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Lau C, Soletti G, Weinsaft JW, Rahouma M, Al Zghari T, Olaria RP, Harik L, Yaghmour M, Dimagli A, Gaudino M, Girardi LN. Risk profile and operative outcomes in patients with and without Marfan syndrome undergoing thoracoabdominal aortic aneurysm repair. J Thorac Cardiovasc Surg 2023; 166:1548-1557.e2. [PMID: 37164052 DOI: 10.1016/j.jtcvs.2023.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/17/2023] [Accepted: 03/29/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVES To compare operative and long-term outcomes between patients with and without Marfan syndrome undergoing thoracoabdominal aortic aneurysm repair. METHODS We identified all consecutive patients undergoing thoracoabdominal aortic aneurysm repair between 1997 and 2022. Primary outcome was composite of major adverse events. Secondary outcomes were individual complications and long-term survival. Inverse probability of treatment weighting was performed. Weighted Kaplan-Meier curves were used to estimate long-term survival. Multivariable analysis identified factors associated with major adverse events. RESULTS Six hundred eighty-four patients underwent open thoracoabdominal aortic aneurysm repair. Ninety (13.1%) had Marfan syndrome, whereas 594 (86.9%) did not. Marfan patients were younger (46 years [range, 36-56 years] vs 69 years [range, 61-76 years]; P < .001). Extent II or III aneurysms (57 out of 90 [63.3%] vs 211 out of 594 [35.6%]; P < .001) and type I or III chronic dissection (77 out of 90 [85.3%] vs 242 out of 594 [40.8%]; P < .001) were more common. Cardiovascular risk factors were less frequent in Marfan patients. There was no difference in major adverse events between groups (12 out of 90 [13.3%] vs 100 out of 594 [16.8%]; P = .49). Operative mortality was similar between groups (3 out of 90 [3.3%] vs 28 out of 594 [4.7%]; P = .75). Unweighted survival at 10 years was 78.7% vs 46.8% (P = .001). Weighted Kaplan-Meier curves showed no difference in long-term survival (adjusted hazard ratio, 0.79; 95% CI, 0.32-1.99; P = .62; Log-rank P = .12). At multivariable analysis, renal insufficiency (odds ratio, 2.29; 95% CI, 1.43-3.68; P < .01) and urgent/emergency procedure (odds ratio, 2.17; 95% CI, 1.35-3.48; P < .01) were associated with major adverse events, whereas Marfan syndrome was not (odds ratio, 1.56; 95% CI, 0.69-3.49; P = .28). CONCLUSIONS Open thoracoabdominal aortic aneurysm repair can be performed with similar operative outcomes in patients with and without Marfan syndrome despite differing risk profiles. Operative/perioperative strategies must be tailored to specific needs of each patient to optimize outcomes.
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Affiliation(s)
- Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.
| | - Giovanni Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | | | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Talal Al Zghari
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | | | - Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Mohammad Yaghmour
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
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Firwana M, Hasan B, Saadi S, Abd-Rabu R, Alabdallah K, Al-Zu'bi H, Shalhub S, Black JH, Prokop LJ, Murad MH. A systematic review supporting the Society for Vascular Surgery guidelines on the management of heritable aortopathies. J Vasc Surg 2023; 78:1077-1082.e12. [PMID: 37327953 DOI: 10.1016/j.jvs.2023.06.004] [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: 04/04/2023] [Revised: 05/29/2023] [Accepted: 06/03/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND To support the development of clinical practice guidelines on the management of patients with genetic aortopathies and arteriopathies, a writing committee from the Society for Vascular Surgery has commissioned this systematic review. METHODS We conducted a systematic review and searched multiple databases for studies addressing six questions identified by the Society for Vascular Surgery guideline committee about evaluating and managing patients with genetic aortopathies and arteriopathies. Studies were selected and appraised by pairs of independent reviewers. RESULTS We included 12 studies in this systematic review. We did not identify studies about the long-term outcomes of endovascular repair for aortic aneurysm in patients with heritable aortopathy or about new aortic events in pregnant women with a history of aortic dissection (AD) or aneurysm. A small case series demonstrated a 100% survival rate and 100% aortic intervention-free survival at 15 months (range, 7-28 months) after endograft repair for type B AD. A positive genetic diagnosis was discovered in 36% of patients with aortic aneurysms and dissections who had no risk factors for hereditary aortopathies, and these patients had a mortality rate of 11% at a median follow-up duration of 5 months. Black patients had lower 30-day mortality than White patients (5.6% vs 9.0%, respectively), but they had a higher overall aortic reintervention rate at 30 days after AD repair (47% vs 27%, respectively). Aortic reinterventions owing to aneurysmal expansion and endoleak at 30 days were higher in Black patients than White patients. The certainty of evidence was judged to be very low across all the outcomes evaluated in this systematic review. CONCLUSIONS The available evidence suggests high survival after thoracic endovascular aortic repair for type B AD in young patients with heritable aortopathies, but with limited long-term follow-up. Genetic testing in patients with acute aortic aneurysms and dissections had a high yield. It was positive for most patients with risk factors for hereditary aortopathies and in more than one-third for all other patients, and was associated with new aortic events within 15 years.
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Affiliation(s)
- Mohammed Firwana
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Bashar Hasan
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Samer Saadi
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Rami Abd-Rabu
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Khaled Alabdallah
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Hossam Al-Zu'bi
- Division of Cardiology, Mount Sinai Medical Center, Miami Beach, FL
| | - Sherene Shalhub
- Division of Vascular Surgery, Oregon Health & Science University, Portland, OR
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
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Single-center experience with thoracoabdominal aortic replacement in patients with Marfan syndrome. JTCVS OPEN 2022; 12:13-19. [PMID: 36590731 PMCID: PMC9801283 DOI: 10.1016/j.xjon.2022.08.005] [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: 05/12/2022] [Revised: 07/24/2022] [Accepted: 08/09/2022] [Indexed: 01/04/2023]
Abstract
Objectives Patients with Marfan syndrome are usually not suitable for endovascular repair of the thoracoabdominal aorta. This study was designed to analyze our center's experience with open surgical thoracoabdominal aortic replacement in Marfan patients. Methods This was a retrospective study with prospective follow-up. Between January 1995 and September 2021, a total of 648 patients underwent thoracoabdominal aortic replacement at our center. Of these, 60 had Marfan syndrome and were included in this study. Results The mean age was 39.5 ± 10.7 years, and 36 (60%) were male. Ten (17%) had aortic aneurysm, 4 (7%) acute/subacute dissection, and 46 (77%) chronic dissection. Patients presented with the following extent of aortic disease according to the Crawford classification: I-17 (28%), II-18 (30%), III-22 (37%), IV-2 (3%), and V-1 (2%). The mean cardiopulmonary bypass time was 173.9 ± 84.7 minutes. Four (7%) patients required stent graft extraction. Postoperatively, 5 (8%) patients required rethoracotomy and 6 (10%) tracheostomy. One (1.7%) patient had permanent paraplegia and 2 (3%) permanent paraparesis. Two (3%) patients had stroke. One (1.7%) patient was discharged with dialysis. The 30-day mortality was 3% (n = 2). Median follow-up time was 21.5 (range, 9.4-33.6) years. The 1-, 5-, and 10-year survival rate was 87%, 80%, and 68%, respectively. There were 16 aortic reinterventions in 9 patients during follow-up. Conclusions Thoracoabdominal aortic replacement remains a complex procedure but can be done extremely safely in Marfan patients. Perioperative mortality rates are very low, and the long-term outcomes are enduring. Because endovascular aortic repair is not recommended for patients with connective tissue disease, open surgery remains an important cornerstone of therapy.
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 61:1328-1335. [DOI: 10.1093/ejcts/ezac052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 01/11/2022] [Accepted: 02/02/2022] [Indexed: 11/13/2022] Open
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6565840. [DOI: 10.1093/ejcts/ezac206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 03/15/2022] [Indexed: 11/14/2022] Open
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Zhang B, Xue Q, Tang Y, Yu S, Fan X, Xu Z, Han L. Efficacy of cardiovascular surgery for Marfan syndrome patients: a single-center 15-year follow-up study. J Thorac Dis 2020; 12:7106-7116. [PMID: 33447399 PMCID: PMC7797851 DOI: 10.21037/jtd-20-2109] [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] [Indexed: 11/06/2022]
Abstract
Background Most Marfan syndrome (MFS) patients have thoracic aortic diseases which is the major cause of death. The aim of the study is to analyze the impact of different surgical procedures on prognosis of MFS patients. Methods We retrospectively analyzed the results of hospitalization and long-term follow-up of MFS patients who underwent surgical intervention in our center. Results Of the 135 MFS patients, 11 died during hospitalization (8.1%). There were no statistical differences in in-hospital mortality between the proximal surgery group and the distal surgery group (P=0.11). Compared to patients who underwent proximal aortic surgery, patients who underwent arch and distal surgery were more likely to have postoperative respiratory dysfunction (P=0.008). The type of surgical procedure was not associated with the incidence of complications during hospitalization. Pre-surgical New York Heart Association (NYHA) Functional Classification IV (P=0.047), EF <50% (P=0.047), pre-surgical atrial fibrillation (P=0.042), and the injury of dissection propagating onto coronary arteries (P=0.02) were independent risk factors for post-surgical mortality. After 15 years of follow-up, there were no deaths in the David group, while the 15-year survival rate for patients in the Bentall group was 73%±13.5%, and 71%±13.9% for patients in the arch surgery group (P=0.42). The probability of patients in the David group not requiring re-surgery after 15 years was 58.9%±20%, while it was 58.7%±12.1% for patients in the Bentall group, 71.5%±10.5% for patients in the Bentall + Arch group, and 12.5%±11.7% for patients in the Arch + Stent group (P=0.007). Conclusions The David procedure was the most beneficial and had the highest long-term patient survival rates.
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Affiliation(s)
- Boyao Zhang
- Department of Cardiovascular Surgery, Changhai Hospital, Naval Medical University (Second Military Medical University), Shanghai, China
| | - Qing Xue
- Department of Cardiovascular Surgery, Changhai Hospital, Naval Medical University (Second Military Medical University), Shanghai, China
| | - Yangfeng Tang
- Department of Cardiovascular Surgery, Changhai Hospital, Naval Medical University (Second Military Medical University), Shanghai, China
| | - Shangyi Yu
- Department of Cardiovascular Surgery, Changhai Hospital, Naval Medical University (Second Military Medical University), Shanghai, China
| | - Xingli Fan
- Department of Cardiovascular Surgery, Changhai Hospital, Naval Medical University (Second Military Medical University), Shanghai, China
| | - Zhiyun Xu
- Department of Cardiovascular Surgery, Changhai Hospital, Naval Medical University (Second Military Medical University), Shanghai, China
| | - Lin Han
- Department of Cardiovascular Surgery, Changhai Hospital, Naval Medical University (Second Military Medical University), Shanghai, China
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Harky A, Hussain SMA, MacCarthy-Ofosu B, Ahmad MU. The Role of Thoracic Endovascular Aortic Repair (TEVAR) of Thoracic Aortic Diseases in Patients with Connective Tissue Disorders - A Literature Review. Braz J Cardiovasc Surg 2020; 35:977-985. [PMID: 33306324 PMCID: PMC7731863 DOI: 10.21470/1678-9741-2019-0367] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To review the currently available literature to define the role of thoracic endovascular aortic repair (TEVAR) in patients with connective tissue disorders (CTD). METHODS A comprehensive electronic database search was performed in PubMed, SCOPUS, Embase, Google scholar, and OVID to identify all the articles that reported on outcomes of utilizing TEVAR in patients with CTD during elective and emergency settings. The search was not limited to time or language of the published study. RESULTS All the relevant studies have been summarized in its correspondence section. The outcomes were analyzed in narrative format. The role of TEVAR has been elaborated as per each study. Currently, there is limited large cohort size studies outlining the use of TEVAR in patients with CTD. The use of endovascular repair in patients with CTD is limited due to progressive aortic dilatations and high possibility of further reinterventions at later stage of life. CONCLUSION Open repair remains the gold standard method of intervention in young patients with progressive CTD, especially in the setting of acute type A aortic dissection. However, TEVAR can be sought as a reliable alternative in emergency setting of diseases involving the descending thoracic aorta; yet the long-term data needs to be published to support such practice.
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Affiliation(s)
- Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK
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Czerny M, Pacini D, Aboyans V, Al-Attar N, Eggebrecht H, Evangelista A, Grabenwöger M, Stabile E, Kolowca M, Lescan M, Micari A, Muneretto C, Nienaber C, de Paulis R, Tsagakis K, Rylski B, Braverman AC, Di Marco L, Eagle K, Falk V, Gottardi R. Current options and recommendations for the use of thoracic endovascular aortic repair in acute and chronic thoracic aortic disease: an expert consensus document of the European Society for Cardiology (ESC) Working Group of Cardiovascular Surgery, the ESC Working Group on Aorta and Peripheral Vascular Diseases, the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC and the European Association for Cardio-Thoracic Surgery (EACTS). Eur J Cardiothorac Surg 2020; 59:65-73. [DOI: 10.1093/ejcts/ezaa268] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 06/04/2020] [Indexed: 12/14/2022] Open
Abstract
Abstract
Since its clinical implementation in the late nineties, thoracic endovascular aortic repair (TEVAR) has become the standard treatment of several acute and chronic diseases of the thoracic aorta. While TEVAR has been embraced by many, this disruptive technology has also stimulated the continuing evolution of open surgery, which became even more important as late TEVAR failures do need open surgical correction justifying the need to unite both treatment options under one umbrella. This fact shows the importance of—in analogy to the heart team—aortic centre formation and centralization of care, which stimulates continuing development and improves outcome . The next frontier to be explored is the most proximal component of the aorta—the aortic root, in particular in acute type A aortic dissection—which remains the main challenge for the years to come. The aim of this document is to provide the reader with a synopsis of current evidence regarding the use or non-use of TEVAR in acute and chronic thoracic aortic disease, to share latest recommendations for a modified terminology and for reporting standards and finally to provide a glimpse into future developments.
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Affiliation(s)
- Martin Czerny
- University Heart Center Freiburg—Bad Krozingen, Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | | | | | - Nawwar Al-Attar
- Golden Jubilee National Hospital, University of Glasgow, Glasgow, UK
| | | | | | | | - Eugenio Stabile
- Department of Advanced Biomedical Sciences, University of Napoli “Federico II”, Naples, Italy
| | | | - Mario Lescan
- Department of Cardiac, Thoracic and Vascular Surgery, University of Tübingen, Tübingen, Germany
| | - Antonio Micari
- Department of Cardiology, Humanitas Gavazzeni, Bergamo, Italy
| | | | | | | | | | - Bartosz Rylski
- University Heart Center Freiburg—Bad Krozingen, Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
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Tanaka A, Charlton-Ouw KM. Open thoracoabdominal aortic aneurysm repair in the endovascular era. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.23736/s1824-4777.19.01428-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Frankel WC, Song HK, Milewski RK, Shalhub S, Pugh NL, Eagle KA, Roman MJ, Pyeritz RE, Maslen CL, Ravekes WJ, Milewicz DM, Coselli JS, LeMaire SA, Asch F, Bavaria J, Desvigne-Nickens P, Devereux R, Dietz H, Eagle K, Habashi J, Holmes K, Kroner B, LeMaire S, McDonnell N, Maslen C, Milewicz D, Milewski R, Morris S, Prakash S, Pyeritz R, Ravekes W, Roman M, Shohet R, Silberbach GM, Song H, Tolunay HE, Tseng H, Weinsaft J. Open Thoracoabdominal Aortic Repair in Patients With Heritable Aortic Disease in the GenTAC Registry. Ann Thorac Surg 2020; 109:1378-1384. [DOI: 10.1016/j.athoracsur.2019.08.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 07/18/2019] [Accepted: 08/15/2019] [Indexed: 01/14/2023]
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Open Descending and Thoracoabdominal Aortic Repairs in Patients Younger Than 50 Years Old. Ann Thorac Surg 2019; 108:693-699. [DOI: 10.1016/j.athoracsur.2019.03.058] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 03/05/2019] [Accepted: 03/18/2019] [Indexed: 11/22/2022]
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Ikeno Y, Yokawa K, Nakai H, Yamanaka K, Inoue T, Tanaka H, Okita Y. Results of staged repair of aortic disease in patients with Marfan syndrome. J Thorac Cardiovasc Surg 2019; 157:2138-2147.e2. [DOI: 10.1016/j.jtcvs.2018.08.109] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 08/11/2018] [Accepted: 08/24/2018] [Indexed: 01/16/2023]
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Holscher CM, Dakour Aridi H, Locham SS, Hicks CW, Canner JK, Malas M, Black JH. Aortic Surgery Outcomes of Marfan Syndrome and Ehlers-Danlos Syndrome Patients at Teaching and Nonteaching Hospitals. Ann Vasc Surg 2019; 55:175-181.e3. [DOI: 10.1016/j.avsg.2018.07.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 05/30/2018] [Accepted: 07/17/2018] [Indexed: 10/28/2022]
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Treatment of thoracoabdominal aortic disease in patients with connective tissue disorders. J Vasc Surg 2018; 68:1257-1267. [DOI: 10.1016/j.jvs.2018.06.199] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 06/21/2018] [Indexed: 11/21/2022]
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Tinelli G, Ferraresi M, Watkins AC, Hertault A, Soler R, Azzaoui R, Fabre D, Sobocinski J, Haulon S. Aortic treatment in connective tissue disease. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 60:518-525. [PMID: 29943958 DOI: 10.23736/s0021-9509.18.10443-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Connective tissue disease (CTD) represents a group of genetic conditions characterized by disruptive matrix remodeling. When this process involves aortic and vascular wall, patients with CTD have a high risk of developing arterial aneurysms, dissections and ruptures. Open surgical repair is still the gold standard therapy for patients with CTD with reasonable morbidity and mortality risk. The surgical treatment of CTD often requires multiple operations. In the endovascular era, fenestrated and branched stent grafts may play a role in reducing the complications of multiple open operations. Although the long-term results of endovascular treatment in the setting of CTD are unknown, it is generally accepted that endovascular treatment is restricted to selected patients with high surgical risk. In an emergency setting, endovascular intervention can serve as a lifesaving bridge to elective open aortic repair. Aortic centers performing a large volume of complex open and endovascular aortic repairs have started to combine these two techniques in a staged fashion. The goal is to reduce the morbidity and mortality associated with extensive aortic repairs in CTD patients. For this reason, recommend endovascular therapy when a "graft-to-graft" approach is possible. In this scenario, the surgeon who performs the open repair must take into consideration future interventions. Surgical repair in any aortic segment should allow creation of proximal and distal landing zones over 4 cm to secure the sealing of a future stent graft. Connective tissue disease should be treated with a multidisciplinary approach, in high volume centers. Endovascular treatment represents a potential option in patients at high risk for open repair. Staged hybrid procedures have emerged as a way to reduce spinal cord ischemia and avoid multiple open surgeries. The aim of this article is to discuss the management of aortic diseases in CTD, focusing on to the role of standard open surgery and emerging endovascular treatment, and to give an overview of the few series published regarding this topic with a small number of patients.
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Affiliation(s)
- Giovanni Tinelli
- Vascular Unit, Department of Cardiovascular Surgery, Gemelli Foundation IRCCS, School of Medicine, Sacred Heart Catholic University, Rome, Italy -
| | - Marco Ferraresi
- Vascular Unit, Department of Cardiovascular Surgery, Gemelli Foundation IRCCS, School of Medicine, Sacred Heart Catholic University, Rome, Italy
| | - Amelia C Watkins
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | | | - Raphael Soler
- Aortic Center, Marie Lannelongue Hospital, Paris Sud University, Le Plessis Robinson, France
| | | | - Dominique Fabre
- Aortic Center, Marie Lannelongue Hospital, Paris Sud University, Le Plessis Robinson, France
| | | | - Stéphan Haulon
- Aortic Center, Marie Lannelongue Hospital, Paris Sud University, Le Plessis Robinson, France
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Minatoya K, Inoue Y, Seike Y, Omura A, Uehara K, Sasaki H, Matsuda H, Kobayashi J. Thoracoabdominal aortic replacement in patients aged 50 and younger. Gen Thorac Cardiovasc Surg 2018; 67:53-58. [PMID: 29611032 DOI: 10.1007/s11748-018-0917-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 03/19/2018] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Open repair of a thoracoabdominal aortic aneurysm (TAAA) has been regarded as one of the most invasive procedures in cardiovascular surgery. Conversely, endovascular technology currently enables the repair of the thoracoabdominal aorta, and this approach is less invasive. However, the long-term durability of this method of endovascular repair remains unknown. This investigation retrospectively analyzed the long-term durability of thoracoabdominal aorta repair in patients aged 50 and younger. PATIENTS AND METHODS Since 1995, 100 patients aged 50 and younger underwent thoracoabdominal aortic replacement at our institution. There were 63 males, and the average age was 38 ± 7. Ninety-six had aortic dissection as an aortic pathology. Marfan syndrome was found in 61 patients, Loeys-Dietz in 10, Acta 2 mutations in 4, aortitis in 2, and Ehlers-Danlos syndrome in 1. There were 2 patients with a type I TAAA, 56 with a type II, 33 with a type III, and 9 with a type IV. RESULTS There were 3 hospital deaths (3%), of which 2 were emergent cases. Spinal cord injury occurred in 1 patient (1%). Two patients (2%) had wound complications. Three patients suffered cerebral hemorrhage and 1 had an intramedullary infection, of which all were associated with cerebrospinal fluid drainage. The 3-year survival rate after the operation was 94%, that of 5 years was 94%, and that of 10 years was 91%. CONCLUSIONS Results of thoracoabdominal aortic replacement in patients aged 50 and younger were favorable. While spinal cord complications were rare, cerebrospinal drainage revealed several complications in this series. Evolving endovascular repair needs to be compared with these results, especially in patients aged 50 and younger.
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Affiliation(s)
| | - Yosuke Inoue
- National Cerebral and Cardiovascular Center, Suita, Japan
| | | | - Atsushi Omura
- National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kyokun Uehara
- National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroaki Sasaki
- National Cerebral and Cardiovascular Center, Suita, Japan
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Abstract
The frequency of endovascular stent grafting procedures to treat various conditions of the thoracic aorta has increased dramatically over the past three decades. Stent grafting has been applied on a limited basis in patients with Marfan syndrome and other connective tissue disorders, despite recommendations from current guidelines and expert consensus statements against its use in this setting. A review of publications reporting outcomes after stent grafting of the descending thoracic aorta in Marfan patients with acute or chronic aortic dissection indicates that these procedures can be accomplished with rates of early mortality, stroke and spinal cord ischemic injury that are comparable to those observed in patients who do not have Marfan syndrome. However, the rates of primary treatment failure (principally endoleak), secondary treatment failure, need for open repair and late death among the Marfan patients are substantially higher than those observed in patients without this condition. In addition, the rates of retrograde aortic dissection and development of stent-graft induced new entry (SINE), are also greater among patients with Marfan syndrome. All of these findings argue strongly against the routine use of endovascular grafts in Marfan patients with type B or residual type A dissection. Few data are available to assess the role of endografting in Marfan patients with aneurysmal disease, but the progressive aortic dilatation noted in these patients argues strongly against its use in this setting as well. At present, the available data indicate that there is no justification for elective stent grafting in Marfan patients with aortic dissection or aneurysm. The only reasonable indications for primary aortic stent grafting are in the setting of acute aortic dissection or rupture, where the intervention is considered life-saving and rarely, considering the relatively young age of these patients, where the risk of open operation is considered to be prohibitive.
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Affiliation(s)
- Nicholas T Kouchoukos
- Division of Cardiovascular and Thoracic Surgery, Missouri Baptist Medical Center, BJC Healthcare, St. Louis, Missouri, USA
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Omura A, Minatoya K, Matsuo J, Inoue Y, Seike Y, Uehara K, Sasaki H, Matsuda H, Kobayashi J. Early and late outcomes of open repair for dissecting aneurysms of the descending or thoraco-abdominal aorta†. Interact Cardiovasc Thorac Surg 2017; 25:950-957. [DOI: 10.1093/icvts/ivx326] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 08/23/2017] [Indexed: 11/14/2022] Open
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Coselli JS, Amarasekara HS, Green SY, Price MD, Preventza O, de la Cruz KI, Zhang Q, LeMaire SA. Open Repair of Thoracoabdominal Aortic Aneurysm in Patients 50 Years Old and Younger. Ann Thorac Surg 2017; 103:1849-1857. [DOI: 10.1016/j.athoracsur.2016.09.058] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 09/06/2016] [Accepted: 09/12/2016] [Indexed: 11/27/2022]
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20
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Results of Open Surgical Repair in Patients With Marfan Syndrome and Distal Aortic Dissection. Ann Thorac Surg 2016; 101:2193-201. [DOI: 10.1016/j.athoracsur.2015.11.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 11/03/2015] [Accepted: 11/04/2015] [Indexed: 12/16/2022]
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21
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Coselli JS, LeMaire SA, Preventza O, de la Cruz KI, Cooley DA, Price MD, Stolz AP, Green SY, Arredondo CN, Rosengart TK. Outcomes of 3309 thoracoabdominal aortic aneurysm repairs. J Thorac Cardiovasc Surg 2016; 151:1323-37. [DOI: 10.1016/j.jtcvs.2015.12.050] [Citation(s) in RCA: 359] [Impact Index Per Article: 44.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 12/01/2015] [Accepted: 12/14/2015] [Indexed: 11/24/2022]
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22
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Overview of current surgical strategies for aortic disease in patients with Marfan syndrome. Surg Today 2015; 46:1006-18. [DOI: 10.1007/s00595-015-1278-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 11/02/2015] [Indexed: 01/16/2023]
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23
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Meyersohn NM, Ghemigian K, Shapiro MD, Shah SV, Ghoshhajra BB, Ferencik M. Role of Computed Tomography in Assessment of the Thoracic Aorta. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:395. [DOI: 10.1007/s11936-015-0395-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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24
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Hybrid Treatment for Thoracoabdominal Aortic Aneurysms in Patients with Marfan Syndrome. Ann Vasc Surg 2015; 29:595.e5-9. [DOI: 10.1016/j.avsg.2014.10.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 10/12/2014] [Accepted: 10/23/2014] [Indexed: 11/20/2022]
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Minami H, Miyahara S, Okada K, Matsumori M, Kano H, Inoue T, Sakamoto T, Okita Y. Clinical outcomes of combined aortic root reimplantation technique and total arch replacement. Eur J Cardiothorac Surg 2014; 48:152-7. [PMID: 25354747 DOI: 10.1093/ejcts/ezu387] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 09/04/2014] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES The goal of this study was to evaluate early and late outcomes of combined valve-sparing aortic root replacement and total arch replacement (TAR). METHODS From October 1999 to May 2014, 195 patients underwent valve-sparing operations using the David reimplantation technique. Thirty-one patients underwent combined TAR for aortic regurgitation (AR) with extended aortic aneurysm from the aortic root to the aortic arch. Aetiologies included acute type A aortic dissection in 12 cases, chronic aortic dissection in 8 cases and non-dissecting aneurysm in 11 cases. There were 9 patients with Marfan syndrome. The preoperative severity of AR was mild in 4, moderate in 16 and severe in 11. Even though half of those were emergent operations for acute aortic dissection, preoperative haemodynamic conditions were stable in all patients. RESULTS No hospital deaths occurred. Postoperative complications included prolonged mechanical ventilation (>48 h) in 1 case and re-exploration for bleeding in 2 cases. Other complications, such as neurological dysfunction or low cardiac output syndrome, were not observed. At hospital discharge, 2 patients had mild AR, 22 had trace AR and 7 had no AR. During follow-up, 2 patients had moderate AR, 7 had mild AR, 18 had trace AR and 3 had no AR. Follow-up was completed in 95.1% of patients, and the mean follow-up period was 60.5 ± 9.1 months. No late death and thromboembolic complication occurred during follow-up. One patient required reoperation for AR. Freedom from reoperation at 5 and 10 years was 100 ± 0 and 83.3 ± 3.5%, respectively. Freedom from moderate or severe AR at 3 and 5 years was 83.3 ± 3.5 and 83.3 ± 3.5%, respectively. CONCLUSIONS Early outcomes of combined aortic root reimplantation and TAR were satisfactory and provided excellent freedom from thromboembolic complication. The rate of freedom from reoperation during long-term follow-up was acceptable. Further follow-up is required to evaluate this procedure.
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Affiliation(s)
- Hitoshi Minami
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shunsuke Miyahara
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masamichi Matsumori
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroya Kano
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takeshi Inoue
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Toshihito Sakamoto
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Iafrancesco M, Ranasinghe AM, Claridge MW, Mascaro JG, Adam DJ. Current results of endovascular repair of thoraco-abdominal aneurysms†. Eur J Cardiothorac Surg 2014; 46:981-4; discussion 984. [PMID: 24652813 DOI: 10.1093/ejcts/ezu090] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Fenestrated and branch endografts represent a totally endovascular solution for high-risk patients with atherosclerotic thoraco-abdominal aortic aneurysms (TAAAs). This study reports the early outcome of endovascular TAAA repair. METHODS Interrogation of a prospective database of consecutive patients who underwent endovascular repair (EVAR) for TAAA between June 2007 and October 2012. RESULTS Sixty-two high-risk patients (55 men; median age 72, range 54-84 years) underwent fenestrated (n = 39) or branch (n = 23) EVAR for non-ruptured TAAA [extent I-III (n = 26) and IV (n = 36)]. Twenty patients had undergone 22 previous aortic procedures. A total of 221 target vessels (coeliac 50, superior mesenteric 61, renal 106, left subclavian 1 and hypogastric 3) were preserved with scallops (n = 17), fenestrations (n = 140) or branches (n = 62) and 201 of these vessels were stent-grafted (coeliac 34, superior mesenteric 58, renal 105, left subclavian 1 and hypogastric 3). The 30-day mortality was 1.6% (n = 1) and one further patient died on postoperative day 62 from respiratory complications. Spinal cord injury (SCI) developed in 5 (8%) patients (3 women and 2 men). Two patients required temporary renal replacement therapy and a further two commenced planned postoperative dialysis. CONCLUSIONS In high-risk patients with TAAA, fenestrated and branch EVAR is associated with low early mortality and requirement for renal support, but the risk of SCI is not insignificant despite the use of cerebrospinal fluid drainage and blood pressure manipulation. Our current practice is to stage the repair of extent I-III aneurysms and this has significantly reduced the incidence of SCI.
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Affiliation(s)
- Mauro Iafrancesco
- Department of Cardiothoracic Surgery/Thoracic Aortic Multidisciplinary Team, Queen Elizabeth University Hospital NHS Foundation Trust, Birmingham, UK Vascular Surgery Department/Thoracic Aortic Multidisciplinary Team, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Aaron M Ranasinghe
- Department of Cardiothoracic Surgery/Thoracic Aortic Multidisciplinary Team, Queen Elizabeth University Hospital NHS Foundation Trust, Birmingham, UK
| | - Martin W Claridge
- Department of Cardiothoracic Surgery/Thoracic Aortic Multidisciplinary Team, Queen Elizabeth University Hospital NHS Foundation Trust, Birmingham, UK Vascular Surgery Department/Thoracic Aortic Multidisciplinary Team, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Jorge G Mascaro
- Department of Cardiothoracic Surgery/Thoracic Aortic Multidisciplinary Team, Queen Elizabeth University Hospital NHS Foundation Trust, Birmingham, UK
| | - Donald J Adam
- Department of Cardiothoracic Surgery/Thoracic Aortic Multidisciplinary Team, Queen Elizabeth University Hospital NHS Foundation Trust, Birmingham, UK Vascular Surgery Department/Thoracic Aortic Multidisciplinary Team, Heart of England NHS Foundation Trust, Birmingham, UK
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Okita Y, Omura A, Yamanaka K, Inoue T, Kano H, Tanioka R, Minami H, Sakamoto T, Miyahara S, Shirasaka T, Ohara T, Nakai H, Okada K. Open reconstruction of thoracoabdominal aortic aneurysms. Ann Cardiothorac Surg 2013; 1:373-80. [PMID: 23977523 DOI: 10.3978/j.issn.2225-319x.2012.09.05] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2012] [Accepted: 09/12/2012] [Indexed: 11/14/2022]
Abstract
Technical details of our strategy for reconstructing the thoracoabdominal aorta are presented. Between October 1999 and June 2012, 152 patients underwent surgery for thoracoabdominal aortic aneurysms (Crawford classification type I =21, type II =43, type III =73, type IV =15). Mean age was 64.6±13.9 years. Sixty-three (41.4%) patients had aortic dissection, including acute type B dissection in 2 (1.2%) and ruptured aneurysms in 17 (11.2%). Eight (5.3%) patients had mycotic aneurysms, and 3 (2.0%) had aortitis. Emergent or urgent surgery was performed in 25 (16.4%) patients. Preoperative computed tomography (CT) scan or magnetic resonance (MR) angiography detected the Adamkiewicz artery in 103 (67.8%) patients. Cerebrospinal fluid drainage (CSFD) was performed in 115 (75.7%) patients and intraoperative motor evoked potentials were recorded in 97 (63.8%). One hundred and seven (70.4%) patients had reconstruction of the intercostal arteries from T7 to L2, 35 of which were reconstructed with the aortic patch technique and 72 with branched grafts. The mean number of reconstructed intercostal arteries was 3.1±2.5 pairs. Mild hypothermic partial cardiopulmonary bypass at 32-34 °C was used in 105 (69.1%) patients, left heart bypass was used in 4 (2.6%), and deep hypothermic cardiopulmonary bypass below 20 °C was used in 42 (27.6%). Thirty-day mortality was 9 (5.9%), and hospital mortality was 20 (13.2%). Independent risk factors for hospital mortality were emergency surgery (OR 13.4, P=0.003) and aortic cross clamping over 2 hours (OR 5.7, P=0.04). Postoperative spinal cord ischemia occurred in 16 (10.5%, 8 patients with paraplegia and 8 with paraparesis). Risk factors for developing spinal cord ischemic complications were prior surgery involving either the descending thoracic or the abdominal aorta (OR 3.75, P=0.05), diabetes mellitus (OR 5.49, P=0.03), and post-bypass hypotension <80 mmHg (OR 1.06, P=0.03). Postoperative survival at 5 years was 83.6±4.5%; 5-year survival was 47.5±8.6% in patients with spinal cord ischemia and 88.9±10.4% in those without spinal cord ischemia.
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Affiliation(s)
- Yutaka Okita
- Division of Cardiovascular Surgery, Department of Surgery, Kobe Graduate School of Medicine, Kobe, Japan
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