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Grandi A, D'Oria M, Panuccio G, Rohlffs F, Eleshra A, Torrealba J, Nana P, Lepidi S, Melloni A, Bertoglio L, Kölbel T. Design, evolution, and experience with the candy plug device for endovascular false lumen occlusion of chronic aortic dissections. Expert Rev Med Devices 2024:1-4. [PMID: 38803133 DOI: 10.1080/17434440.2024.2360987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 05/17/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION The management of the false lumen (FL) when dealing with aortic dissection is a crucial aspect since inducing its thrombosis is necessary in order to achieve aortic remodeling. One of the pitfalls of endovascular treatment of aortic dissection (AD) is retrograde distal FL perfusion and pressurization, which prevents FL thrombosis and thus aortic remodeling, while being associated with aneurysmal degeneration of the FL and poor long-term outcomes. AREAS COVERED Currently, there is no CE/FDA approved device for FL closure, however different techniques and devices have been proposed to overcome this challenge, the most known of which is the Candy Plug (CP). This review aims to describe the CP device, its implantation technique, and the available data in the literature (PubMed, Cochrane, and EMBASE databases; last queried, December 31, 2023). EXPERT OPINIONS While the treatment of AD remains technically challenging, the use of the CP technique to close any distal FL reperfusion proved to be feasible and safe with excellent rates of both technical and clinical success. Furthermore, recent studies have shown a quick learning curve with this technique.
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Affiliation(s)
- Alessandro Grandi
- German Aortic Center Hamburg, Department of Vascular Medicine, University Medical Center Eppendorf, Hamburg, Germany
- Division of Vascular Surgery, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Department of Clinical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, Department of Vascular Medicine, University Medical Center Eppendorf, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center Hamburg, Department of Vascular Medicine, University Medical Center Eppendorf, Hamburg, Germany
| | - Ahmed Eleshra
- German Aortic Center Hamburg, Department of Vascular Medicine, University Medical Center Eppendorf, Hamburg, Germany
| | - Jose Torrealba
- German Aortic Center Hamburg, Department of Vascular Medicine, University Medical Center Eppendorf, Hamburg, Germany
| | - Petroula Nana
- German Aortic Center Hamburg, Department of Vascular Medicine, University Medical Center Eppendorf, Hamburg, Germany
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Department of Clinical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Andrea Melloni
- Division of Vascular Surgery, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Medical Center Eppendorf, Hamburg, Germany
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Ge YY, Zhang HP, Guo W. A Novel Endovascular Double-Disc Implant for Sealing Intimal Tears in Aortic Dissection. JACC. ASIA 2023; 3:937-941. [PMID: 38155784 PMCID: PMC10751688 DOI: 10.1016/j.jacasi.2023.09.009] [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: 08/22/2023] [Revised: 09/25/2023] [Accepted: 09/29/2023] [Indexed: 12/30/2023]
Abstract
Postdissection thoracoabdominal aortic aneurysm incidence after thoracic endovascular aortic repair for type B aortic dissection is high, with residual distal tears being a major reason for persistent blood flow in the false lumen. The EndoPatch is an endovascular double-disc implant for sealing re-entry tears in aortic dissection, isolating blood flow in the false lumen and promoting thrombosis formation. Compared with conventional endovascular treatment techniques, this endovascular double-disc implant's small size and minimal working space requirements may reduce the risk of spinal ischemia and offer flexible vascular access. Although several barriers still impede this endovascular device's broad application, its innovative design, flexible vascular access, and streamlined surgical process make it a promising alternative for managing intimal tears in aortic dissection, either alone or as a supplementary method combined with conventional endovascular techniques. (Guo's Entry Tear Repair: The First in Man Study of Endopatch System; NCT04745039).
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Affiliation(s)
- Yang Yang Ge
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Hong Peng Zhang
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Wei Guo
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
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Loschi D, Santoro A, Rinaldi E, Anselmi C, Grignani C, Chiesa R, Melissano G. Open and endovascular reinterventions after Candy Plug false lumen embolization of type B aortic dissection. J Vasc Surg 2023; 78:1409-1417. [PMID: 37572890 DOI: 10.1016/j.jvs.2023.07.063] [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: 05/27/2023] [Revised: 07/24/2023] [Accepted: 07/28/2023] [Indexed: 08/14/2023]
Abstract
OBJECTIVE In the majority of patients with chronic type B aortic dissection, there is persistent retrograde flow in the false lumen (FL) through distal re-entry tears. Among several endovascular techniques proposed for FL management, the "Candy Plug" (CP) technique has gained acceptance with good early results. The aim of this study is to report the types and outcomes of open and endovascular reinterventions and identify mechanisms of procedure failure as well as other causes for reinterventions. METHODS All patients with type B aortic dissection submitted to thoracic endovascular aneurysm repair and CP implantation for FL embolization from January 2016 to December 2022 at our institution were included in this study. The preoperative, intraoperative, and postoperative data of the primary intervention and secondary reinterventions, when performed, were prospectively collected and retrospectively analyzed. Preoperative and postoperative computed tomography angiography were also analyzed. RESULTS During the study period, 33 patients were submitted to thoracic endovascular aneurysm repair and CP implantation. Twenty-three patients (69.7%) showed thoracic FL complete thrombosis with aortic stability or positive remodeling at a mean follow-up of 45 ± 23.1 months. Ten patients (30.3%) underwent aortic reinterventions (male, n = 9; mean age, 60.5 ± 7.6 years). Of these 10 patients, in four patients, complete thrombosis of the FL was never achieved, leading to ongoing perfusion of the FL, defined as "primary failure." The other six patients underwent reinterventions for different causes: two patients, after initial sealing, showed a progressive enlargement of the abdominal FL leading to distal degeneration. One patient showed proximal degeneration, two patients showed a type II thoracoabdominal aortic aneurysm and CP implantation was used as a planned procedure to reduce the extent of the surgical procedure, and one patient had recurrent, intractable back pain despite complete thrombosis of the FL. Reinterventions were open in five cases and endovascular in five. One in-hospital death (postoperative day 27) after a type II thoracoabdominal aortic aneurysm open repair was recorded. In addition, two cases of delayed spinal cord ischemia after open reintervention were recorded: one resulting in permanent paraplegia and one transitory with complete recovery. CONCLUSIONS The CP technique was safe and effective; however, a significant rate of aortic-related reintervention was observed. Several mechanisms led to reinterventions either in terms of "primary failure" of the CP or subsequent aneurysmal degeneration. Complex reinterventions were often necessary, with a high rate of major complications in case of open repair. Life-long and closer surveillance might be required in these patients.
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Affiliation(s)
- Diletta Loschi
- "Vita-Salute" University, Scientific Institute H. San Raffaele, Milan, Italy.
| | - Annarita Santoro
- "Vita-Salute" University, Scientific Institute H. San Raffaele, Milan, Italy
| | - Enrico Rinaldi
- "Vita-Salute" University, Scientific Institute H. San Raffaele, Milan, Italy
| | - Claudia Anselmi
- "Vita-Salute" University, Scientific Institute H. San Raffaele, Milan, Italy
| | - Camilla Grignani
- "Vita-Salute" University, Scientific Institute H. San Raffaele, Milan, Italy
| | - Roberto Chiesa
- "Vita-Salute" University, Scientific Institute H. San Raffaele, Milan, Italy
| | - Germano Melissano
- "Vita-Salute" University, Scientific Institute H. San Raffaele, Milan, Italy
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Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
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Eleshra A, Haulon S, Bertoglio L, Lindsay T, Rohlffs F, Dias N, Tsilimparis N, Panuccio G, Kölbel T. Custom Made Candy Plug for Distal False Lumen Occlusion in Aortic Dissection: International Experience. Eur J Vasc Endovasc Surg 2023; 66:50-56. [PMID: 36958480 DOI: 10.1016/j.ejvs.2023.03.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 02/26/2023] [Accepted: 03/13/2023] [Indexed: 03/25/2023]
Abstract
OBJECTIVE To evaluate early and midterm outcomes of the Candy Plug (CP) technique for distal false lumen (FL) occlusion in thoracic endovascular aortic repair for aortic dissection (AD) in a more real world cohort of patients from an international multicentre registry. METHODS A multicentre retrospective study was conducted of all consecutive patients from the contributing centres with subacute and chronic AD treated with the CP technique from October 2013 to April 2020 at 18 centres. RESULTS A custom made CP was used in 155 patients (92 males, mean age 62 ± 11 years). Fourteen (9%) presented with ruptured false lumen aneurysms. Technical success was achieved in all patients (100%). Clinical success was achieved in 138 patients (89%). The median hospital stay was 7 days (1 - 77). The 30 day mortality rate was 3% (n = 5). Stroke occurred in four patients (3%). Spinal cord ischaemia occurred in three patients (2%). The 30 day computed tomography angiogram (CTA) confirmed successful CP placement at the intended level in all patients. Early complete FL occlusion was achieved in 120 patients (77%). Early (30 day) CP related re-intervention was required in four patients (3%). The early (30 day) stent graft related re-intervention rate was 8% (n = 12). Follow up CTA was available in 142 patients (92%), with a median follow up of 23 months (6 - 87). Aneurysmal regression was achieved in 68 of 142 patients (47%); the aneurysm diameter remained stable in 69 of 142 patients (49%) and increased in five of 142 patients (4%). A higher rate of early FL occlusion was detected in the largest volume centre patients (50 [88%] vs. 70 [71%] from other centres; p = .019). No other differences in outcome were identified regarding volume of cases or learning curve. CONCLUSION This international CP technique experience confirmed its feasibility and low mortality and morbidity rates. Aortic remodelling and false lumen thrombosis rates were high and support the concept of distal FL occlusion in AD using the CP technique.
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Affiliation(s)
- Ahmed Eleshra
- German Aortic Centre, University Heart & Vascular Centre, University Medical Centre Eppendorf, Hamburg, Germany; Department of Vascular Surgery, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
| | | | - Luca Bertoglio
- San Raffaele Hospital, Milan, Italy; Division of Vascular Surgery, Department of Sperimental and Clinical Sciences (DSCS), University and ASST Spedali Civili Hospital of Brescia, Brescia, Italy
| | | | - Fiona Rohlffs
- German Aortic Centre, University Heart & Vascular Centre, University Medical Centre Eppendorf, Hamburg, Germany
| | - Nuno Dias
- Skåne University Hospital, Malmö, Sweden
| | - Nikolaos Tsilimparis
- German Aortic Centre, University Heart & Vascular Centre, University Medical Centre Eppendorf, Hamburg, Germany; University Hospital, LMU, Munich, Germany
| | - Giuseppe Panuccio
- German Aortic Centre, University Heart & Vascular Centre, University Medical Centre Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Centre, University Heart & Vascular Centre, University Medical Centre Eppendorf, Hamburg, Germany
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Blitzer DN, Pereira GA, Drucker C, Rolle N, Nagarsheth K, Karwowski J, Hall M, Taylor B, Ghoreishi M, Toursavadkohi S. The Caged Knickerbocker: A Novel Modification to Targeted False Lumen Management in Complex Aortic Dissection. Vasc Endovascular Surg 2023; 57:197-202. [PMID: 36416309 DOI: 10.1177/15385744221141228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Targeted false lumen management has been described for complex presentations of aortic dissection. The "Knickerbocker" technique is often referenced and includes dilating a focal portion of an oversized endograft in the true lumen to purposefully rupture the false lumen septum, but at the expense of increased risk for visceral propagation and malperfusion. This case series describes a novel modification of the Knickerbocker technique by caging the distal end of the endograft prior to focal dilation. METHODS A retrospective chart review was conducted at a tertiary academic center from 2018-2020. Patients were included if they had a history or current presentation of aortic dissection and underwent a Caged Knickerbocker (CKB) repair. Data were collected to include demographics, indications for repair, technical success, perioperative outcomes, hospital course, mortality, and further aortic interventions. RESULTS Five patients were included in our evaluation. Four patients (80%) presented with chronic Type B aortic dissection (cTBAD) and concomitant aneurysmal degeneration of the thoracic aorta; 1 patient (20%) presented with an acute rupture secondary to cTBAD. Three patients (60%) had previous aortic repairs, 2 of which were for Type A Aortic Dissection that additionally required redo sternotomy and total arch replacement prior to CKB. CKB was technically successful in all cases with no peri-operative complications. Two (40%) patients required further aortic intervention due to aneurysmal degeneration. CONCLUSION Achieving complete false lumen thrombosis is a considerable challenge when managing complex aortic dissections. Our data demonstrate the technical feasibly and early successful outcomes with the CKB approach. Importantly, CKB facilitates future distal extension into the para-visceral aorta in cases of complex thoracoabdominal aortic aneurysms. Further research should focus on discerning individual patients who will benefit from targeted false lumen management and compare outcomes between different approaches.
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Affiliation(s)
- David N Blitzer
- Department of Surgery, Division of Vascular Surgery, 1479University of Maryland Medical Center, Baltimore, MD, USA
| | - Gabriel A Pereira
- Department of Surgery, Division of Vascular Surgery, 1479University of Maryland Medical Center, Baltimore, MD, USA
| | - Charles Drucker
- Department of Surgery, Division of Vascular Surgery, 1479University of Maryland Medical Center, Baltimore, MD, USA
| | - Nicholas Rolle
- 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Khanjan Nagarsheth
- Department of Surgery, Division of Vascular Surgery, 1479University of Maryland Medical Center, Baltimore, MD, USA
| | - John Karwowski
- Department of Surgery, Division of Vascular Surgery, 1479University of Maryland Medical Center, Baltimore, MD, USA
| | - Michael Hall
- Department of Surgery, Division of Vascular Surgery, 1479University of Maryland Medical Center, Baltimore, MD, USA
| | - Bradley Taylor
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Mehrdad Ghoreishi
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Shahab Toursavadkohi
- Department of Surgery, Division of Vascular Surgery, 1479University of Maryland Medical Center, Baltimore, MD, USA
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Carrel T, Sundt TM, von Kodolitsch Y, Czerny M. Acute aortic dissection. Lancet 2023; 401:773-788. [PMID: 36640801 DOI: 10.1016/s0140-6736(22)01970-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/04/2022] [Accepted: 09/27/2022] [Indexed: 01/13/2023]
Abstract
Although substantial progress has been made in the prevention, diagnosis, and treatment of acute aortic dissection, it remains a complex cardiovascular event, with a high immediate mortality and substantial morbidity in individuals surviving the acute period. The past decade has allowed a leap forward in understanding the pathophysiology of this disease; the existing classifications have been challenged, and the scientific community moves towards a nomenclature that is likely to unify the current definitions according to morphology and function. The most important pathophysiological pathway, namely the location and extension of the initial intimal tear, which causes a disruption of the media layer of the aortic wall, together with the size of the affected aortic segments, determines whether the patient should undergo emergency surgery, an endovascular intervention, or receive optimal medical treatment. The scientific evidence for the management and follow-up of acute aortic dissection continues to evolve. This Seminar provides a clinically relevant overview of potential prevention, diagnosis, and management of acute aortic dissection, which is the most severe acute aortic syndrome.
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Affiliation(s)
- Thierry Carrel
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland.
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts' General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yskert von Kodolitsch
- Department of Vascular Medicine, German Aortic Center, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Germany; Faculty of Medicine, Albert Ludwig University Freiburg, Freiburg, Germany
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Mougin J, Schwein A, Postiglione TJ, Guihaire J, Fabre D, Haulon S. Management of the False Lumen in Post Type A Aortic Dissection Arch Aneurysms Treated With Branched Endografts. J Endovasc Ther 2023:15266028221149912. [PMID: 36632664 DOI: 10.1177/15266028221149912] [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: 01/13/2023]
Abstract
INTRODUCTION The treatment of chronic postdissection aneurysms of the aortic arch is a challenge. This study aims to describe false lumen management after aortic arch endovascular repair of post-type A dissection aneurysms treated with a branched endograft. METHODS In this single-center retrospective observational study, all consecutive patients undergoing endovascular treatment of aneurysmal degeneration of chronic type A aortic dissections following open repair were enrolled. The primary endpoint was maximal aortic diameter evolution measured on computed tomography angiography (CTA) performed during follow-up. Secondary endpoints included procedural success, aortic re intervention, and remodeling during follow-up. RESULTS Between January 2017 and June 2020, 22 patients underwent endovascular branched arch repair for post type A dissection aneurysms. Technical success was 100%. Thirteen patients (59%) had dissection involvement of at least 1 supra-aortic vessel. Midterm follow-up CTA was performed for 20 patients, 23.1 (±13.3) months after the procedure. Maximal aortic diameter at the level of the repair was decreasing in 13 (65%) patients, increasing in 2 (10%) patients, and no change was observed in 5 (25%) patients. During follow-up, 7 patients (35%) required aortic reintervention. Thoracic candy plugs were implanted for distal false lumen occlusion in 15 patients and associated with a high rate of complete remodeling (6/15 patients, 40%). CONCLUSION Arch branch endografting of aneurysmal evolution of a post type A dissection aortic arch is a safe and feasible option in experienced hands. Candy plug use in favorable anatomies seems to be associated with accelerated remodeling of the aorta. CLINICAL IMPACT There are currently no recommendations on dissected supra- aortic vessels management and the use of thoracic aorta false lumen occlusion devices during endovascular repair of chronic post dissection aneurysm of the aortic arch with branched endografts. Based on our clinical experience reported in the current manuscript, we propose a treatment algorithm for the management of the false lumen in this setting.
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Affiliation(s)
- J Mougin
- Aortic Center, Department of Cardiac and Vascular Surgery, Hôpital Marie Lannelongue, Groupe hospitalier Paris Saint Joseph, INSERM UMR_S 999, Université Paris-Saclay, Paris, France
| | - A Schwein
- Service de Chirurgie Vasculaire, CHU Strasbourg, Strasbourg, France
| | | | - J Guihaire
- Aortic Center, Department of Cardiac and Vascular Surgery, Hôpital Marie Lannelongue, Groupe hospitalier Paris Saint Joseph, INSERM UMR_S 999, Université Paris-Saclay, Paris, France
| | - D Fabre
- Aortic Center, Department of Cardiac and Vascular Surgery, Hôpital Marie Lannelongue, Groupe hospitalier Paris Saint Joseph, INSERM UMR_S 999, Université Paris-Saclay, Paris, France
| | - S Haulon
- Aortic Center, Department of Cardiac and Vascular Surgery, Hôpital Marie Lannelongue, Groupe hospitalier Paris Saint Joseph, INSERM UMR_S 999, Université Paris-Saclay, Paris, France
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Oberhuber A, Raddatz A, Betge S, Ploenes C, Ito W, Janosi RA, Ott C, Langheim E, Czerny M, Puls R, Maßmann A, Zeyer K, Schelzig H. Interdisciplinary German clinical practice guidelines on the management of type B aortic dissection. GEFASSCHIRURGIE 2023; 28:1-28. [PMCID: PMC10123596 DOI: 10.1007/s00772-023-00995-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 08/13/2023]
Affiliation(s)
- A. Oberhuber
- German Society of Vascular Surgery and Vascular Medicine (DGG); Department of Vascular and Endovascular Surgery, University Hospital of Münster, Münster, Germany
| | - A. Raddatz
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI); Department of Anaesthesiology, Critical Care and Pain Medicine, Saarland University Hospital, Homburg, Germany
| | - S. Betge
- German Society of Angiology and Vascular Medicine (DGG); Department of Internal Medicine and Angiology, Helios Hospital Salzgitter, Salzgitter, Germany
| | - C. Ploenes
- German Society of Geriatrics (DGG); Department of Angiology, Schön Klinik Düsseldorf, Düsseldorf, Germany
| | - W. Ito
- German Society of Internal Medicine (GSIM) (DGIM); cardiovascular center Oberallgäu Kempten, Hospital Kempten, Kempten, Germany
| | - R. A. Janosi
- German Cardiac Society (DGK); Department of Cardiology and Angiology, University Hospital Essen, Essen, Germany
| | - C. Ott
- German Society of Nephrology (DGfN); Department of Nephrology and Hypertension, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
- Department of Nephrology and Hypertension, Paracelsus Medical University, Nürnberg, Germany
| | - E. Langheim
- German Society of prevention and rehabilitation of cardiovascular diseaese (DGPR), Reha Center Seehof, Teltow, Germany
| | - M. Czerny
- German Society of Thoracic and Cardiovascular Surgery (DGTHG), Department University Heart Center Freiburg – Bad Krozingen, Freiburg, Germany
- Albert Ludwigs University Freiburg, Freiburg, Germany
| | - R. Puls
- German Radiologic Society (DRG); Institute of Diagnostic an Interventional Radiology and Neuroradiology, Helios Klinikum Erfurt, Erfurt, Germany
| | - A. Maßmann
- German Society of Interventional Radiology (DeGIR); Department of Diagnostic an Interventional Radiology, Saarland University Hospital, Homburg, Germany
| | - K. Zeyer
- Marfanhilfe e. V., Weiden, Germany
| | - H. Schelzig
- German Society of Surgery (DGCH); Department of Vascular and Endovascular Surgery, University Hospital of Düsseldorf, Düsseldorf, Germany
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Shen J, Mastrodicasa D, Al Bulushi Y, Lin MC, Tse JR, Watkins AC, Lee JT, Fleischmann D. Thoracic Endovascular Aortic Repair for Chronic Type B Aortic Dissection: Pre- and Postprocedural Imaging. Radiographics 2022; 42:1638-1653. [PMID: 36190862 DOI: 10.1148/rg.220028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Aortic dissection is a chronic disease that requires lifelong clinical and imaging surveillance, long after the acute event. Imaging has an important role in prognosis, timing of repair, device sizing, and monitoring for complications, especially in the endovascular therapy era. Important anatomic features at preprocedural imaging include the location of the primary intimal tear and aortic zonal and branch vessel involvement, which influence the treatment strategy. Challenges of repair in the chronic phase include a small true lumen in conjunction with a stiff intimal flap, complex anatomy, and retrograde perfusion from distal reentry tears. The role of thoracic endovascular aortic repair (TEVAR) remains controversial for treatment of chronic aortic dissection. Standard TEVAR is aimed at excluding the primary intimal tear to decrease false lumen perfusion, induce false lumen thrombosis, promote aortic remodeling, and prevent aortic growth. In addition to covering the primary intimal tear with an endograft, several adjunctive techniques have been developed to mitigate retrograde false lumen perfusion. These techniques are broadly categorized into false lumen obliteration and landing zone optimization strategies, such as the provisional extension to induce complete attachment (PETTICOAT), false lumen embolization, cheese-wire fenestration, and knickerbocker techniques. Familiarity with these techniques is important to recognize expected changes and complications at postintervention imaging. The authors detail imaging options, provide examples of simple and complex endovascular repairs of aortic dissections, and highlight complications that can be associated with various techniques. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Jody Shen
- From the Departments of Radiology (J.S., D.M., Y.A.B., M.C.L., J.R.T., D.F.); Cardiothoracic Surgery (A.C.W.), and Vascular Surgery (J.T.L.), Stanford University School of Medicine, 453 Quarry Rd, Mail Code 5659, Palo Alto, CA 94304
| | - Domenico Mastrodicasa
- From the Departments of Radiology (J.S., D.M., Y.A.B., M.C.L., J.R.T., D.F.); Cardiothoracic Surgery (A.C.W.), and Vascular Surgery (J.T.L.), Stanford University School of Medicine, 453 Quarry Rd, Mail Code 5659, Palo Alto, CA 94304
| | - Yarab Al Bulushi
- From the Departments of Radiology (J.S., D.M., Y.A.B., M.C.L., J.R.T., D.F.); Cardiothoracic Surgery (A.C.W.), and Vascular Surgery (J.T.L.), Stanford University School of Medicine, 453 Quarry Rd, Mail Code 5659, Palo Alto, CA 94304
| | - Margaret C Lin
- From the Departments of Radiology (J.S., D.M., Y.A.B., M.C.L., J.R.T., D.F.); Cardiothoracic Surgery (A.C.W.), and Vascular Surgery (J.T.L.), Stanford University School of Medicine, 453 Quarry Rd, Mail Code 5659, Palo Alto, CA 94304
| | - Justin R Tse
- From the Departments of Radiology (J.S., D.M., Y.A.B., M.C.L., J.R.T., D.F.); Cardiothoracic Surgery (A.C.W.), and Vascular Surgery (J.T.L.), Stanford University School of Medicine, 453 Quarry Rd, Mail Code 5659, Palo Alto, CA 94304
| | - Amelia C Watkins
- From the Departments of Radiology (J.S., D.M., Y.A.B., M.C.L., J.R.T., D.F.); Cardiothoracic Surgery (A.C.W.), and Vascular Surgery (J.T.L.), Stanford University School of Medicine, 453 Quarry Rd, Mail Code 5659, Palo Alto, CA 94304
| | - Jason T Lee
- From the Departments of Radiology (J.S., D.M., Y.A.B., M.C.L., J.R.T., D.F.); Cardiothoracic Surgery (A.C.W.), and Vascular Surgery (J.T.L.), Stanford University School of Medicine, 453 Quarry Rd, Mail Code 5659, Palo Alto, CA 94304
| | - Dominik Fleischmann
- From the Departments of Radiology (J.S., D.M., Y.A.B., M.C.L., J.R.T., D.F.); Cardiothoracic Surgery (A.C.W.), and Vascular Surgery (J.T.L.), Stanford University School of Medicine, 453 Quarry Rd, Mail Code 5659, Palo Alto, CA 94304
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11
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Spanos K, Kodolitsch Y, Detter NC, Panuccio G, Rohlffs F, Eleshra A, Kölbel T. Endovascular treatment of aortic aneurysms and dissections in patients with genetically triggered aortic diseases. Semin Vasc Surg 2022; 35:320-333. [DOI: 10.1053/j.semvascsurg.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/20/2022] [Accepted: 06/27/2022] [Indexed: 11/11/2022]
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12
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Burbelko M, Wagner HJ, Mahnken AH. [Chronic type B aortic dissection-what to do?]. RADIOLOGIE (HEIDELBERG, GERMANY) 2022; 62:556-562. [PMID: 35737001 DOI: 10.1007/s00117-022-01022-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/24/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Chronic type B aortic dissection requires optimal medical therapy. However, secondary complications like organ or extremity malperfusion or development of aneurysmal dilatation require interventional therapy. OBJECTIVES Presentation of different endovascular treatment options for complications of chronic type B aortic dissection. MATERIALS AND METHODS Analysis of current literature with regard to indications, techniques, results, and differential indications of interventional techniques for the treatment of chronic type B aortic dissection complications. RESULTS Endovascular implantation of an aortic stent graft is interventional standard therapy for treatment of aneurysmal dilatation of the aorta following type B dissection. Technical problems are the proximal and distal landing zones and the treatment of persistent flow in the false lumen. CONCLUSION Endovascular treatment of chronic complicated type B aortic dissection is increasingly used compared to open surgical treatment because not only are more complex stent grafts (fenestrated and branched devices) available but also because of newly developed techniques for effective occlusion of flow in the false lumen (e.g., candy plug).
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Affiliation(s)
- Michael Burbelko
- Institut für Radiologie und Interventionelle Therapie, Vivantes Klinikum im Friedrichshain, Landsberger Allee 49, 10249, Berlin, Deutschland
| | - Hans-Joachim Wagner
- Institut für Radiologie und Interventionelle Therapie, Vivantes Klinikum im Friedrichshain, Landsberger Allee 49, 10249, Berlin, Deutschland.
| | - Andreas H Mahnken
- Klinik für Diagnostische und Interventionelle Radiologie, UKGM Marburg, Philipps-Universität Marburg, Marburg, Deutschland
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13
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MacGillivray TE, Gleason TG, Patel HJ, Aldea GS, Bavaria JE, Beaver TM, Chen EP, Czerny M, Estrera AL, Firestone S, Fischbein MP, Hughes GC, Hui DS, Kissoon K, Lawton JS, Pacini D, Reece TB, Roselli EE, Stulak J. The Society of Thoracic Surgeons/American Association for Thoracic Surgery clinical practice guidelines on the management of type B aortic dissection. J Thorac Cardiovasc Surg 2022; 163:1231-1249. [PMID: 35090765 DOI: 10.1016/j.jtcvs.2021.11.091] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 01/16/2023]
Affiliation(s)
| | - Thomas G Gleason
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | | | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Md
| | - Davide Pacini
- Department of Cardiac Surgery, University of Bologna, Bologna, Italy
| | - T Brett Reece
- Department of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
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14
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MacGillivray TE, Gleason TG, Patel HJ, Aldea GS, Bavaria JE, Beaver TM, Chen EP, Czerny M, Estrera AL, Firestone S, Fischbein MP, Hughes GC, Hui DS, Kissoon K, Lawton JS, Pacini D, Reece TB, Roselli EE, Stulak J. The Society of Thoracic Surgeons/American Association for Thoracic Surgery Clinical Practice Guidelines on the Management of Type B Aortic Dissection. Ann Thorac Surg 2022; 113:1073-1092. [PMID: 35090687 DOI: 10.1016/j.athoracsur.2021.11.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 02/07/2023]
Affiliation(s)
| | - Thomas G Gleason
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Florida
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Texas
| | | | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, California
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Davide Pacini
- Department of Cardiac Surgery, University of Bologna, Bologna, Italy
| | - T Brett Reece
- Department of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
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15
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Fleischmann D, Afifi RO, Casanegra AI, Elefteriades JA, Gleason TG, Hanneman K, Roselli EE, Willemink MJ, Fischbein MP. Imaging and Surveillance of Chronic Aortic Dissection: A Scientific Statement From the American Heart Association. Circ Cardiovasc Imaging 2022; 15:e000075. [PMID: 35172599 DOI: 10.1161/hci.0000000000000075] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
All patients surviving an acute aortic dissection require continued lifelong surveillance of their diseased aorta. Late complications, driven predominantly by chronic false lumen degeneration and aneurysm formation, often require surgical, endovascular, or hybrid interventions to treat or prevent aortic rupture. Imaging plays a central role in the medical decision-making of patients with chronic aortic dissection. Accurate aortic diameter measurements and rigorous, systematic documentation of diameter changes over time with different imaging equipment and modalities pose a range of practical challenges in these complex patients. Currently, no guidelines or recommendations for imaging surveillance in patients with chronic aortic dissection exist. In this document, we present state-of-the-art imaging and measurement techniques for patients with chronic aortic dissection and clarify the need for standardized measurements and reporting for lifelong surveillance. We also examine the emerging role of imaging and computer simulations to predict aortic false lumen degeneration, remodeling, and biomechanical failure from morphological and hemodynamic features. These insights may improve risk stratification, individualize contemporary treatment options, and potentially aid in the conception of novel treatment strategies in the future.
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16
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Isomura S, Azuma T, Yokoi Y, Domoto S, Niinami H. Modified Candy-Plug Device for the Dilated False Lumen Occlusion - is a Candle Better than a Candy? Ann Thorac Surg 2021; 114:e219-e221. [PMID: 34953785 DOI: 10.1016/j.athoracsur.2021.11.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 11/15/2021] [Indexed: 11/18/2022]
Abstract
The AFX stent graft has an active seal mechanism, which can conform to an irregular vascular lumen. We modified the candy-plug technique using an AFX VERA suprarenal extension with restricted purse-string sutures to shape it into a candle-like contraption. We treated two patients with patent, dilated false lumina (FL) after central aortic repair using this technique. This plug was deployed into the FL to block retrograde blood flow proximally. Partial or complete thrombosis of the FL was observed in both patients six months after surgery. This technique was feasible for FL occlusion.
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Affiliation(s)
- Shogo Isomura
- Department of Cardiovascular Surgery, Tokyo Women's Medical University, Tokyo, Japan.
| | - Takashi Azuma
- Department of Cardiovascular Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoshihiko Yokoi
- Department of Cardiovascular Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Satoru Domoto
- Department of Cardiovascular Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Hiroshi Niinami
- Department of Cardiovascular Surgery, Tokyo Women's Medical University, Tokyo, Japan
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17
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Vargo PR, Maigrot JL, Roselli EE. Chronic thoracoabdominal aortic dissection: endovascular options to obliterate the false lumen. Ann Cardiothorac Surg 2021; 10:778-783. [PMID: 34926180 DOI: 10.21037/acs-2021-taes-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/13/2021] [Indexed: 11/06/2022]
Abstract
Background Persistent false lumen patency in chronic thoracoabdominal aortic dissections after thoracic endovascular aortic repair (TEVAR) contributes to negative aortic remodeling. We have previously described the evolution of various endovascular techniques to treat persistent false lumen perfusion including false lumen embolization. Objectives of this study are to describe endovascular techniques to obliterate the false lumen and present updated outcomes in a recent series of patients undergoing false lumen embolization for chronic aortic dissection. Methods From January 2018 to May 2021, 17 patients with chronic dissection underwent false lumen embolization with coils, iliac plugs, and nitinol plugs. This was often in conjunction with or following TEVAR and balloon fracture fenestration. Mean follow-up 354±324 days. Results After false lumen embolization there was no mortality, stroke, spinal cord ischemia, or visceral and limb ischemia. No patients required dialysis, though 1 (5.9%) did experience acute kidney injury. There was 1 (5.9%) patient that required endovascular re-intervention on the thoracoabdominal aorta. No patients underwent subsequent open surgical repair. Conclusions TEVAR with adjunctive false lumen embolization and balloon fracture fenestration are techniques to obliterate retrograde flow into the false lumen of chronic thoracoabdominal aortic dissections in appropriately selected patients.
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Affiliation(s)
- Patrick R Vargo
- Department of Thoracic and Cardiovascular Surgery, Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jean-Luc Maigrot
- Department of Thoracic and Cardiovascular Surgery, Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
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18
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Matar A, Arnaoutakis DJ. Endovascular treatment of thoracoabdominal aortic aneurysms. Semin Vasc Surg 2021; 34:205-214. [PMID: 34911626 DOI: 10.1053/j.semvascsurg.2021.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 10/08/2021] [Accepted: 10/10/2021] [Indexed: 11/11/2022]
Abstract
Endovascular repair of thoracoabdominal aneurysms using fenestrated and/or branched stent grafts is technically feasible and efficacious but carries a steep learning curve. This innovative surgical approach is associated with less perioperative morbidity than traditional open repair and its early and mid-term outcomes are very favorable. Spinal cord ischemia remains a devastating complication after these procedures, hence the importance of various neuroprotective strategies. Widespread applicability remains limited in the United States, as no custom-made or off-the-shelf endografts are commercially available. Access to these devices remains limited to physician-sponsored or industry-sponsored clinical trials, but results from the Cook p-Branch and Gore Thoracoabdominal Branch Endoprosthesis trials are on the horizon.
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Affiliation(s)
- Andrew Matar
- Division of Vascular Surgery, University of South Florida, 2 Tampa General Circle, 7th Floor, Room 7007, Tampa, FL 33629
| | - Dean J Arnaoutakis
- Division of Vascular Surgery, University of South Florida, 2 Tampa General Circle, 7th Floor, Room 7007, Tampa, FL 33629.
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19
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Tolva VS, Kahlberg A, Bertoglio L, Trimarchi S, Miloro R, Casana R, Chiesa R. Complex Regional Pain Syndrome with Aortic Distress after Thoracic Endovascular Aortic Repair and False Lumen Exclusion with "Candy Plug" Technique. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2021; 9:113-115. [PMID: 34644804 PMCID: PMC8598316 DOI: 10.1055/s-0041-1730007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A 41-year-old male presented for pain treated with oxycodone. A zone-2 thoracic endovascular aortic repair with distal PETTICOAT (provisional extension to induce complete attachment) for complicated Type-IIIB aortic dissection was performed 18 months before. Repeated hospitalizations did not show any issues to justify the recurrent pain. The aortic nature of the pain was suspected considering the plug as a pain trigger. Through a left thoracoabdominal incision in the eighth intercostal space, the candy plug was removed. Pain diminished after thoracoabdominal surgery steadily.
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Affiliation(s)
- Valerio S Tolva
- Department of Vascular Surgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Andrea Kahlberg
- Department of Vascular Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Luca Bertoglio
- Department of Vascular Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Santi Trimarchi
- Department of Vascular Surgery, Fondazione Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Riccardo Miloro
- Department of Vascular Surgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Renato Casana
- Laboratory of Vascular Research, Istituto Auxologico Italiano, Milan, Italy.,Department of Surgery, Istituto Auxologico Italiano, Milan, Italy
| | - Roberto Chiesa
- Department of Vascular Surgery, Vita-Salute San Raffaele University, Milan, Italy
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20
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Clark MR, Taylor AC, Farivar BS, Williams CA, Khaja MS, Angle JF. Secondary Interventions After TEVAR for Aortic Dissection. Tech Vasc Interv Radiol 2021; 24:100753. [PMID: 34602270 DOI: 10.1016/j.tvir.2021.100753] [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: 11/16/2022]
Abstract
The goal of thoracic endograft placement in type B aortic dissection is to prevent aneurysmal degeneration and other complications. Although TEVAR is a highly effective tool for managing type B aortic dissection, many patients will require additional interventions. In this article, we present a case-based review of techniques for the management of persistent false lumen perfusion and stent-graft induced new entry tears after TEVAR for aortic dissection.
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Affiliation(s)
- Meghan R Clark
- Division of Vascular and Interventional Radiology, Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA
| | - Amy C Taylor
- Division of Vascular and Interventional Radiology, Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA
| | - Behzad S Farivar
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA
| | - Carlin A Williams
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA
| | - Minhaj S Khaja
- Division of Vascular and Interventional Radiology, Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA
| | - John F Angle
- Division of Vascular and Interventional Radiology, Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA.
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21
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Endovascular Management of Chronic Type B Aortic Dissection. Tech Vasc Interv Radiol 2021; 24:100752. [PMID: 34602265 DOI: 10.1016/j.tvir.2021.100752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Acute uncomplicated type B aortic dissection (aTBAD) is often treated non operatively, with medical management primarily focused on blood pressure and heart rate control. After a 3 month period following the initial diagnosis, the dissection is considered chronic. Frequent clinical and imaging follow-up is performed to evaluate for dissection stability, aneurysmal degeneration, and visceral malperfusion, which would represent indication for surgical or endovascular repair. In this article we discuss four cases of chronic type B aortic dissection (cTBAD) managed with thoracic endovascular aortic repair (TEVAR) and varying techniques.
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22
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Makhija RR, Mukherjee D. Endovascular therapies for Type B Aortic Dissection. Cardiovasc Hematol Disord Drug Targets 2021; 21:167-178. [PMID: 34565325 DOI: 10.2174/1871529x21666210924141446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 07/30/2021] [Accepted: 08/20/2021] [Indexed: 11/22/2022]
Abstract
Aortic dissection is a life-threatening condition resulting from a tear in the intimal layer of the aorta, requiring emergent diagnosis and prompt multi-disciplinary management strategy for best patient outcomes. While type A dissection involving ascending aorta is best managed surgically due to high early mortality, type B aortic dissection (TBAD) involving descending aorta generally has better outcomes with conservative management and medical therapy as primary strategy is favored. However, there has been a recent paradigm shift in management of TBAD due to late aneurysmal degeneration of TBAD increasing morbidity and mortality at longer-term. Late surgical intervention can be prevented by early endovascular intervention when combined with optimal medical therapy. In this narrative review, we explore available literature on different endovascular therapies for TBAD in different populations of patients.
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Affiliation(s)
- Rakhee R Makhija
- Division of Cardiovascular Medicine, Texas Tech University, El Paso. United States
| | - Debabrata Mukherjee
- Department of Internal Medicine, Division of Cardiovascular Medicine, Texas Tech University, El Paso, United States. United States
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23
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Liu J, Yan C, Li L, Feng H, Xie S, Zhang G, Cheng W, Guo M, Liu M. Extended Stent Coverage Decreases Distal Aortic Segmental Enlargement After the Endovascular Repair of Acute Complicated Type B Aortic Dissection: A Multi-Center Retrospective Study of 814 Patients. J Endovasc Ther 2021; 29:96-108. [PMID: 34399592 DOI: 10.1177/15266028211036479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE This study aimed to investigate the effect of distal aortic segmental enlargement (DASE) after thoracic endovascular aortic repair for complicated type B aortic dissection (cTBAD). MATERIALS AND METHODS From March 2003 to October 2018, 814 patients with acute cTBAD from 5 medical centers were retrospectively identified. DASE is indicated as the enlargement of distal aortic segmental volume ≥1.6 fold of the preoperative volume compared with the most recent postoperative computed tomography angiography (CTA) scan. Of these patients, 635 (78%) were identified as non-DASE, and 179 (22%) were identified as DASE. Competing risk analysis was performed to compare late death and distal aortic reintervention between the groups. The morphological variables and false lumen thrombosis at 7 aortic levels were measured based on the preoperative CTA and the most recent CTA. Univariate and multivariate Cox regression analyses were used to assess the independent predictors of DASE. RESULTS The mean follow-up time of the entire cohort was 5.6 years (interquartile range: 2.4-8.3 years). There were total of 208 late deaths, including 94 (14.8%) deaths in non-DASE group versus 114 (63.7%) deaths in the DASE group. Distal aortic reintervention was observed in 89 patients, with 43(6.7%) in the non-DASE group versus 46 (25.7%) in the DASE group. The cumulative incidence of late death and distal aortic reintervention were significantly higher in the DASE than in the non-DASE group (p<0.001). In morphological analysis, significant incomplete false lumen thrombosis was observed in all distal aortic segments above the aortic level of celiac artery (p<0.01). According to multivariate analysis, the Marfan syndrome, stent coverage to the level of diaphragm and the level of celiac artery were independent predictors of the DASE (p<0.001). Patients with extended stent coverage to the level of celiac artery have shown a lower incidence of DASE (p<0.010). CONCLUSION Compared with the non-DASE group, patients with DASE demonstrated a higher rate of late death and distal aortic reintervention. For the cTBAD population, extended stent-graft coverage to the aortic section between diaphragm and celiac artery might serve as a "cost-efficient" cutoff point aiming to reduce the risk of DASE.
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Affiliation(s)
- Junjun Liu
- Department of Vascular Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chaojun Yan
- Department of Cardiac Surgery, The Southwest Hospital Affiliated to Army Medical University (Third Military Medical University), Chongqing, China
| | - Lubin Li
- Department of Vascular Surgery, Yantai Yuhuangding Hospital, Yantai, China
| | - Hai Feng
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Shengmao Xie
- Department of Critical Care Medicine, The 969th Hospital of the Joint Logistics Support Force of PLA, Huhehaote, China
| | - Guohui Zhang
- Department of Dermatology & STD, Nancheng People's Hospital, Fuzhou, China
| | - Wei Cheng
- Department of Cardiac Surgery, The Southwest Hospital Affiliated to Army Medical University (Third Military Medical University), Chongqing, China
| | - Mingjin Guo
- Department of Vascular Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - MingYuan Liu
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Department of Vascular Surgery, Peking University People's Hospital, Beijing, China
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Another Endogarment to Choose From, But Where Does This Fit in to the Treatment Algorithm for TBAD? Eur J Vasc Endovasc Surg 2021; 62:575. [PMID: 34332837 DOI: 10.1016/j.ejvs.2021.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 11/23/2022]
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25
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Leo E, Molinari ACL, Ferraresi M, Rossi G. Short Term Outcomes of Distal Extended EndoVascular Aortic Repair (DEEVAR) Petticoat in Acute and Subacute Complicated Type B Aortic Dissection. Eur J Vasc Endovasc Surg 2021; 62:569-574. [PMID: 34301462 DOI: 10.1016/j.ejvs.2021.05.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 05/07/2021] [Accepted: 05/29/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the peri-operative and short term results of institutional experience with the Distal Extended EndoVascular Aortic Repair PETTICOAT (DEEVAR PETTICOAT) procedure. METHODS This was a single centre, observational study. From January 2015 to December 2019, 53 patients were admitted to the institution for treatment of acute and subacute complicated type B aortic dissection. Among them, data on 16 patients deemed suitable for a PETTICOAT procedure extended at infrarenal and iliac level by means of a bifurcated endograft were prospectively collected. Patients with persistent pain, visceral or lower limb malperfusion, true lumen collapse, and distal extension with computed tomography angiography (CTA) evidence of entry tears in the infrarenal or iliac zone were included. A CTA scan was performed in all patients at the baseline, before hospital discharge and then at six and 12 months post-operatively to assess aortic remodelling. Complete aortic remodelling was defined as stable aortic size (maximum enlargement < 5 mm) with complete true lumen re-expansion and complete false lumen exclusion or disappearance. RESULTS Technical success was obtained in all patients. One patient (7%) had intra-operative infrarenal aortic rupture during balloon dilation of the distal end of the bare stent, successfully treated by deployment of a bifurcated endograft. Additional covered stenting of the visceral arteries was necessary in nine patients (56%) and malperfusion resolved immediately in all cases. There were no spinal cord ischaemia or other peri-procedural complications, and no post-operative death, stroke, paraplegia/paraparesis, or acute renal failure was observed. Follow up ranged from one month to 24 months (median 7.5 months). One patient (7%) with a history of drug abuse died from sepsis. At the last CTA check, all patients showed complete remodelling of the thoraco-abdominal aorta and iliac arteries without vessel enlargement. CONCLUSION The present findings suggest that the DEEVAR PETTICOAT procedure provides effective sealing of all distal tears without increased risk of major peri-procedural complications. Further studies with larger number of patients and longer follow up are needed to confirm the safety and durability of this technique.
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Affiliation(s)
- Enrico Leo
- Division of Vascular Surgery, Department of Cardiovascular Diseases, A. Manzoni Hospital, Lecco, Italy.
| | - Alessandro C L Molinari
- Division of Vascular Surgery, Department of Cardiovascular Diseases, A. Manzoni Hospital, Lecco, Italy
| | - Marco Ferraresi
- Postgraduate School of Vascular Surgery, University of Milan, Milan, Italy
| | - Giovanni Rossi
- Division of Vascular Surgery, Department of Cardiovascular Diseases, A. Manzoni Hospital, Lecco, Italy
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26
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Eleshra A, Rohlffs F, Spanos K, Panuccio G, Heidemann F, Tsilimparis N, Kölbel T. Aortic Remodeling After Custom-Made Candy-Plug for Distal False Lumen Occlusion in Aortic Dissection. J Endovasc Ther 2021; 28:399-406. [PMID: 33634714 DOI: 10.1177/1526602821996722] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To report a single-center experience with the use of a custom-made Candy-Plug (CP) for distal false-lumen (FL) occlusion in subacute and chronic aortic dissection (AD). MATERIALS AND METHODS A retrospective single-center analysis was conducted on consecutive patients with subacute and chronic AD who were treated with a custom-made CP for distal FL occlusion using 3 design generations (CP I to CP III) from October 2013 to September 2019. RESULTS A custom-made CP was used in 57 patients. Of these, 34 patients (29 males, mean age 62±10 years) were treated with a CP I vs 23 patients (16 males, mean age 59±17 years) with CP II/III. Technical success was achieved in 57 (100%) patients. Clinical success was achieved in 54 (95%) patients; 33 (97%) in CP I group vs 21 (91%) patients in CP II/III group, p=0.116. The mean hospital stay was 10±8 days (9±5 days in CP I group vs 13±9 days in CP II/III, p=0.102). The 30-day computed tomography angiography (CTA) confirmed successful CP placement at the intended level in all patients within both groups. Early complete FL occlusion was achieved in 50 (88%) patients; 30 (88%) patients in CP I group vs 20 (87%) in CP II/III group, p=0.894. Follow up CTA was available in 44 (77%) patients. Of these; 30/34 (88%) patients in CP I group with mean follow-up 29±17 months) vs. 14/23 (61%) patients with mean follow-up 14±5 months in CP II/III group. Thoracic aortic remodeling was achieved in 34/44 (77%) patients; 25/30 (83%) patients in CP I group vs 9/14 (64%) patients in CP II/III group, p=0.197. The aneurysm size remained stable in 9/44 (20%) patients; 5/30 (17%) patients in CP I group vs 4/14 (29%) patients in CP II/III group, p=0.741. The thoracic aneurysm increased size was seen in 1/44 (2%) patient. This patient was in CPII/III group. CONCLUSION CP technique using custom-made devices is technically feasible with a low mortality and morbidity, and a high rate of aortic remodeling. Both, the original design (CP I) and newer designs with a self-closing central sleeve (CP II and CP III) showed similar excellent outcomes.
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Affiliation(s)
- Ahmed Eleshra
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Germany
| | - Konstantinos Spanos
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Germany
| | - Franziska Heidemann
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Germany
| | - Nikolaos Tsilimparis
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Germany
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27
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Hynes N, Berguer R, Parodi JC, Acharya Y, Sultan S. Management of complicated aortic dissection: natural history, translational research, simulation, bioconvergence, clinical evidence and literature review. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.23736/s1824-4777.20.01473-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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28
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Soler RJ, Bartoli MA, Bourenne J, Riberi A, Lagier D, Amabile P, Sarlon-Bartoli G, Magnan PE. STABILISE Technique for a Non-A Non-B Acute Aortic Dissection in Marfan Syndrome. Ann Vasc Surg 2020; 70:569.e5-569.e10. [PMID: 32920025 DOI: 10.1016/j.avsg.2020.08.132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/21/2020] [Accepted: 08/18/2020] [Indexed: 01/16/2023]
Abstract
A 35-year-old man, with a deep pectus excavatum due to a Marfan syndrome treated 9 years before for an acute type A dissection involving only the aortic arch, by a Bentall surgery, was admitted for acute chest pain. Computed tomography (CT) scan showed an acute type non-A non-B dissection extending to the iliac. After 5 days with strict arterial blood pressure management, the patient had recurrent refractory chest pain and a hybrid technique associating full supra-aortic vessels debranching and STABILISE technique during the same procedure was performed. The patient had an uneventful recovery with CT scan showing complete aortic arch aneurysm exclusion.
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Affiliation(s)
- Raphael J Soler
- Aix-Marseille Université, APHM, Hôpital de la Timone, Service de Chirurgie Vasculaire, Marseille, France
| | - Michel A Bartoli
- Aix-Marseille Université, APHM, Hôpital de la Timone, Service de Chirurgie Vasculaire, Marseille, France.
| | - Jeremy Bourenne
- Aix-Marseille Université, APHM, Hôpital de la Timone, Service de Réanimation, Marseille, France
| | - Alberto Riberi
- Aix-Marseille Université, APHM, Hôpital de la Timone, Service de Chirurgie Cardiaque, Marseille, France
| | - David Lagier
- Aix-Marseille Université, APHM, Hôpital de la Timone, Service de Réanimation, Marseille, France
| | - Philippe Amabile
- Aix-Marseille Université, APHM, Hôpital de la Timone, Service de Chirurgie Vasculaire, Marseille, France
| | - Gabrielle Sarlon-Bartoli
- Aix-Marseille Université, APHM, Hôpital de la Timone, Service de Chirurgie Vasculaire, Marseille, France
| | - Pierre-Edouard Magnan
- Aix-Marseille Université, APHM, Hôpital de la Timone, Service de Chirurgie Vasculaire, Marseille, France
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29
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Nikol S, Mathias K, Olinic DM, Blinc A, Espinola-Klein C. Aneurysms and dissections - What is new in the literature of 2019/2020 - a European Society of Vascular Medicine annual review. VASA 2020; 49:1-36. [PMID: 32856993 DOI: 10.1024/0301-1526/a000865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
More than 6,000 publications were found in PubMed concerning aneurysms and dissections, including those Epub ahead of print in 2019, printed in 2020. Among those publications 327 were selected and considered of particular interest.
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Affiliation(s)
- Sigrid Nikol
- Department of Angiology, ASKLEPIOS Klinik St. Georg, Hamburg, Germany.,University of Münster, Germany
| | - Klaus Mathias
- World Federation for Interventional Stroke Treatment (WIST), Hamburg, Germany
| | - Dan Mircea Olinic
- Medical Clinic No. 1, University of Medicine and Pharmacy and Interventional Cardiology Department, Emergency Hospital, Cluj-Napoca, Romania
| | - Aleš Blinc
- Department of Vascular Diseases, University Medical Centre Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Slovenia
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30
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Lovato L, Cefarelli M, Gatta E, Di Eusanio M, Fattori R. Devices for thoracic endovascular aortic repair of type B aortic dissection: is there any chance for Marfan syndrome? Expert Rev Med Devices 2020; 17:683-696. [DOI: 10.1080/17434440.2020.1782735] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Luigi Lovato
- Cardio-Thoracic-Vascular Department, Cardiovascular Radiology Unit and Marfan Center; S.Orsola-Malpighi Hospital; University of Bologna, Italy
| | - Mariano Cefarelli
- Cardiovascular Department, Cardiac Surgery Unit and Marfan Center; Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Emanuele Gatta
- Cardiovascular Department, Vascular Surgery Unit and Marfan Center; Lancisi Cardiovascular Center, Ancona, Italy
| | - Marco Di Eusanio
- Cardiovascular Department, Cardiac Surgery Unit and Marfan Center; Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Rossella Fattori
- Cardiovascular Department, Marfan Center; Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
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31
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Ge YY, Rong D, Ge XH, Miao JH, Fan WD, Liu XP, Guo W. The 301 Classification: A Proposed Modification to the Stanford Type B Aortic Dissection Classification for Thoracic Endovascular Aortic Repair Prognostication. Mayo Clin Proc 2020; 95:1329-1341. [PMID: 32622443 DOI: 10.1016/j.mayocp.2020.03.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 02/05/2020] [Accepted: 03/05/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To assess the usefulness of a modified Stanford classification for risk stratification of complications after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD). PATIENTS AND METHODS This retrospective analysis included 201 patients from an observational multicenter cohort study who underwent TEVAR for TBAD from January 1, 2011, to December 31, 2016. The patients were divided by using a modified Stanford classification, termed 301, into 3 groups: types B1 (n=62) and B3 (n=24), with a true and false lumen, respectively, descending closely along the thoracic vertebral bodies, and type B2 (n=115), a semi-spiral or spiral configuration. The value of the 301 classification in assessing the risk for post-TEVAR thoracic aortic expansion, as main outcome, and other complications was assessed by using the Kaplan-Meier method and multivariable Cox proportional hazards models. RESULTS Median follow-up duration was 26.37 months, and the 24-month cumulative rate of freedom from thoracic aortic enlargement was 0.58 (95% CI, 0.25 to 0.81) for type B3, 0.75 (95% CI, 0.64 to 0.83) for type B2, and 0.97 (95% CI, 0.88 to 0.99) for type B1. In the multivariable Cox regression models, types B2 and B3 with type B1 as reference were independently associated with the risk for thoracic aortic expansion (type B2: hazard ratio, 7.81; 95% CI, 1.84 to 33.13; type B3: hazard ratio, 13.91; 95% CI, 2.86 to 67.69). CONCLUSION The 301 classification, a modified Stanford classification system in the era of endovascular repair, appears to improve the risk stratification of patients with TBAD undergoing TEVAR. TRIAL REGISTRATION Chinese Clinical Trial Registry number: ChiCTR-POC-17011726.
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Affiliation(s)
- Yang Y Ge
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Dan Rong
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Xiao H Ge
- Department of Vascular Surgery, People's Hospital of Xinjiang Uygur Autonomous Region, Urumchi, China
| | - Jian H Miao
- Department of General Surgery, Zhongshan People's Hospital, Zhongshan, China
| | - Wei D Fan
- Department of Cardiology, Henan Provincial Chest Hospital, Zhengzhou, China
| | - Xiao P Liu
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Wei Guo
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China.
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32
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Spanos K, Kölbel T. Role of Endoluminal Techniques in the Management of Chronic Type B Aortic Dissection. Cardiovasc Intervent Radiol 2020; 43:1808-1820. [PMID: 32601718 PMCID: PMC8490267 DOI: 10.1007/s00270-020-02566-7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 06/20/2020] [Indexed: 12/22/2022]
Abstract
In recent guidelines of international societies, the most frequent indication for treatment after chronic type B aortic dissection (cTBAD) is aneurysmal dilatation. Endovascular repair is recommended in patients with moderate to high surgical risk or with contraindications to open repair. During the last decade, many advances have been made in the field of endovascular techniques and devices. The aim of this article is to address the current status of endoluminal techniques for the management of cTBAD including standard thoracic endovascular repair, new devices, fenestrated and branched abdominal aortic devices and false lumen occlusion techniques.
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Affiliation(s)
- Konstantinos Spanos
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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33
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Miletic KG, Kindzelski BA, Hodges KE, Beach J, Tong MZ, Bakaeen F, Johnston DR, Desai M, Lyden S, Roselli EE. Impact of Endovascular False Lumen Embolization on Thoracic Aortic Remodeling in Chronic Dissection. Ann Thorac Surg 2020; 111:495-501. [PMID: 32525030 DOI: 10.1016/j.athoracsur.2020.04.093] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 03/14/2020] [Accepted: 04/13/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Retrograde false lumen (FL) perfusion after thoracic endovascular aortic repair (TEVAR) for chronic dissection is a mode of treatment failure. Thrombosis of the FL is associated with favorable reverse remodeling. Objectives are to describe FL embolization (FLE) strategy and assess aortic remodeling and survival. METHODS From January 2009 to December 2017, 51 patients with chronic dissection underwent FLE, most after previous TEVAR. Devices included a combination of iliac plug (29 patients), coils (19 patients), or nitinol plug (3 patients). Computed tomography was performed before discharge, at 3 months, and annually (median follow-up 2 years [range, 1 month to 7 years]). RESULTS After FLE, mean maximum aortic diameter decreased (64.2 ± 12 mm to 61.0 ± 13 mm; P = .03), true lumen diameter increased (24.7 ± 10 mm to 33.7 ± 8 mm; P < .001), and FL diameter decreased (36.7 ± 12 mm to 25.6 ± 15 mm, P < .001). For reverse remodeling, FL thrombosis with ≥10% decrease in diameter and ≥10% increase in true lumen diameter was achieved in 20 (39.2%; 16 primarily, 4 secondarily). Nine patients progressed after the first FLE: persistent FL flow with increase in aortic diameter and underwent repeat FLE with complete thrombosis (n = 4) or open thoracoabdominal completion (n = 5). A total of 26 patients had indeterminate response (FL thrombosis without change in maximum diameter), and none have required reoperation. Six patients had complete obliteration of the entire FL. At last follow-up, 42 (82%) patients were alive. Three deaths were related to aortic pathology. CONCLUSIONS FLE is an important endovascular adjunct to TEVAR promoting reverse aortic remodeling in select patients with chronic aortic dissection and persistent retrograde FL perfusion.
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Affiliation(s)
- Kyle G Miletic
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bogdan A Kindzelski
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kevin E Hodges
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jocelyn Beach
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael Z Tong
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Faisal Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Milind Desai
- Aorta Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Cardiology, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sean Lyden
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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Spanos K, Panuccio G, Rohlffs F, Heidemann F, Tsilimparis N, Kölbel T. Technical Aspects of Branched Thoracic Arch Graft Implantation for Aortic Arch Pathologies. J Endovasc Ther 2020; 27:792-800. [PMID: 32431247 DOI: 10.1177/1526602820925443] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To describe the implantation steps and tips and tricks for the Inner Branch Arch Endograft designed to treat aortic arch aneurysm and chronic type A aortic dissection. TECHNIQUE Anatomical suitability criteria should be met in order to use this device. The proximal segment of the graft lands in the ascending aorta distally to the sinotubular junction and the distal segment lands in the descending aorta. The device includes 2 inner branches; the proximal branch is used for a connection to the innominate artery (positioned slightly posterior at 12:30 o'clock), while the second branch is positioned slightly anterior at 11:30 o'clock and is used as a connection to the left common carotid artery. Access, implantation technique, deployment of the device, and catheterization of the branches are described thoroughly. CONCLUSION This Inner Branch Arch Endograft is an appealing alternative to treat aortic arch pathology, especially in patients unsuitable for open repair. Nevertheless, complex aortic arch repair is associated with a learning curve. Meticulous preoperative planning and a high level of concentration intraoperatively are mandatory.
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Affiliation(s)
- Konstantinos Spanos
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Franziska Heidemann
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Nikolaos Tsilimparis
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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35
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Mougin J, Charbonneau P, Guihaire J, Schwein A, Tyrrell MR, Maurel B, Fabre D, Haulon S. Endovascular management of chronic post-dissection aneurysms of the aortic arch. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:402-415. [PMID: 32337939 DOI: 10.23736/s0021-9509.20.11395-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
This article reviews endovascular management of chronic post-dissection aneurysms of the aortic arch. Therapeutic strategies intended for this complex aortic condition are evolving rapidly to allow the treatment of various hostile aortic anatomy and frail patients. Principles, technical considerations, devices and outcomes of each technique are reviewed and summarized. Hybrid repair offer similar early mortality and stroke rates compared to open conventional surgery. Arch chimney and other parallel graft techniques present poor long term outcome, and should be limited to emergency situations where no other option is available. Fenestrated stent-grafting is subjected to many technical challenges in aortic arch due to difficulties in stent-graft orientation and fenestration positioning. In situ fenestration is an off-label technique that should only be used as an emergency bailout maneuver, considering that temporary coverage of supra aortic trunk vessel and its long-term durability raise concern. Finally, in experienced hands and appropriate anatomic conditions, arch branched graft technology has shown itself to be a safe and effective alternative to open conventional surgery. No randomized controlled trials have yet compared total endovascular aortic arch repair with hybrid techniques and open arch repair. The management of chronic post-dissection aneurysms of the aortic arch is challenging, decision-making and interventions should continue to be performed in high-volume centers with a dedicated aortic team with an expertise in both open and endovascular repairs.
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Affiliation(s)
- Justine Mougin
- Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France
| | - Philippe Charbonneau
- Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France
| | - Julien Guihaire
- Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France
| | - Adeline Schwein
- Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France
| | | | - Blandine Maurel
- Service of Vascular Surgery, Thorax Institute, Nantes University Hospital, Nantes, France
| | - Dominique Fabre
- Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France
| | - Stéphan Haulon
- Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France -
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36
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Rakestraw S, Feghali A, Nguyen K, Salvatore D, DiMuzio P, Abai B. False lumen embolization as a rescue technique in the setting of acute and chronic dissecting aneurysms as adjunct to thoracic endovascular aortic repair. J Vasc Surg Cases Innov Tech 2020; 6:110-117. [PMID: 32095669 PMCID: PMC7033463 DOI: 10.1016/j.jvscit.2019.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 12/11/2019] [Indexed: 11/23/2022] Open
Abstract
Complicated type B aortic dissection (TBAD) is a life-threatening condition requiring surgical intervention. One such complication in the acute or chronic setting is aneurysmal degeneration. The dissected aortic wall is weakened, and the pressures in the false lumen are often high. In the past decade, thoracic endovascular aortic repair (TEVAR) has become the treatment of choice for TBAD. TEVAR can be complicated by lack of false lumen thrombosis, increasing the risk of death. We present three cases of TBAD with patent false lumens after TEVAR that were treated by false lumen coil embolization.
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Affiliation(s)
| | | | | | | | | | - Babak Abai
- Department of Vascular Surgery, Thomas Jefferson University Hospital, Philadelphia, Pa
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37
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Carta N, Salvati S, Melissano G, Chiesa R, Bertoglio L. Staged Fenestrated/Branched Repair of Postdissecting Thoracoabdominal Aneurysm With Candy-Plug False Lumen Occlusion for Spinal Cord Preconditioning. J Endovasc Ther 2020; 27:221-227. [DOI: 10.1177/1526602820906856] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To describe a possible application of thoracic false lumen occlusion techniques with a Candy-Plug occluder to induce false lumen thrombosis for preconditioning the spinal cord during staged fenestrated repair of postdissecting thoracoabdominal aneurysms. Technique: A Candy-Plug occluder is deployed within the thoracic false lumen after proximal entry tear coverage with a standard thoracic stent-graft during staged repair of postdissecting thoracoabdominal aneurysms. The blockade of thoracic false lumen retrograde reperfusion from distal entry tears induces a controlled thrombosis of both the thoracic false lumen and intercostal arteries. Then, when the fenestrated device is delivered 4 to 6 weeks later, the procedure is completed with standard techniques according to the staging protocols of individual centers. Conclusion: A new possible application of a Candy-Plug false lumen occlusion technique might be an intermediate procedure aimed at preconditioning the spinal cord by occluding the thoracic false lumen during complex staged fenestrated thoracoabdominal repairs.
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Affiliation(s)
- Niccolò Carta
- Division of Vascular Surgery, “Vita–Salute” University, Scientific Institute H. San Raffaele, Milan, Italy
| | - Simone Salvati
- Division of Vascular Surgery, “Vita–Salute” University, Scientific Institute H. San Raffaele, Milan, Italy
| | - Germano Melissano
- Division of Vascular Surgery, “Vita–Salute” University, Scientific Institute H. San Raffaele, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, “Vita–Salute” University, Scientific Institute H. San Raffaele, Milan, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, “Vita–Salute” University, Scientific Institute H. San Raffaele, Milan, Italy
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Sultan S, Barrett N, Kamal MH, Tawfick W, Atteia EM, Clarkson K, Alawy M, Hynes N. Staged Hybrid Single Lumen Reconstruction (TIGER) in Management of Chronic Symptomatic Complex Type B Aortic Dissection, Techniques, and Literature Review. Ann Vasc Surg 2020; 65:261-270. [PMID: 32007594 DOI: 10.1016/j.avsg.2019.12.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/03/2019] [Accepted: 12/18/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endovascular intervention for chronic symptomatic type B aortic dissection (CS-TBAD) induces aortic wall stress with negative hemodynamic cardiovascular consequences. CS-TBAD risks increased morbidity and mortality due to septum maturation with significant impact on false lumen modulation, and partial lumen thrombosis conveying the worst outcome. The aim of the TIGER technique is total aortic remodeling with true lumen expansion, false lumen regression and complete thrombosis, and stabilization of overall aortic diameter. METHODS We report 5 cases of aortic dissection with a mean follow-up of 16 months (6-28 months). All had aneurysmal dilation, with 3 having acute pan aortic dissection and 2 having CS-TBAD. All were managed by sTaged HybrId sinGle lumEn Reconstruction (TIGER). Our first approach was to create one single lumen from the supraceliac, infradiaphragmatic aorta to both common iliac arteries with open surgical patching of the visceral arteries; then, we performed a TEVAR 3 months later. RESULTS Three patients required a left subclavian artery chimney graft and one required bilateral subclavian to carotid artery transposition. No spinal drainage was required, and all patients had intraoperative transesophageal echo for wire guidance. We had no aortic rupture or retrograde type A dissection, and we experienced no renal, visceral, cardiac, pulmonary, or spinal complications. All patients, but one, went off their antihypertensive medication. All patients had normal estimated glomerular filtration rate postoperatively, and they all demonstrated accelerated aortic modulation. CONCLUSIONS TIGER was not only effective at the semiacute stage to initiate remodeling and prevent malperfusion, it also facilitated a straightforward TEVAR at stage 2, which was made easier by avoiding visceral branch stenting. Moreover, it decreased the length of aortic segment, which was stented, thereby avoiding critical shattering, branch dislodgment, and visceral compromise; spinal ischemia; and negative cardiovascular consequences.
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Affiliation(s)
- Sherif Sultan
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland, Galway, Ireland; Galway Clinic, Royal College of Surgeons of Ireland/ National University of Ireland Affiliated Teaching Hospitals, Galway, Ireland.
| | - Nora Barrett
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Mohamed Hatem Kamal
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Wael Tawfick
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Emad Magdy Atteia
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Kevin Clarkson
- Galway Clinic, Royal College of Surgeons of Ireland/ National University of Ireland Affiliated Teaching Hospitals, Galway, Ireland; Department of Anaesthesia, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Mahmoud Alawy
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Niamh Hynes
- Galway Clinic, Royal College of Surgeons of Ireland/ National University of Ireland Affiliated Teaching Hospitals, Galway, Ireland
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