old. Conclusions Octogenarians required more red blood cells during surgery for AAD and exhibited isolated APTT prolongation.
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Affiliation(s)
- Tetsuhito Masubuchi
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, 6-1, Kishibeshimmachi, Suita, Osaka, 564-8565, Japan
| | - Kenji Yoshitani
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, 6-1, Kishibeshimmachi, Suita, Osaka, 564-8565, Japan.
| | - Kimito Minami
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, 6-1, Kishibeshimmachi, Suita, Osaka, 564-8565, Japan
| | - Chisaki Yokoyama
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, 6-1, Kishibeshimmachi, Suita, Osaka, 564-8565, Japan
| | - Akito Tsukinaga
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, 6-1, Kishibeshimmachi, Suita, Osaka, 564-8565, Japan
| | - Takahisa Goto
- Department of Anesthesiology, Yokohama City University Hospital, 3-9, Fukuura, Yokohama, Kanagawa, 236-0004, Japan
| | - Yoshihiko Ohnishi
- Department of Anesthesiology, Yokohama City University Hospital, 3-9, Fukuura, Yokohama, Kanagawa, 236-0004, Japan
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10
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Al-Adhami A, Harky A, Bashir M, Kolvekar S. Replacing the ascending aorta in the elderly: do or do not. Indian J Thorac Cardiovasc Surg 2019; 35:106-111. [PMID: 33061074 DOI: 10.1007/s12055-018-0734-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/15/2018] [Accepted: 08/17/2018] [Indexed: 01/16/2023] Open
Abstract
Advanced age is a proven independent factor for perioperative morbidity and mortality in all forms of aortic surgery and forms an important variable in most available risk scores. Improvements in selection and perioperative management of high-risk elderly cohorts have reduced the incidence of adverse outcomes. Concerns remain however in the surgical and anesthesiology community that exposing elderly frail patients to ascending aortic surgery is associated with significant risk. As with many clinical scenarios, individualization of care for each patient is of paramount importance. With advances in our understanding of perioperative and intraoperative care, age should no longer be considered in isolation as a contraindication to ascending aortic surgery.
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Affiliation(s)
- Ahmed Al-Adhami
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, G81 4DY UK
| | - Amer Harky
- Department of Vascular Surgery, Countess of Chester, Chester, CH1 2UL UK
| | - Mohamad Bashir
- Department of Aortovascular Surgery, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UK
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Aoyama T, Kunisawa S, Fushimi K, Sawa T, Imanaka Y. Comparison of surgical and conservative treatment outcomes for type a aortic dissection in elderly patients. J Cardiothorac Surg 2018; 13:129. [PMID: 30563552 PMCID: PMC6299624 DOI: 10.1186/s13019-018-0814-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 12/03/2018] [Indexed: 11/24/2022] Open
Abstract
Background In recent years, surgical outcomes have improved, and positive reports on surgery for type A aortic dissection (AAD) in the elderly are increasing. However, the difference between surgical and conservative treatments in the elderly remains unclear. Therefore, we conducted this study to determine whether surgery should be performed for Stanford (AAD) in elderly patients. Methods Data of patients aged 80 years or older who were hospitalized for AAD from April 2014 to March 2016 were extracted from the Japanese national inpatient database. Outcome measures were all-cause in-hospital death, stroke, acute kidney injury and tracheotomy, and composite adverse events (consisting of all-cause in-hospital death, stroke, acute kidney injury, and tracheotomy), and we compared them between surgical and conservative treatments using propensity score matching. Results The study cohort included 3258 patients, with 845 matched pairs (1690 patients) in the propensity score matching. All-cause in-hospital death was significantly lower in the surgical treatment group than in the conservative treatment group before and after matching (15.6% vs. 51.1%, p < 0.001; 16.7% vs. 31.6%, p < 0.001, respectively); however, there was no significant difference in composite adverse events after matching (36.0%, conservative vs. 37.2%, surgical; p = 0.65), and adjusted odds ratio was 1.06 and 95% confidence interval was 0.86–1.29 (p = 0.61) with reference to conservative treatment. Conclusions All-cause in-hospital death among elderly patients with AAD was significantly lower in patients treated surgically than in those undergoing conservative treatment. However, there was no significant difference between the two groups in the event-free survival, which is important for the elderly. These findings may be used in the consideration of treatment course for elderly patients with AAD. Electronic supplementary material The online version of this article (10.1186/s13019-018-0814-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Takeshi Aoyama
- Department of Anesthesiology, Graduate School of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan.,Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan.,Department of Anesthesiology, Omihachiman Community Medical Center, Shiga, Japan
| | - Susumu Kunisawa
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Teiji Sawa
- Department of Anesthesiology, Graduate School of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuichi Imanaka
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan.
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Furukawa H, Yamane N, Honda T, Yamasawa T, Kanaoka Y, Tanemoto K. Initial clinical evaluation of preoperative frailty in surgical patients with Stanford type A acute aortic dissection. Gen Thorac Cardiovasc Surg 2018; 67:208-213. [PMID: 30136032 DOI: 10.1007/s11748-018-0994-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/17/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND We retrospectively assessed the initial clinical role of preoperative frailty in surgical patients with Stanford type A acute aortic dissection (AAAD). METHODS One hundred and fourteen consecutive patients who underwent emergent or urgent surgical interventions for AAAD in our institute between April 2000 and March 2016 participated in this retrospective study. Patients with more than three of the following six modalities were defined as being frail: age older than 75 years, preoperative requirement of assistance in daily living, body mass index less than 18.5 kg/m2, female, history of major stroke, and chronic kidney disease greater than class 3b. Twenty-three patients (20.2%) were diagnosed with frailty (group F), while 91 patients (79.8%) were not (group N). Early clinical outcomes, major postoperative complications, postoperative recovery of activity, and early or mid-term survival were evaluated. RESULTS Although early clinical outcomes and the prevalence of major postoperative complications were similar in both groups, postoperative activity of daily living (ADL), such as the rate of being ambulatory on discharge (p < 0.05) and home discharge (p < 0.01), was significantly lower in group F than in group N. A Kaplan-Meier analysis revealed that 1- and 5-year survival rates were similar in groups F (85.9 and 76.4%, respectively) and N (86.0 and 76.9%, respectively). CONCLUSIONS Preoperative frailty in AAAD surgical patients has potential as a prognostic factor that affects delays in ADL recovery, but does not influence the early or mid-term clinical outcomes of prompt surgical strategies for life rescue in AAAD patients with frailty.
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Affiliation(s)
- Hiroshi Furukawa
- Department of Cardiovascular Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan.
| | - Naoki Yamane
- Department of Cardiovascular Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Takeshi Honda
- Department of Cardiovascular Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Takahiko Yamasawa
- Department of Cardiovascular Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Yuji Kanaoka
- Department of Cardiovascular Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
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13
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Castaño M, Gualis J, Martínez-Comendador JM, Martín E, Maiorano P, Castillo L. Emergent aortic surgery in octogenarians: is the advanced age a contraindication? J Thorac Dis 2017; 9:S498-S507. [PMID: 28616346 DOI: 10.21037/jtd.2017.04.51] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Surgery of both the ascending and descending aortic segments in the context of an acute aortic syndrome is one of the greatest challenges for the cardiac surgeon. In the case of surgery of the descending aorta, surgical risk increases due to the technical complexity, the required aggressive approach and because surgical indication is usually established as a result of complications and therefore involves, almost always, critically ill patients. The aging of the population is causing such surgery to be considered in an increasing number of octogenarians. The present review analyzes the available scientific evidence on the surgical indications and outcomes of these complex procedures in this population, particularly in the emergent scenario. Ascending and descending thoracic aortic diseases are reviewed separately, and the role of both the current risk scores and frailty assessments are comprehensively discussed.
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Affiliation(s)
- Mario Castaño
- Department of Cardiac Surgery, University Hospital of Leon, León, Spain
| | - Javier Gualis
- Department of Cardiac Surgery, University Hospital of Leon, León, Spain
| | | | - Elio Martín
- Department of Cardiac Surgery, University Hospital of Leon, León, Spain
| | - Pasquale Maiorano
- Department of Cardiac Surgery, University Hospital of Leon, León, Spain
| | - Laura Castillo
- Department of Cardiac Surgery, University Hospital of Leon, León, Spain
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Kamohara K, Koga S, Takaki J, Yoshida N, Furukawa K, Morita S. Long-term durability of preserved aortic root after repair of acute type A aortic dissection. Gen Thorac Cardiovasc Surg 2017; 65:441-448. [DOI: 10.1007/s11748-017-0783-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 05/11/2017] [Indexed: 12/01/2022]
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15
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Nienaber CA, Sakalihasan N, Clough RE, Aboukoura M, Mancuso E, Yeh JS, Defraigne JO, Cheshire N, Rosendahl UP, Quarto C, Pepper J. Thoracic endovascular aortic repair (TEVAR) in proximal (type A) aortic dissection: Ready for a broader application? J Thorac Cardiovasc Surg 2017; 153:S3-S11. [DOI: 10.1016/j.jtcvs.2016.07.078] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 07/06/2016] [Accepted: 07/30/2016] [Indexed: 10/21/2022]
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16
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Bruno VD, Chivasso P, Guida G, Vohra HA. Surgical repair of Stanford type A aortic dissection in elderly patients: a contemporary systematic review and meta-analysis. Ann Cardiothorac Surg 2016; 5:257-64. [PMID: 27563539 DOI: 10.21037/acs.2016.06.03] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The results of surgical treatment of type A aortic dissection (AAD) in the elderly are controversial and aggravated by a higher operative mortality rate. The studies published in this subset of patients are mainly retrospective analyses or small samples from international registries. We sought to investigate this topic by conducting a contemporary meta-analysis of the most recent observational studies. METHODS A systematic literature search was conducted for any study published in the last five years on aortic dissection treated surgically in patients 70 years and older. A pooled risk-ratio meta-analysis has been conducted three main post-operative outcomes: short-term mortality, stroke and acute kidney injury. RESULTS A total of 11 retrospective observational studies have been included in the quantitative meta-analysis. Pooled meta-analysis showed an increased risk of short term mortality for the elderly population [relative risk (RR) =2.25; 95% CI, 1.79-2.83; I (2)=0%; P<0.0001], and this has been confirmed in a sub-analysis of patients 80 years and older. The risk of having stroke (RR =1.15; 95% CI, 0.89-1.5; I (2)=0%; P=0.28) and acute kidney injury (RR =0.79; 95% CI, 0.5-1.25, I (2)=14%, P=0.31) after surgery were comparable to the younger cohort of patients. CONCLUSIONS Although affected by an increased risk of short-term mortality in the elderly, surgical repair remains the treatment of choice for AAD. The main post-operative outcomes are comparable to younger patients and the mid-term survival rates are acceptable.
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Affiliation(s)
- Vito D Bruno
- Cardiac Surgery Department, Bristol Heart Institute, Bristol, UK
| | | | - Gustavo Guida
- Cardiac Surgery Department, Bristol Heart Institute, Bristol, UK
| | - Hunaid A Vohra
- Cardiac Surgery Department, Bristol Heart Institute, Bristol, UK
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Uchino G, Ohashi T, Iida H, Tadakoshi M, Kageyama S, Furui M, Kodani N. Predictors of patent false lumen of the aortic arch after hemiarch replacement. Gen Thorac Cardiovasc Surg 2016; 64:722-727. [DOI: 10.1007/s11748-016-0691-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 07/20/2016] [Indexed: 11/30/2022]
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18
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Tochii M, Takami Y, Hattori K, Ishikawa H, Ishida M, Higuchi Y, Takagi Y. Early and Late Outcomes of Surgical Repair for Stanford A Acute Aortic Dissection in Octogenarians. Circ J 2016; 80:2468-2472. [DOI: 10.1253/circj.cj-16-0918] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Masato Tochii
- Department of Cardiovascular Surgery, Fujita Health University
| | | | - Koji Hattori
- Department of Cardiovascular Surgery, Fujita Health University
| | | | - Michiko Ishida
- Department of Cardiovascular Surgery, Fujita Health University
| | - Yoshiro Higuchi
- Department of Cardiovascular Surgery, Fujita Health University
| | - Yasushi Takagi
- Department of Cardiovascular Surgery, Fujita Health University
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