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de Beaufort HWL, Vos JA, Heijmen RH. Initial Single-Center Experience With the Knickerbocker Technique During Thoracic Endovascular Aortic Repair to Block Retrograde False Lumen Flow in Patients With Type B Aortic Dissection. J Endovasc Ther 2024; 31:597-605. [PMID: 36342189 DOI: 10.1177/15266028221134889] [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: 02/17/2024]
Abstract
OBJECTIVE Effectiveness of thoracic endovascular aortic repair in type B aortic dissection is impaired by persistent retrograde false lumen flow via distal re-entry tears. Controlled, stentgraft-assisted balloon dilatation of the true lumen at its lower end, or Knickerbocker technique, may block retrograde false lumen flow and consequently improve effectiveness by inducing immediate thrombosis along the entire descending thoracic aorta. MATERIALS AND METHODS A single-center retrospective analysis was performed for all consecutive patients with aortic dissection treated with the Knickerbocker technique to block retrograde false lumen flow. RESULTS Eleven patients were included for analysis. Intraoperative control angiography showed successful occlusion of the false lumen at the level of balloon dilatation in 9 out of 11 patients (82%). There was one perioperative mortality (9%), due to stroke. There were 2 early reinterventions, due to retroperitoneal bleeding and due to chyle leakage in the neck after left subclavian artery bypass. Median clinical follow-up duration was 6 (interquartile range [IQR] 2-11] months. There were 2 deaths during follow-up, one at 2 months after TEVAR from unknown cause of death, and one after 11 months due to rupture of an ascending aortic pseudoaneurysm. The Knickerbocker technique led to positive aortic remodeling. At 3 months follow-up, 100% of patients showed complete false lumen thrombosis in the thoracic aorta proximal to the level of balloon dilatation, with decreasing false lumen diameters (100%) and stable (44%) or decreasing (56%) total aortic diameters. In most patients, the false lumen distal to the stentgraft (i.e. at visceral level) remained patent (11% false lumen thrombosis rate), leading to ≥2 mm dilatation at this level (78% of patients) and in the infrarenal abdominal aorta (56% of patients) at 3 months postoperatively. No distal stent-graft-induced new entry tears were noticed during follow-up. CONCLUSION The Knickerbocker technique is feasible and effective, leading to positive aortic remodeling of the aorta covered by stentgraft in all of a small cohort of patients. CLINICAL IMPACT Persistent, retrograde false lumen perfusion from distal re-entries following thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection, may lead to progressive, aneurysmal dilatation. Controlled, stent graft-assisted balloon dilatation of the true lumen in the distal descending aorta (i.e. Knickerbocker technique) during TEVAR effectively excludes the false lumen from persistent flow resulting in positive aortic remodeling in our small cohort of patients, and hence potentially eliminates the risk of late post-dissection aneurysm formation in the descending thoracic aorta.
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Affiliation(s)
| | - Jan Albert Vos
- Department of Interventional Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Robin H Heijmen
- Department of Cardiothoracic Surgery, Radboud university medical center, Nijmegen, The Netherlands
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2
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Agrafiotis E, Zimpfer D, Mächler H, Holzapfel GA. Review of Systemic Mock Circulation Loops for Evaluation of Implantable Cardiovascular Devices and Biological Tissues. J Endovasc Ther 2024:15266028241235876. [PMID: 38528650 DOI: 10.1177/15266028241235876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
CLINICAL IMPACT On needs-based ex vivo monitoring of implantable devices or tissues/organs in cardiovascular simulators provides new insights and paves new paths for device prototypes. The insights gained could not only support the needs of patients, but also inform engineers, scientists and clinicians about undiscovered aspects of diseases (during routine monitoring). We analyze seminal and current work and highlight a variety of opportunities for developing preclinical tools that would improve strategies for future implantable devices. Holistically, mock circulation loop studies can bridge the gap between in vivo and in vitro approaches, as well as clinical and laboratory settings, in a mutually beneficial manner.
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Affiliation(s)
| | - Daniel Zimpfer
- Division of Cardiac Surgery, Medical University of Graz, Graz, Austria
| | - Heinrich Mächler
- Division of Cardiac Surgery, Medical University of Graz, Graz, Austria
| | - Gerhard A Holzapfel
- Institute of Biomechanics, Graz University of Technology, Graz, Austria
- Department of Structural Engineering, Norwegian University of Science and Technology, Trondheim, Norway
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3
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Mandigers TJ, Pascaner AF, Conti M, Schembri M, Jelic S, Favilli A, Bissacco D, Domanin M, van Herwaarden JA, Auricchio F, Trimarchi S. Type III aortic arch angulation increases aortic stiffness: Analysis from an ex vivo porcine model. JTCVS OPEN 2024; 17:37-46. [PMID: 38420559 PMCID: PMC10897663 DOI: 10.1016/j.xjon.2023.10.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 10/10/2023] [Accepted: 10/30/2023] [Indexed: 03/02/2024]
Abstract
Objective The relationship among increased aortic arch angulation, aortic flow dynamics, and vessel wall stiffness remains unclear. This experimental ex vivo study investigated how increased aortic arch angulation affects aortic stiffness and stent-graft induced aortic stiffening, assessed by pulse wave velocity (PWV). Methods Porcine thoracic aortas were connected to a circulatory mock loop in a Type I and Type III aortic arch configuration. Baseline characteristics and blood pressures were measured. Proximal and distal flow curves were acquired to calculate PWV in both arch configurations. After that, a thoracic stent-graft (VAMF2626C100TU) was deployed in aortas with adequate proximal landing zone diameters to reach 10% t0 20% oversizing. Acquisitions were repeated for both arch configurations after stent-graft deployment. Results Twenty-four aortas were harvested, surgically prepared, and mounted. Cardiac output was kept constant for both arch configurations (Type I: 4.74 ± 0.40 and Type III: 4.72 ± 0.38 L/minute; P = .703). Compared with a Type I arch, aortic PWV increased significantly in the Type III arch (3.53 ± 0.40 vs 3.83 ± 0.40 m/second; P < .001), as well as blood pressures. A stent-graft was deployed in 15 aortas. After deployment, Type I arch PWV increased (3.55 ± 0.39 vs 3.81 ± 0.44 m/second; P < .001) and Type III arch PWV increased although not significantly (3.86 ± 0.42 vs 4.03 ± 0.46 m/second; P = .094). Type III arch PWV resulted the highest and significantly higher compared with the Type I arch after stent-graft deployment (3.81 ± 0.44 vs 4.03 ± 0.46 m/second; P = .023). Conclusions Increased aortic arch angulation-as in a Type III arch-is associated with higher aortic PWV and blood pressures and this may negatively influence cardiovascular health.
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Affiliation(s)
- Tim J. Mandigers
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Ariel F. Pascaner
- Civil Engineering and Architecture Department, Università degli Studi di Pavia, Pavia, Italy
| | - Michele Conti
- Civil Engineering and Architecture Department, Università degli Studi di Pavia, Pavia, Italy
| | - Martina Schembri
- Civil Engineering and Architecture Department, Università degli Studi di Pavia, Pavia, Italy
| | - Sonja Jelic
- Civil Engineering and Architecture Department, Università degli Studi di Pavia, Pavia, Italy
| | - Alessandra Favilli
- Veterinary and Food Safety of Animal Origin Department, ATS Pavia, Pavia, Italy
| | - Daniele Bissacco
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Domanin
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | | | - Ferdinando Auricchio
- Civil Engineering and Architecture Department, Università degli Studi di Pavia, Pavia, Italy
| | - Santi Trimarchi
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
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Stonko DP, Edwards J, Abdou H, Treffalls RN, Walker P, DeMartino RR, Mendes BC, Hicks CW, Morrison JJ. Thoracic Endovascular Aortic RepairAcutely Augments Left Ventricular Biomechanics in An Animal Model: A Mechanism for Postoperative Heart Failure and Hypertension. Ann Vasc Surg 2023; 97:18-26. [PMID: 37068623 PMCID: PMC10754260 DOI: 10.1016/j.avsg.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/27/2023] [Accepted: 04/05/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Thoracic aortic stent grafts are thought to decrease aortic compliance and may contribute to hypertension and heart failure after thoracic endovascular aortic repair (TEVAR). Left ventricular (LV) biomechanics immediately after TEVAR, however, have not been quantified. Pressure-volume (PV) loop analysis provides gold-standard LV functional information. The aim of this study is to use an LV PV loop catheter and analysis to characterize the LV biomechanics before and acutely after TEVAR. METHODS Anesthetized Yorkshire swine (N = 6) were percutaneously instrumented with an LV PV loop catheter. A 20 mm × 10 cm stent graft was deployed distal to the left subclavian via the femoral artery under fluoroscopy. Cardiac biomechanics were assessed before and after TEVAR. As a sensitivity analysis, inferior vena cava occlusion with PV loop assessment was performed pre and post-TEVAR in 1 animal to obtain preload and afterload-independent end-systolic and end-diastolic PV relationships (ESPVR and EDPVR). RESULTS All animals underwent successful instrumentation and TEVAR. Post-TEVAR, all 6 animals had higher mean LV ESP (106 vs. 118 mm Hg, P = 0.04), with no change in the EDPVR. inferior vena cava occlusion also moved the ESPVR curve upward and leftward, indicating increased LV work per unit time. There was no augmentation of EDPVR following TEVAR (P > 0.05). Postmortem exams in all animals revealed appropriate stent placement and no technical complications. CONCLUSIONS TEVAR was associated with an acute increase in LV end-systolic pressure and shift in the ESPVR, indicating increased ventricular work. This data provides potential mechanistic insights into the development of post-TEVAR hypertension and heart failure. Future stent graft innovation should focus on minimizing the changes in cardiac physiology.
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Affiliation(s)
- David P Stonko
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD; R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | - Joseph Edwards
- R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | - Hossam Abdou
- R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | | | - Patrick Walker
- R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | | | - Bernardo C Mendes
- Divison of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
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5
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Ratner M, Chang H, Rockman C, Jacobowitz G, Cayne N, Patel V, Jung A, Ramkhelawon B, Siracuse JJ, Garg K. Depressed Ejection Fraction Does Not Affect Perioperative Mortality After Thoracic Endovascular Aortic Repair for Type B Aortic Dissection. Ann Vasc Surg 2023; 96:81-88. [PMID: 37253406 DOI: 10.1016/j.avsg.2023.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/02/2023] [Accepted: 05/07/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Despite the expanded application of thoracic endovascular aortic repair (TEVAR) in patients with significant cardiac comorbidities, the effect of decreased left ventricular ejection fraction (EF) on outcomes remains unknown. The aim of this study was to compare outcomes in patients with normal and abnormal EFs undergoing TEVAR for type-B aortic dissection (TBAD). METHODS The Vascular Quality Initiative database was reviewed from 2012 to 2020. Patients were categorized into severely reduced (EF ≤ 30%), reduced (EF 30-50%) and normal EF (EF>50%). Baseline characteristics, procedural details and 18-month outcomes were compared. Multivariable logistic regression identified factors associated with mortality, major adverse cardiac events (MACEs), and aortic-related reintervention. RESULTS Of 1,993 patients, 38 (2%) and 208 (10%) patients had severely reduced ejection fraction (SREF) and reduced ejection fraction (REF). Patients with abnormal EF were more likely to have cardiac comorbidities and be prescribed angiotensin-converting enzyme inhibitors and anticoagulants. Perioperatively, patients with SREF were more likely to experience mortality (13.2% vs. 6.7% vs. 4.4%, P = 0.018), MACE (26.3% vs. 11.5% vs. 8%, P < 0.001), hemodialysis (13.5% vs. 5% vs. 2.9%, P = 0.001) and aortic related reintervention (21.1% vs. 13% vs. 10%, P = 0.041), compared to REF and normal ejection fraction (NEF) patients. However, these associations were not present on multivariable analysis. At 18 months, mortality was significantly higher in patients with SREF, which was confirmed on multivariable analysis, but depressed EF was not associated with increased aortic reintervention compared to NEF. CONCLUSIONS SREF was not independently associated with perioperative mortality or MACE compared to NEF. REF had similar risk of morbidity and mortality compared to NEF in both the perioperative and early postoperative periods. TEVAR-related complications were similar among the cohorts. As such, TEVAR may be offered to appropriately selected patients regardless of EF.
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Affiliation(s)
- Molly Ratner
- Division of Vascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY.
| | - Heepeel Chang
- Division of Vascular Surgery, Department of Surgery, Westchester Medical Center, Valhalla, NY
| | - Caron Rockman
- Division of Vascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Glenn Jacobowitz
- Division of Vascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Neal Cayne
- Division of Vascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Virendra Patel
- Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, New York Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Albert Jung
- Division of Cardiology, Department of Medicine, New York University Langone Medical Center, New York, NY
| | - Bhama Ramkhelawon
- Division of Vascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston Medical Center, Boston, MA
| | - Karan Garg
- Division of Vascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
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Kim T, Tjahjadi NS, He X, van Herwaarden JA, Patel HJ, Burris NS, Figueroa CA. Three-Dimensional Characterization of Aortic Root Motion by Vascular Deformation Mapping. J Clin Med 2023; 12:4471. [PMID: 37445507 DOI: 10.3390/jcm12134471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 06/29/2023] [Accepted: 07/02/2023] [Indexed: 07/15/2023] Open
Abstract
The aorta is in constant motion due to the combination of cyclic loading and unloading with its mechanical coupling to the contractile left ventricle (LV) myocardium. This aortic root motion has been proposed as a marker for aortic disease progression. Aortic root motion extraction techniques have been mostly based on 2D image analysis and have thus lacked a rigorous description of the different components of aortic root motion (e.g., axial versus in-plane). In this study, we utilized a novel technique termed vascular deformation mapping (VDM(D)) to extract 3D aortic root motion from dynamic computed tomography angiography images. Aortic root displacement (axial and in-plane), area ratio and distensibility, axial tilt, aortic rotation, and LV/Ao angles were extracted and compared for four different subject groups: non-aneurysmal, TAA, Marfan, and repair. The repair group showed smaller aortic root displacement, aortic rotation, and distensibility than the other groups. The repair group was also the only group that showed a larger relative in-plane displacement than relative axial displacement. The Marfan group showed the largest heterogeneity in aortic root displacement, distensibility, and age. The non-aneurysmal group showed a negative correlation between age and distensibility, consistent with previous studies. Our results revealed a strong positive correlation between LV/Ao angle and relative axial displacement and a strong negative correlation between LV/Ao angle and relative in-plane displacement. VDM(D)-derived 3D aortic root motion can be used in future studies to define improved boundary conditions for aortic wall stress analysis.
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Affiliation(s)
- Taeouk Kim
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Nic S Tjahjadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Xuehuan He
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
| | - J A van Herwaarden
- Department of Vascular Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Nicholas S Burris
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
| | - C Alberto Figueroa
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA
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Bianchi D, Conti M, Bissacco D, Domanin M, Trimarchi S, Auricchio F. Impact of thoracic endovascular aortic repair on aortic biomechanics: Integration of in silico and ex vivo analysis using porcine model. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2023; 39:e3594. [PMID: 35340129 DOI: 10.1002/cnm.3594] [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: 10/30/2021] [Revised: 02/09/2022] [Accepted: 03/16/2022] [Indexed: 05/12/2023]
Abstract
Thoracic endovascular aortic repair (TEVAR) is widespread in clinical practice for treating aortic diseases but it has relevant systemic complications, such as increase of the cardiac workload due to post-TEVAR aortic stiffening, and local issues such as re-entry tears due to the tissue damage caused by endograft interaction. The present study aims to elucidate these aortic biomechanical mechanisms by coupling ex vivo and in silico analysis. By ex vivo tests, the pulse wave velocity before and after TEVAR is measured. Uni-axial tensile tests are performed to measure regional mechanical response of tissue samples, supplied as input data for the in silico analysis. Numerical analysis is finally performed to compute the wall stress induced by the stent-graft deployment and the arterial pressurization. The ex vivo results highlight an increase of baseline PWV by a mean .78 m/s or 12% after TEVAR with a 100 mm stent-graft (p <.013). In the in silico analysis, the average von Mises stress in the landing zone increases of about 15% and 20% using, respectively stent-graft with radial oversizing of 10% and 20%. This work shows the effectiveness of integrated framework to analyze the biomechanical post TEVAR mechanisms. Moreover, the obtained results quantify the effect of prosthesis selection on the stiffening of the aorta after TEVAR and on the local increase of the aortic wall stress that is proportional to the stent-graft oversizing.
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Affiliation(s)
- Daniele Bianchi
- Department of Civil Engineering and Architecture (DICAr), University of Pavia, Pavia, Italy
| | - Michele Conti
- Department of Civil Engineering and Architecture (DICAr), University of Pavia, Pavia, Italy
| | - Daniele Bissacco
- Department of Health and Community Sciences, University of Milan, Milan, Italy
- Operative Unit of Vascular Surgery, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico Milano, Milan, Italy
| | - Maurizio Domanin
- Department of Health and Community Sciences, University of Milan, Milan, Italy
- Operative Unit of Vascular Surgery, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico Milano, Milan, Italy
| | - Santi Trimarchi
- Department of Health and Community Sciences, University of Milan, Milan, Italy
- Operative Unit of Vascular Surgery, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico Milano, Milan, Italy
| | - Ferdinando Auricchio
- Department of Civil Engineering and Architecture (DICAr), University of Pavia, Pavia, Italy
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Agrafiotis E, Mayer C, Grabenwöger M, Zimpfer D, Regitnig P, Mächler H, Holzapfel GA. Global and local stiffening of ex vivo-perfused stented human thoracic aortas: A mock circulation study. Acta Biomater 2023; 161:170-183. [PMID: 36849029 DOI: 10.1016/j.actbio.2023.02.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/25/2023] [Accepted: 02/20/2023] [Indexed: 02/27/2023]
Abstract
The effects of thoracic endovascular repair (TEVAR) on the biomechanical properties of aortic tissue have not been adequately studied. Understanding these features is important for the management of endograft-triggered complications of a biomechanical nature. This study aims to examine how stent-graft implantation affects the elastomechanical behavior of the aorta. Non-pathological human thoracic aortas (n=10) were subjected to long-standing perfusion (8h) within a mock circulation loop under physiological conditions. To quantify compliance and its mismatch in the test periods without and with a stent, the aortic pressure and the proximal cyclic circumferential displacement were measured. After perfusion, biaxial tension tests (stress-stretch) were carried out to examine the stiffness profiles between non-stented and stented tissue, followed by a histological assessment. Experimental evidence shows: (i) a significant reduction in aortic distensibility after TEVAR, indicating aortic stiffening and compliance mismatch, (ii) a stiffer behavior of the stented samples compared to the non-stented samples with an earlier entry into the nonlinear part of the stress-stretch curve and (iii) strut-induced histological remodeling of the aortic wall. The biomechanical and histological comparison of the non-stented and stented aortas provides new insights into the interaction between the stent-graft and the aortic wall. The knowledge gained could refine the stent-graft design to minimize the stent-induced impacts on the aortic wall and the resulting complications. STATEMENT OF SIGNIFICANCE: Stent-related cardiovascular complications occur the moment the stent-graft expands on the human aortic wall. Clinicians base their diagnosis on the anatomical morphology of CT scans while neglecting the endograft-triggered biomechanical events that compromise aortic compliance and wall mechanotransduction. Experimental replication of endovascular repair in cadaver aortas within a mock circulation loop may have a catalytic effect on biomechanical and histological findings without an ethical barrier. Demonstrating interactions between the stent and the wall can help clinicians make a broader diagnosis such as ECG-triggered oversizing and stent-graft characteristics based on patient-specific anatomical location and age. In addition, the results can be used to optimize towards more aortophilic stent grafts.
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Affiliation(s)
| | - Christian Mayer
- Department of Cardiac Surgery, Medical University of Graz, Austria
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Graz, Austria
| | - Peter Regitnig
- Institute of Pathology, Medical University of Graz, Austria
| | - Heinrich Mächler
- Department of Cardiac Surgery, Medical University of Graz, Austria
| | - Gerhard A Holzapfel
- Institute of Biomechanics, Graz University of Technology, Graz, Austria; Department of Structural Engineering, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
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Mandigers TJ, Conti M, Allievi S, Dedola F, Bissacco D, Bianchi D, Marconi S, Domanin M, Van Herwaarden JA, Auricchio F, Trimarchi S. Comparison of Two Generations of Thoracic Aortic Stent Grafts and Their Impact on Aortic Stiffness in an Ex Vivo Porcine Model. EJVES Vasc Forum 2023; 59:8-14. [PMID: 37213485 PMCID: PMC10199196 DOI: 10.1016/j.ejvsvf.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 02/09/2023] [Accepted: 04/05/2023] [Indexed: 05/23/2023] Open
Abstract
Objective Little is known about the cardiovascular changes after TEVAR and regarding the impact on aortic stiffness for different stent graft generations specifically, following changes in device design. The present study evaluated the stent graft induced aortic stiffening of two generations of the Valiant thoracic aortic stent graft. Methods This was an ex vivo porcine investigation using an experimental mock circulatory loop. Thoracic aortas of young healthy pigs were harvested and connected to the mock circulatory loop. At a 60 bpm heart rate and stable mean arterial pressure, baseline aortic characteristics were obtained. Pulse wave velocity (PWV) was calculated before and after stent graft deployment. Paired and independent sample t tests or their non-parametric alternatives were performed to test for differences where appropriate. Results Twenty porcine thoracic aortas were divided into two equal subgroups, in which a Valiant Captivia or a Valiant Navion stent graft was deployed. Both stent grafts were similar in diameter and length. Baseline aortic characteristics did not differ between the subgroups. Mean arterial pressure values did not change after either stent graft, while pulse pressures increased statistically significantly after Captivia (mean 44 ± 10 mmHg to 51 ± 13 mmHg, p = .002) but not after Navion. Mean baseline PWV increased after both Captivia (4.4 ± 0.6 m/s to 4.8 ± 0.7 m/s, p = .007) and Navion (4.6 ± 0.7 m/s to 4.9 ± 0.7 m/s, p = .002). There was no statistically significant difference in the mean percentage increase in PWV for either subgroup (8 ± 4% vs. 6 ± 4%, p = .25). Conclusion These experimental findings showed no statistically significant difference in the percentage increase of aortic PWV after either stent graft generation and confirm that TEVAR increases aortic PWV. As a surrogate for aortic stiffness, this calls for further improvements in future thoracic aortic stent graft designs regarding device compliance.
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Affiliation(s)
- Tim J. Mandigers
- Department of Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
- Corresponding author. Department of Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.
| | - Michele Conti
- Civil Engineering and Architecture Department, Università Degli Studi di Pavia, Pavia, Italy
| | - Sara Allievi
- Department of Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Dedola
- Civil Engineering and Architecture Department, Università Degli Studi di Pavia, Pavia, Italy
| | - Daniele Bissacco
- Department of Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniele Bianchi
- Civil Engineering and Architecture Department, Università Degli Studi di Pavia, Pavia, Italy
| | - Stefania Marconi
- Civil Engineering and Architecture Department, Università Degli Studi di Pavia, Pavia, Italy
| | - Maurizio Domanin
- Department of Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Clinical and Community Sciences Department, Università Degli Studi di Milano, Milan, Italy
| | | | - Ferdinando Auricchio
- Civil Engineering and Architecture Department, Università Degli Studi di Pavia, Pavia, Italy
| | - Santi Trimarchi
- Department of Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Clinical and Community Sciences Department, Università Degli Studi di Milano, Milan, Italy
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10
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Mandigers TJ, Trimarchi S, Van Herwaarden JA, Piffaretti G. The ongoing dynamic interaction between thoracic stent grafts and the aorta demands knowledge and further optimalization. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2022; 63:6968980. [PMID: 36610455 DOI: 10.1093/ejcts/ezad002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/03/2023] [Indexed: 01/09/2023]
Affiliation(s)
- Tim J Mandigers
- Department of Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Santi Trimarchi
- Department of Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Clinical and Community Sciences Department, Università degli Studi di Milano, Milan, Italy
| | | | - Gabriele Piffaretti
- Vascular Surgery-Department of Medicine and Surgery, University of Insubria, Varese, Italy
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11
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Mandigers TJ, Bissacco D, Domanin M, D’Alessio I, Tolva VS, Piffaretti G, van Herwaarden JA, Trimarchi S. Cardiac and aortic modifications after endovascular repair for blunt thoracic aortic injury: a systematic review. Eur J Vasc Endovasc Surg 2022; 64:176-187. [DOI: 10.1016/j.ejvs.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/09/2022] [Accepted: 05/01/2022] [Indexed: 11/24/2022]
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12
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Qiao Y, Mao L, Ding Y, Zhu T, Luo K, Fan J. Fluid-structure interaction: Insights into biomechanical implications of endograft after thoracic endovascular aortic repair. Comput Biol Med 2021; 138:104882. [PMID: 34600328 DOI: 10.1016/j.compbiomed.2021.104882] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/04/2021] [Accepted: 09/19/2021] [Indexed: 10/20/2022]
Abstract
Thoracic endovascular aortic repair (TEVAR) has developed to be the most effective treatment for aortic diseases. This study aims to evaluate the biomechanical implications of the implanted endograft after TEVAR. We present a novel image-based, patient-specific, fluid-structure computational framework. The geometries of blood, endograft, and aortic wall were reconstructed based on clinical images. Patient-specific measurement data was collected to determine the parameters of the three-element Windkessel. We designed three postoperative scenarios with rigid wall assumption, blood-wall interaction, blood-endograft-wall interplay, respectively, where a two-way fluid-structure interaction (FSI) method was applied to predict the deformation of the composite stent-wall. Computational results were validated with Doppler ultrasound data. Results show that the rigid wall assumption fails to predict the waveforms of blood outflow and energy loss (EL). The complete storage and release process of blood flow energy, which consists of four phases is captured by the FSI method. The endograft implantation would weaken the buffer function of the aorta and reduce mean EL by 19.1%. The closed curve area of wall pressure and aortic volume could indicate the EL caused by the interaction between blood flow and wall deformation, which accounts for 68.8% of the total EL. Both the FSI and endograft have a slight effect on wall shear stress-related-indices. The deformability of the composite stent-wall region is remarkably limited by the endograft. Our results highlight the importance of considering the interaction between blood flow, the implanted endograft, and the aortic wall to acquire physiologically accurate hemodynamics in post-TEVAR computational studies and the deformation of the aortic wall is responsible for the major EL of the blood flow.
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Affiliation(s)
- Yonghui Qiao
- State Key Laboratory of Clean Energy Utilization, Zhejiang University, Hangzhou, China
| | - Le Mao
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ying Ding
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ting Zhu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Kun Luo
- State Key Laboratory of Clean Energy Utilization, Zhejiang University, Hangzhou, China.
| | - Jianren Fan
- State Key Laboratory of Clean Energy Utilization, Zhejiang University, Hangzhou, China.
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13
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Concannon J, Moerman KM, Hynes N, Sultan S, McGarry JP. Influence of shape-memory stent grafts on local aortic compliance. Biomech Model Mechanobiol 2021; 20:2373-2392. [PMID: 34541627 PMCID: PMC8595172 DOI: 10.1007/s10237-021-01514-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/18/2021] [Indexed: 12/19/2022]
Abstract
The effect of repair techniques on the biomechanics of the aorta is poorly understood, resulting in significant levels of postoperative complications for patients worldwide. This study presents a computational analysis of the influence of Nitinol-based devices on the biomechanical performance of a healthy patient-specific human aorta. Simulations reveal that Nitinol stent-grafts stretch the artery wall so that collagen is stretched to a straightened high-stiffness configuration. The high-compliance regime (HCR) associated with low diastolic lumen pressure is eliminated, and the artery operates in a low-compliance regime (LCR) throughout the entire cardiac cycle. The slope of the lumen pressure–area curve for the LCR post-implantation is almost identical to that of the native vessel during systole. This negligible change from the native LCR slope occurs because the stent-graft increases its diameter from the crimped configuration during deployment so that it reaches a low-stiffness unloading plateau. The effective radial stiffness of the implant along this unloading plateau is negligible compared to the stiffness of the artery wall. Provided the Nitinol device unloads sufficiently during deployment to the unloading plateau, the degree of oversizing has a negligible effect on the pressure–area response of the vessel, as each device exerts approximately the same radial force, the slope of which is negligible compared to the LCR slope of the native artery. We show that 10% oversizing based on the observed diastolic diameter in the mid descending thoracic aorta results in a complete loss of contact between the device and the wall during systole, which could lead to an endoleak and stent migration. 20% oversizing reaches the Dacron enforced area limit (DEAL) during the pulse pressure and results in an effective zero-compliance in the later portion of systole.
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Affiliation(s)
- J Concannon
- Biomedical Engineering, College of Engineering and Informatics, National University of Ireland, Galway, Ireland
| | - K M Moerman
- Biomedical Engineering, College of Engineering and Informatics, National University of Ireland, Galway, Ireland
| | - N Hynes
- Western Vascular Institute, National University of Ireland Galway, Galway, Ireland
| | - S Sultan
- Western Vascular Institute, National University of Ireland Galway, Galway, Ireland
| | - J P McGarry
- Biomedical Engineering, College of Engineering and Informatics, National University of Ireland, Galway, Ireland.
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14
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Gil-Sala D, Guala A, Garcia Reyes ME, Azancot MA, Dux-Santoy L, Allegue Allegue N, Teixido Turà G, Goncalves Martins G, Ruiz Muñoz A, Constenla García I, Evangelista A, Tello Díaz C, Ferreira González I, Rodríguez-Palomares JF, Bellmunt S. Geometric, Biomechanic and Haemodynamic Aortic Abnormalities Assessed by 4D Flow Cardiovascular Magnetic Resonance in Patients Treated by TEVAR Following Blunt Traumatic Thoracic Aortic Injury. Eur J Vasc Endovasc Surg 2021; 62:797-807. [PMID: 34511317 DOI: 10.1016/j.ejvs.2021.07.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 06/29/2021] [Accepted: 07/25/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Thoracic endovascular aortic repair (TEVAR) is widely used for the treatment of patients with blunt traumatic thoracic aortic injury (BTAI). However, aortic haemodynamic and biomechanical implications of this intervention are poorly investigated. This study aimed to assess whether patients treated by TEVAR following BTAI have thoracic aortic abnormalities in geometry, stiffness, and haemodynamics. METHODS Patients with BTAI treated by TEVAR at Vall d'Hebron Hospital between 1999 and 2019 were compared with propensity score matched healthy volunteers (HVs). All subjects underwent cardiovascular magnetic resonance (CMR) comprising a 4D flow CMR sequence. Spatially resolved aortic diameter, length, volume, and curvature were assessed. Pulse wave velocity, distensibility, and longitudinal strain (all measurements of aortic stiffness) were determined regionally. Moreover, advanced haemodynamic descriptors were quantified: systolic flow reversal ratio (SFRR), quantifying backward flow during systole, and in plane rotational flow (IRF), measuring in plane strength of helical flow. RESULTS Twenty-six BTAI patients treated by TEVAR were included and matched with 26 HVs. They did not differ in terms of age, sex, and body surface area. Patients with TEVAR had a larger and longer ascending aorta (AAo) and marked abnormalities in local curvature. Aortic stiffness was greater in the aortic segments proximal and distal to TEVAR compared with controls. Moreover, TEVAR patients presented strongly altered flow dynamics compared with controls: a reduced IRF from the distal AAo to the proximal descending aorta and an increased SFRR in the whole thoracic aorta. These differences persisted adjusting for cardiovascular risk factors and were independent of time elapsed since TEVAR implantation. CONCLUSION At long term follow up, previously healthy patients who underwent TEVAR implantation following BTAI had increased diameter, length and volume of the ascending aorta, and increased aortic stiffness and abnormal flow patterns in the whole thoracic aorta compared with matched controls. Further studies should address whether these alterations have clinical implications.
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Affiliation(s)
- Daniel Gil-Sala
- Vascular and Endovascular Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Departament de Cirurgia. Universitat Autònoma de Barcelona (UAB), Bellaterra, Spain
| | - Andrea Guala
- Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; CIBER-CV, Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Marvin E Garcia Reyes
- Vascular and Endovascular Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
| | - Maria A Azancot
- Department of Nephrology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | | | - Gisela Teixido Turà
- Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; CIBER-CV, Instituto de Salud Carlos III (ISCIII), Madrid, Spain; Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Gabriela Goncalves Martins
- Vascular and Endovascular Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Departament de Cirurgia. Universitat Autònoma de Barcelona (UAB), Bellaterra, Spain
| | - Aroa Ruiz Muñoz
- Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; CIBER-CV, Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Ivan Constenla García
- Vascular and Endovascular Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Arturo Evangelista
- Departament de Cirurgia. Universitat Autònoma de Barcelona (UAB), Bellaterra, Spain; Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; CIBER-CV, Instituto de Salud Carlos III (ISCIII), Madrid, Spain; Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Instituto del Corazón. Quirónsalud-Teknon. Barcelona, Spain
| | - Cristina Tello Díaz
- Vascular and Endovascular Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Ignacio Ferreira González
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; CIBER-ESP, Instituto de Salud Carlos III, Madrid, Spain; Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Jose F Rodríguez-Palomares
- Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; CIBER-CV, Instituto de Salud Carlos III (ISCIII), Madrid, Spain; Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Sergi Bellmunt
- Vascular and Endovascular Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Departament de Cirurgia. Universitat Autònoma de Barcelona (UAB), Bellaterra, Spain
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15
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Takano T, Iwai-Takano M, Tsuboko Y, Shiraishi Y, Yambe T, Igarashi T, Yokoyama H. Reflected wave intensity increases based on aortic diameter after endovascular aortic therapy in a goat model. Sci Rep 2021; 11:3830. [PMID: 33589686 PMCID: PMC7884737 DOI: 10.1038/s41598-020-80920-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 12/30/2020] [Indexed: 11/09/2022] Open
Abstract
Reflected wave increases after endovascular aortic repair (EVAR) in patients with aortic aneurysm. This affects the left ventricular (LV) diastolic function and leads to a poor prognosis. This study aimed to evaluate the relationship between increased reflected wave amplitude and aortic diameter after EVAR. EVAR was performed in seven healthy goats. We assessed wave intensity (WI), aortic diameter, and stiffness parameter β. Moreover, we evaluated the relationship between negative reflected wave (NW, reflected waves toward the heart from the periphery by WI) and other parameters after EVAR. Results showed an increase in stiffness parameter β (3.5 ± 0.3 vs 15.9 ± 4.7, p = 0.018) and a decrease in the change of aortic diameter (6.9 ± 0.7 vs 2.7 ± 0.4%, p = 0.018) after EVAR. The NW was significantly amplified after EVAR from baseline (−589.8 ± 143.4 to − 1192.3 ± 303.7 mmHg-m/sec3, p = 0.043). The NW showed a significant correlation with maximum aortic diameter (R = 0.707, p = 0.038) and minimum aortic diameter (R = 0.724, p = 0.033). The reflected wave was enhanced after EVAR and was correlated to the aortic diameter at the stent-graft site. It is important to consider that patients with smaller aortic diameters in landing zone who undergo EVAR may develop LV dysfunction.
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Affiliation(s)
- Tomohiro Takano
- Department of Cardiovascular Surgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295, Japan.
| | - Masumi Iwai-Takano
- Department of Cardiovascular Surgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295, Japan. .,Department of Epidemiology, Fukushima Medical University, Fukushima, Japan. .,Fukushima Prefectural General Hygiene Institute, Fukushima, Japan. .,Graduate School of Biomedical Engineering, Tohoku University, Sendai, Japan.
| | - Yusuke Tsuboko
- Waseda Research Institute for Science and Engineering, Waseda University, Tokyo, Japan.,Institute of Development Aging and Cancer, Tohoku University, Sendai, Japan
| | - Yasuyuki Shiraishi
- Institute of Development Aging and Cancer, Tohoku University, Sendai, Japan
| | - Tomoyuki Yambe
- Institute of Development Aging and Cancer, Tohoku University, Sendai, Japan
| | - Takashi Igarashi
- Department of Cardiovascular Surgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Hitoshi Yokoyama
- Department of Cardiovascular Surgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295, Japan
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16
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Yamashita Y, Oishi Y, Matsuyama S, Ushijima T, Fujita S, Kimura S, Sonoda H, Tanoue Y, Shiose A. Determinants of Changes in Arterial Stiffness after Thoracic Endovascular Aortic Repair. Ann Vasc Surg 2020; 70:474-480. [PMID: 32634557 DOI: 10.1016/j.avsg.2020.06.062] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/26/2020] [Accepted: 06/26/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Aortic stent grafting can cause aortic stiffening and increase pulse wave velocity (PWV), which can potentially affect long-term cardiovascular outcomes. The aim of this study was to clarify the factors contributing to increases in PWV after thoracic endovascular aortic repair (TEVAR). METHODS We included 64 patients with thoracic aortic pathology (51 men; mean age, 73 years) who underwent elective TEVAR, in this study. TEVAR was performed for degenerative aortic aneurysm (n = 43) or aortic dissection (n = 21), and the treatment length was 175 ± 52 mm. Brachial-ankle PWV (baPWV) was obtained before and 1 week after TEVAR. Univariable and multivariable logistic regression analyses were used to determine the predictors of increases in baPWV of ≥100 cm/sec after TEVAR. RESULTS baPWV increased from 1,851 ± 392 cm/sec to 2,047 ± 479 cm/sec, and the change in baPWV (ΔbaPWV) was 195 ± 339 cm/sec (95% confidence interval, 111-280). Thirty-seven patients (58%) had ΔbaPWV ≥100 cm/sec after TEVAR. In the multivariable analysis, in addition to Δheart rate and Δsystolic blood pressure, age (odds ratio, 1.21/year; 95% confidence interval, 1.05-1.40) and coronary artery disease (odds ratio, 12.0; 95% confidence interval, 1.20-121) were independent determinants of ΔbaPWV ≥100 cm/sec after TEVAR, whereas ΔbaPWV ≥100 cm/sec was not associated with treatment length or device type. CONCLUSIONS TEVAR was associated with PWV progression, especially in older patients with coronary artery disease, whereas treatment length or device type was not a predictor of PWV progression after TEVAR.
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Affiliation(s)
- Yoshiyuki Yamashita
- Department of Cardiovascular Surgery, Kyushu University Hospital, Higashi-ku, Fukuoka, Japan
| | - Yasuhisa Oishi
- Department of Cardiovascular Surgery, Kyushu University Hospital, Higashi-ku, Fukuoka, Japan
| | - Sho Matsuyama
- Department of Cardiovascular Surgery, Kyushu University Hospital, Higashi-ku, Fukuoka, Japan
| | - Tomoki Ushijima
- Department of Cardiovascular Surgery, Kyushu University Hospital, Higashi-ku, Fukuoka, Japan
| | - Satoshi Fujita
- Department of Cardiovascular Surgery, Kyushu University Hospital, Higashi-ku, Fukuoka, Japan
| | - Satoshi Kimura
- Department of Cardiovascular Surgery, Kyushu University Hospital, Higashi-ku, Fukuoka, Japan
| | - Hiromichi Sonoda
- Department of Cardiovascular Surgery, Kyushu University Hospital, Higashi-ku, Fukuoka, Japan
| | - Yoshihisa Tanoue
- Department of Cardiovascular Surgery, Kyushu University Hospital, Higashi-ku, Fukuoka, Japan
| | - Akira Shiose
- Department of Cardiovascular Surgery, Kyushu University Hospital, Higashi-ku, Fukuoka, Japan.
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17
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Moulakakis KG, Ikonomidis I, Manopoulos C, Kakisis J. Changes in aortic stiffness and the hemodynamics following endovascular repair of the thoracic aorta of patients with blunt thoracic aortic injury. VASA 2020; 49:253-255. [PMID: 32578518 DOI: 10.1024/0301-1526/a000863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
| | - Ignatios Ikonomidis
- 2nd Department of Cardiology, "Attikon" University Hospital, National and Kapodistrian University of Athens, Greece
| | - Christos Manopoulos
- Biofluid Mechanics and Biomedical Engineering Laboratory, Fluids Section, School of Mechanical Engineering, National Technical University of Athens, Greece
| | - John Kakisis
- Department of Vascular Surgery, Attikon University Hospital, Athens, National and Kapodistrian University οf Athens, Greece
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18
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Bero EH, Nguyen-Ho CT, Patel PJ, Foley WD, Lee CJ. Aortic Remodeling and Clinical Outcomes Following Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury. J Surg Res 2020; 255:124-129. [PMID: 32543377 DOI: 10.1016/j.jss.2020.04.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 04/02/2020] [Accepted: 04/16/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is currently limited data assessing the long-term consequences of thoracic endovascular aortic repair (TEVAR) in otherwise healthy aortic segments remote from the site of endograft coverage. The aim of this study is to retrospectively evaluate aortic remodeling and long-term outcomes of blunt thoracic aortic injury (BTAI) patients treated with TEVAR. Our hypothesis is that significant changes to the aorta proximal to the graft-covered segment are suspected following TEVAR. METHODS An institutional review board-approved retrospective review of patients who underwent TEVAR for BTAI at a level I trauma center from 2004 to 2018 was performed. Forty-six patients were identified and of these, 32 patients with high-resolution computed tomographic angiography imaging follow-up were included in the study. Computed tomographic angiography measurements of aortic dimensions and branch vessels proximal, distal, and adjacent to the stent grafted segment were recorded preprocedure and postprocedure and analyzed. Primary device-related outcomes such as birdbeaking, mural thrombus, stent migration, and persistent endoleak were assessed. Patient outcomes including mortality, graft-related morbidity, and need for secondary interventions were also analyzed. RESULTS Mean follow-up of the selected patients in the study was 1.52 y (range, 0.06-8.0 y). Following TEVAR, the ascending aortic length increased significantly (mean 5.7 ± 4.6 mm, P < 0.001). The mean diameters of the ascending aorta (1.5 ± 1.5, P < 0.001 mm), the midaortic arch (1.3 ± 1.7 mm, P < 0.001), and proximal and the distal endograft landing zones (1.9 ± 2.1 mm and 2.2 ± 1.6 mm, respectively, P < 0.001) also increased significantly following TEVAR. Clinically relevant device-related outcomes occurred with the presence of endograft infolding and subsequent development of endograft mural thrombus (P < 0.001). The need for secondary intervention following TEVAR for BTAI was associated with endograft mural thrombus (P < 0.05). CONCLUSIONS TEVAR for BTAI causes significant geometric changes in the aorta proximal to the stented grafted segment of the aorta. Direct consequences of the graft at the stented segment includes mural thrombus development within the endograft which was associated with the need for secondary intervention. Although clinical significance is yet to be determined, post-TEVAR changes in aortic architecture warrant continued aortic surveillance following BTAI.
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Affiliation(s)
- Emily H Bero
- Department of Surgery, Medical College of Wisconsin, Milwuakee, Wisonsin
| | - Calvin T Nguyen-Ho
- Department of Surgery, Medical College of Wisconsin, Milwuakee, Wisonsin
| | - Parag J Patel
- Division of Interventional Radiology, Department of Radiology, Medical College of Wisconsin, Milwuakee, Wisonsin
| | - William D Foley
- Division of Abdominal and Body Imaging, Department of Radiology, Medical College of Wisconsin, Milwuakee, Wisonsin
| | - Cheong J Lee
- Division of Vascular Surgery, Department of Surgery NorthShore University Health System, A Teaching Affiliate of the University of Chicago Pritzker School of Medicine, Evanston, Illinois.
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19
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Worsham J, DeAnda A. Commentary: Measuring the impact of thoracic endovascular aortic repair on the heart. JTCVS Tech 2020; 1:14. [PMID: 34346929 PMCID: PMC8288820 DOI: 10.1016/j.xjtc.2019.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 11/25/2019] [Accepted: 11/29/2019] [Indexed: 11/28/2022] Open
Affiliation(s)
- Jennifer Worsham
- Division of Vascular and Endovascular Surgery, UTMB-Galveston, Galveston, Tex
| | - Abe DeAnda
- Division of Cardiovascular and Thoracic Surgery, UTMB-Galveston, Galveston, Tex
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20
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Kreibich M, Morlock J, Beyersdorf F, Berger T, Allweier S, Kondov S, Pingpoh C, Czerny M, Siepe M, Rylski B. Decreased biventricular function following thoracic endovascular aortic repair. Interact Cardiovasc Thorac Surg 2019; 30:600-604. [DOI: 10.1093/icvts/ivz298] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 11/08/2019] [Accepted: 11/20/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
Preclinical studies have suggested acute stiffening of the aorta following experimental thoracic endovascular aortic repair (TEVAR), resulting in acute elevated pulse pressure, hypertension and possibly heart failure. The aim of this study was to evaluate cardiac remodelling following TEVAR.
METHODS
From 2005 to 2018, 519 TEVAR procedures were performed at a single centre. Transthoracic echocardiography was performed pre- and post-TEVAR in 31 patients without previous replacement of the thoracic aorta. Patient characteristics, drug information, radiographic and follow-up data were evaluated. Aortic details were measured in multiplanar reconstruction.
RESULTS
Transthoracic echocardiography was performed 2 ± 2 years after TEVAR. At this time, patients received significantly more antihypertensive drugs compared to the pre-TEVAR intake (beta-blocker therapy: P = 0.037; calcium channel blocker: P = 0.022). Compared to pre-TEVAR, there was a significant reduction in the left ventricular ejection fraction (P = 0.008) and tricuspid annular plane systolic excursion (P = 0.013) post-TEVAR. A significant increase in the left ventricular mass was not detected in this study (P = 0.95). The mean distance of 163 ± 66 mm of the descending aorta was covered.
CONCLUSIONS
This study suggests negative cardiac remodelling with a decrease in the left and right ventricular function following TEVAR despite an increase in oral antihypertensive medication. The impact of stiffer endovascular grafts compared with the native aortic wall should be considered by endovascular specialists and manufacturers.
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Affiliation(s)
- Maximilian Kreibich
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Center Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Julia Morlock
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Center Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Center Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Tim Berger
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Center Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Stephan Allweier
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Center Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Center Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Clarence Pingpoh
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Center Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Center Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Center Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Center Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
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21
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Yamashita Y, Oishi Y, Motomatsu Y, Hirayama K, Harada T, Ushijima T, Fujita S, Kimura S, Sonoda H, Tatewaki H, Tanoue Y, Sunagawa G, Nishikawa T, Saku K, Shiose A. Thoracic endografting increases cardiac afterload and leads to left ventricular hypertrophy in dogs. Eur J Cardiothorac Surg 2018; 55:618-625. [DOI: 10.1093/ejcts/ezy402] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/19/2018] [Accepted: 10/13/2018] [Indexed: 12/11/2022] Open
Affiliation(s)
- Yoshiyuki Yamashita
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yasuhisa Oishi
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yuma Motomatsu
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Kazuto Hirayama
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Takeaki Harada
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Tomoki Ushijima
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Satoshi Fujita
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Satoshi Kimura
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Hiromichi Sonoda
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Hideki Tatewaki
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yoshihisa Tanoue
- Department of Advanced Cardiopulmonary Failure, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Genya Sunagawa
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Takuya Nishikawa
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Keita Saku
- Department of Advanced Risk Stratification for Cardiovascular Diseases, Center for Disruptive Cardiovascular Medicine, Kyushu University, Fukuoka, Japan
| | - Akira Shiose
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
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Spinella G, Finotello A, Faggiano E, Pane B, Conti M, Gazzola V, Auricchio F, Palombo D. Midterm Follow-up Geometrical Analysis of Thoracoabdominal Aortic Aneurysms Treated with Multilayer Flow Modulator. Ann Vasc Surg 2018; 53:97-104.e2. [DOI: 10.1016/j.avsg.2018.04.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 04/18/2018] [Accepted: 04/19/2018] [Indexed: 10/28/2022]
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Ullery BW, Suh GY, Hirotsu K, Zhu D, Lee JT, Dake MD, Fleischmann D, Cheng CP. Geometric Deformations of the Thoracic Aorta and Supra-Aortic Arch Branch Vessels Following Thoracic Endovascular Aortic Repair. Vasc Endovascular Surg 2018; 52:173-180. [DOI: 10.1177/1538574417753452] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To utilize 3-D modeling techniques to better characterize geometric deformations of the supra-aortic arch branch vessels and descending thoracic aorta after thoracic endovascular aortic repair. Methods: Eighteen patients underwent endovascular repair of either type B aortic dissection (n = 10) or thoracic aortic aneurysm (n = 8). Computed tomography angiography was obtained pre- and postprocedure, and 3-D geometric models of the aorta and supra-aortic branch vessels were constructed. Branch angle of the supra-aortic branch vessels and curvature metrics of the ascending aorta, aortic arch, and stented thoracic aortic lumen were calculated both at pre- and postintervention. Results: The left common carotid artery branch angle was lower than the left subclavian artery angles preintervention ( P < .005) and lower than both the left subclavian and brachiocephalic branch angles postintervention ( P < .05). From pre- to postoperative, no significant change in branch angle was found in any of the great vessels. Maximum curvature change of the stented lumen from pre- to postprocedure was greater than those of the ascending aorta and aortic arch ( P < .05). Conclusion: Thoracic endovascular aortic repair results in relative straightening of the stented aortic region and also accentuates the native curvature of the ascending aorta when the endograft has a more proximal landing zone. Supra-aortic branch vessel angulation remains relatively static when proximal landing zones are distal to the left common carotid artery.
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Affiliation(s)
- Brant W. Ullery
- Providence Heart and Vascular Institute, Portland, OR, USA
- Both authors contributed equally to this work
| | - Ga-Young Suh
- Division of Vascular Surgery, Stanford University, Stanford, CA, USA
- Both authors contributed equally to this work
| | - Kelsey Hirotsu
- Stanford School of Medicine, Stanford University, Stanford, CA, USA
| | - David Zhu
- Division of Vascular Surgery, Stanford University, Stanford, CA, USA
| | - Jason T. Lee
- Division of Vascular Surgery, Stanford University, Stanford, CA, USA
| | - Michael D. Dake
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
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Changes in aortic pulse wave velocity of four thoracic aortic stent grafts in an ex vivo porcine model. PLoS One 2017; 12:e0186080. [PMID: 28982135 PMCID: PMC5642022 DOI: 10.1371/journal.pone.0186080] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 09/25/2017] [Indexed: 01/16/2023] Open
Abstract
Objectives Thoracic endovascular aortic repair (TEVAR) has been shown to lead to increased aortic stiffness. The aim of this study was to investigate the effect of stent graft type and stent graft length on aortic stiffness in a controlled, experimental setting. Methods Twenty porcine thoracic aortas were connected to a pulsatile mock loop system. Intraluminal pressure was recorded at two sites in order to measure pulse wave velocity (PWV) for each aorta: before stent graft deployment (t1); after deployment of a 100-mm long stent graft (t2); and after distal extension through deployment of a second 100-mm long stent graft (t3). Four different types of stent grafts (Conformable Gore® TAG® Device, Bolton Relay® Device, Cook Zenith Alpha™, and Medtronic Valiant®) were evaluated. Results For the total cohort of 20 aortas, PWV increased by a mean 0.6 m/s or 8.9% of baseline PWV after deployment of a 100-mm proximal stent graft (P<0.001), and by a mean 1.4 m/s or 23.0% of baseline PWV after distal extension of the stent graft (P<0.001). Univariable regression analysis showed a significant correlation between aortic PWV and extent of stent graft coverage, (P<0.001), but no significant effect of baseline aortic length, baseline aortic PWV, or stent graft type on the percentual increase in PWV at t2 or at t3. Conclusions In this experimental set-up, aortic stiffness increased significantly after stent graft deployment with each of the four types of stent graft, with the increase in aortic stiffness depending on the extent of stent graft coverage.
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