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Wang B, Qiu C, Yu X, He Y, Chen T, Lin R, Wang X, Pan J, Wang X, Zhang H, Wu Z. Abdominal Penetrating Aortic Ulcer and Endovascular Treatments: A Systematic Review and Meta-Analysis. Vasc Endovascular Surg 2023; 57:838-847. [PMID: 37267067 DOI: 10.1177/15385744231180678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Abdominal penetrating aortic ulcer (aPAU) is defined as an ulceration of the aortic intima and media lamina, even with rupture of the internal elastic lamina. Recently, there have been an increasing number of publications on endovascular treatment for aPAU. This review aimed to assess the efficacy and safety of endovascular treatment and provide clinicians with the latest evidence-based medical data. METHODS 3 academic databases (Embase, PubMed, and Scopus) were systematically searched for literature reporting on aPAU from 1986 (the earliest appearance of the concept of aPAU) to September 1, 2021, and related data were collected and evaluated. A fixed/random effects model was used to construct the forest plots. Funnel plots and linear regression tests were used to assess the publication bias. RESULTS 6 articles including 121 patients were included in the analysis. The average age was 71.4 years, with 72.7% of males and 85.6% with hypertension. Saccular aneurysms (SA) were the most prevalent complication (35.5%). Endovascular treatment had a perioperative mortality rate of .24% (95% CI, .00-2.70). The technical success rate was 99.15% (95% CI, 96.49-100). The type-II endoleak rate was 5.69% (95% CI, .00-12.13). The 1-year survival rate was 95.69% (95% CI, 90.49-100). The revascularization rate was 7.20% (95% CI, .07-14.32). Endovascular treatments for aPAU would lead to a high rate of technical success, few complications, and satisfactory 1-year survival. CONCLUSIONS aPAU are a common disease that mainly affects elderly males with hypertension and hyperlipidemia. Endovascular treatment is required when an ulcer progresses rapidly or manifests symptoms. Endovascular treatment is associated with high technical success, low complication, and satisfactory 1-year survival. Further investigation into the long-term results of endovascular treatment is necessary.
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Affiliation(s)
- Bing Wang
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Chenyang Qiu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xinyu Yu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yangyan He
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Tianchi Chen
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ruoran Lin
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaohui Wang
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jun Pan
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xun Wang
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hunkun Zhang
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ziheng Wu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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2
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Bellomo TR, DeCarlo C, Khoury MK, Lella SK, Png CYM, Kim Y, Pendleton AA, Majumdar M, Zacharias N, Dua A. Outcomes of symptomatic penetrating aortic ulcer and intramural hematoma in the endovascular era. J Vasc Surg 2023; 78:1180-1187. [PMID: 37482141 DOI: 10.1016/j.jvs.2023.06.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/10/2023] [Accepted: 06/17/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND Although endovascular technology has resulted in a paradigm shift in treatment, medical management remains the standard of care for penetrating aortic ulcer (PAU) and intramural hematoma (IMH). This study aimed to detail the short- and long-term outcomes of symptomatic PAU/IMH. METHODS Institutional data on symptomatic PAU/IMH were gathered (2005-2020). The primary outcome was the composite of recurrent symptoms, radiographic progression, intervention, rupture, and death from related or unknown cause. Factors associated with the primary outcome were determined using a Fine-Gray model with death from an unrelated cause as a competing risk. RESULTS A total of 83 symptomatic patients treated with medical management aside from ruptures and type A dissections: 21 isolated PAU, 30 isolated IMH, and 32 IMH and PAU. Adverse outcomes included symptom recurrence in 14 (16.9%), radiographic progression to dissection or saccular aneurysm in 17 (20.5%), surgery in 20 (24.1%) (17 thoracic endovascular aortic repair, 1 endovascular aortic repair, 1 frozen elephant trunk, and 1 open repair), and rupture in 4 (4.8%). Twenty-seven patients (32.5%) died during follow-up: 6 from IMH treatment complications, 8 from an unknown cause, and 13 from other causes. The 30-day, 1-year, and 5-year cumulative incidences of the primary outcome was 26.5% (95% confidence interval [CI], 16.9%-37.0%), 44.9% (95% CI, 32.8%-56.2%), and 57.5% (95% CI, 42.4%-69.9%), respectively. IMH with PAU was associated with a significantly higher risk of the primary outcome compared with isolated IMH (subdistribution hazard ratio, 2.21; 95% CI, 1.09-4.50; P = .027) and isolated PAU (subdistribution hazard ratio, 3.58; 95% CI, 1.44-8.88; P = .006). CONCLUSIONS Complications from symptomatic PAU and IMH are frequent, with intervention, recurrent symptoms, radiographic progression, rupture, or death affecting 25% of patients at 30 days after diagnosis and almost one-half of patients 1 year after diagnosis. Given the high rate of adverse events in this population, investigation into a more aggressive interventional strategy may warranted, especially in patients with a combined IMH and PAU.
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Affiliation(s)
- Tiffany R Bellomo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Mitri K Khoury
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Srihari K Lella
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - C Y Maximilian Png
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Young Kim
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - A Alaska Pendleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Monica Majumdar
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Nikolaos Zacharias
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Beckerman WE, Lajos PS. Management of Acute Aortic Syndromes. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch74] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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4
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Bossone E, Gorla R, Ranieri B, Russo V, Jakob H, Erbel R. A New Era of Diagnosis and Therapy in Acute Aortic Syndromes: The Mainz-Essen Experience (Part II)-Management and Outcomes. AORTA (STAMFORD, CONN.) 2021; 9:201-214. [PMID: 34963160 PMCID: PMC8714317 DOI: 10.1055/s-0041-1739466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 07/02/2021] [Indexed: 10/25/2022]
Abstract
Over the years, the cardiovascular department of Johannes Gutenberg University in Mainz-West-German Heart Centre in Essen (Germany) designed and implemented the hybrid operating room (2003) along with advanced endovascular and surgical procedures, including the frozen elephant trunk technique. For the study purpose, the Mainz-Essen experience on acute aortic syndromes was summarized by considering original articles from single-center or multicenter studies performed at West German Heart Centre, Essen, Germany, or at the cardiovascular department of Johannes Gutenberg University, Mainz, Germany. We present the 35-year-long Mainz-Essen research, education, and patient management journey in creating an integrated multidisciplinary "Aortic Center" in the heart of Europe.
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Affiliation(s)
- Eduardo Bossone
- Division of Cardiology, Antonio Cardarelli Hospital, Naples, Italy
| | - Riccardo Gorla
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Brigida Ranieri
- Cardiovascular Imaging Division, IRCCS SDN (Scientific Institute for Research, Hospitalization and Healthcare), Naples, Italy
| | - Valentina Russo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Heinz Jakob
- Department of Thoracic and Cardiovascular Surgery, West German Heart Center, University of Duisburg-Essen, University Hospital Essen, Essen, Germany
| | - Raimund Erbel
- Institute for Medical Informatics, Biometry and Epidemiology (IMIBE), University of Duisburg-Essen, University Hospital Essen, Essen, Germany
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5
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Zhang R, Sun L, Sun W, Yang S, Hao Y. Endovascular repair of penetrating aortic ulcers: Indications and single-center mid-term results. Ann Vasc Surg 2021; 81:129-137. [PMID: 34775025 DOI: 10.1016/j.avsg.2021.09.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 09/05/2021] [Accepted: 09/11/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Although endovascular repair is used to treat penetrating aortic ulcers (PAUs), the indications for endovascular repair in PAUs remain controversial. The current study evaluated the mid-term results of endovascular repair for PAUs and further explored the endovascular indications for PAUs. METHODS We retrospectively reviewed the clinical data of patients who were diagnosed with PAUs and underwent endovascular repair in our department from October 2018 to August 2020. Endovascular indication included persistent or recurring symptoms, a maximum diameter of the PAU of greater than 20 mm, a maximum depth of the PAU of greater than 10 mm, an increase in the diameter of the aorta at the ulcer of greater than 10 mm annually, and multiple ulcers at the same or adjacent level of the aorta. Patient characteristics, anatomical parameters of the PAU, characteristics of endovascular repair and follow-up data were analyzed. RESULTS Fifteen patients were included in the study. Three patients had PAUs in the aortic arch, 6 PAUs were in the descending thoracic aorta, 4 PAUs were in the abdominal aorta, and 2 PAUS were in the descending thoracic and abdominal aortas. The average age was 70.60±8.27 years. Eight patients were symptomatic. The average depth of the PAUs was 7.32±2.74 mm, and the average diameter was 15.03±6.10 mm. The average operation time was 95.60±33.11 min. Postoperative hospital stay was 3.33±0.61 days. A left subclavian artery chimney stent was implanted in 3 aortic arch cases and 1 occluded case without adverse symptoms during the follow-up period. A bifurcated stent graft was placed in 3 abdominal aorta cases and exhibited good patency during the follow-up period. The duration of follow-up ranged from 3 to 24 months. The follow-up results showed that all PAUs were treated satisfactorily by endovascular repair, and no endoleaks or stent graft-related complications occurred. CONCLUSIONS Endovascular repair is a safe and effective treatment for PAUs, and it may be safely performed in elderly patients and patients with comorbidities. The endovascular indications for PAUs must be further studied and optimized.
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Affiliation(s)
- Rongjie Zhang
- Department of Vascular Surgery, Southwest Hospital, Army Medical University (Third Military Medical University), 30 Gaotanyan Street, Shapingba District, Chongqing 400038, China
| | - Long Sun
- Department of Vascular Surgery, Southwest Hospital, Army Medical University (Third Military Medical University), 30 Gaotanyan Street, Shapingba District, Chongqing 400038, China
| | - Wei Sun
- Department of Vascular Surgery, Southwest Hospital, Army Medical University (Third Military Medical University), 30 Gaotanyan Street, Shapingba District, Chongqing 400038, China
| | - Shiwei Yang
- Department of Vascular Surgery, Southwest Hospital, Army Medical University (Third Military Medical University), 30 Gaotanyan Street, Shapingba District, Chongqing 400038, China.
| | - Yingxue Hao
- Department of Vascular Surgery, Southwest Hospital, Army Medical University (Third Military Medical University), 30 Gaotanyan Street, Shapingba District, Chongqing 400038, China.
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6
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Pandey G, Sharma P. The Management of Patients With Penetrating Aortic Ulcers: A Systematic Review. Vasc Endovascular Surg 2021; 55:730-740. [PMID: 34044670 DOI: 10.1177/15385744211017110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Penetrating aortic ulcers (PAUs) are an entity within acute aortic syndrome. They often remain undiagnosed and are found incidentally or when they become symptomatic. Management is currently guided by clinical judgment. This review aims to identify indications for treatment and inform management. METHODS We searched PubMed for studies on the management of PAUs. The outcome measures were mortality, progression and resolution of symptoms. RESULTS This review incorporates 27 studies involving 1356 patients with PAU. Data was available regarding symptoms for 1213 patients (494 symptomatic, 719 asymptomatic). Overall late mortality for PAUs was found to be higher than 30-day mortality. Early mortality was higher for symptomatic patients as compared to those with asymptomatic PAUs. Early mortality was lowest for PAUs treated with endovascular interventions (5%), followed by PAUs managed medically and highest following open surgical management. Indications for treatment included symptoms, progression/instability, aortic diameter >5 cm, concomitant aortic pathology or pleural effusion. 13% of patients managed conservatively at initial presentation demonstrated progression and were considered for intervention subsequently. 9% of patients required reintervention after initial endovascular surgery. CONCLUSION Endovascular treatment, if anatomically suitable, should be considered as first line treatment for symptomatic PAUs. Patients with asymptomatic PAUs, if associated with high-risk features such as PAU diameter >20 mm, PAU depth >10 mm, aortic diameter >42 mm, concomitant pathology, morphological change or an infective etiology, should also be considered for intervention. Small asymptomatic PAUs with no high-risk features may be managed conservatively but must undergo regular surveillance.
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Affiliation(s)
- Gargi Pandey
- Department of Vascular Surgery, 112001Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Paritosh Sharma
- Department of Vascular Surgery, 112001Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
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7
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Rodríguez R, López Gómez A, Zebdi N, Ríos Barrera R, Forteza A, Legarra Calderón JJ, Garrido Martín P, Hernando B, Sanjuan A, González Bardanca S, Varela Martínez MÁ, Fernández FE, Llorens R, Valera Martínez FJ, Gómez Felices A, Aranda Granados PJ, Sádaba Sagredo R, Echevarría JR, Guillén RV, Silva Guisasola J. RETRACTED: Anesthesic and surgical guideline for the treatment of the thoraco-abdominal aorta. Consensus Document of the Spanish Societies of Anesthesia and Cardiovascular Surgery. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:258-279. [PMID: 33775419 DOI: 10.1016/j.redar.2020.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 12/01/2020] [Indexed: 11/24/2022]
Abstract
Este artículo ha sido retirado por indicación del Editor Jefe de la revista, después de constatar que parte de su contenido había sido plagiado, sin mencionar la fuente original: European Heart Journal (2014) 35, 2873 926.: https://academic.oup.com/eurheartj/article/35/41/2873/407693#89325738 El autor de correspondencia ha sido informado de la decisión y está de acuerdo con la retirada del artículo. El Comité Editorial lamenta las molestias que esta decisión pueda ocasionar. Puede consultar la política de Elsevier sobre la retirada de artículos en https://www.elsevier.com/about/our-business/policies/article-withdrawal
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Affiliation(s)
- R Rodríguez
- Servicio de Cirugía Cardiaca, Hospital Universitario Vall d'Hebron, Barcelona, España.
| | - A López Gómez
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - N Zebdi
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - R Ríos Barrera
- Servicio de Cirugía Cardiaca, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - A Forteza
- Servicio de Cirugía Cardiaca, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | | | - P Garrido Martín
- Servicio de Cirugía Cardiaca, Hospital Universitario de Canarias, España
| | - B Hernando
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario Miguel Servet, Zaragoza, España
| | - A Sanjuan
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario Miguel Servet, Zaragoza, España
| | - S González Bardanca
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Complejo Hospitalario Universitario de A Coruña, España
| | - M Á Varela Martínez
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Álvaro Cunqueiro de Vigo, España
| | - F E Fernández
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario Central de Asturias, España
| | - R Llorens
- Servicio de Cirugía Cardiaca, Hospital Hospiten Rambla, Tenerife, España
| | - F J Valera Martínez
- Servicio de Cirugía Cardiaca, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - A Gómez Felices
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario Vall d'Hebron, Barcelona, España
| | | | - R Sádaba Sagredo
- Servicio de Cirugía Cardiaca. Complejo Hospitalario de Navarra, España
| | - J R Echevarría
- Servicio de Cirugía Cardíaca. Hospital Universitario de Valladolid, España
| | - R V Guillén
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - J Silva Guisasola
- Servicio de Cirugía Cardíaca. Hospital Universitario Central de Asturias, España
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RETRACTED: Guía anestésico-quirúrgica en el tratamiento de la patología de aorta toracoabdominal. Documento de Consenso de la Sociedad Española de Cirugía Cardiovascular Endovascular y la Sociedad Española de Anestesiología, Reanimación y Terapeútica del Dolor. CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2020.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Abstract
PURPOSE OF REVIEW Penetrating aortic ulcer (PAU) is defined as ulceration of an aortic atherosclerotic plaque penetrating through the internal elastic lamina into the media. With the advances in imaging techniques, the differential diagnosis between PAU and other aortic ulcers remains a challenge. This review aims to summarize the latest insight into PAU, based on clinical context and the newest imaging characteristics, to aid treatment decision-making. RECENT FINDINGS Most PAUs are asymptomatic and do not require urgent invasive treatment. Nevertheless, when PAU leads to an acute aortic syndrome, emergency invasive therapy is recommended. A differential diagnosis with other lesions, such as ulcerated plaques or intimal disruptions within the context of an aortic intramural hematoma, is required as the risk of complications and management differ. Imaging technique plays a pivotal role in the correct diagnosis of aortic ulcers. SUMMARY The differential diagnosis of PAU with other aortic ulcers based on clinical and imaging technique information is mandatory as it may imply different prognosis and management. This diagnosis is particularly important when PAU is the cause of acute aortic syndromes as urgent invasive treatment should be recommended.
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10
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Short- and long-term outcomes in isolated penetrating aortic ulcer disease. J Vasc Surg 2020; 72:84-91. [DOI: 10.1016/j.jvs.2019.09.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/12/2019] [Indexed: 01/16/2023]
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Evangelista A, Moral S, Ballesteros E, Castillo-Gandía A. Beyond the term penetrating aortic ulcer: A morphologic descriptor covering a constellation of entities with different prognoses. Prog Cardiovasc Dis 2020; 63:488-495. [PMID: 32497587 DOI: 10.1016/j.pcad.2020.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Penetrating aortic ulcer (AU) is defined as localized disruption of the intimal layer of the aortic wall, resulting in a crater-like lesion outpouching from the vessel contour. AU is a generic term which encompasses a constellation of entities with different etiologies and prognoses and may be a complication of infective, inflammatory, traumatic, iatrogenic, atherosclerotic processes or intramural hematoma. One of the most challenging scenarios of AU for a differential diagnosis, but also for treatment implications, is when they are associated with acute aortic syndrome. Despite advances in the field of aortic disease, lack of consensus defining these lesions and the significant semantic confusion in the medical literature of the acronym PAU (for penetrating aortic ulcer but also for penetrating atherosclerotic ulcer) have given rise to controversy in guidelines and expert consensus, leading to the same treatment being recommended for entities with different etiology and prognosis. Moreover, in the medical literature, most diagnoses were mainly based on imaging techniques which identified AU regardless of clinical symptoms, surrounding imaging findings or dynamic morphologic changes. In this Review, we provide the latest insight into the differential diagnosis between AU, also called penetrating aortic ulcers, based on clinical context and the newest imaging characteristics to aid treatment decision-making.
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Affiliation(s)
- Arturo Evangelista
- Cardiology Department, Hospital General Universitari Vall d'Hebron, VHIR, CIBER-CV, Barcelona, Spain; Heart Institute, Quirónsalud-Teknon, Barcelona, Spain.
| | - Sergio Moral
- Cardiology Department, Hospital Universitari Doctor Josep Trueta, CIBER-CV, Girona, Spain
| | - Esther Ballesteros
- Radiology Department, Centro de atención primaria Pare Claret, Institut Català de la Salut, Barcelona, Spain
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Abstract
Penetrating aortic ulceration (PAU) is part of the spectrum of acute aortic syndromes (AAS), and is defined as an ulcerated intimal disruption due to atherosclerotic disease. PAU may be simple, isolated and asymptomatic, or it may be symptomatic, aneurysmal and extensive; these may progress and lead to rupture. This review aims to evaluate the treatment options for PAU. Treatment options range from radiological surveillance, risk factor modification, best medical therapy and open or endovascular surgical repair. Patients with PAU are frequently older and comorbid with relatively damaged aortic tissue; this can make open surgical repair more challenging. Endovascular repairs for larger, symptomatic, aneurysmal PAU may be performed with acceptable outcomes. Complex endovascular repairs may be required depending on the pathology. Patients with small, asymptomatic, uncomplicated PAU may be safely followed up with surveillance. PAU with concomitant intramural haematoma (IMH) should be closely monitored to observe for resolution or progression following conservative and medical management strategies. PAU is a unique entity and its natural history should be studied independently to better understand appropriate management strategies. This research is currently lacking, and larger studies or registries may be helpful in optimising PAU management.
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13
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Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J 2019; 39:739-749d. [PMID: 29106452 DOI: 10.1093/eurheartj/ehx319] [Citation(s) in RCA: 201] [Impact Index Per Article: 40.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 06/13/2017] [Indexed: 01/16/2023] Open
Abstract
Acute aortic syndromes (AAS) encompass a constellation of life-threatening medical conditions including classic acute aortic dissection (AAD), intramural haematoma, and penetrating atherosclerotic aortic ulcer. Given the non-specific symptoms and physical signs, a high clinical index of suspicion is necessary to detect the disease before irreversible lethal complications occur. In order to reduce the diagnostic time delay, a comprehensive flowchart for decision-making based on pre-test sensitivity of AAS has been designed by the European Society of Cardiology guidelines on aortic diseases and should be thus applied in the emergency scenario. When the definitive diagnosis is made, prompt and appropriate therapeutic interventions should be undertaken if indicated by a highly specialized aortic team. Urgent surgery for AAD involving the ascending aorta (Type A) and medical therapy alone for AAD not involving the ascending aorta (Type B) are typically recommended. In complicated Type B AAD, thoracic endovascular aortic repair (TEVAR) is generally indicated. On the other hand, in uncomplicated Type B AAD, pre-emptive TEVAR rather than medical therapy alone to prevent late complications, while intuitive, requires further study in randomized cohorts. Finally, it should be highlighted that there is an urgent need to increase awareness of AAS worldwide, including dedicated education/prevention programmes, and to improve diagnostic and therapeutic strategies, outcomes, and lifelong surveillance.
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Affiliation(s)
| | - Troy M LaBounty
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr, Ann Arbor, MI 48105, USA
| | - Kim A Eagle
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr, Ann Arbor, MI 48105, USA
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Kotsis T, Spyropoulos BG, Asaloumidis N, Christoforou P, Katseni K, Papaconstantinou I. Penetrating Atherosclerotic Ulcers of the Abdominal Aorta: A Case Report and Review of the Literature. Vasc Specialist Int 2019; 35:152-159. [PMID: 31620401 PMCID: PMC6774427 DOI: 10.5758/vsi.2019.35.3.152] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 06/29/2019] [Accepted: 07/01/2019] [Indexed: 11/21/2022] Open
Abstract
Penetrating atherosclerotic ulcers (PAUs) of the aorta are defined as atherosclerotic lesions with aortic intima and media ulceration, which may lead to a complete rupture of the adventitial wall. The present article aimed to report an unusual case of a surgically treated patient with abdominal aorta PAU with an illustration of the key features and to review and analyze the existing literature data. PAUs typically develop in elderly and hypertensive patients and in patients with advanced atherosclerosis. Although originally described for the descending thoracic aorta, a similar clinicopathological entity also occurs in the abdominal aorta. Patients with symptoms of a PAU should be treated immediately if they are fit for surgery. Exceptive observation by imaging modalities is necessary in patients with asymptomatic small (<2 cm) PAU, with or without focal dissection.
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Affiliation(s)
- Thomas Kotsis
- Vascular Division, 2nd Department of Surgery, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Basileios Georgiou Spyropoulos
- 2nd Department of Surgery, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Asaloumidis
- Vascular Division, 2nd Department of Surgery, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagitsa Christoforou
- Vascular Division, 2nd Department of Surgery, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantina Katseni
- Vascular Division, 2nd Department of Surgery, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Papaconstantinou
- 2nd Department of Surgery, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Piffaretti G, Fontana F, Tadiello M, Guttadauro C, Piacentino F, Bush RL, Socrate AM, Tozzi M. Arch and access vessel complications in penetrating aortic ulcer managed with thoracic endovascular aortic repair. Ann Cardiothorac Surg 2019; 8:471-482. [PMID: 31463209 DOI: 10.21037/acs.2019.06.07] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background To analyze our experience and to describe access and arch-related challenges when performing thoracic endovascular aortic repair (TEVAR) for penetrating aortic ulcers (PAUs). Methods This is a single-center, observational, cohort study. Between October 2003 and February 2019, 48 patients with PAU were identified; 37 (77.1%) treated with TEVAR were retrospectively analyzed. Primary major outcomes were early (<30 days) and late survival, freedom from aortic-related mortality (ARM), and a composite endpoint of arch/vascular access-related complications. Results On admission, 17 (45.9%) patients were symptomatic with 4 (10.8%) presenting with rupture. In-hospital mortality was 8.1% (n=3). We observed 10 (27.0%) arch/access-related complications. There were 4 (10.8%) arch issues: 2 transient ischemic attacks and 2 retrograde acute type A dissections which required emergent open conversion for definitive repair. Access issues occurred in 6 (16.2%) patients: 3 (8.1%) required common iliac artery conduit, and 1 (2.7%) patient required iliac artery angioplasty to deliver the stent-graft. In addition, 2 (5.4%) patients developed access complications which required operative repair [femoral patch angioplasty (n=2), and femoral pseudoaneurysmectomy (n=1)]. Arch/access-related mortality rate was 5.4% (n=2) and median follow-up was 24 (range, 1-156; IQR, 3-52) months. Estimated survival was 87.1% (standard error: 0.6; 95% CI: 71.2-84.9%) at 1 year, and 63.3% (SE: 0.9; 95% CI: 44.1-79%) at 4 years. Estimated freedom from reintervention was 88.9% (SE: 0.5; 95% CI: 74.8-95.6%) at 1 year, and 84.2% (SE: 0.7; 95% CI: 67.3-93.2%) at 4 years. No arch/access-related issues developed during the follow-up period. Conclusions Our experience confirms that vascular access and aortic arch issues are still a challenging aspect of performing TEVAR for PAUs. Our cumulative 27% rate of access/arch issues is lower than previously reported due to both technological advancements and meticulous management of both access routes and arch anatomy.
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Affiliation(s)
- Gabriele Piffaretti
- Vascular Surgery, Department of Medicine and Surgery, Circolo University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
| | - Federico Fontana
- Interventional Radiology, Department of Medicine and Surgery, Circolo University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
| | - Marco Tadiello
- Vascular Surgery, Department of Medicine and Surgery, Circolo University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
| | - Chiara Guttadauro
- Vascular Surgery, Department of Medicine and Surgery, Circolo University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
| | - Filippo Piacentino
- Interventional Radiology, Department of Medicine and Surgery, Circolo University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
| | - Ruth L Bush
- University of Houston College of Medicine, Houston, TX, USA
| | | | - Matteo Tozzi
- Vascular Surgery, Department of Medicine and Surgery, Circolo University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
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Oderich GS, Kärkkäinen JM, Reed NR, Tenorio ER, Sandri GA. Penetrating Aortic Ulcer and Intramural Hematoma. Cardiovasc Intervent Radiol 2018; 42:321-334. [DOI: 10.1007/s00270-018-2114-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 11/01/2018] [Indexed: 01/10/2023]
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Abstract
Rarely, penetrating atherosclerotic ulcers can rupture into the wall of the aorta, resulting in acute aortic dissection. This article describes a woman with an incidental diagnosis of type A aortic dissection secondary to a penetrating atherosclerotic ulcer of the ascending aorta. Although surgical repair of the aortic root was recommended, the patient refused treatment and left against medical advice.
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18
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Nienaber CA, Clough RE. Management of Acute Aortic Syndromes. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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19
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Actualización sobre las características pronósticas y el manejo terapéutico de la úlcera aórtica penetrante. ANGIOLOGIA 2016. [DOI: 10.1016/j.angio.2015.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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20
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Melissano G, Bertoglio L, Civilini E, Marone EM, Calori G, Setacci F, Chiesa R. Results of Thoracic Endovascular Grafting in Different Aortic Segments. J Endovasc Ther 2016; 14:150-7. [PMID: 17484530 DOI: 10.1177/152660280701400206] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To compare the results of thoracic endovascular grafting of different aortic segments performed with commercially available stent-grafts. Methods: Between January 1999 and October 2006, 178 patients (150 men; mean age 69.4±10.2 years) underwent endovascular grafting of the thoracic aorta (68 hybrid procedures) with commercially produced stent-grafts from 4 manufacturers. Patients were divided into 3 groups according to the aortic segment involved: 64 aortic arch cases (37 hybrids for supra-aortic trunks revascularization), 100 descending thoracic aorta (DTA) cases (17 hybrid: 12 for access and 5 for associated abdominal aortic aneurysm), and 14 thoracoabdominal aorta (TaA) patients excluded from conventional repair (14 hybrids for renal and splanchnic revascularization). Results: The technical success was 93.8% (167/178). Overall 30-day mortality was 5.6% (10/178). There were 10 (5.6%) type I endoleaks. Initial clinical success was 88.2% (157/178). At a mean follow-up of 29.3±21.2 months, the midterm clinical success was 89.9% (160/178). In the arch group, the technical success was 85.9% (55/64). Thirty-day mortality was 6.3% (4/64). There were 8 (12.5%) type I endoleaks. Initial and midterm clinical success rates were 79.7% (51/64) and 85.9% (55/64), respectively. In the 100-patient DTA group, the technical success was 98.0%. Thirty-day mortality was 2.0%. The type I endoleak rate was 2.0%. Clinical success was 96.0% initially and 95.0% at midterm. All 14 of the TaA cases were completed successfully, but 30-day mortality was 28.6% (4/14). There were no type I endoleaks. Clinical success rates initially and at midterm were both 71.4% (10/14). Conclusion: Over the last 6 years, synergy between endovascular and surgical procedures allowed treatment of all segments of the thoracic aorta. Overall perioperative and medium-term results were reasonably favorable; however, they were more satisfactory when the descending thoracic aorta alone was involved. Hybrid procedures allowed treatment of all aortic segments, but they decreased the success rates significantly. Endovascular grafting is currently our preferred method of treating pathologies involving the DTA and aortic arch, while our data suggest limiting the use of stent-grafts to high-risk patients or compassionate indications when the thoracoabdominal aorta is involved.
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Affiliation(s)
- Germano Melissano
- Department of Vascular Surgery, Vita - Salute University, Scientific Institute H. San Raffaele, Milan, Italy.
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Ruppert V, Erz K, Bürklein D, Treitl M, Steckmeier B, Stelter W, Umscheid T. Double Tube Stent-Grafts for Infrarenal Aortic Aneurysm: A New Concept. J Endovasc Ther 2016; 14:144-9. [PMID: 17484529 DOI: 10.1177/152660280701400205] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To present the concept of double tube stent-grafts and examine the indications for and results achieved with these devices. Methods: From January 1, 2000, to December 31, 2005, 759 patients who underwent endovascular repair of infrarenal aortic aneurysms at 2 centers. Of these, 45 (5.9%) patients received a double tube stent-graft; complete operative and follow-up data were available for retrospective analysis in 41 patients (33 men; mean age 73.1±8.9 years). Diameters measured before stent-graft implantation and at follow-up (12, 24, 36, and 48 months) with clinical examination, 2-phase computed tomographic angiography, duplex sonography, and biplanar abdominal radiography were tested for significant changes using ANOVA with the Bonferroni-Dunn correction. Late outcomes (clinical success and endoleak) were analyzed by the Kaplan-Meier method. Results: The postoperative complication rate was 12.2%, with 2.4% systemic complications (1 patient with angina pectoris); the early mortality rate was 0%. Mean follow-up was 21.9±12.8 months (range 12–61) for the 41 patients. Four (9.8%) patients died during follow-up of cardiac causes (n=2), lung cancer (n=1), and bowel ischemia (n=1). Four (9.8%) endoleaks were observed during follow-up: 1 distal type I, 2 type II, and 1 type III. Maximum aneurysm diameters shrank from 52.0±9.5 mm preoperatively to 44.0±10.8 mm (p<0.0001) postoperatively at the latest available follow-up. Conclusion: Our study supports the use of this double tube technique for repair of appropriate saccular infrarenal aortic aneurysms. The double tube stent-graft method appears safe in terms of endoleaks and migration, so we recommend that it be considered an option of endovascular aortic aneurysm therapy.
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Affiliation(s)
- Volker Ruppert
- Department of Surgery, Hospital of Ludwig Maximilian University Munich-Campus Innenstadt, Germany.
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22
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Pararenal Aortic Ulcer Repair. Eur J Vasc Endovasc Surg 2016; 51:504-10. [DOI: 10.1016/j.ejvs.2015.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Accepted: 12/02/2015] [Indexed: 11/22/2022]
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23
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The History of Incidentally Discovered Penetrating Aortic Ulcers of the Abdominal Aorta. Ann Vasc Surg 2016; 31:8-17. [DOI: 10.1016/j.avsg.2015.08.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 08/27/2015] [Accepted: 08/31/2015] [Indexed: 11/17/2022]
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Jánosi RA, Gorla R, Tsagakis K, Kahlert P, Horacek M, Bruckschen F, Dohle DS, Jakob H, Schlosser T, Eggebrecht H, Bossone E, Erbel R. Thoracic Endovascular Repair of Complicated Penetrating Aortic Ulcer. J Endovasc Ther 2015; 23:150-9. [PMID: 26511894 DOI: 10.1177/1526602815613790] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Purpose: To analyze an 11-year single-center experience of treating complicated penetrating aortic ulcer (PAU) using thoracic endovascular aortic repair (TEVAR). Methods: This study included 63 consecutive patients (mean age 69.1±11.5 years; 40 men) with complicated PAU (42 symptomatic, 22 with rupture) who underwent TEVAR between 2002 and 2013. The PAUs were located in the aortic arch (n=11), the descending thoracic aorta (n=43), and the thoracoabdominal aorta (n=9). Results: TEVAR was performed within 14 days of diagnosis in 33 (52.3%) cases (19 ruptures treated immediately); the other 30 (47.6%) patients had an average interval between diagnosis and intervention of 40±39 days. Technical success was 98.4% (62/63). One patient had a type I endoleak after stent-graft repair of a PAU in the aortic arch without great vessel transposition; another procedure was required for carotid-subclavian bypass and proximal stent-graft extension. No patient experienced spinal cord ischemia after TEVAR. Five (7.9%) patients died in-hospital; 3 had severe cardiac complications, 1 died from complications of aortic rupture, and the other succumbed to septic shock. Mean follow-up was 45.6±47.2 months, during which 12 (19.0%) patients needed a secondary intervention because of late endoleaks (n=4, 6.3%) or new complications due to disease progression. Multivariate analysis indicated that a PAU depth >15 mm was an independent predictor of mortality (hazard ratio 6.92, p=0.03). In the biomarker analysis, symptomatic patients had significantly higher D-dimer and troponin levels compared to asymptomatic patients [559.5±460.7 vs 283.2±85.2 µg/L (p=0.016) and 0.22±0.61 vs 0.02±0.03 ng/mL (p=0.04), respectively]. Conclusion: Patients with PAU suffer from underlying severe atherosclerotic disease and have a significant number of cardiovascular comorbidities that lead to relevant mortality and morbidity after TEVAR. As a PAU diameter >15 mm represented high risk for disease progression, these patients may be candidates for early intervention. D-dimer levels may help identify patients at risk and with progression of PAU.
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Affiliation(s)
- Rolf Alexander Jánosi
- Department of Cardiology, West-German Heart and Vascular Center Essen and University Duisburg-Essen, Essen, Germany
| | - Riccardo Gorla
- Department of Cardiology, West-German Heart and Vascular Center Essen and University Duisburg-Essen, Essen, Germany
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen and University Duisburg-Essen, Essen, Germany
| | - Philipp Kahlert
- Department of Cardiology, West-German Heart and Vascular Center Essen and University Duisburg-Essen, Essen, Germany
| | - Michael Horacek
- Department of Cardiology, West-German Heart and Vascular Center Essen and University Duisburg-Essen, Essen, Germany
| | - Florian Bruckschen
- Department of Cardiology, West-German Heart and Vascular Center Essen and University Duisburg-Essen, Essen, Germany
| | - Daniel-Sebastian Dohle
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen and University Duisburg-Essen, Essen, Germany
| | - Heinz Jakob
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen and University Duisburg-Essen, Essen, Germany
| | - Thomas Schlosser
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | | | | | - Raimund Erbel
- Institute of Medical Informatics, Biometry and Epidemiology (IMIBE), University Hospital Essen, University Duisburg-Essen, Essen, Germany
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26
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Evangelista A, Czerny M, Nienaber C, Schepens M, Rousseau H, Cao P, Moral S, Fattori R. Interdisciplinary expert consensus on management of type B intramural haematoma and penetrating aortic ulcer. Eur J Cardiothorac Surg 2014; 47:209-17. [DOI: 10.1093/ejcts/ezu386] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Mousa AY, Bozzay J, AbuRahma AF. Natural history and outcome of patients with intramural hematomas and penetrating aortic ulcers. Vascular 2014; 23:305-9. [PMID: 25183699 DOI: 10.1177/1708538114547253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
All pathologies of acute aortic syndromes should be precisely diagnosed for prompt therapy. Intramural hematomas, as well as penetrating ulcers can be encountered in these patients. Presentations, clinical scenarios, and proper management are outlined in this review, which sums up available current literature to provide the vascular specialist with an adequate understanding of these unique syndromes.
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Affiliation(s)
- Albeir Y Mousa
- Vascular Center of Excellence, Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, USA
| | - Joseph Bozzay
- Vascular Center of Excellence, Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, USA
| | - Ali F AbuRahma
- Vascular Center of Excellence, Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, USA
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28
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Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, Grabenwöger M, Haverich A, Iung B, Manolis AJ, Meijboom F, Nienaber CA, Roffi M, Rousseau H, Sechtem U, Sirnes PA, Allmen RSV, Vrints CJM. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J 2014; 35:2873-926. [PMID: 25173340 DOI: 10.1093/eurheartj/ehu281] [Citation(s) in RCA: 2843] [Impact Index Per Article: 284.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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29
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Surgical repair of distal arch psendoaneurysm from ruptured penetrating aortic ulcer with the frozen elephant trunk technique. J Cardiothorac Surg 2014; 9:68. [PMID: 24708758 PMCID: PMC4234984 DOI: 10.1186/1749-8090-9-68] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 03/31/2014] [Indexed: 11/10/2022] Open
Abstract
Ruptured Penetrating Ulcer and aortic arch pseudo-aneurysm is a rare condition but one which carries a high risk of rupture. We report the case of a 74-year-old man with aortic arch pseudo-aneurysm, in which a Frozen Elephant Trunk procedure was successfully performed. There were no postoperative complications at 6 months follow-up. The Computed Tomography Angiogram demonstrated thrombus formation in the pseudo-aneurysm lumen, with no endoleak on the stented part of the descending thoracic aorta and complete patency of all branches of aortic arch. This case demonstrates that the Frozen Elephant Trunk technique may be the treatment of choice when treating such complex aortic arch lesions provided there is no absolute contraindication to radical surgical intervention. However, long-term clinical efficacy and safety have yet to be confirmed.
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Surgical or Endovascular Therapy of Abdominal Penetrating Aortic Ulcers and Their Natural History: A Systematic Review. J Vasc Interv Radiol 2013; 24:1437-49.e3. [DOI: 10.1016/j.jvir.2013.05.067] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 05/28/2013] [Accepted: 05/29/2013] [Indexed: 11/23/2022] Open
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31
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Georgiadis GS, Trellopoulos G, Antoniou GA, Georgakarakos EI, Nikolopoulos ES, Pelekas D, Pitta X, Lazarides MK. Endovascular therapy for penetrating ulcers of the infrarenal aorta. ANZ J Surg 2013; 83:758-63. [PMID: 23336937 DOI: 10.1111/ans.12074] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND We sought to investigate the short- and mid-term results of the endovascular repair of infrarenal abdominal penetrating aortic ulcers (aPAUs). METHODS Patients with infrarenal aPAUs treated by endovascular means between March 2004 and June 2012 were recruited. Pre-interventional imaging included computed tomography (CT) or CT angiography. Endoprostheses were chosen and deployed according to standard elective endovascular aneurysm repair anatomical requirements. Endpoints included 30-day survival, in-hospital mortality, 1-year PAU-related mortality, 1-year all-cause mortality, freedom from death and freedom from cumulative complication and interventions. Statistically, the Kaplan-Meier method was applied. RESULTS Nineteen patients (18 men, median age 70 years (interquartile range, IQR = 59-75)) suffering aPAUs (n = 29, infrarenal = 25) were detected. The median co-morbid severity scoring was 1.0 (IQR = 0.4-1.4). The median follow-up period was 33 months (IQR = 8-51.5). Furthermore, 94.7% of patients had hypertension. Fourteen patients (73.7%) had symptoms, including four of them admitted with shock from large-contained PAU rupture. Endoluminal stent grafting was successfully delivered in all patients. In-hospital mortality was 10.5%. Two patients required secondary interventions (10.5%). The 30-day survival, 1-year PAU-related mortality and 1-year all-cause mortality were 94.7%, 89.5% and 89.5%, respectively. Freedom from death and freedom from cumulative complications and interventions was 86.4% and 86.4%, 78.9% and 78.9%, and 67.9% and 71.2% at 12, 24 and 36 months, respectively. CONCLUSIONS Urgent and elective endovascular repair of aPAUs can be achieved with high technical success. The significant co-morbid status of the treated patients is illustrated in the considerable in-hospital mortality and underlines the advantage of such treatment over open surgical repair.
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Affiliation(s)
- George S Georgiadis
- Department of Vascular Surgery, 'Demokritus' University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece
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Roldan CJ. Penetrating Atherosclerotic Ulcerative Disease of the Aorta: Do Emergency Physicians Need to Worry? J Emerg Med 2012; 43:196-203. [DOI: 10.1016/j.jemermed.2011.01.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Revised: 10/08/2010] [Accepted: 01/03/2011] [Indexed: 11/16/2022]
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Mestres G, Rodríguez R, García-Madrid C, Montañà X, Burrel M, Cruz LF, Flores C, Riambau V. Tratamiento endovascular de las úlceras penetrantes de aorta torácica: seguimiento a medio plazo. Rev Esp Cardiol 2012; 65:54-9. [DOI: 10.1016/j.recesp.2011.07.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Accepted: 07/27/2011] [Indexed: 11/26/2022]
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Czerny M, Funovics M, Sodeck G, Dumfarth J, Schoder M, Juraszek A, Dziodzio T, Loewe C, Reineke D, Krähenbühl E, Grimm M, Ehrlich M. Results After Thoracic Endovascular Aortic Repair in Penetrating Atherosclerotic Ulcers. Ann Thorac Surg 2011; 92:562-6; discussion 566-7. [DOI: 10.1016/j.athoracsur.2011.02.087] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Revised: 02/23/2011] [Accepted: 02/24/2011] [Indexed: 10/18/2022]
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Cassagnes L, Chabrot P, Ravel A, Dumousset E, Boyer L. [Acute aortic syndrome and endovascular treatment: good indications of stent-graft, stent and aortic fenestration]. Presse Med 2010; 40:62-71. [PMID: 21126849 DOI: 10.1016/j.lpm.2010.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Accepted: 10/20/2010] [Indexed: 10/18/2022] Open
Abstract
Acute aortic syndrome of the descending aorta can be treated with stent-graft thanks to technical and material development. Ruptured aneurysms, aortic dissection, wall hematoma and penetrating ulcers can be treated with stent-graft. According to the type of initial lesion, and the clinical tolerance, the emergency of treatment can be different. Non covered stent and aortic fenestration are used in case of visceral ischemia in aortic dissection, according to the type of ischemia.
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Affiliation(s)
- Lucie Cassagnes
- Centre hospitalier universitaire, pôle d'imagerie, service de radiologie B, Université d'Auvergne Clermont 1, faculté de médecine, EA 3295, BP 38, 63001 Clermont-Ferrand cedex 1, France
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Lansman SL, Saunders PC, Malekan R, Spielvogel D. Acute aortic syndrome. J Thorac Cardiovasc Surg 2010; 140:S92-7; discussion S142-S146. [DOI: 10.1016/j.jtcvs.2010.07.062] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Revised: 07/20/2010] [Accepted: 07/26/2010] [Indexed: 11/25/2022]
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Dahm T, Voigtländer T, Schrödter J, Schmermund A. [Hemoptysis as the first sign of ruptured thoracic aorta]. Chirurg 2010; 82:442, 444-6. [PMID: 20967527 DOI: 10.1007/s00104-010-1994-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Acute aortic rupture is associated with a high mortality. The leading symptoms are chest pain, dyspnea and hemodynamic instability as well as hemoptysis. In the current case report a patient with known coronary artery disease and prior coronary artery bypass surgery presented with hemoptysis. He was initially treated for a presumed gastroenterological disorder. The chest X-ray delineated a structure suggestive of aortic rupture and this diagnosis was confirmed by computed tomography. Emergency treatment was performed by implantation of an endovascular stent prosthesis. This procedure is currently regarded the standard treatment of rupture of the descending thoracic aorta. We conclude our case report with a discussion of epidemiology, symptoms, pathogenesis and therapy of this clinically dramatic disease.
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Affiliation(s)
- T Dahm
- Zentrum für Gefässchirurgie, Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Deutschland
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Eggebrecht H, Plicht B, Kahlert P, Erbel R. Intramural hematoma and penetrating ulcers: indications to endovascular treatment. Eur J Vasc Endovasc Surg 2009; 38:659-65. [PMID: 19800821 DOI: 10.1016/j.ejvs.2009.09.001] [Citation(s) in RCA: 124] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2009] [Accepted: 09/04/2009] [Indexed: 01/05/2023]
Abstract
Intramural hematoma (IMH) of the aorta and penetrating aortic ulcer (PAU) are important variant forms of classic double-barrel aortic dissection in patients presenting with acute aortic syndrome. Recent insights provided by modern high-resolution imaging are currently challenging previous pathophysiologic concepts underlying IMH and PAU, suggesting a close relationship of both entities. Thoracic endovascular aortic repair (TEVAR) offers a less invasive approach to the treatment of affected patients with very encouraging early to midterm results. This review discusses current indication for TEVAR in IMH and PAU patients in the view of an improved understanding of these diseases.
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Affiliation(s)
- H Eggebrecht
- Department of Cardiology, West-German Heart Center Essen, University of Duisburg-Essen, Hufelandstrasse 55, Essen, Germany.
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Geisbüsch P, Kotelis D, Weber TF, Hyhlik-Dürr A, Kauczor HU, Böckler D. Early and midterm results after endovascular stent graft repair of penetrating aortic ulcers. J Vasc Surg 2008; 48:1361-8. [DOI: 10.1016/j.jvs.2008.07.058] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2008] [Revised: 07/16/2008] [Accepted: 07/16/2008] [Indexed: 11/16/2022]
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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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Lindblad B, Holst J, Kölbel T, Ivancev K. What to Do When Evidence is Lacking — Implications on Treatment of Aortic Ulcers, Pseudoaneurysms and Aorto-Enteric Fistulae. Scand J Surg 2008; 97:165-73. [DOI: 10.1177/145749690809700220] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Present knowledge on natural history and how to treat penetrating aortic ulcers or different forms of pseudoaneurysms with or without infection is limited as there are only case reports and small series of unusual aortic pathology and its treatment available. Material: From our centre we collected 65 patients treated with open (n=15) or endovascular reconstruction (n=50) during a 20-year period in the abdominal aorta. These patients are presented including a review of contemporary treatment. Results: Endovascular reconstructions seem to reduce morbidity and mortality compared to otherwise extensive open surgery. Even for patients with infectious etiology (mycotic aneurysms, aorto-enteric fistula) endovascular treatment may be a first-hand option bridging to a more elective open repair. However, a large proportion of patients being unfit for further open surgery were solely treated endovascularly and had no major infectious complications in the follow-up. Registers of cases with unusual aortic pathology, not only of those treated but also of those managed conservatively, are needed to define who to treat and if endovascular or open repair should be recommended. Conclusion: Endovascular technique is a promising technique for treatment of aortic pseudoaneurysms of different etiologies. We firmly recommend, despite the lack of evidence, that the work up of patients with penetrating aortic ulcers, mycotic or other types of pseudoanerysms as well as aorto-enteric fistulae should enclose both endovascular and open (or combined) treatment modalities. However, our knowledge of the natural history is limited. Therefore, registers of cases with unusual aortic pathology, not only of those treated but also of those managed conservatively, are needed to define who to treat and if endovascular or open repair should be recommended.
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Affiliation(s)
- B. Lindblad
- Centre of Vascular Disease, Malmö University Hospital, Lund University, Malmö, Sweden
| | - J. Holst
- Centre of Vascular Disease, Malmö University Hospital, Lund University, Malmö, Sweden
| | - T. Kölbel
- Centre of Vascular Disease, Malmö University Hospital, Lund University, Malmö, Sweden
| | - K. Ivancev
- Centre of Vascular Disease, Malmö University Hospital, Lund University, Malmö, Sweden
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Affiliation(s)
- Warren Swee
- From the Department of Radiology, Division of Angiography and Interventional Radiology, University of Virginia Health System, Charlottesville, Va
| | - Michael D. Dake
- From the Department of Radiology, Division of Angiography and Interventional Radiology, University of Virginia Health System, Charlottesville, Va
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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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Pitton MB, Herber S, Schmiedt W, Neufang A, Dorweiler B, Düber C. Long-Term Follow-Up After Endovascular Treatment of Acute Aortic Emergencies. Cardiovasc Intervent Radiol 2007; 31:23-35. [PMID: 17943352 DOI: 10.1007/s00270-007-9175-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2007] [Revised: 07/12/2007] [Accepted: 08/29/2007] [Indexed: 11/30/2022]
Affiliation(s)
- M B Pitton
- Department of Diagnostic and Interventional Radiology, University Hospital of Mainz, Johannes Gutenberg University of Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany.
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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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Ruppert V, Leurs LJ, Hobo R, Buth J, Rieger J, Umscheid T. Tube Stent-Grafts for Infrarenal Aortic Aneurysm: A Matched-Paired Analysis Based on EUROSTAR Data. Cardiovasc Intervent Radiol 2007; 30:611-8. [PMID: 17573551 DOI: 10.1007/s00270-007-9066-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2007] [Revised: 04/03/2007] [Accepted: 04/06/2007] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Tube stent-grafts for treatment of infrarenal aortic aneurysms (AAAs) are a nearly forgotten concept. For focal aortic pathologies tube stent-grafts may be a treatment option. We have performed a retrospective matched-paired analysis of the EUROSTAR registry regarding the outcome of tube vs. bifurcated stent-grafts for AAA. Tapered aortomonoiliac stent-grafts were not the objective of this study. MATERIALS AND METHODS From July 1997 to June 2006, 7581 patients who underwent an endovascular AAA repair were entered in the EUROSTAR registry by 164 centers. One hundred fifty-three patients were treated with tube stent-grafts. For each of these 153 patients we selected one patient from a bifurcated stent-graft group (BGG-original, 7428 patients) matched according to gender, ASA, age, AAA diameter, and type of anesthesia. Differences in preoperative details between the two study groups were analyzed using chi-square test for discrete variables and Wilcoxon rank-sum test for continuous variables. Multivariate logistic regression analysis was performed on early complications. Midterm outcomes (>30 days) were analyzed by Kaplan-Meier and multivariate Cox proportional hazard model. RESULTS The duration of the procedure was shorter in the tube stent-graft group (TGG; 102.3 +/- 52.2) than in BGG (128.3 +/- 55.0; p = 0.0002). Type II endoleak was less frequent in TGG (4.0%; mean follow-up, 23.12 +/- 23.9 months) than in BGG (14.3%; mean follow-up, 20.77 +/- 20.0 months; p = 0.0394). Type I endoleaks and migration were distributed equally, without significant differences between the groups. Combined 30-day and late mortality was higher for TGG (p = 0.0346) and was obviously not aneurysm related. CONCLUSIONS We conclude that after selection of patients, tube stent-grafts for infrarenal aortic repair can be performed with great safety regarding endoleaks and migration. The combined higher 30-day mortality and non-aneurysm-related mortality during follow-up were mainly caused by cardiac failures in our sample.
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Affiliation(s)
- Volker Ruppert
- Department of Vascular and Endovascular Surgery, Klinikum Ingolstadt, Krumenauerstrasse 25, D-85049, Ingolstadt, Germany.
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Melissano G, Bertoglio L, Civilini E, Marone EM, Calori G, Setacci F, Chiesa R. Results of Thoracic Endovascular Grafting in Different Aortic Segments. J Endovasc Ther 2007. [DOI: 10.1583/1545-1550(2007)14[150:rotegi]2.0.co;2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Ruppert V, Erz K, Bürklein D, Treitl M, Steckmeier B, Stelter W, Umscheid T. Double Tube Stent-Grafts for Infrarenal Aortic Aneurysm: A New Concept. J Endovasc Ther 2007. [DOI: 10.1583/1545-1550(2007)14[144:dtsfia]2.0.co;2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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