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Cui C, Wang B, Liu W. Outcomes of fenestrated endovascular abdominal aortic repair in distal entry tears of chronic debakey IIIb aortic dissection. PLoS One 2024; 19:e0288218. [PMID: 38412141 PMCID: PMC10898741 DOI: 10.1371/journal.pone.0288218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 01/23/2024] [Indexed: 02/29/2024] Open
Abstract
Currently, there have been very few reports within the literature which specifically address using fenestrated and branched stent grafts to completely isolate and repair distal entry tears of chronic DeBakey IIIb aortic dissection. This study aimed to evaluate the clinical outcomes of a 3-dimensional (3D) printed aortic model-guided fenestrated stent in the treatment of distal tears of chronic DeBakey IIIb aortic dissection after thoracic endovascular aortic repair (TEVAR). The study was a one-center retrospective study comprising 36 patients who underwent TEVAR and fenestrated endovascular abdominal aortic repair (F-EVAR) between April 2014 and December 2022. Patient data was compiled and analysed for preoperative, intraoperative, and perioperative characteristics. In total, 36 patients (12 females and 24 males) were incorporated into this study. All of the patients included in this study had hypertension, and among them, the leading cause for undergoing II-stage F-EVAR was the progression of a false lumen, accounting for 24 cases (66.7% of the total). The technical success rate was 97.2% and there were no cases of 30-day mortality, myocardial infarction, permanent paraparesis, or organ failure. One year post-F-EVAR treatment, surviving patients showed significant false and true lumen remodelling with 100% complete false-lumen thrombosis. A total of five patients died during the follow-up, two patients died related to aorta complications and three patients died of heart failure, multiple organ failure, or septic shock. II-stage F-EVAR was safe and feasible operation to repair all distal tears of chronic DeBakey IIIb aortic dissection.
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Affiliation(s)
- Chi Cui
- Center of Vascular and Interventional Surgery, Department of General Surgery, The Third People's Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University & The Second Affiliated Hospital of Chengdu, Chongqing Medical University, Chengdu, China
| | - Bisi Wang
- Center of Vascular and Interventional Surgery, Department of General Surgery, The Third People's Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University & The Second Affiliated Hospital of Chengdu, Chongqing Medical University, Chengdu, China
| | - Wei Liu
- Center of Vascular and Interventional Surgery, Department of General Surgery, The Third People's Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University & The Second Affiliated Hospital of Chengdu, Chongqing Medical University, Chengdu, China
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Sultan S, Acharya Y, Chua Vi Long K, Hatem M, Hezima M, Veerasingham D, Soliman O, Hynes N. Management of acute aortic syndrome with evolving individualized precision medicine solutions: Lessons learned over two decades and literature review. Front Surg 2023; 10:1157457. [PMID: 37065997 PMCID: PMC10097442 DOI: 10.3389/fsurg.2023.1157457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
BackgroundThoracoabdominal acute aortic syndrome is associated with high morbidity and mortality. We aim to scrutinize our evolving strategies for acute aortic syndrome (AAS) management using minimally invasive and adaptive surgical techniques over two decades.MethodsThis is a longitudinal observational study at our tertiary vascular centre from 2002 to 2021. Out of 22,349 aortic referrals, we performed 1,555 aortic interventions over twenty years. Amongst 96 presented with symptomatic aortic thoracic pathology, 71 patients had AAS. Our primary endpoint is combined aneurysm-related and cardiovascular-related mortality.ResultsThere were 43 males and 28 females (5 Traumatic Aortic Transection (TAT), 8 Acute Aortic Intramural Hematoma (IMH), 27 Symptomatic Aortic Dissection (SAD) and 31 Thoracic Aortic Aneurysm (TAA) post-SAD) with a mean age of 69. All the patients with AAS received optimal medical therapy (OMT), but TAT patients underwent emergency thoracic endovascular aortic repair (TEVAR). Fifty-eight patients had an aortic dissection, of which 31 developed TAA. These 31 patients with SAD and TAA received OMT initially and interval surgical intervention with TEVAR or sTaged hybrId sinGle lumEn Reconstruction (TIGER). To increase our landing area, we performed a left subclavian chimney graft with TEVAR in twelve patients. The average follow-up duration was 78.2 months, and eleven patients (15.5%) had combined aneurysm and cardiovascular-related mortality. Twenty-six percentage of the patients developed endoleaks (EL), of which 15% required re-intervention for type II and III. Four patients who had paraplegia (5.7%) and developed renal failure died. None of our patients had a stroke or bowel ischaemia. Twenty patients had OMT, eight of these were patients with acute aortic hematoma, and all eight died within 30 days of presentation.ConclusionAcute aortic hematoma is a sinister finding, which must be closely monitored, and consideration is given to early intervention. Paraplegia and renal failure result in an increased mortality rate. TIGER technique with interval TEVAR has salvaged complex situations in young patients. Left subclavian chimney increases our landing area and abolishes SINE. Our experience shows that minimally invasive techniques could be a viable option for AAS.
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Affiliation(s)
- Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
- Correspondence: Sherif Sultan
| | - Yogesh Acharya
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
| | - Keegan Chua Vi Long
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
| | - Mohamed Hatem
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
| | - Mohieldin Hezima
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
| | - David Veerasingham
- Department of Cardiothoracic Surgery, University Hospital Galway, University of Galway, Galway, Ireland
| | - Osama Soliman
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
| | - Niamh Hynes
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
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Gusev MV, Leong BV, Patel ST. A reversed strategy for treating type B aortic dissection with open aortoiliac replacement prior to thoracic endovascular aortic repair. J Vasc Surg Cases Innov Tech 2022; 8:781-786. [DOI: 10.1016/j.jvscit.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 10/19/2022] [Indexed: 11/23/2022] Open
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Sultan S, Acharya Y, Soliman O, Parodi JC, Hynes N. TEVAR and EVAR, the unknown knowns of the cardiovascular hemodynamics; and the immediate and long-term consequences of fabric material on major adverse clinical outcome. Front Surg 2022; 9:940304. [PMID: 36111231 PMCID: PMC9468223 DOI: 10.3389/fsurg.2022.940304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/11/2022] [Indexed: 11/29/2022] Open
Abstract
This review discusses the impact of endovascular aneurysm repair on cardiovascular (CV) hemodynamics and the role of stent-graft material, i.e., polytetrafluoroethylene (PTFE) vs. polyester in post-procedural outcomes. Endovascular aneurysm repair has been widely employed in the last decades for thoracic and abdominal aneurysm repair. However, aortic endografts are stiff and alter the native flow hemodynamics. This failure to simulate the native aorta could lead to added strain on the heart, manifesting as increased left ventricular strain, higher pulse pressure, and congestive heart failure later. This could result in adverse CV outcomes. Also, evidence is mounting to support the implication of stent-graft materials, i.e., PTFE vs. polyester, in adverse post-procedural outcomes. However, there is an absence of level one evidence. Therefore, the only way forward is to plan and perform a randomised controlled trial to demonstrate the alterations in the CV hemodynamics in the short and long run and compare the available stent-graft materials regarding procedural and clinical outcomes. We believe the best solution, for now, would be to reduce the stented length of the aorta. At the same time, in the longer term, encourage continuous improvement in stent-graft materials and design.
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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, Doughiska, Royal College of Surgeons in Ireland and the National University of Ireland, Galway Affiliated Hospital, Galway, Ireland
- CÚRAM-CORRIB-Vascular Group, National University of Ireland, Galway, Ireland
- Correspondence: Sherif Sultan ,
| | - Yogesh Acharya
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland, Galway, Ireland
- Galway Clinic, Doughiska, Royal College of Surgeons in Ireland and the National University of Ireland, Galway Affiliated Hospital, Galway, Ireland
| | - Osama Soliman
- CÚRAM-CORRIB-Vascular Group, National University of Ireland, Galway, Ireland
| | - Juan Carlos Parodi
- Department of Vascular Surgery and Biomedical Engineering Department, University of Buenos Aires, Buenos Aires, Argentina
| | - Niamh Hynes
- CÚRAM-CORRIB-Vascular Group, National University of Ireland, Galway, Ireland
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Aortic remodeling after endovascular aortic repair and tailored distal entry tears exclusion in Crawford type III or IV dissection aneurysm. J Formos Med Assoc 2022; 121:2520-2526. [PMID: 35717417 DOI: 10.1016/j.jfma.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 05/23/2022] [Accepted: 06/01/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) can only promote 55-80% false lumen (FL) thrombosis when only the proximal primary tear is covered during the repair of type B aortic dissection (TBAD). This study evaluated the effectiveness and clinical outcome of tailored exclusion of the primary entry tear with TEVAR and distal fenestrations with ancillary devices in patients with subacute or chronic Crawford type III and IV aortic dissection aneurysm. METHODS All patients underwent either TEVAR for primary entry tear; subsequently, various ancillary devices were applied on each distal fenestration. These techniques included covered stent occlusion of detached visceral artery entry tears, TL stenting and FL occlusion with vascular plugs in the common iliac artery dissection, or TEVAR coverage for multiple fenestrations from segmental arteries. This case series included nine patients (seven men and two women; mean age: 63.4 years) during January 2013 to May 2019. Outcome analysis included the rates of technical success and procedure-related complications, completeness of FL occlusion, aortic remodeling, and midterm mortality at 2 years. RESULTS The mean follow-up duration was 37.7 months without in-hospital mortality. One patient was lost to follow-up at the second month, the rest of patients were all alive during the follow-up period. All patients achieved complete FL thrombosis, and six patients exhibited aneurysm diameter shrinkage. CONCLUSION Tailored exclusion of visceral and iliac distal fenestrations with proximal primary tear coverage can promote FL thrombosis and aortic remodeling in the visceral aortic segment in patients with Crawford type III or IV aortic dissection aneurysm.
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Zhang Y, Fan J, Xiu Y, Zhang L, Chen G, Fan J, Lin X, Ding C, Feng M, Wang R, Liu Y. Numerical simulation flow dynamics of an intracranial aneurysm. Biomed Mater Eng 2021; 33:123-129. [PMID: 34633312 DOI: 10.3233/bme-211270] [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: 11/15/2022]
Abstract
BACKGROUND Computational fluid dynamics provides a new method for the study of the blood flow characteristics of the formation and development of intracranial aneurysms. OBJECTIVE To compare blood flow characteristics between the healthy internal carotid artery and normal intracranial aneurysms. METHODS The internal carotid arteries were simulated to obtain hemodynamic parameters in one patient. RESULTS The internal carotid artery associated with aneurysm presents low wall shear stress, high oscillatory shear index, and high particle retention time compared with the normal internal carotid artery. CONCLUSIONS There are differences in blood flow between the normal internal carotid artery and intracranial aneurysm. The vortex of the aneurysm will produce turbulence, indicating that it is unstable, which results in the growth and rupture of the aneurysm.
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Affiliation(s)
- Yang Zhang
- Laboratory of the Second Hospital Attached to Mudanjiang Medical University, Heilongjiang, Mudanjiang, China.,Department of Immunology, Mudanjiang Medical University, Heilongjiang, Mudanjiang, China
| | - Junjie Fan
- School of Health Management, Mudanjiang Medical University, Heilongjiang, Mudanjiang, China
| | - Yunxia Xiu
- Laboratory of the Second Hospital Attached to Mudanjiang Medical University, Heilongjiang, Mudanjiang, China
| | - Luyao Zhang
- Department of Immunology, Mudanjiang Medical University, Heilongjiang, Mudanjiang, China
| | - Guangxin Chen
- School of Imaging, Mudanjiang Medical University, Heilongjiang, Mudanjiang, China
| | - Jinyu Fan
- The First Clinical Medical School, Mudanjiang Medical University, Heilongjiang, Mudanjiang, China
| | - Xiao Lin
- Department of Immunology, Mudanjiang Medical University, Heilongjiang, Mudanjiang, China
| | - Chen Ding
- Department of Immunology, Mudanjiang Medical University, Heilongjiang, Mudanjiang, China
| | - Mingming Feng
- School of Imaging, Mudanjiang Medical University, Heilongjiang, Mudanjiang, China
| | - Ruliang Wang
- Department of Imaging, Hongqi Hospital Attached to Mudanjiang Medical University, Heilongjiang, Mudanjiang, China
| | - Yang Liu
- The Academic Affairs Office of Mudanjiang Medical University, Heilongjiang, Mudanjiang, China
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Concannon J, Moerman KM, Hynes N, Sultan S, McGarry JP. Influence of shape-memory stent grafts on local aortic compliance. Biomech Model Mechanobiol 2021; 20:2373-2392. [PMID: 34541627 PMCID: PMC8595172 DOI: 10.1007/s10237-021-01514-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/18/2021] [Indexed: 12/19/2022]
Abstract
The effect of repair techniques on the biomechanics of the aorta is poorly understood, resulting in significant levels of postoperative complications for patients worldwide. This study presents a computational analysis of the influence of Nitinol-based devices on the biomechanical performance of a healthy patient-specific human aorta. Simulations reveal that Nitinol stent-grafts stretch the artery wall so that collagen is stretched to a straightened high-stiffness configuration. The high-compliance regime (HCR) associated with low diastolic lumen pressure is eliminated, and the artery operates in a low-compliance regime (LCR) throughout the entire cardiac cycle. The slope of the lumen pressure–area curve for the LCR post-implantation is almost identical to that of the native vessel during systole. This negligible change from the native LCR slope occurs because the stent-graft increases its diameter from the crimped configuration during deployment so that it reaches a low-stiffness unloading plateau. The effective radial stiffness of the implant along this unloading plateau is negligible compared to the stiffness of the artery wall. Provided the Nitinol device unloads sufficiently during deployment to the unloading plateau, the degree of oversizing has a negligible effect on the pressure–area response of the vessel, as each device exerts approximately the same radial force, the slope of which is negligible compared to the LCR slope of the native artery. We show that 10% oversizing based on the observed diastolic diameter in the mid descending thoracic aorta results in a complete loss of contact between the device and the wall during systole, which could lead to an endoleak and stent migration. 20% oversizing reaches the Dacron enforced area limit (DEAL) during the pulse pressure and results in an effective zero-compliance in the later portion of systole.
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Affiliation(s)
- J Concannon
- Biomedical Engineering, College of Engineering and Informatics, National University of Ireland, Galway, Ireland
| | - K M Moerman
- Biomedical Engineering, College of Engineering and Informatics, National University of Ireland, Galway, Ireland
| | - N Hynes
- Western Vascular Institute, National University of Ireland Galway, Galway, Ireland
| | - S Sultan
- Western Vascular Institute, National University of Ireland Galway, Galway, Ireland
| | - J P McGarry
- Biomedical Engineering, College of Engineering and Informatics, National University of Ireland, Galway, Ireland.
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Sultan S, Acharya Y, Salahat H, Hynes N. Staged hybrid single lumen reconstruction (TIGER) with bilateral subclavian transposition coupled with thoracic endovascular aneurysm repair in the management of acute symptomatic complex type B aortic dissection in a patient with arteria lusoria. BMJ Case Rep 2021; 14:e244137. [PMID: 34433533 PMCID: PMC8388275 DOI: 10.1136/bcr-2021-244137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2021] [Indexed: 12/16/2022] Open
Abstract
We present a 54-year-old Caucasian woman, who presented with acute symptomatic type B aortic dissection with deteriorating renal function. She was a known smoker with a 2-year history of dysphagia. CT angiography documented the artery of lusoria arising from the mid-thoracic aorta, aneurysmal dilation of her descending aorta, and kinetic and static flaps around her visceral ostia. The patient was managed by staged hybrid single lumen reconstruction and bilateral subclavian to carotid transpositions. During follow-up, there was no aortic rupture or retrograde type A dissection. There were no renal, visceral, cardiac, pulmonary or spinal complications. The patient went off her antihypertensive medication with a normal estimated glomerular filtration rate and accelerated aortic modulation.
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Affiliation(s)
- Sherif Sultan
- Vascular and Endovascular Surgery, National University of Ireland Galway, Galway, Ireland
| | - Yogesh Acharya
- Vascular and Endovascular Surgery, National University of Ireland Galway, Galway, Ireland
| | - Hiba Salahat
- Vascular and Endovascular Surgery, Western Vascular Institute, Galway, Ireland
| | - Niamh Hynes
- CÚRAM, National University of Ireland, Galway, Galway, Ireland
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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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Sultan S, Acharya Y, Hynes N. Commentary: When Promising Innovators Lack Strategic Vision: The Concept of Flow Modulation in Aortic Dissection. J Endovasc Ther 2020; 28:32-35. [DOI: 10.1177/1526602820954450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
- Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Royal College of Surgeons in Ireland, and National University of Ireland, Galway Affiliated Hospital, Galway, Ireland
| | - Yogesh Acharya
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
- Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Royal College of Surgeons in Ireland, and National University of Ireland, Galway Affiliated Hospital, Galway, Ireland
| | - Niamh Hynes
- Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Royal College of Surgeons in Ireland, and National University of Ireland, Galway Affiliated Hospital, Galway, Ireland
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