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Lau C, Soletti G, Weinsaft JW, Rahouma M, Al Zghari T, Olaria RP, Harik L, Yaghmour M, Dimagli A, Gaudino M, Girardi LN. Risk profile and operative outcomes in patients with and without Marfan syndrome undergoing thoracoabdominal aortic aneurysm repair. J Thorac Cardiovasc Surg 2023; 166:1548-1557.e2. [PMID: 37164052 DOI: 10.1016/j.jtcvs.2023.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/17/2023] [Accepted: 03/29/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVES To compare operative and long-term outcomes between patients with and without Marfan syndrome undergoing thoracoabdominal aortic aneurysm repair. METHODS We identified all consecutive patients undergoing thoracoabdominal aortic aneurysm repair between 1997 and 2022. Primary outcome was composite of major adverse events. Secondary outcomes were individual complications and long-term survival. Inverse probability of treatment weighting was performed. Weighted Kaplan-Meier curves were used to estimate long-term survival. Multivariable analysis identified factors associated with major adverse events. RESULTS Six hundred eighty-four patients underwent open thoracoabdominal aortic aneurysm repair. Ninety (13.1%) had Marfan syndrome, whereas 594 (86.9%) did not. Marfan patients were younger (46 years [range, 36-56 years] vs 69 years [range, 61-76 years]; P < .001). Extent II or III aneurysms (57 out of 90 [63.3%] vs 211 out of 594 [35.6%]; P < .001) and type I or III chronic dissection (77 out of 90 [85.3%] vs 242 out of 594 [40.8%]; P < .001) were more common. Cardiovascular risk factors were less frequent in Marfan patients. There was no difference in major adverse events between groups (12 out of 90 [13.3%] vs 100 out of 594 [16.8%]; P = .49). Operative mortality was similar between groups (3 out of 90 [3.3%] vs 28 out of 594 [4.7%]; P = .75). Unweighted survival at 10 years was 78.7% vs 46.8% (P = .001). Weighted Kaplan-Meier curves showed no difference in long-term survival (adjusted hazard ratio, 0.79; 95% CI, 0.32-1.99; P = .62; Log-rank P = .12). At multivariable analysis, renal insufficiency (odds ratio, 2.29; 95% CI, 1.43-3.68; P < .01) and urgent/emergency procedure (odds ratio, 2.17; 95% CI, 1.35-3.48; P < .01) were associated with major adverse events, whereas Marfan syndrome was not (odds ratio, 1.56; 95% CI, 0.69-3.49; P = .28). CONCLUSIONS Open thoracoabdominal aortic aneurysm repair can be performed with similar operative outcomes in patients with and without Marfan syndrome despite differing risk profiles. Operative/perioperative strategies must be tailored to specific needs of each patient to optimize outcomes.
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Affiliation(s)
- Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.
| | - Giovanni Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | | | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Talal Al Zghari
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | | | - Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Mohammad Yaghmour
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
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Doukas P, Bassett C, Krabbe H, Frankort J, Jacobs MJ, Elfeky M, Gombert A. IFABP levels predict visceral malperfusion in the first hours after open thoracoabdominal aortic repair. Front Cardiovasc Med 2023; 10:1200967. [PMID: 37441698 PMCID: PMC10333487 DOI: 10.3389/fcvm.2023.1200967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/16/2023] [Indexed: 07/15/2023] Open
Abstract
Introduction Intestinal ischemia after open thoracoabdominal aortic repairs, is a rare but devastating complication, associated with high mortality. Notoriously challenging to diagnose, visceral malperfusion necessitates immediate surgical attention. Intestinal fatty acid-binding protein (IFABP) has been proposed as a biomarker for the diagnosis of intestinal wall damage. In this prospectively conducted, observational study we evaluated the diagnostic capacity of IFABP levels in patients' serum and their correlation with visceral malperfusion. Methods 23 patients undergoing open thoracoabdominal aortic repairs were included in this study and 8 of them were diagnosed postoperatively with visceral malperfusion-defined as a partial or complete thrombotic occlusion of the superior mesenteric artery and/or the coeliac trunk. IFABP levels and laboratory parameters often associated with intestinal ischemia (leucocytes, CRP, PCT and lactate) were measured at baseline, directly postoperatively, and at 12, 24 and 48 h after surgery. Postoperative visceral malperfusion-as revealed in CT angiography-was assessed and the predictive ability of IFABP levels to detect visceral malperfusion was evaluated with receiver-operator curve analysis. Results Patients with visceral malperfusion had a relevant risk for a fatal outcome (p = .001). IFABP levels were significantly elevated directly postoperatively and at 12 h after surgery in cases of visceral malperfusion. High IFABP concentrations in serum detected visceral malperfusion accurately during the first 12 h after surgery, with the maximum diagnostic ability achieved immediately after surgery (AUC 1, Sensitivity 100%, Specificity 100%, p < .001). Conclusion We conclude, that IFABP measurements during the first postoperative hours after open thoracoabdominal aortic surgery can be a valuable tool for reliable and timely detection of visceral malperfusion.
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Intraoperative Hemoadsorption (Cytosorb™) during Open Thoracoabdominal Aortic Repair: A Pilot Randomized Controlled Trial. J Clin Med 2023; 12:jcm12020546. [PMID: 36675474 PMCID: PMC9866403 DOI: 10.3390/jcm12020546] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/04/2023] [Accepted: 01/09/2023] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The efficacy of cytokine adsorption in controlling the early inflammation cascade after open thoracoabdominal aortic (TAAA) repair has not been investigated. The aim of this pilot randomized controlled trial was to assess the feasibility and effect of perioperative hemoadsorption during open TAAA repair. METHODS Patients scheduled for open TAAA repair with the use of cardiopulmonary bypass (CPB) were included. The patients were randomized the day before surgery to either intraoperative hemoadsorption during CPB or standard of care. RESULTS A total of 10 patients were randomly assigned to the intervention group, whereas the control group consisted of 17 patients (mean age of the total cohort, 51.1 ± 11.2 years, 67% male, 3 patients not randomized). The majority of baseline and perioperative characteristics were similar, and no device-related adverse events were reported. A trend to shorter ventilation times in the intervention group was observed (median 88 h vs. 510 h, p = 0.08, Δ422). Severe acute respiratory distress syndrome was significantly less in the intervention patients (p = 0.02). CONCLUSIONS This is the first pilot study showing that the intraoperative use of hemoadsorption in open TAAA repair patients may be feasible and safe, yet larger trials are needed to evaluate whether intraoperative hemoadsorption is associated with improved clinical outcomes.
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Jonsson M, Blohmé L, Daryapeyma A, Günther A, Lundberg G, Nilsson L, Wahlgren CM, Franco-Cereceda A, Olsson C. Outcomes of descending and thoracoabdominal aortic repair in connective tissue disorder patients. SCAND CARDIOVASC J 2022; 56:352-359. [PMID: 36151718 DOI: 10.1080/14017431.2022.2125174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 08/17/2022] [Accepted: 09/10/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES Open surgical repair (OSR) of descending and thoracoabdominal aortic aneurysms carries risks of mortality and major complications. Patients with connective tissue disorders (CTD) are younger and require safe, efficient treatment with long-term durability. This study provides current outcome data to help inform treatment decisions. METHODS All OSRs of descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) from January 2011 to July 2021 were included in a retrospective cohort study. Primary outcome measures were early and follow-up mortality and reintervention. Secondary outcome measures were major complications. Kaplan-Meier methods were used to estimate reintervention-free survival. RESULTS A total of 26 OSRs (7 DTAA, 19 TAAA) were performed in 23 patients: 20 (77%) Marfan and 6 (23%) Loeys-Dietz syndrome; median age 43 years. Aortic dissection was present in 100% and 3/26 (12%) were urgent. Early mortality was 1/26 (3.8%). No patient suffered spinal cord ischemia, stroke, vocal cord paralysis, or re-exploration for bleeding. The transient respiratory failure occurred in 19% (5/26) and transient renal replacement therapy in 15% (4/26). Renal function normalized in all patients within 3 months. During follow-up (median 4.6, range 0-11 years) there were no deaths and only one re-intervention on a previously operated aortic segment, resulting in 92% reintervention-free survival at 5 years. CONCLUSIONS In dedicated units, open surgical DTAA and TAAA repair in patients with CTD can be performed with a very low risk of death, severe complications and, late re-intervention. For CTD patients with reasonable risk, OSR should remain the first line of treatment.
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Affiliation(s)
- Magnus Jonsson
- Department of Vascular Surgery, Karolinska University Hospital,, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Linus Blohmé
- Department of Vascular Surgery, Karolinska University Hospital,, Stockholm, Sweden
| | - Alireza Daryapeyma
- Department of Vascular Surgery, Karolinska University Hospital,, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Anders Günther
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiothoracic Anesthesia, Karolinska University Hospital, Stockholm, Sweden
| | - Göran Lundberg
- Department of Vascular Surgery, Karolinska University Hospital,, Stockholm, Sweden
| | - Lena Nilsson
- Department of Cardiothoracic Anesthesia, Karolinska University Hospital, Stockholm, Sweden
| | - Carl-Magnus Wahlgren
- Department of Vascular Surgery, Karolinska University Hospital,, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Anders Franco-Cereceda
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Sweden
| | - Christian Olsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Sweden
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Onset of Adverse Abdominal Events Due to Intestinal Ischemia-Reperfusion Injury after Aortic Cross-Clamping Is Associated with Elevated HSP70 Serum Levels in the Early Postoperative Phase. Int J Mol Sci 2022; 23:ijms232315063. [PMID: 36499389 PMCID: PMC9736142 DOI: 10.3390/ijms232315063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/18/2022] [Accepted: 11/28/2022] [Indexed: 12/05/2022] Open
Abstract
Tissue injury of the viscera during open thoracoabdominal aortic (TAA) reconstructions has been reported as the aftermath of the ischemia-reperfusion mechanism following supracoeliac aortic cross-clamping. Abdominal complications after open aortic reconstructions, although rare through the intraoperative implementation of selective visceral artery blood perfusion, are associated with high rates of reinterventions and a poor prognosis. Recent animal experiments demonstrated that provoking mesenteric ischemia in rats induces the leukocyte-mediated transcription of heat-shock protein 70 (HSP70), a chaperone belonging to the danger-associated molecular pattern proteins (DAMPs). Translating these findings clinically, we investigated the serum levels of HSP70 in patients undergoing open aortic reconstructions with supracoeliac clamping. We postoperatively observed a relevant induction of HSP70, which remained significantly elevated in cases of postoperative abdominal complications (paralytic ileus, abdominal compartment syndrome, and visceral malperfusion). The receiver-operator curve analysis revealed the reliable prognostic accuracy of HSP70 as a biomarker for these complications as soon as 12 h post-operation (AUC 0.908, sensitivity 88.9%, specificity 83.3%). In conclusion, measuring HSP70 serum levels in the early postoperative phase may serve as a further adjutant in the diagnostic decision making for both the vascular surgeon and intensivist for the timely detection and management of abdominal complications following open TAA surgery.
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Single-center experience with thoracoabdominal aortic replacement in patients with Marfan syndrome. JTCVS OPEN 2022; 12:13-19. [PMID: 36590731 PMCID: PMC9801283 DOI: 10.1016/j.xjon.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/24/2022] [Accepted: 08/09/2022] [Indexed: 01/04/2023]
Abstract
Objectives Patients with Marfan syndrome are usually not suitable for endovascular repair of the thoracoabdominal aorta. This study was designed to analyze our center's experience with open surgical thoracoabdominal aortic replacement in Marfan patients. Methods This was a retrospective study with prospective follow-up. Between January 1995 and September 2021, a total of 648 patients underwent thoracoabdominal aortic replacement at our center. Of these, 60 had Marfan syndrome and were included in this study. Results The mean age was 39.5 ± 10.7 years, and 36 (60%) were male. Ten (17%) had aortic aneurysm, 4 (7%) acute/subacute dissection, and 46 (77%) chronic dissection. Patients presented with the following extent of aortic disease according to the Crawford classification: I-17 (28%), II-18 (30%), III-22 (37%), IV-2 (3%), and V-1 (2%). The mean cardiopulmonary bypass time was 173.9 ± 84.7 minutes. Four (7%) patients required stent graft extraction. Postoperatively, 5 (8%) patients required rethoracotomy and 6 (10%) tracheostomy. One (1.7%) patient had permanent paraplegia and 2 (3%) permanent paraparesis. Two (3%) patients had stroke. One (1.7%) patient was discharged with dialysis. The 30-day mortality was 3% (n = 2). Median follow-up time was 21.5 (range, 9.4-33.6) years. The 1-, 5-, and 10-year survival rate was 87%, 80%, and 68%, respectively. There were 16 aortic reinterventions in 9 patients during follow-up. Conclusions Thoracoabdominal aortic replacement remains a complex procedure but can be done extremely safely in Marfan patients. Perioperative mortality rates are very low, and the long-term outcomes are enduring. Because endovascular aortic repair is not recommended for patients with connective tissue disease, open surgery remains an important cornerstone of therapy.
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Steinmetz LM, Coselli JS. Endovascular Repair in Patients with Marfan Syndrome: Concerns Amid Controversy. Ann Vasc Surg 2022:S0890-5096(22)00236-9. [PMID: 35595210 DOI: 10.1016/j.avsg.2022.04.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 04/21/2022] [Indexed: 11/25/2022]
Abstract
Endovascular aortic repair is widely used to treat patients with degenerative aneurysms or aortic dissection within the distal aorta. Thoracic endovascular aortic repair (TEVAR) is generally associated with fewer short-term complications than open surgical repair, which is particularly important for older patients with significant comorbid conditions. However, for patients with Marfan syndrome, a heritable thoracic aortic disease associated with aortic dilatation, dissection, and rupture, the utility of endovascular aortic repair remains questionable. Marfan patients have friable aortic tissue and are typically treated at a relatively young age; they therefore need a durable solution. Furthermore, those who need distal aortic repair tend to have chronic aortic dissection. Although TEVAR is generally superior to open surgery with regard to short-term complications, it is less durable, and TEVAR reintervention rates are highest in patients with chronic aortic dissection. Thus, Marfan patients seeking definitive aortic repair are often better served by open repair. Nonetheless, TEVAR may be useful in patients with Marfan syndrome as a bridge to open repair or as treatment for late complications of previous open repair.
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Affiliation(s)
- Leah M Steinmetz
- Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas, USA; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas, USA.
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Outcome of elective and emergency open thoracoabdominal aortic aneurysm repair in 255 cases-a retrospective single center study. Eur J Vasc Endovasc Surg 2022; 63:578-586. [DOI: 10.1016/j.ejvs.2022.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 01/27/2022] [Accepted: 02/01/2022] [Indexed: 11/22/2022]
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6548221. [DOI: 10.1093/ejcts/ezac137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 02/03/2022] [Accepted: 02/26/2022] [Indexed: 11/14/2022] Open
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Buja LM, Schoen FJ. The pathology of cardiovascular interventions and devices for coronary artery disease, vascular disease, heart failure, and arrhythmias. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00024-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Rolles B, Wessels I, Doukas P, Kotelis D, Rink L, Vieri M, Beier F, Jacobs M, Gombert A. Retrospective observational study evaluating zinc plasma level in patients undergoing thoracoabdominal aortic aneurysm repair and its correlation with outcome. Sci Rep 2021; 11:24348. [PMID: 34934131 PMCID: PMC8692510 DOI: 10.1038/s41598-021-03877-6] [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: 09/30/2021] [Accepted: 12/06/2021] [Indexed: 01/08/2023] Open
Abstract
Thoracoabdominal aortic aneurysm (TAAA) repair is related to a relevant morbidity and in-hospital mortality rate. In this retrospective observational single-center study including serum zinc levels of 33 patients we investigated the relationship between zinc and patients’ outcome following TAAA repair. Six patients died during the hospital stay (18%). These patients showed significantly decreased zinc levels before the intervention (zinc levels before intervention: 60.09 µg/dl [survivors] vs. 45.92 µg/dl [non-survivors]). The post-interventional intensive care SOFA-score (Sepsis-related organ failure assessment) (at day 2) as well as the SAPS (Simplified Acute Physiology Score) (at day 2) showed higher score points in case of low pre-interventional zinc levels. No significant correlation between patient comorbidities and zinc level before intervention, except for peripheral arterial disease (PAD), which was significantly correlated to reduced baseline zinc levels, was observed. Septic shock, pneumonia and urinary tract infections were not associated to reduced zinc levels preoperatively as well as during therapy. Patients with adverse outcome after TAAA repair showed reduced pre-interventional zinc levels. We speculate that decreased zinc levels before intervention may be related to a poorer outcome because of poorer physical status as well as negatively altered perioperative inflammatory response.
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Affiliation(s)
- Benjamin Rolles
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.,Center for Integrated Oncology, Aachen Bonn Cologne Duesseldorf (CIO ABCD), Cologne, Germany.,Institute of Immunology, Faculty of Medicine, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Inga Wessels
- Institute of Immunology, Faculty of Medicine, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Panagiotis Doukas
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany
| | - Drosos Kotelis
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany
| | - Lothar Rink
- Institute of Immunology, Faculty of Medicine, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Margherita Vieri
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.,Center for Integrated Oncology, Aachen Bonn Cologne Duesseldorf (CIO ABCD), Cologne, Germany
| | - Fabian Beier
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.,Center for Integrated Oncology, Aachen Bonn Cologne Duesseldorf (CIO ABCD), Cologne, Germany
| | - Michael Jacobs
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany
| | - Alexander Gombert
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany.
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Gombert A, Ketting S, Rückbeil MV, Hundertmark AK, Barbati M, Keschenau P, Pedersoli F, Schurink GW, Mees B, Kotelis D, Jacobs MJ. Perioperative and long-term outcome after ascending aortic and arch repair with elephant trunk and open thoracoabdominal aortic aneurysm repair. J Vasc Surg 2021; 75:824-832. [PMID: 34606958 DOI: 10.1016/j.jvs.2021.09.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 09/12/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To describe the outcome of open thoracoabdominal aortic aneurysm (TAAA) repair following previous aortic arch repair including elephant trunk (ET) or frozen elephant trunk (FET) for acute and chronic pathologies. METHODS This was a retrospective, observational, multicenter study including 32 patients treated between 2006 and 2019 in two aortic centers using identical surgical protocols. Assessment focused on perioperative and long-term outcome, namely in-hospital morbidity and mortality, as well as procedure-related reintervention rate and aortic-related mortality rate. Kaplan-Meier curves with 95% confidence intervals were used to analyze the overall survival after surgery within the cohort. RESULTS Thirty-two patients (mean age, 45.0 ± 13.6 years; 20 males [62.5%]) were treated because of acute (34.38% [n = 11]) or chronic (65.62% [n = 21]) aortic pathologies, including residual dissection following acute, symptomatic type A dissection (n = 7) and symptomatic mega aortic syndrome (n = 4), as well as post-dissection TAAA (n = 18) and asymptomatic mega aortic syndrome (n = 3). Twenty-eight patients (87.5%) received type II repair, and 4 patients (12.5%) received type III repair after previous ascending aorta and arch repair including ET/FET. Concomitant infrarenal and iliac vessel repair was performed in 38.7% (n = 12) and 29.4% (n = 10), respectively. The in-hospital mortality rate was 18.75% (n = 6). Spinal cord ischemia occurred in two cases, both after one-stage emergency procedure with one case of permanent paraplegia. Temporary acute kidney injury occurred in 41.94% (n = 13). The estimated 1-year survival rate was 78.1% (95% confidence interval, 63.9%-95.6%), with a median follow-up time of 1.29 years (interquartile range, 0.26-3.88 years). No procedure-related reinterventions and one case of aortic-related mortality, namely sepsis because of graft infection, was observed. CONCLUSIONS Open TAAA repair following aortic arch repair including ET or FET because of acute or chronic aortic pathologies is associated with a relevant perioperative morbidity and mortality rate. During follow-up, a low aortic-related mortality rate and procedure-related reintervention rate were observed.
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Affiliation(s)
- Alexander Gombert
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Aachen, Germany.
| | - Shirley Ketting
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marcia Viviane Rückbeil
- Department of Medical Statistics, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Ann-Kathrin Hundertmark
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Mohammad Barbati
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Paula Keschenau
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Federico Pedersoli
- Department of Radiology, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Geert W Schurink
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Barend Mees
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Drosos Kotelis
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Michael J Jacobs
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Aachen, Germany; Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
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Harky A, Hussain SMA, MacCarthy-Ofosu B, Ahmad MU. The Role of Thoracic Endovascular Aortic Repair (TEVAR) of Thoracic Aortic Diseases in Patients with Connective Tissue Disorders - A Literature Review. Braz J Cardiovasc Surg 2020; 35:977-985. [PMID: 33306324 PMCID: PMC7731863 DOI: 10.21470/1678-9741-2019-0367] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To review the currently available literature to define the role of thoracic endovascular aortic repair (TEVAR) in patients with connective tissue disorders (CTD). METHODS A comprehensive electronic database search was performed in PubMed, SCOPUS, Embase, Google scholar, and OVID to identify all the articles that reported on outcomes of utilizing TEVAR in patients with CTD during elective and emergency settings. The search was not limited to time or language of the published study. RESULTS All the relevant studies have been summarized in its correspondence section. The outcomes were analyzed in narrative format. The role of TEVAR has been elaborated as per each study. Currently, there is limited large cohort size studies outlining the use of TEVAR in patients with CTD. The use of endovascular repair in patients with CTD is limited due to progressive aortic dilatations and high possibility of further reinterventions at later stage of life. CONCLUSION Open repair remains the gold standard method of intervention in young patients with progressive CTD, especially in the setting of acute type A aortic dissection. However, TEVAR can be sought as a reliable alternative in emergency setting of diseases involving the descending thoracic aorta; yet the long-term data needs to be published to support such practice.
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Affiliation(s)
- Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK
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Zechendorf E, Gombert A, Bülow T, Frank N, Beckers C, Peine A, Kotelis D, Jacobs MJ, Marx G, Martin L. The Role of Ribonuclease 1 and Ribonuclease Inhibitor 1 in Acute Kidney Injury after Open and Endovascular Thoracoabdominal Aortic Aneurysm Repair. J Clin Med 2020; 9:jcm9103292. [PMID: 33066382 PMCID: PMC7602227 DOI: 10.3390/jcm9103292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/11/2020] [Accepted: 10/12/2020] [Indexed: 11/16/2022] Open
Abstract
Acute kidney injury (AKI) is one of the most common post-operative complications and is closely associated with increased mortality after open and endovascular thoracoabdominal aortic aneurysm (TAAA) repair. Ribonuclease (RNase) 1 belongs to the group of antimicrobial peptides elevated in septic patients and indicates the prediction of two or more organ failures. The role of RNase 1 and its antagonist RNase inhibitor 1 (RNH1) after TAAA repair is unknown. In this study, we analyzed RNase 1 and RNH1 serum levels in patients undergoing open (n = 14) or endovascular (n = 19) TAAA repair to determine their association with post-operative AKI and in-hospital mortality. Increased RNH1 serum levels after open TAAA repair as compared with endovascular TAAA repair immediately after surgery and 12, 48, and 72 h after surgery (all p < 0.05) were observed. Additionally, elevated RNase 1 and RNH1 serum levels 12, 24, and 48 h after surgery were shown to be significantly associated with AKI (all p < 0.05). RNH1 serum levels before and RNase 1 serum levels 12 h after TAAA repair were significantly correlated with in-hospital mortality (both p < 0.05). On the basis of these findings, RNase 1 and RNH1 may be therapeutically relevant and may represent biomarkers for post-operative AKI and in-hospital mortality.
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Affiliation(s)
- Elisabeth Zechendorf
- Department of Intensive Care and Intermediate Care, University Hospital RWTH Aachen, 52062 Aachen, Germany; (E.Z.); (N.F.); (C.B.); (A.P.); (G.M.)
| | - Alexander Gombert
- European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, 52062 Aachen, Germany; (A.G.); (D.K.); (M.J.J.)
| | - Tanja Bülow
- Department of Medical Statistics, University Hospital RWTH Aachen, 52062 Aachen, Germany;
| | - Nadine Frank
- Department of Intensive Care and Intermediate Care, University Hospital RWTH Aachen, 52062 Aachen, Germany; (E.Z.); (N.F.); (C.B.); (A.P.); (G.M.)
| | - Christian Beckers
- Department of Intensive Care and Intermediate Care, University Hospital RWTH Aachen, 52062 Aachen, Germany; (E.Z.); (N.F.); (C.B.); (A.P.); (G.M.)
| | - Arne Peine
- Department of Intensive Care and Intermediate Care, University Hospital RWTH Aachen, 52062 Aachen, Germany; (E.Z.); (N.F.); (C.B.); (A.P.); (G.M.)
| | - Drosos Kotelis
- European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, 52062 Aachen, Germany; (A.G.); (D.K.); (M.J.J.)
| | - Michael J. Jacobs
- European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, 52062 Aachen, Germany; (A.G.); (D.K.); (M.J.J.)
| | - Gernot Marx
- Department of Intensive Care and Intermediate Care, University Hospital RWTH Aachen, 52062 Aachen, Germany; (E.Z.); (N.F.); (C.B.); (A.P.); (G.M.)
| | - Lukas Martin
- Department of Intensive Care and Intermediate Care, University Hospital RWTH Aachen, 52062 Aachen, Germany; (E.Z.); (N.F.); (C.B.); (A.P.); (G.M.)
- Correspondence: ; Tel.: +49-(0)-241-8037606
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Gombert A, Kotelis D, Rückbeil MV, Barbati M, Martin L, Marx G, Grommes J, Jacobs MJ, Schälte G. Increase of urinary TIMP-2 and IGFBP7 as potential predictor of acute kidney injury requiring renal replacement therapy and patients' outcome following complex endovascular and open thoracic abdominal aortic aneurysm surgery - a prospective observational study. VASA 2020; 50:101-109. [PMID: 32815460 DOI: 10.1024/0301-1526/a000902] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: Acute kidney injury (AKI) as complication after open and endovascular repair of thoracoabdominal aortic aneurysm (TAAA) is one major predictor of mortality and postoperative complications. We evaluated tissue inhibitor of metalloproteinase 2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7) as combined early biomarker for AKI detection and predictor of patients' outcome. Patients and methods: Between 2014 and 2015, 52 patients have been enrolled in this observational study, of whom 29 (55.8%) underwent elective open repair and 23 (44.2%) endovascular repair. TIMP2 × IGFBP7 were measured until 48 hours after admission on intensive-care unit (ICU) and were analyzed regarding their predictive ability for AKI (defined according to the KDIGO criteria) requiring temporary renal replacement therapy (RRT) and 90-day mortality using ROC curves. Results: Mean patient age was 64.5 years (Min: 43, Max: 85), endovascular treated patients were older (p <0.0001). 40.4% (n = 21) developed AKI, and 21.2% (n = 11) required renal replacement therapy. In-hospital and total mortality rates were 7.7% (n = 4) and 9.6% (n = 5), respectively. At no time a significant difference in TIMP2 × IGFB7 levels between patients undergoing open or endovascular surgery was observed. The predictive quality of the TIMP2 × IGFBP7 value on ICU admission was sound regarding AKI requiring temporary renal replacement therapy (sensitivity: 55.56% [38.1-72.1%], specificity: 90.91% [58.7-99.8%] with an area under the curve [AUC]: 0.694 [0.543-0.820]). Mean follow-up was 13.2 months (Min: 2, Max: 20), regarding the 90-day mortality, the predictive property of the TIMP2 × IGFBP7 value was not sufficient (sensitivity: 80% [28.4-99.5%], specificity: 52.38% [36.4-68%], and AUC: 0.607 [0.454-0.746]). Conclusions: TIMP2 × IGFBP7 level measured 6-12 hrs postoperatively may be useful as an early detectable biomarker for AKI requiring temporary renal replacement therapy. It seems not suited to predict patients' outcome following complex thoracoabdominal aortic surgery, regardless if performed by open or endovascular repair.
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Affiliation(s)
- Alexander Gombert
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Germany
| | - Drosos Kotelis
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Germany
| | - Marcia V Rückbeil
- Department of Medical Statistics, University Hospital Aachen, RWTH Aachen University, Germany
| | - Mohammad Barbati
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Germany
| | - Lukas Martin
- Department of Intensive Care and Intermediate Care, University Hospital Aachen, RWTH Aachen University, Germany
| | - Gernot Marx
- Department of Intensive Care and Intermediate Care, University Hospital Aachen, RWTH Aachen University, Germany
| | - Jochen Grommes
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Germany
| | - Michael J Jacobs
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Germany
| | - Gereon Schälte
- Department of Anesthesiology, University Hospital Aachen, RWTH Aachen University, Germany
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Cho JW, Choo SJ, Lee CH, Kim HJ, Kim JB, Jung SH, Chung CH, Shinn SH, Lee JW. A 10-year study of surgical results of descending aorta aneurysm repair following chronic aortic dissection. J Vasc Surg 2020; 72:1288-1297. [PMID: 32723689 DOI: 10.1016/j.jvs.2020.01.047] [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: 05/20/2019] [Accepted: 01/13/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients presenting with descending aortic aneurysms developing after aortic dissection often undergo continued aortic expansion which may require operative interventions to address the risk of aortic rupture. In light of the current advances in various treatment options, including endovascular approaches, we analyzed our experience with open surgical repair (OSR) of aneurysms of the descending aorta following aortic dissection. METHODS Patients who underwent open repair for aneurysmal changes of the descending aorta after chronic dissection were retrospectively studied. The 30-day operative mortality rate, midterm survival, and major complications were analyzed. Patients were divided into two categories; primary chronic type B aortic dissection and remnant repaired type A aortic dissection (RTAAD). RESULTS There were 149 patients with enlargement of the descending thoracic aorta developing after aortic dissection. Of these, 49 patients had medical management, while the remaining 100 patients received OSR. These patients were included in the present analysis. The 30-day mortality and permanent paraplegia rates were 9% and 4%, respectively. The 1-, 3-, and 5-year survival rates were 83%, 80.9%, and 76.1%, respectively. The 1- and 5-year survival rates between the primary chronic type B aortic dissection and remnant RTAAD groups showed no significant between-group differences at 86.7% and 84.3%, and 80% and 71.3%, respectively (P = .289). The overall outcomes of other complications such as renal injury, bleeding reoperation, and extracorporeal membrane oxygenation support showed no significant between-group differences, including an insignificantly higher neurologic complication rate in the remnant RTAAD group. The survival rate in patients with Marfan syndrome was significantly higher than in the patients without Marfan syndrome (P = .033). CONCLUSIONS OSR for descending aortic aneurysms developing after chronic aortic dissection showed good early and mid- to long-term outcomes, with acceptably low complication rates. OSR for descending aortic aneurysm after chronic aortic dissection associated with Marfan syndrome also showed good early and mid- to long-term outcomes.
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Affiliation(s)
- Jun Woo Cho
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Catholic University of Daegu, Daegu, South Korea
| | - Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
| | - Chul Ho Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ho Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Cheol Hyun Chung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung Ho Shinn
- Department of Thoracic and Cardiovascular Surgery, Cheju Halla General Hospital, Cheju, South Korea
| | - Jae Won Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Gombert A, Rückbeil MV, Kotelis D, Bürger S, Brugmayer T, Mess WH, Jacobs MJ. Assessment of Neurone-Specific Enolase, Glial Fibrillary Acidic Protein and S100 B as Spinal Cord Ischemia Biomarkers in Patients Undergoing Open and Endovascular Complex Aortic Surgery: A Single-Center Experience. Ann Vasc Surg 2020; 66:424-433. [DOI: 10.1016/j.avsg.2020.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/30/2019] [Accepted: 01/02/2020] [Indexed: 12/15/2022]
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Jayarajan SN, Downing BD, Sanchez LA, Jim J. Trends of vascular surgery procedures in Marfan syndrome and Ehlers-Danlos syndrome. Vascular 2020; 28:834-841. [DOI: 10.1177/1708538120925597] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives Marfan syndrome and Ehlers-Danlos syndrome represent two connective tissue vascular diseases requiring unique consideration in their vascular surgical care. A comprehensive national review encompassing all hospitalizations for the Marfan Syndrome and Ehlers-Danlos syndrome patient population is lacking. Methods The National (Nationwide) Inpatient Sample from 2010 to 2014 was reviewed for all inpatient vascular surgery procedures including those with a diagnosis of Marfan syndrome and Ehlers-Danlos syndrome. National estimates of vascular surgery rates were generated from provided weights. Patient demographics, procedure type, and outcomes were assessed. Results There were 3103 Marfan syndrome and 476 Ehlers-Danlos syndrome vascular procedures identified as well as 3,895,381 vascular procedures in the remainder of population (control group). The percent of aortic procedures from all vascular procedures in Marfan syndrome (23.5%) and Ehlers-Danlos syndrome (23.5%) were 2.5-fold higher than controls (9.1%), p < 0.0001. Open aortic aneurysm repair was also significantly greater in both Marfan syndrome (16.8%) and Ehlers-Danlos syndrome (11.2%) compared to controls (4.4%), p < 0.0001. Endovascular aortic repair ( p < 0.2302) was similar among the groups. Marfan syndrome (7.7%) and Ehlers-Danlos syndrome (5.1%) had more thoracic endovascular aortic repair performed than controls (0.7%), p < 0.0001. Percutaneous procedures were fewer in Marfan syndrome (6.3%) than controls (31.3%) and Ehlers-Danlos syndrome (26.3%), p < 0.0001, while repair of peripheral arteries was greater in Marfan syndrome (5.9%) and Ehlers-Danlos syndrome (4.1%) than controls (1.5%), p < 0.0001. For total aortic procedures, the mean age of aortic procedures was 68.2 years in controls vs 45.8 years in Marfan syndrome and 55.3 years in Ehlers-Danlos syndrome, p < 0.0001. Marfan syndrome and Ehlers-Danlos syndrome had fewer comorbidities overall, while controls had significantly higher rates of coronary artery disease (controls 39.9% vs Marfan syndrome 8.3% and Ehlers-Danlos syndrome 13.0%, p < 0.0001), peripheral vascular disease (controls 34.5% vs Marfan syndrome 4.2% and Ehlers-Danlos syndrome 8.7%, p < 0.0001), and diabetes (controls 20.6% vs Marfan syndrome 6.6 and Ehlers-Danlos syndrome 4.4%, p < 0.0001). Marfan syndrome and Ehlers-Danlos syndrome had higher overall complication rate (65.5% and 52.2%) compared to controls (44.6%), p < 0.0001. Postoperative hemorrhage was more likely in Marfan syndrome (42.9%) and Ehlers-Danlos syndrome (39.1%) than controls (22.2%), p < 0.0001. Increased respiratory failure was noted in Marfan syndrome (20.2%) vs controls (10.7%) and Ehlers-Danlos syndrome (8.7%), p = .0003. Finally, length of stay was increased in Marfan syndrome 12.5 days vs Ehlers-Danlos syndrome 7.4 days and controls 7.2 days ( p < 0.0001) as well as a higher median costs of index hospitalization in Marfan syndrome ($57,084 vs Ehlers-Danlos syndrome $22,032 and controls $26,520, p < 0.0001). Conclusions Patients with Marfan syndrome and Ehlers-Danlos syndrome differ from other patients undergoing vascular surgical procedures, with a significantly higher proportion of aortic procedures including open aneurysm repair and thoracic endovascular aortic repair. While they are younger with fewer comorbidities, due to the unique pathogenesis of their underlying connective tissue disorder, there is an overall higher rate of procedural complications and increased length of stay and cost for Marfan syndrome patients undergoing aortic surgery.
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Affiliation(s)
- Senthil N Jayarajan
- Section of Vascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Brandon D Downing
- Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Luis A Sanchez
- Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jeffrey Jim
- Section of Vascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA
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Cervino G, Cicciù M, De Stefano R, Falcomatà D, Bianchi A, Crimi S, Laino L, Herford AS, Gaeta M, Fiorillo L. Oral health in patients with Marfan syndrome. Arch Oral Biol 2020; 116:104745. [PMID: 32446937 DOI: 10.1016/j.archoralbio.2020.104745] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 04/03/2020] [Accepted: 04/30/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The role of this study is to highlight a correlation between patients with Marfan syndrome and oral health status by evaluating and reviewing the relevant scientific literature. The syndrome is characterized by an abnormal production of the fibrillin1 protein. The manifestations of Marfan syndrome affect organs that contain connective tissue such as the skeletal system, the eyes, the heart and the blood vessels, the lungs and the fibrous membranes that cover the brain and the spine. The facial bony and soft structures can therefore be affected, influencing the stage of tooth formation and the structure of the teeth, we also want to analyze in this study, the periodontal complications and the management of the latter, with the use of surgical techniques that include the use of biomaterials. MATERIALS AND METHODS A comprehensive review of the literature was conducted according to PRISMA guidelines. After a careful analysis of the work obtained by two independent academics, there have been 18. All data from the studies were compared and many of these highlighted the presence of abnormalities in the oral district. RESULTS The studies taken into consideration a whole series of oral manifestations related to the Marfan syndrome. Oral mucosa, periodontal, dental abnormalities, bone abnormalities or joint dysfunction are frequently involved in patients affected by this disease. CONCLUSIONS All the research have given positive results in terms of dental or oral anomalies. This information may be essential to limit and intervene early improving the oral health of syndromic patients.
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Affiliation(s)
- Gabriele Cervino
- Department of Biomedical and Dental Sciences, Morphological and Functional Images, School of Dentistry, University of Messina, ME, Italy
| | - Marco Cicciù
- Department of Biomedical and Dental Sciences, Morphological and Functional Images, School of Dentistry, University of Messina, ME, Italy
| | - Rosa De Stefano
- Department of Biomedical and Dental Sciences, Morphological and Functional Images, University of Messina, ME, Italy
| | - Domenico Falcomatà
- Department of Biomedical and Dental Sciences, Morphological and Functional Images, School of Dentistry, University of Messina, ME, Italy
| | - Alberto Bianchi
- Department of General Surgery and Medical-Surgery Specialities, University of Catania, 95100 Catania CT, Italy
| | - Salvatore Crimi
- Department of General Surgery and Medical-Surgery Specialities, University of Catania, 95100 Catania CT, Italy
| | - Luigi Laino
- Department of Biomedical and Surgical, Biomedical Sciences Naples University, Naples, NA, Italy
| | - Alan Scott Herford
- Department of Maxillofacial Surgery, Loma Linda University, Loma Linda, CA 92354, USA
| | - Michele Gaeta
- Department of Biomedical and Dental Sciences, Morphological and Functional Images, University of Messina, ME, Italy
| | - Luca Fiorillo
- Department of Biomedical and Dental Sciences, Morphological and Functional Images, School of Dentistry, University of Messina, ME, Italy.
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Frankel WC, Song HK, Milewski RK, Shalhub S, Pugh NL, Eagle KA, Roman MJ, Pyeritz RE, Maslen CL, Ravekes WJ, Milewicz DM, Coselli JS, LeMaire SA, Asch F, Bavaria J, Desvigne-Nickens P, Devereux R, Dietz H, Eagle K, Habashi J, Holmes K, Kroner B, LeMaire S, McDonnell N, Maslen C, Milewicz D, Milewski R, Morris S, Prakash S, Pyeritz R, Ravekes W, Roman M, Shohet R, Silberbach GM, Song H, Tolunay HE, Tseng H, Weinsaft J. Open Thoracoabdominal Aortic Repair in Patients With Heritable Aortic Disease in the GenTAC Registry. Ann Thorac Surg 2020; 109:1378-1384. [DOI: 10.1016/j.athoracsur.2019.08.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 07/18/2019] [Accepted: 08/15/2019] [Indexed: 01/14/2023]
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Gombert A, Doukas P, Marx G, Hartmann O, Bergmann D, Schulte J, Stoppe C, Jacobs M, Simon T. Postoperatively increased bioactive adrenomedullin is related to adverse outcome after complex aortic surgery. VASA 2020; 49:187-194. [DOI: 10.1024/0301-1526/a000848] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Summary: Background: Open and endovascular thoracoabdominal aortic aneurysm repair is related to major complications and increased mortality rates. Up to now, specific biomarkers for adverse outcome are scarce, although routine usage of such biomarkers could enable an earlier and more appropriate treatment of complications during the postoperative course after complex aortic aneurysm repair. Patients and methods: In a prospective single-center study including 33 patients (48.5 % women, mean age 63.0 ± 16.2 years) undergoing elective complex open and endovascular aortic aneurysm repair, bioactive adrenomedullin (bio-ADM) was measured for 72 h perioperatively and an association with clinical endpoints, namely cardiogenic shock, death and the combined endpoint of the two aforementioned parameters was assessed. Furthermore, the association between bio-ADM and baseline characteristics and perioperative details including sepsis biomarkers score were assessed. Results: 51.5 % (n = 17) of patients developed postoperative acute kidney injury, 21.2 % (n = 7) pneumonia and 18.2 % (n = 6) sepsis. Cardiogenic shock was observed in 12.1 % (n = 4) patients. The in-hospital mortality rate was 18.2 % (n = 6), and 24.2 % (n = 8) of patients developed cardiogenic shock and/or died in hospital. A significant correlation of bio-ADM concentrations from all available time points was observed with leukocytes (r = 0.37, P < 0.0001), C-reactive protein (r = 0.56, P < 0.001) and serum creatinine levels (r = 0.52, P < 0.001). Increased bio-ADM at 12 h, 24 h, 48 h and 72 h after admission to ICU was associated with both, in-hospital death and cardiogenic shock, with an area under the curve for the combined endpoint of 0.598, 0.720, 0.880 and 0.967. Bio-ADM concentrations at 48 h and 72 h after admission to ICU were predictive for in-hospital death and cardiogenic shock (both P < 0.01). Conclusions: Bio-ADM may serve as postoperative biomarker for cardiogenic shock and death after complex open and endovascular aortic aneurysm repair, potentially enabling an earlier and by that more adequate treatment of adverse outcome after major surgery.
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Affiliation(s)
- Alexander Gombert
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Germany
| | - Panagiotis Doukas
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Germany
| | - Gernot Marx
- Department of Intensive Care and Intermediate Care, University Hospital Aachen, RWTH Aachen University, Germany
| | | | | | | | - Christian Stoppe
- Department of Intensive Care and Intermediate Care, University Hospital Aachen, RWTH Aachen University, Germany
| | - Michael Jacobs
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Germany
| | - Tim Simon
- Department of Intensive Care and Intermediate Care, University Hospital Aachen, RWTH Aachen University, Germany
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SLPI - a Biomarker of Acute Kidney Injury after Open and Endovascular Thoracoabdominal Aortic Aneurysm (TAAA) Repair. Sci Rep 2020; 10:3453. [PMID: 32103084 PMCID: PMC7044192 DOI: 10.1038/s41598-020-60482-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 02/13/2020] [Indexed: 11/08/2022] Open
Abstract
Acute kidney injury (AKI) is a relevant complication following thoracoabdominal aortic aneurysm repair (TAAA). Biomarkers, such as secretory leucocyte peptidase inhibitor (SLPI), may enable a more accurate diagnosis. In this study, we tested if SLPI measured in serum is an appropriate biomarker of AKI after TAAA repair. In a prospective observational single-center study including 33 patients (51.5% women, mean age 63.0 ± 16.2 years) undergoing open and endovascular aortic aneurysm repair in 2017, SLPI was measured peri-operatively (until 72 h after surgery). After surgery, the postoperative complications AKI, as defined according to the KDIGO diagnostic criteria, sepsis, death, MACE (major cardiovascular events) and, pneumonia were assessed. In a subgroup analysis, patients with preexisting kidney disease were excluded. Of 33 patients, 51.5% (n = 17) of patients developed AKI. Twelve hours after admission to the intensive care unit (ICU), SLPI serum levels were significantly increased in patients who developed AKI. Multivariable logistic regression revealed a significant association between SLPI 12 hours after admission to ICU and AKI (P = 0.0181, OR = 1.055, 95% CI = 1.009-1.103). The sensitivity of SLPI for AKI prediction was 76.47% (95% CI = 50.1-93.2) and the specificity was 87.5% (95% CI = 61.7-98.4) with an AUC = 0.838 (95% CI = 0.7-0.976) for an optimal cut-off 70.03 ng/ml 12 hours after surgery. In patients without pre-existing impaired renal function, an improved diagnostic quality of SLPI for AKI was observed (Sensitivities of 45.45-91.67%, Specificities of 77.7-100%, AUC = 0.716-0.932). There was no association between perioperative SLPI and the incidence of sepsis, death, MACE (major cardiovascular events), pneumonia. This study suggests that SLPI might be a post-operative biomarker of AKI after TAAA repair, with a superior diagnostic accuracy for patients without preexisting impaired renal function.
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Open surgical thoracoabdominal aortic aneurysm repair: The Heidelberg experience. J Thorac Cardiovasc Surg 2018; 156:2067-2073. [DOI: 10.1016/j.jtcvs.2018.05.081] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 04/24/2018] [Accepted: 05/01/2018] [Indexed: 01/18/2023]
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Treatment of thoracoabdominal aortic disease in patients with connective tissue disorders. J Vasc Surg 2018; 68:1257-1267. [DOI: 10.1016/j.jvs.2018.06.199] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 06/21/2018] [Indexed: 11/21/2022]
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Gombert A, Prior I, Martin L, Grommes J, Barbati ME, Foldenauer AC, Schälte G, Marx G, Schürholz T, Greiner A, Jacobs MJ, Kalder J. Urine neutrophil gelatinase-associated lipocalin predicts outcome and renal failure in open and endovascular thoracic abdominal aortic aneurysm surgery. Sci Rep 2018; 8:12676. [PMID: 30140016 PMCID: PMC6107559 DOI: 10.1038/s41598-018-31183-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 08/13/2018] [Indexed: 12/15/2022] Open
Abstract
Urine neutrophil gelatinase–associated lipocalin (uNGAL) has been evaluated as a biomarker for AKI detection and adverse outcome in open and endovascular thoracoabdominal aortic aneurysm surgery. This observational, retrospective study included 52 patients. UNGAL was measured peri-operatively (48 h) and correlated with AKI requiring dialysis, tracheotomy and adverse outcome. Mean patients’ age was 64.5 years. A total of 26.9% (n = 14) developed AKI, and 21.1% (n = 11) required dialysis, tracheotomy rate was 19.2% (n = 10) and in-hospital mortality rate was 7.6% (n = 4). uNGAL levels were related to AKI requiring dialysis at ICU (p = 0.0002), need for tracheotomy at baseline and admission on ICU (p = 0.0222, p = 0.0028, respectively), as well as adverse discharge modality (p = 0.0051, p = 0.0048, respectively). Diagnostic quality was good for uNGAL levels at admission to ICU regarding AKI requiring dialysis (sensitivity: 81.8% [48.2–97.7]; specificity: 87.8% [73.8–95.9]; area under the curve (AUC): 0.874 [0.752–0.949]). The diagnostic quality of uNGAL was favorable for the prediction of tracheotomy (sensitivity: 70.0% [34.8–93.3]; specificity: 83.3% [68.6–93.0]; AUC: 0.807 [0.674–0.903]) and adverse discharge (sensitivity: 77.8% [40.0–97.2]; specificity: 83.7% [69.3–93.2]; AUC: 0.817 [0.685–0.910]). uNGAL may be valuable as an post-operative predictor of AKI and adverse outcome after open and endovascular TAAA repair.
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Affiliation(s)
- A Gombert
- European Vascular Center Aachen, University Hospital Aachen, RWTH Aachen University, Maastricht, Germany.
| | - I Prior
- European Vascular Center Aachen, University Hospital Aachen, RWTH Aachen University, Maastricht, Germany
| | - L Martin
- Department of Intensive Care and Intermediate Care, University Hospital Aachen, RWTH Aachen University, Maastricht, Germany
| | - J Grommes
- European Vascular Center Aachen, University Hospital Aachen, RWTH Aachen University, Maastricht, Germany
| | - M E Barbati
- European Vascular Center Aachen, University Hospital Aachen, RWTH Aachen University, Maastricht, Germany
| | - A C Foldenauer
- Department of Medical Statistics, University Hospital Aachen, RWTH Aachen University, Maastricht, Germany
| | - G Schälte
- Department of Anesthesiology, University Hospital Aachen, RWTH Aachen University, Maastricht, Germany
| | - G Marx
- Department of Intensive Care and Intermediate Care, University Hospital Aachen, RWTH Aachen University, Maastricht, Germany
| | - T Schürholz
- Department of Anaesthesia and Intensive Care, University of Rostock, Rostock, Germany
| | - A Greiner
- Department of Vascular Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - M J Jacobs
- European Vascular Center Aachen, University Hospital Aachen, RWTH Aachen University, Maastricht, Germany
| | - J Kalder
- European Vascular Center Aachen, University Hospital Aachen, RWTH Aachen University, Maastricht, Germany
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Editor's Choice – Open Thoracic and Thoraco-abdominal Aortic Repair After Prior Endovascular Therapy. Eur J Vasc Endovasc Surg 2018; 56:57-67. [DOI: 10.1016/j.ejvs.2018.03.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 03/12/2018] [Indexed: 11/18/2022]
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Tinelli G, Ferraresi M, Watkins AC, Hertault A, Soler R, Azzaoui R, Fabre D, Sobocinski J, Haulon S. Aortic treatment in connective tissue disease. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 60:518-525. [PMID: 29943958 DOI: 10.23736/s0021-9509.18.10443-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Connective tissue disease (CTD) represents a group of genetic conditions characterized by disruptive matrix remodeling. When this process involves aortic and vascular wall, patients with CTD have a high risk of developing arterial aneurysms, dissections and ruptures. Open surgical repair is still the gold standard therapy for patients with CTD with reasonable morbidity and mortality risk. The surgical treatment of CTD often requires multiple operations. In the endovascular era, fenestrated and branched stent grafts may play a role in reducing the complications of multiple open operations. Although the long-term results of endovascular treatment in the setting of CTD are unknown, it is generally accepted that endovascular treatment is restricted to selected patients with high surgical risk. In an emergency setting, endovascular intervention can serve as a lifesaving bridge to elective open aortic repair. Aortic centers performing a large volume of complex open and endovascular aortic repairs have started to combine these two techniques in a staged fashion. The goal is to reduce the morbidity and mortality associated with extensive aortic repairs in CTD patients. For this reason, recommend endovascular therapy when a "graft-to-graft" approach is possible. In this scenario, the surgeon who performs the open repair must take into consideration future interventions. Surgical repair in any aortic segment should allow creation of proximal and distal landing zones over 4 cm to secure the sealing of a future stent graft. Connective tissue disease should be treated with a multidisciplinary approach, in high volume centers. Endovascular treatment represents a potential option in patients at high risk for open repair. Staged hybrid procedures have emerged as a way to reduce spinal cord ischemia and avoid multiple open surgeries. The aim of this article is to discuss the management of aortic diseases in CTD, focusing on to the role of standard open surgery and emerging endovascular treatment, and to give an overview of the few series published regarding this topic with a small number of patients.
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Affiliation(s)
- Giovanni Tinelli
- Vascular Unit, Department of Cardiovascular Surgery, Gemelli Foundation IRCCS, School of Medicine, Sacred Heart Catholic University, Rome, Italy -
| | - Marco Ferraresi
- Vascular Unit, Department of Cardiovascular Surgery, Gemelli Foundation IRCCS, School of Medicine, Sacred Heart Catholic University, Rome, Italy
| | - Amelia C Watkins
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | | | - Raphael Soler
- Aortic Center, Marie Lannelongue Hospital, Paris Sud University, Le Plessis Robinson, France
| | | | - Dominique Fabre
- Aortic Center, Marie Lannelongue Hospital, Paris Sud University, Le Plessis Robinson, France
| | | | - Stéphan Haulon
- Aortic Center, Marie Lannelongue Hospital, Paris Sud University, Le Plessis Robinson, France
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Yuan X, Mitsis A, Ghonem M, Iakovakis I, Nienaber CA. Conservative management versus endovascular or open surgery in the spectrum of type B aortic dissection. J Vis Surg 2018; 4:59. [PMID: 29682469 DOI: 10.21037/jovs.2018.02.15] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 02/09/2018] [Indexed: 01/16/2023]
Abstract
Background Type B aortic dissection is a life-threatening acute aortic condition often with acute ischemic signs or symptoms. With initial management focusing on alleviating malperfusion and pain, and avoiding propagation of dissection or rupture both systolic blood and pulse pressure should be reduced initially by an aggressive medical approach. In the setting of persistent signs of complications endovascular strategies have replaced open surgery and led to a fourfold increase in early survival and better long-term outcomes. Methods An electronic health database search was performed on articles published between January 2006 and July 2017. Publications were included in this review if (I) the index aortic pathology was type B aortic (distal) dissection; (II) when medical management, open surgical replacement or thoracic endovascular aortic repair were among those options; (III) when at least one of all basic outcome criteria such as survival, spinal cord ischemia and cerebrovascular accident was reported; (IV) when ≥15 serial patients were included. A total of 62 studies were eligible and analysed. Results Our manuscript has summarized data collected over 12 years on management specific outcomes in the setting of distal aortic dissection and provides an up-to-date interpretation of the published evidence. For complicated cases, treated acutely, the 30-day or in-hospital mortality was 7.3% when managed by endovascular means, whereas the pooled rate for 30-day or in-hospital mortality was 19.0% when subjected to open repair. For acute uncomplicated type B dissection usually treated with blood pressure lowering medications, the pooled 30-day or in-hospital mortality rate was 2.4%. Survival rates at 5 years averaged at 60% (40% mortality). Freedom from any aortic event ranged from 34.0% to 83.9%, underlining an inherent risk of progression and late complications. For chronic complicated type B dissection, the rates of stroke, paraplegia and operative mortality following endovascular repair ranged from 5% to 13%, 2% to 13% and 2 to 13%, respectively, while 5-year survival rates after open repair ranged from 60% to 90%. In chronic uncomplicated type B dissection almost 90% of patients survive initial hospitalization and were subjected to medical management with a 5-year survival of 50-80%. However, up to 20-55% of medically treated patients develop aneurysmal degeneration after 5 years with an unknown risk of rupture. Conclusions Currently, the less invasive strategy of endovascular repair (as compared to open surgery) provides improved 30-day or in-hospital survival in the setting of complicated acute type B aortic dissection and may seek broad application. Open surgical aortic reconstruction should be left to experienced aortic centres if endovascular management is not an option.
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Affiliation(s)
- Xun Yuan
- Cardiology and Aortic Centre, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, UK
| | - Andreas Mitsis
- Cardiology and Aortic Centre, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, UK
| | - Mohammed Ghonem
- Cardiology and Aortic Centre, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, UK
| | - Ilias Iakovakis
- Cardiac Surgery Department, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, UK
| | - Christoph A Nienaber
- Cardiology and Aortic Centre, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, UK
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Waked K, Schepens M. State-of the-art review on the renal and visceral protection during open thoracoabdominal aortic aneurysm repair. J Vis Surg 2018; 4:31. [PMID: 29552513 DOI: 10.21037/jovs.2018.01.12] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 01/10/2018] [Indexed: 12/13/2022]
Abstract
During open thoracoabdominal aortic aneurysm repair (OTAAAR), there is an inevitable organ ischemic period that occurs when the abdominal arteries are being reattached to the aortic graft. Despite various protective techniques, the incidence of renal and visceral complications remains substantial. This state-of-the-art review gives an overview of the current and most evidence-based organ protection methods during OTAAAR, based on the most recent publications and personal experience. An electronic search was performed in four medical databases, using the following MeSH terms: thoracoabdominal aneurysm, TAAAR, visceral protection, renal protection, kidney, perfusion, and intestines. Every publication type was considered. The literature search was ended on August 31st, 2017. The left heart bypass (LHB) is currently the most frequent adjunct to provide distal aortic perfusion (DAP) during aortic clamping. Together with systemic hypothermia, it forms the cornerstone in organ protection during aortic clamping. Further renal protection can be obtained by selective renal perfusion (SRP) with cold blood or cold crystalloid solution, the latter enriched with mannitol. The perfusion should be administered in a volume- and pressure-controlled way and, if possible, by use of a pulsatile pump. Selective visceral perfusion (SVP) is not routinely used, as it does not provide adequate blood flow for visceral protection. The best way to protect the intestines is by minimizing the ischemic time. The preservation of renal and visceral function after OTAAAR can only be obtained with specific strategies before, during, and after the operation. This involves a series of measures, including selective digestive decontamination (SDD), avoidance of nephrotoxic drugs, minimizing the renal and intestinal ischemic time, systemic cooling, avoidance of hemodynamic instability, and regional protective perfusion of the kidneys. Future innovations in catheters, cardiac bypass flow types, mechanical components, hybrid vascular grafts, and pharmaceutical protection measures will hopefully further reduce organ complications.
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Affiliation(s)
- Karl Waked
- Department of Cardiovascular Surgery, AZ Sint Jan Hospital, Brugge, Belgium
| | - Marc Schepens
- Department of Cardiovascular Surgery, AZ Sint Jan Hospital, Brugge, Belgium
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Afifi RO, Tanaka A, Yazji I, Safi HJ, Estrera AL. Thoracoabdominal aortic aneurysm repair in Marfan syndrome: how we do it. Ann Cardiothorac Surg 2017; 6:709-711. [PMID: 29270385 DOI: 10.21037/acs.2017.11.04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Rana O Afifi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.,Memorial Hermann Heart & Vascular Institute, Houston, TX, USA
| | - Akiko Tanaka
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Ibrahim Yazji
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Hazim J Safi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.,Memorial Hermann Heart & Vascular Institute, Houston, TX, USA
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.,Memorial Hermann Heart & Vascular Institute, Houston, TX, USA
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Abstract
The frequency of endovascular stent grafting procedures to treat various conditions of the thoracic aorta has increased dramatically over the past three decades. Stent grafting has been applied on a limited basis in patients with Marfan syndrome and other connective tissue disorders, despite recommendations from current guidelines and expert consensus statements against its use in this setting. A review of publications reporting outcomes after stent grafting of the descending thoracic aorta in Marfan patients with acute or chronic aortic dissection indicates that these procedures can be accomplished with rates of early mortality, stroke and spinal cord ischemic injury that are comparable to those observed in patients who do not have Marfan syndrome. However, the rates of primary treatment failure (principally endoleak), secondary treatment failure, need for open repair and late death among the Marfan patients are substantially higher than those observed in patients without this condition. In addition, the rates of retrograde aortic dissection and development of stent-graft induced new entry (SINE), are also greater among patients with Marfan syndrome. All of these findings argue strongly against the routine use of endovascular grafts in Marfan patients with type B or residual type A dissection. Few data are available to assess the role of endografting in Marfan patients with aneurysmal disease, but the progressive aortic dilatation noted in these patients argues strongly against its use in this setting as well. At present, the available data indicate that there is no justification for elective stent grafting in Marfan patients with aortic dissection or aneurysm. The only reasonable indications for primary aortic stent grafting are in the setting of acute aortic dissection or rupture, where the intervention is considered life-saving and rarely, considering the relatively young age of these patients, where the risk of open operation is considered to be prohibitive.
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Affiliation(s)
- Nicholas T Kouchoukos
- Division of Cardiovascular and Thoracic Surgery, Missouri Baptist Medical Center, BJC Healthcare, St. Louis, Missouri, USA
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Keschenau PR, Kotelis D, Bisschop J, Barbati ME, Grommes J, Mees B, Gombert A, Peppelenbosch AG, Schurink GWH, Kalder J, Jacobs MJ. Editor's Choice – Open Thoracic and Thoraco-abdominal Aortic Repair in Patients with Connective Tissue Disease. Eur J Vasc Endovasc Surg 2017; 54:588-596. [DOI: 10.1016/j.ejvs.2017.07.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 07/27/2017] [Indexed: 01/02/2023]
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Glebova NO, Hicks CW, Alam R, Lue J, Propper BW, Black JH. Technical aspects of branched graft aortic reconstruction in patients with connective tissue disorders. J Vasc Surg 2016; 64:520-525. [DOI: 10.1016/j.jvs.2016.04.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 04/25/2016] [Indexed: 10/21/2022]
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Abstract
Aortic dissection is a life-threatening condition caused by a tear in the intimal layer of the aorta or bleeding within the aortic wall, resulting in the separation (dissection) of the layers of the aortic wall. Aortic dissection is most common in those 65-75 years of age, with an incidence of 35 cases per 100,000 people per year in this population. Other risk factors include hypertension, dyslipidaemia and genetic disorders that involve the connective tissue, such as Marfan syndrome. Swift diagnostic confirmation and adequate treatment are crucial in managing affected patients. Contemporary management is multidisciplinary and includes serial non-invasive imaging, biomarker testing and genetic risk profiling for aortopathy. The choice of approach for repairing or replacing the damaged region of the aorta depends on the severity and the location of the dissection and the risks of complication from surgery. Open surgical repair is most commonly used for dissections involving the ascending aorta and the aortic arch, whereas minimally invasive endovascular intervention is appropriate for descending aorta dissections that are complicated by rupture, malperfusion, ongoing pain, hypotension or imaging features of high risk. Recent advances in the understanding of the underlying pathophysiology of aortic dissection have led to more patients being considered at substantial risk of complications and, therefore, in need of endovascular intervention rather than only medical or surgical intervention.
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Results of Open Surgical Repair in Patients With Marfan Syndrome and Distal Aortic Dissection. Ann Thorac Surg 2016; 101:2193-201. [DOI: 10.1016/j.athoracsur.2015.11.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 11/03/2015] [Accepted: 11/04/2015] [Indexed: 12/16/2022]
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Coselli JS, LeMaire SA, Preventza O, de la Cruz KI, Cooley DA, Price MD, Stolz AP, Green SY, Arredondo CN, Rosengart TK. Outcomes of 3309 thoracoabdominal aortic aneurysm repairs. J Thorac Cardiovasc Surg 2016; 151:1323-37. [DOI: 10.1016/j.jtcvs.2015.12.050] [Citation(s) in RCA: 359] [Impact Index Per Article: 44.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 12/01/2015] [Accepted: 12/14/2015] [Indexed: 11/24/2022]
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Buja L, Schoen F. The Pathology of Cardiovascular Interventions and Devices for Coronary Artery Disease, Vascular Disease, Heart Failure, and Arrhythmias. Cardiovasc Pathol 2016. [DOI: 10.1016/b978-0-12-420219-1.00032-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Overview of current surgical strategies for aortic disease in patients with Marfan syndrome. Surg Today 2015; 46:1006-18. [DOI: 10.1007/s00595-015-1278-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 11/02/2015] [Indexed: 01/16/2023]
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Hybrid Treatment for Thoracoabdominal Aortic Aneurysms in Patients with Marfan Syndrome. Ann Vasc Surg 2015; 29:595.e5-9. [DOI: 10.1016/j.avsg.2014.10.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 10/12/2014] [Accepted: 10/23/2014] [Indexed: 11/20/2022]
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The Risk for Type B Aortic Dissection in Marfan Syndrome. J Am Coll Cardiol 2015; 65:246-54. [DOI: 10.1016/j.jacc.2014.10.050] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 10/08/2014] [Accepted: 10/21/2014] [Indexed: 01/16/2023]
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Omura A, Tanaka A, Miyahara S, Sakamoto T, Nomura Y, Inoue T, Oka T, Minami H, Okada K, Okita Y. Early and Late Results of Graft Replacement for Dissecting Aneurysm of Thoracoabdominal Aorta in Patients With Marfan Syndrome. Ann Thorac Surg 2012; 94:759-65. [DOI: 10.1016/j.athoracsur.2012.04.061] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Revised: 04/12/2012] [Accepted: 04/16/2012] [Indexed: 11/24/2022]
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The impact of selective visceral perfusion on intestinal macrohemodynamics and microhemodynamics in a porcine model of thoracic aortic cross-clamping. J Vasc Surg 2012; 56:149-58. [DOI: 10.1016/j.jvs.2011.11.126] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2011] [Revised: 11/15/2011] [Accepted: 11/19/2011] [Indexed: 11/18/2022]
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Geisbuesch S, Schray D, Bischoff MS, Lin HM, Di Luozzo G, Griepp RB. Frequency of Reoperations in Patients With Marfan Syndrome. Ann Thorac Surg 2012; 93:1496-501. [DOI: 10.1016/j.athoracsur.2011.12.068] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Revised: 12/20/2011] [Accepted: 12/22/2011] [Indexed: 10/28/2022]
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Geisbüsch P, Hoffmann S, Kotelis D, Able T, Hyhlik-Dürr A, Böckler D. Reinterventions during midterm follow-up after endovascular treatment of thoracic aortic disease. J Vasc Surg 2011; 53:1528-33. [DOI: 10.1016/j.jvs.2011.01.066] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Revised: 01/15/2011] [Accepted: 01/21/2011] [Indexed: 11/25/2022]
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Greiner A, Mess W, Schmidli J, Dick F, Grommes J, Jacobs M. Möglichkeiten des grenzüberschreitenden Telemonitorings bei Ersatzoperationen des thorakoabdominellen Aortenaneurysmas. GEFASSCHIRURGIE 2010. [DOI: 10.1007/s00772-010-0785-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Rajagopal K, Rogers JG, Lodge AJ, Gaca JG, McCann RL, Milano CA, Hughes GC. Two-stage total cardioaortic replacement for end-stage heart and aortic disease in Marfan syndrome: case report and review of the literature. J Heart Lung Transplant 2010; 28:958-63. [PMID: 19716050 DOI: 10.1016/j.healun.2009.05.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2008] [Revised: 04/15/2009] [Accepted: 05/06/2009] [Indexed: 11/18/2022] Open
Abstract
A 24-year-old man with Marfan syndrome underwent mitral valve repair for prolapse at age 13. He sustained an acute type A aortic dissection at age 20 and underwent aortic root/ascending aortic replacement with a mechanical valved conduit. He initially did well after the latter procedure, but end-stage heart disease developed 4 years later, apparently secondary to primary cardiomyopathy. Pre-transplant evaluation revealed residual chronic dissection with aneurysmal dilatation of the distal ascending aorta, transverse arch, and descending thoracic aorta. He underwent combined orthotopic heart transplantation (OHT) and total arch replacement (stage I elephant trunk procedure). Subsequently, he underwent extent II thoracoabdominal aneurysm repair, leaving no residual aortic disease. The 2 procedures resulted in total cardioaortic replacement, thus definitively managing his cardiomyopathy and aortic disease resulting from Marfan syndrome. The operative strategies employed represent a novel approach in this clinical setting. This report emphasizes that patients with this disease should not be denied potentially life-saving OHT on the basis of concomitant aortic disease, but rather should be treated in centers offering expertise in both areas of surgical therapy.
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Affiliation(s)
- Keshava Rajagopal
- Department of Surgery (Division of Thoracic and Cardiovascular Surgery), Duke University Medical Center, Durham, North Carolina 27710, USA
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Mommertz G, Langer S, Koeppel TA, Schurink GW, Mess WH, Jacobs MJ. Brain and spinal cord protection during simultaneous aortic arch and thoracoabdominal aneurysm repair. J Vasc Surg 2009; 49:886-92. [DOI: 10.1016/j.jvs.2008.11.040] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Revised: 10/28/2008] [Accepted: 11/09/2008] [Indexed: 11/25/2022]
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Brülls CS, Dembinski R, Jacobs MJ, Mahnken AH, Rossaint R, Rex S. Fatal necrotic pancreatitis as a rare complication after thoracoabdominal aortic surgery. J Cardiothorac Vasc Anesth 2009; 23:926-9. [PMID: 19297195 DOI: 10.1053/j.jvca.2009.01.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2008] [Indexed: 11/11/2022]
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Cooper DG, Walsh SR, Sadat U, Hayes PD, Boyle JR. Treating the Thoracic Aorta in Marfan Syndrome: Surgery or TEVAR? J Endovasc Ther 2009; 16:60-70. [DOI: 10.1583/08-2561.1] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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