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Mylonas KS, Zoupas I, Tasoudis PT, Vitkos E, Stavridis GT, Avgerinos DV. Endovascular Treatment of Type A Aortic Dissection: A Systematic Review and Meta-Analysis Using Reconstructed Time-to-Event Data. J Clin Med 2023; 12:7051. [PMID: 38002665 PMCID: PMC10672308 DOI: 10.3390/jcm12227051] [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: 10/11/2023] [Revised: 10/31/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
OBJECTIVE The undisputed gold standard of treatment for type A aortic dissections (TAAD) is open surgery. Anecdotal reports have assessed thoracic endovascular aortic repair (TEVAR) as a last resort for highly selected candidates. The present study aims to evaluate endovascular outcomes in TAAD patients who are unsuitable for open surgery whilst having TEVAR-compatible aortic anatomy. METHODS A PRISMA-compliant systematic search of the PubMed, Scopus, and Cochrane databases was performed up to 19 May 2022. Time-to-event data were reconstructed using Kaplan-Meier curves from the source literature. RESULTS In 20 eligible studies, 311 patients underwent TEVAR for acute, subacute, or chronic TAAD. Mean age at the time of the operation was 60.70 ± 8.00 years and 75.48% (95% Confidence Interval [CI], 60.33-88.46%) of the included patients were males. Mean operative time was 169.40 ± 30.70 min. Overall, 0.44% (95% CI, 0.00-4.83%) of the cases were converted to salvage open surgery. Technical failure, stroke, and endoleaks occurred in 0.22%, 0.1%, and 8.52% of the cohort, respectively. Thirty-day postoperative complication rate was 7.08% (95% CI, 1.52-14.97%), whereas late complications developed in 16.89% (95% CI, 7.75-27.88%) of the patients. One-, three-, and five-year survival rates were estimated at 87.15%, 82.52% and 82.31%, respectively. Reintervention was required in 8.38% of the cohort over a mean follow-up of 32.40 ± 24.40 months. CONCLUSIONS TEVAR seems to be feasible in highly selected patients with TAAD who cannot tolerate open surgery. Overcoming technical limitations and acquiring long-term data are warranted to safely define the place of endovascular treatment in the armamentarium of TAAD repair.
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Affiliation(s)
- Konstantinos S. Mylonas
- Department of Cardiac Surgery, Onassis Cardiac Surgery Center, 176 74 Athens, Greece; (K.S.M.)
- School of Medicine, National and Kapodistrian University of Athens, Mikras Asias Str. 75, 115 27 Athens, Greece
| | - Ioannis Zoupas
- School of Medicine, National and Kapodistrian University of Athens, Mikras Asias Str. 75, 115 27 Athens, Greece
- Surgery Working Group, Society of Junior Doctors, 151 23 Athens, Greece;
| | | | - Evangelos Vitkos
- Department of General Surgery, General Hospital of Katerini, 601 00 Katerini, Greece
| | - George T. Stavridis
- Department of Cardiac Surgery, Onassis Cardiac Surgery Center, 176 74 Athens, Greece; (K.S.M.)
| | - Dimitrios V. Avgerinos
- Department of Cardiac Surgery, Onassis Cardiac Surgery Center, 176 74 Athens, Greece; (K.S.M.)
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Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
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3
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Peng Y, Lin W, Lou D, Luo S, Li B, Su M, Liu J, Tang Y, Luo J. Feasibility and safety of Stanford A aortic dissection complete endovascular repair system in a porcine model. BMC Cardiovasc Disord 2023; 23:455. [PMID: 37704996 PMCID: PMC10500764 DOI: 10.1186/s12872-023-03494-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 09/04/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Acute type A aortic dissection (ATAAD) is a catastrophic disease with high morbidity and mortality. Although open surgery is still the gold standard for the treatment of ATAAD, some patients, with advanced age and multiple comorbidities, can only receive medical management alone. Nowadays, thoracic aortic endovascular repair (TEVAR) provides a potential treatment option for the patient with ATAAD, but traditional stent grafts (SGs), which are not designed for the ATAAD, are inapplicable to the unique anatomy of the aortic arch. Therefore, we innovatively created the BRIDGE system (Chuangxin Medical, Shenzhen, China), a complete endovascular reconstruction system designed to treat ATAAD. This study aimed to evaluate the feasibility and safety of the novel Stanford A aortic dissection complete endovascular reconstruction system in a porcine model. METHOD The BRIDGE system consists of the type A stent system and the type C stent system. Between November 2020 and March 2021, three white swine were utilized in the study. The BRIDGE system was deployed via the transcatheter approach under angiographic guidance. The swine(n = 3) treated with our system were evaluated using angiography before sacrifice 1-month after implantation, which was followed by gross specimen evaluation and histological examination of harvested tissues. RESULT The acute procedure success rate was 100% (3/3). The immediate post-procedural angiography showed that both type A SGs and type C SGs were deployed in satisfactory locations, with patency of the supra-aortic trunk and no endoleak. The cumulative mortality of 30-day was 0% without any adverse events. No device migration or leakage was observed angiographically, before sacrifice. The gross observation confirmed a type A SG covered part of the entry of anonyma. Favorable endothelialization, no thrombogenesis, and slight inflammatory infiltration of the tissues around the device were confirmed by microscopic examinations in all pigs. CONCLUSION It was feasible and secure to use Stanford A aortic dissection complete endovascular reconstruction system to implement a transcatheter endovascular repair in a porcine model. With this novel system, treating acute type A aortic dissection may be more efficient and secure in human.
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Affiliation(s)
- Yucheng Peng
- Foshan Fosun Chancheng Hospital, 3 Sanyou South Road, Chancheng District, Foshan, China
| | - Wenhui Lin
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Deda Lou
- Chuangxin Medical Technology CO.Ltd, Shenzhen, China
| | - Songyuan Luo
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Bo Li
- Cardiovascular Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Mingcheng Su
- Chuangxin Medical Technology CO.Ltd, Shenzhen, China
| | - Jitao Liu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Yue Tang
- Cardiovascular Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China.
| | - Jianfang Luo
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China.
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Teymouri M, Mehta M, Paty P, Jayakumar L, Kostun ZW. Complete zone 0-10 aortic endovascular reconstruction. J Vasc Surg Cases Innov Tech 2023; 9:101111. [PMID: 37152909 PMCID: PMC10160783 DOI: 10.1016/j.jvscit.2023.101111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 01/07/2023] [Indexed: 05/09/2023] Open
Abstract
To the best of our knowledge, the present report is the first on the safety and efficacy of complete endovascular aortic reconstruction from zone 0 to 10 using a standardized approach and parallel stent graft configurations in high-risk patients considered unfit for surgery. During a 7-year period, five patients with complex thoracoabdominal aortic aneurysms and dissections involving zone 0-10 presented with rupture (n = 1; 20%), were symptomatic (n = 2; 40%), or had an aortic pseudoaneurysm (n = 2; 40%) and underwent complete endovascular zone 0-10 reconstruction using off-the-shelf stent grafts in parallel configurations that included chimneys, periscopes, and endovascular docking stations. The zone 0-5 complete arch chimney thoracic endovascular repair included chimneys that extended from the ascending thoracic aorta to the innominate, left common carotid, and left subclavian arteries and a thoracic stent graft extending from zone 0 to 5. The zone 5-10 aortic reconstructions were staged. Stage 1 included either thoracic stent graft and antegrade four visceral chimney placement or abdominal aortic stent graft and retrograde four visceral chimney placement. Stage II included completion of the remainder of the aortic reconstruction with cerebrospinal fluid drainage. A total of 15 aortic procedures included 34 chimneys (14 aortic arch and 20 visceral). Two patients (40%) underwent zone 0-5 aortic reconstruction first, and three patients (60%) underwent zone 5-10 aortic reconstruction first. The incidence of 30-day mortality, spinal cord ischemia, myocardial infarction, stroke, and visceral ischemia was 0%. At a mean follow-up of 4.5 ± 3.1 years, the aortic reconstruction-related mortality was 0%. All-cause mortality was 20%; one patient had died of pneumonia at 3 years postoperatively. Two endoleaks each occurred in zone 0-5 and zone 5-10 (40% for both groups). All endoleaks were treated with coil embolization. Complete endovascular zone 0-10 aortic reconstruction using parallel stent grafts with a docking station is a feasible and relatively safe technique that offers the ability to customize off-the-shelf devices for the treatment of high-risk patients with limited morbidity and mortality.
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Affiliation(s)
| | - Manish Mehta
- Correspondence: Manish Mehta, MD, MPH, Center for Vascular Awareness, Vascular Health Partners, 713 Troy-Schenectady Rd, Ste 125, Latham, NY 12110
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Rylski B, Schilling O, Czerny M. Acute aortic dissection: evidence, uncertainties, and future therapies. Eur Heart J 2023; 44:813-821. [PMID: 36540036 DOI: 10.1093/eurheartj/ehac757] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 10/27/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
Remarkable progress has become especially apparent in aortic medicine in the last few decades, leading to essential changes in how thoracic aortic dissection is understood and treated. This state-of-the-art review article addresses the mechanisms of acute aortic dissection, explaining the role of its primary entry location, proximal, and distal dissection extension in their clinical presentation and impact on the decision-making process towards the best treatment approach. The latest evidence on novel treatment methods for acute aortic syndromes is presented, and the diverse dissection classification systems that remain uncertain are discussed, which reveals the need for shared terminology and more clarity. Finally, future aspects are discussed in treating acute aortic dissection, such as the endovascular treatment of aortic dissection Type A and biomarkers for acute aortic syndromes.
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Affiliation(s)
- Bartosz Rylski
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Hugstetter Str. 55, 79106 Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Oliver Schilling
- Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany.,Institute for Surgical Pathology, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Hugstetter Str. 55, 79106 Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
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6
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Suematsu Y, Inoue T, Nishi S, Kurahashi K, Yoshimoto A. Aortic Remodeling After Stepwise External Wrapping for Type A Acute Aortic Dissection. Ann Thorac Surg 2023; 115:51-60. [PMID: 35863391 DOI: 10.1016/j.athoracsur.2022.05.070] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/07/2022] [Accepted: 05/29/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND The optimal repair technique for type A acute aortic dissection is graft replacement; however, the treatment approach in high-risk patients remains controversial or suboptimal. METHODS We have retrospectively analyzed a cohort of high-risk patients who were admitted to our center for type A acute aortic dissection and who were treated by a new surgical approach using artificial grafts (stepwise external wrapping) between January 2016 and January 2020. The primary endpoints included inhospital mortality and survival during follow-up. Secondary endpoints included the assessment of aortic remodeling after ascending aorta wrapping. RESULTS Among the 134 patients admitted for type A acute aortic dissection, 43 patients underwent stepwise external wrapping. The mean patient age was 79.1 ± 6.8 years. The new standard European System for Cardiac Operative Risk Evaluation score was 64% ± 12%. There was one hospital death (2.3%). There were two major complications of persistent cerebral disorder (4.6%). Minor complications included temporary neurologic disorder (2.3%) and renal failure (2.3%). The intensive care unit and hospital stays were 2.8 ± 1.0 days and 11.7 ± 2.5 days, respectively. The follow-up survival rate was 95.3% ± 6.2% and 91% ± 10.2% at 1 and 3 years, respectively, after surgery. There was no aortic-related death during follow-up. At 1 year after surgery, complete remodeling of the ascending aorta was obtained in 30 patients (85.7%), and 5 patients (14.3%) showed partial remodeling. CONCLUSIONS Our stepwise external wrapping technique was associated with excellent outcomes for high-risk patients with type A acute aortic dissection.
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Affiliation(s)
- Yoshihiro Suematsu
- Department of Cardiovascular Surgery, Tsukuba Memorial Hospital, Tsukuba, Ibaraki, Japan.
| | - Takafumi Inoue
- Department of Cardiovascular Surgery, Tsukuba Memorial Hospital, Tsukuba, Ibaraki, Japan
| | - Satoshi Nishi
- Department of Cardiovascular Surgery, Tsukuba Memorial Hospital, Tsukuba, Ibaraki, Japan
| | - Kanan Kurahashi
- Department of Cardiovascular Surgery, Tsukuba Memorial Hospital, Tsukuba, Ibaraki, Japan
| | - Akihiro Yoshimoto
- Department of Cardiovascular Surgery, Tsukuba Memorial Hospital, Tsukuba, Ibaraki, Japan
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7
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Matsuda H. Current management of acute type B dissection in 2021. Asian Cardiovasc Thorac Ann 2023; 31:37-41. [PMID: 35473408 DOI: 10.1177/02184923221097172] [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: 11/16/2022]
Abstract
The rationale for thoracic endovascular aortic repair (TEVAR) for type B aortic dissection depends on the phase of disease: acute phase, which is 'complicated', subacute to early chronic phase, which requires 'preemptive TEVAR' and chronic phase, which entails 'prevention of further dilatation and rupture'. Low operative mortality and morbidity after TEVAR for complicated acute type B aortic dissection have been reported with significant improvement during midterm survival. 'Retrograde' type A dissection, which can be described as type B0,X (X>3) according to a new reporting standard, has reportedly been treated with TEVAR with less invasiveness. TEVAR is the first and possibly the only effective strategy for acute type B dissection, so that expansion of indications for type B0,X, as described in the new reporting standard has been validated.
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Affiliation(s)
- Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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8
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Yuan X, Mitsis A, Nienaber CA. Current Understanding of Aortic Dissection. Life (Basel) 2022; 12:1606. [PMID: 36295040 PMCID: PMC9605578 DOI: 10.3390/life12101606] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/24/2022] [Accepted: 10/12/2022] [Indexed: 06/16/2023] Open
Abstract
The aorta is the largest artery in the body, delivering oxygenated blood from the left ventricle to all organs. Dissection of the aorta is a lethal condition caused by a tear in the intimal layer of the aorta, followed by blood loss within the aortic wall and separation of the layers to full dissection. The aorta can be affected by a wide range of causes including acute conditions such as trauma and mechanical damage; and genetic conditions such as arterial hypertension, dyslipidaemia, and connective tissue disorders; all increasing the risk of dissection. Both rapid diagnostic recognition and advanced multidisciplinary treatment are critical in managing aortic dissection patients. The treatment depends on the severity and location of the dissection. Open surgical repair is the gold standard of treatment for dissections located to the proximal part of the aorta and the arch, while endovascular interventions are recommended for most distal or type B aortic dissections. In this review article, we examine the epidemiology, pathophysiology, contemporary diagnoses, and management of aortic dissection.
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Affiliation(s)
- Xun Yuan
- Cardiology and Aortic Centre, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London SW3 6NP, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London SW7 2BX, UK
| | - Andreas Mitsis
- Cardiology Department, Nicosia General Hospital, Strovolos 2029, Cyprus
| | - Christoph A. Nienaber
- Cardiology and Aortic Centre, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London SW3 6NP, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London SW7 2BX, UK
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Tan SZ, Singh S, Austin NJ, Alfonso Palanca J, Jubouri M, Girardi LN, Chen EP, Bashir M. Duration of deep hypothermic circulatory arrest for aortic arch surgery: is it a myth, fiction, or scientific leap? THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:243-253. [PMID: 35238523 DOI: 10.23736/s0021-9509.22.12275-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The use of deep hypothermic circulatory arrest (DHCA) to provide aortic surgeons with a bloodless operative field while simultaneously protecting the brain and peripheries from ischemic damage revolutionized cardiac and aortic surgery, and is currently used in specialist centers across the globe. However, it is associated with manifold adverse outcomes, including neurocognitive dysfunction and mortality. This review seeks to analyze the relationship between DHCA duration and clinical outcome, and evaluate the controversies and limitations surrounding its use. EVIDENCE ACQUISITION We performed a review of available literature with statistical analysis to evaluate the relationship between DHCA duration (<40 min and >40 min) and key clinical outcomes, including mortality, permanent and temporary neurological deficit, renal damage, admission length, and reintervention rate. The controversies surrounding DHCA use and future directions for care are also explored. EVIDENCE SYNTHESIS Statistical analysis revealed no significant association (P>0.05) between DHCA duration and clinical outcomes (early and late mortality rates, neurological deficit, admission length, and reintervention rate), both with and without adjunctive perfusion techniques. CONCLUSIONS Available literature suggests that the relationships between DHCA duration (with and without adjunctive perfusion) and clinical outcomes are unclear, and at present not statistically significant. Alternative surgical and endovascular techniques have been identified as promising novel approaches not requiring DHCA, as have the use of biomarkers to enable early diagnosis and intervention for aortic pathologies.
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Affiliation(s)
- Sven Z Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sidhant Singh
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Natasha J Austin
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Joaquin Alfonso Palanca
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mohamad Bashir
- Vascular and Endovascular Surgery, Health and Education Improvement Wales, Nantgarw, UK -
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10
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Yuan X, Mitsis A, Mozalbat D, Nienaber CA. Alternative management of proximal aortic dissection: concept and application. Indian J Thorac Cardiovasc Surg 2021; 38:183-192. [PMID: 35463707 PMCID: PMC8980987 DOI: 10.1007/s12055-021-01281-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/20/2021] [Accepted: 09/21/2021] [Indexed: 11/17/2022] Open
Abstract
Open surgery remains the mainstay of treatment for acute type A aortic dissection and should be offered to most patients. However, there are elderly patients in which surgical treatment may be deemed extremely high risk or futile. Endovascular treatment approaches have been applied to a small number of these patients and data are limited to case reports and small series. The application of endovascular therapies to ascending aorta is currently limited by anatomical and technical challenges posed by the dynamic motion of the ascending aorta and the proximity of vital structures to intended landing zones (aortic valve, coronary arteries, and supra-aortic branches) and lack of specially designed endografts to address these issues. While thoracic endovascular aortic repair (TEVAR) has replaced open aortic repair for a suitable lesion in distal aortic dissection, some selected patients with type A aortic dissection at high surgical may be candidates. Hence, there is potential because, in proximal (Stanford type A) dissections, 10–30% of patients are not accepted for surgery, and 30–50% are technically amenable for TEVAR. Recent experience has shown that carefully selected patients with favorable anatomical characteristics may be subject to endovascular stent-graft treatment as a last resort with mixed results. Technical improvement is necessary to offer. satisfactory endovascular options in non-surgical candidates.
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11
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Brown JA, Arnaoutakis GJ, Szeto WY, Serna-Gallegos D, Sultan I. Endovascular repair of the aortic arch: State of the art. J Card Surg 2021; 36:4292-4300. [PMID: 34405439 DOI: 10.1111/jocs.15920] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 08/08/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Open total arch replacement remains the gold standard treatment for aneurysms and dissections involving the aortic arch. However, high-risk surgical candidates may benefit from endovascular techniques to reduce the risk of perioperative mortality and morbidity, especially neurologic complications. Numerous endografts are available for investigational use in the aortic arch as part of investigational device exemption (IDE) programs. Some devices are fenestrated or scalloped, while others are branched, ranging from single branch to triple branch stent-grafts. Furthermore, chimney techniques and in situ fenestration may be utilized in bailout or emergent situations. RESULTS Initial results describing outcomes of complete endovascular repair of the aortic arch are encouraging, with current data estimating that technical success ranges from 84.2% to 100%. Moreover, operative mortality may be as high as 13.2%, while neurologic complications also remain common, with stroke rates being as high as 20% and spinal cord ischemia being as high as 3.1%. However, more data are necessary to determine the comparative treatment effect of endovascular stent-grafting of the aortic arch, compared with conventional open and hybrid repairs. Longitudinal follow-up is also lacking, which will determine the long-term durability of endografts in the aortic arch. Nevertheless, endovascular repair represents an important opportunity for improving outcomes in patients with complex and potentially devastating pathologies of the aortic arch.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - George J Arnaoutakis
- Division of Cardiovascular Surgery, University of Florida, Gainesville, Florida, USA
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Derek Serna-Gallegos
- UPMC Center for Thoracic Aortic Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,UPMC Center for Thoracic Aortic Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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12
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Shi J, Liu L, Wei X, Ma M. Back-Table Modified Stent-Graft for Endovascular Repair of Ascending Aorta. J Endovasc Ther 2021; 28:888-896. [PMID: 34190632 DOI: 10.1177/15266028211028201] [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: 11/16/2022]
Abstract
OBJECTIVES To investigate the effectiveness of modified stent-grafts (SGs) for the management of ascending aortic pathologies. MATERIALS AND METHODS From January 2015 to December 2019, 31 individuals were treated by ascending aortic endovascular repair with a back-table modified SG for acute (n=4) or chronic (n=1) type A aortic dissections, penetrating aortic ulcers (n=18), pseudoaneurysms (n=2), anastomotic fistula (n=1), and endoleaks after thoracic endovascular aortic repair (TEVAR) (n=5). The commercially available thoracic aortic SGs were modified with a fenestration or truncation technique on the back-table according to aortography during the operation. RESULTS The 30-day mortality and aorta-related mortality rates were 12.9% and 6.5%, respectively. There were 2 strokes, 3 respiratory insufficiencies, and 6 endoleaks during hospitalization. During a mean follow-up of 28.8±16.6 months, the overall survival rates at 1 year and 3 years were both 80.6%. Free from adverse event rates at 1 year and 3 years were 88.9% and 84.7%, respectively. There were 2 deaths during follow-up: One patient died of cachexia 1 month after discharge, and the other patient died of acute myocardial infarction 3 months after discharge. One patient with a pseudoaneurysm underwent open ascending aorta replacement 3 months after discharge for a type Ia endoleak. Another patient suffered from cerebellar infarction 17 months after discharge. CONCLUSION The modified SG for endovascular repair of the ascending aorta is a practicable alternative and presents acceptable outcomes in high-risk patients.
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Affiliation(s)
- Juan Shi
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ligang Liu
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiang Wei
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Mingjia Ma
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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13
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Hauck SR, Kupferthaler A, Stelzmüller M, Eilenberg W, Ehrlich M, Neumayer C, Wolf F, Loewe C, Funovics MA. Endovascular Stent-Graft Repair of the Ascending Aorta: Assessment of a Specific Novel Stent-Graft Design in Phantom, Cadaveric, and Clinical Application. Cardiovasc Intervent Radiol 2021; 44:1448-1455. [PMID: 34180002 PMCID: PMC8382630 DOI: 10.1007/s00270-021-02859-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 04/24/2021] [Indexed: 11/24/2022]
Abstract
Purpose To test a stent-graft specifically designed for the ascending aorta in phantom, cadaver, and clinical application, and to measure deployment accuracy to overcome limitations of existing devices. Methods A stent-graft has been designed with support wires to fixate the apices toward the inner curvature, thereby eliminating the forward movement of the proximal end which can happen with circumferential tip capture systems. The device was deployed in three aortic phantoms, and in four cadavers, deployment precision was measured. Subsequently, the device was implanted in a patient to exclude a pseudoaneurysm originating from the distal anastomosis after ascending aortic replacement. Results The stent-grafts were successfully deployed in all phantoms and cadavers. Deployment accuracy of the proximal end of the stent-graft was within 1 mm proximally and 14 mm distally to the intended landing zone on the inner curvature, and 2–8 mm distal to the intended landing zone on the outer curvature. In clinical application, the pseudoaneurysm could be successfully excluded without complications. Conclusion The novel stent-graft design promises accurate placement in the ascending aorta. The differential deployment of the apices at the inner and outer curvatures allows deployment perpendicular to the aortic axis. Level of Evidence No level of evidence.
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Affiliation(s)
- Sven R Hauck
- Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Alexander Kupferthaler
- Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria.,Department of Diagnostic and Interventional Radiology, Ordensklinikum Linz, Linz, Austria
| | - Marlies Stelzmüller
- Department of Cardiothoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Wolf Eilenberg
- Department of Vascular Surgery, Medical University of Vienna, Vienna, Austria
| | - Marek Ehrlich
- Department of Cardiothoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Christoph Neumayer
- Department of Vascular Surgery, Medical University of Vienna, Vienna, Austria
| | - Florian Wolf
- Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Christian Loewe
- Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Martin A Funovics
- Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria.
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14
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Wang C, von Segesser LK, Berdajs D, Ferrari E. Endovascular treatment of the dissected proximal aortic arch: a systematic review. Interact Cardiovasc Thorac Surg 2021; 33:746-754. [PMID: 34056647 DOI: 10.1093/icvts/ivab161] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 04/26/2021] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES Surgical repair of aortic dissection involving the proximal aortic arch is associated with higher morbidity and mortality, in particular when elderly high-risk patients are concerned. Endovascular treatments for this disease are under evaluation and some reports exist. We investigated the current use of catheter-based treatments for the dissected proximal aortic arch repair. METHODS We searched in PubMed and MEDLINE databases up to the end of June 2020 for studies on endovascular treatment of the dissected proximal aortic arch. Data on demographic, procedure and stent graft (SG) details, access route, mortality with cause of death, complications and follow-up were extracted. A systematic review on the employed technology, procedure and outcome was performed. RESULTS A total number of 15 articles (13 retrospective reports and 2 case reports) were deemed eligible and were included in the study. In total, 140 patients (mean age: 56.7 years in 106 cases) received endovascular treatments for the dissected proximal aortic arch (unspecific aortic dissection: 14; acute and subacute type A aortic dissection: 88; chronic type A aortic dissection: 23; type B aortic dissection with retrograde type A dissection: 15). The procedure strategy included unspecific thoracic endovascular aorta repair (TEVAR) (n = 8), TEVAR + supra-aortic debranching (n = 2), TEVAR + cervical bypass (n = 8), TEVAR + periscope SG (n = 12), TEVAR + chimney graft (n = 8), TEVAR + branched SG (n = 21) and TEVAR + fenestration (n = 81). Procedural success rate was 95.6% for 116 reported cases. Complications included endoleaks (postoperative: 2; late: 5), stroke (n = 4), late SG-induced new entry (n = 3) and new false lumen formation (n = 1). Hospital mortality was 5% (6 cases) in 13 reports (120 patients). The mean follow-up time was 26.2 ± 29.4 months and 2 patients died during follow-up. CONCLUSIONS As an alternative to surgery for high-risk patients with a dissected proximal aortic arch, the endovascular treatment seems to be promising in highly selected cases. Further studies with long-term results and specifically designed devices are required to standardize this approach.
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Affiliation(s)
- Changtian Wang
- Department of Cardiovascular Surgery, Jinling Hospital, Nanjing University, School Medicine, Nanjing, China
| | - Ludwig Karl von Segesser
- Department of Surgery and Anaesthesiology, Cardiovascular Research Unit, University Hospital of Lausanne, Lausanne, Switzerland
| | - Denis Berdajs
- Department of Cardiovascular Surgery, University of Basel, Basel, Switzerland
| | - Enrico Ferrari
- Department of Cardiac Surgery, Cardiocentro Ticino, Lugano, Switzerland
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15
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Grewal A, Odonkor P, Ghoreishi M, Deshpande SP. Anesthetic Considerations in Endovascular Repair of the Ascending Aorta. J Cardiothorac Vasc Anesth 2021; 35:3085-3097. [PMID: 34059437 DOI: 10.1053/j.jvca.2021.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 04/10/2021] [Accepted: 04/14/2021] [Indexed: 11/11/2022]
Abstract
Since the first endovascular aortic repair in 1990, endovascular devices and the indications for their use have significantly grown. Considerable progress has been made in endovascular devices and techniques, such that endovascular repair is now considered first-line treatment for patients with descending aortic disease. However, for patients with ascending aortic disease, open surgical repair with cardiopulmonary bypass and hypothermic cardiac arrest was the only option until recently. Although the outcomes for open surgical repair of the ascending aorta have improved over the years, approximately 30% of patients with an emergent surgical indication, such as type A aortic dissection, are considered to be too high risk for open repair. For these patients, endovascular repair of the ascending aorta offers a life-saving procedure. The ascending aorta is regarded as the final frontier for endovascular therapy. Endovascular repair of it has posed a formidable challenge thus far, due to its unique anatomy, hemodynamic forces, and lack of an appropriate stent-graft designed specifically for the ascending aorta. Although currently there are no comprehensive data from randomized clinical trials, there are several case series and case reports that have shown favorable outcomes. Improvements in available devices soon will drive an exponential increase in the number of patients undergoing endovascular ascending aortic repair. In this review, the authors discuss multiple aspects of endovascular ascending aortic repair including the unique surgical and anesthetic considerations, the devices used, and the available outcomes data, and future directions are also explored.
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Affiliation(s)
- Ashanpreet Grewal
- Department of Anesthesiology, Division of Cardiothoracic Anesthesiology, University of Maryland School of Medicine, Baltimore, MD.
| | - Patrick Odonkor
- Department of Anesthesiology, Division of Cardiothoracic Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Mehrdad Ghoreishi
- Department of Surgery, Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Seema P Deshpande
- Department of Anesthesiology, Division of Cardiothoracic Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
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16
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De Freitas S, Rossi MJ, Abramowitz SD, Fatima J, Kiguchi MM, Vallabhaneni R, Walsh SR, Woo EY. Systematic review and meta-analysis of endovascular interventions for Stanford type A aortic dissection. J Vasc Surg 2021; 74:1721-1731.e4. [PMID: 33592292 DOI: 10.1016/j.jvs.2021.01.054] [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: 10/07/2020] [Accepted: 01/14/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The standard surgical approach to Stanford type A aortic dissection is open repair. However, up to one in four patients will be declined surgery because of prohibitive risk. Patients who are treated nonoperatively have an unacceptably high mortality. Endovascular repair of the ascending aorta is emerging as an alternative treatment for a select group of patients. The reported rates of technical success, mortality, stroke, and reintervention have varied. The objective of the study was to systematically report outcomes for acute type A dissections repaired using an endovascular approach. METHODS The systematic review and meta-analysis was conducted in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. We performed online literature database searches through April 2020. The demographic and procedural characteristics of the individual studies were tabulated. Data on technical success, short-term mortality, stroke, and reintervention were extracted and underwent meta-analysis using a random effects model. RESULTS Fourteen studies with 80 cases of aortic dissection (55 acute and 25 subacute) were included in the final analysis. A wide variation was found in technique and device design across the studies. The outcomes rates were estimated at 17% (95% confidence interval [CI], 10%-26%) for mortality, 15% (95% CI, 8%-23%) for technical failure, 11% (95% CI, 6%-19%) for stroke and 18% (95% CI, 9%-31%) for reintervention. The mean Downs and Black quality assessment score was 13.9 ± 3.2. CONCLUSION The technique for endovascular repair of type A aortic dissection is feasible and reproducible. The results of our meta-analysis demonstrate an acceptable safety profile for inoperable patients who otherwise would have an extremely poor prognosis. Data from clinical trials are required before the technique can be introduced into routine clinical practice.
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Affiliation(s)
- Simon De Freitas
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC.
| | - Matthew J Rossi
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | - Steven D Abramowitz
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | - Javairiah Fatima
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | - Misaki M Kiguchi
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | | | - Stewart R Walsh
- Lambe Institute for Translational Research, National University of Ireland Galway, Galway, Ireland
| | - Edward Y Woo
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
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17
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Ahmed Y, Houben IB, Figueroa CA, Burris NS, Williams DM, Moll FL, Patel HJ, van Herwaarden JA. Endovascular ascending aortic repair in type A dissection: A systematic review. J Card Surg 2021; 36:268-279. [PMID: 33169411 PMCID: PMC8463007 DOI: 10.1111/jocs.15192] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/01/2020] [Accepted: 09/08/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Up to 10% of acute type A aortic dissection (TAAD) patients are deemed unfit for open surgical repair, exposing these patients to high mortality rates. In recent years, thoracic endovascular aortic repair has proven to be a promising alternative treatment modality in specific cases. This study presents a comprehensive overview of the current state of catheter-based interventions in the setting of primary TAAD. METHODS A literature search was conducted, using MEDLINE and PubMed databases according to PRISMA guidelines, updated until January 2020. Articles were selected if they reported on the endovascular repair of DeBakey Type I and II aortic dissections. The exclusion criteria were retrograde type A dissection, hybrid procedures, and combined outcome reporting of mixed aortic pathologies (e.g., pseudoaneurysm and intramural hematoma). RESULTS A total of 31 articles, out of which 19 were case reports and 12 case series, describing a total of 92 patients, were included. The median follow-up was 6 months for case reports and the average follow-up was 14 months for case series. Overall technical success was 95.6% and 30-day mortality of 9%. Stroke and early endoleak rates were 6% and 18%, respectively. Reintervention was required in 14 patients (15%). CONCLUSION This review not only demonstrates that endovascular repair in the setting of isolated TAAD is feasible with acceptable outcomes at short-term follow-up, but also underlines a lack of mid-late outcomes and reporting consistency. Studies with longer follow-up and careful consideration of patient selection are required before endovascular interventions can be widely introduced.
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Affiliation(s)
- Yunus Ahmed
- Department of Vascular Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Ignas B. Houben
- Department of Vascular Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - C. Alberto Figueroa
- Departments of Surgery & Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicholas S. Burris
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - David M. Williams
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Frans L. Moll
- Department of Vascular Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Himanshu J. Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
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18
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Trimarchi S, Grassi V, Lomazzi C, Domanin M, Bissacco D, Bellosta R, Piffaretti G. Endovascular type A aortic repair-When? J Card Surg 2020; 36:1742-1744. [PMID: 33029800 DOI: 10.1111/jocs.15103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/10/2020] [Accepted: 09/24/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Santi Trimarchi
- Department of Surgery, Vascular Surgery, Ospedale Maggiore Policlinico, Fondazione IRCCS Cà Granda, Milan, Italy.,Department of Clinical and Community Sciences, University of Milan School of Medicine, Milan, Italy
| | - Viviana Grassi
- Department of Surgery, Vascular Surgery, Ospedale Maggiore Policlinico, Fondazione IRCCS Cà Granda, Milan, Italy
| | - Chiara Lomazzi
- Department of Surgery, Vascular Surgery, Ospedale Maggiore Policlinico, Fondazione IRCCS Cà Granda, Milan, Italy
| | - Maurizio Domanin
- Department of Surgery, Vascular Surgery, Ospedale Maggiore Policlinico, Fondazione IRCCS Cà Granda, Milan, Italy.,Department of Clinical and Community Sciences, University of Milan School of Medicine, Milan, Italy
| | - Daniele Bissacco
- Department of Surgery, Vascular Surgery, Ospedale Maggiore Policlinico, Fondazione IRCCS Cà Granda, Milan, Italy
| | - Raffaello Bellosta
- Vascular Surgery, Cardiovascular Department, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Gabriele Piffaretti
- Vascular Surgery, Department of Medicine and Surgery, ASST Settelaghi University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
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19
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Wang C, von Segesser LK, Maisano F, Ferrari E. Catheter-based treatment of the dissected ascending aorta: a systematic review. Eur J Cardiothorac Surg 2020; 59:80-91. [DOI: 10.1093/ejcts/ezaa238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/30/2020] [Accepted: 05/26/2020] [Indexed: 12/11/2022] Open
Abstract
Summary
OBJECTIVES
Type A aortic dissection requires immediate surgical repair. Despite improvements in surgery and anaesthesia, there is still a considerable risk when high-risk patients are concerned. Less invasive endovascular treatments are under evaluation. We investigated the current status of catheter-based treatment for type A aortic dissection with the entry tear located in the ascending aorta.
METHODS
A PubMed search was supplemented by searching through bibliographies and key articles. Demographics, risk score, stent graft detail, access route, mortality, cause of death, complications, reinterventions and follow-up data were extracted and analysed.
RESULTS
Thirty-one articles (7 retrospective reports; 24 case reports/series) were included in the study. In total, 104 patients (mean age 71 ± 14 years) received endovascular treatment for acute (63) or chronic (41) type A dissection. A history of a major cardiac or aortic operation was present in 29 patients. The mean EuroSCORE II was 30 ± 20 in 4 reports. A total of 114 stent grafts were implanted: ‘off-the-shelf’, 65/114; custom made, 12/114; and modified, 7/114. Hospital complications included intraprocedural conversion to open surgery (2/104), stroke (2/104), coronary stenting (2/104), early endoleak (9/104) and repeat aortic endovascular treatment for endoleak (5/104). Hospital mortality was 10% (intraoperative death 2/104). Mean duration of follow-up time was 21 ± 21 months (range 1–81 months); follow-up data were available for 86 patients: 10 patients died of non-aortic-related causes; reintervention for aortic disease (endovascular repair or open surgery) was performed in 8 patients.
CONCLUSIONS
Catheter-based ascending aorta repair for type A aortic dissection with the entry tear in the ascending aorta can be considered in carefully selected high-risk patients. Further analysis and specifically designed devices are required.
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Affiliation(s)
- Changtian Wang
- Department of Cardiovascular Surgery. Jinling Hospital, Nanjing University, School Medicine, Nanjing, China
| | - Ludwig Karl von Segesser
- Department of Surgery and Anesthesiology, Cardiovascular Research Unit, University Hospital of Lausanne, Lausanne, Switzerland
| | - Francesco Maisano
- Department of Cardiovascular Surgery, University Hospital of Zurich, Zurich, Switzerland
| | - Enrico Ferrari
- Department of Cardiovascular Surgery, University Hospital of Zurich, Zurich, Switzerland
- Department of Cardiac Surgery, Cardiocentro Ticino Foundation, Lugano, Switzerland
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20
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Suematsu Y, Nishi S, Arima D, Yoshimoto A. Zone 0 Thoracic Endovascular Repair After Aortic Wrapping for Acute Aortic Syndrome. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2020; 15:386-388. [PMID: 32757965 DOI: 10.1177/1556984520933966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We report a successful treatment of type A acute aortic syndrome (AAS)-associated aortic arch aneurysm in a 71-year-old man with major comorbidities. The ascending aorta was wrapped with artificial graft, and supra-aortic debranching was constructed. Then, Zone 0 thoracic endovascular aneurysm repair (TEVAR) with plug occlusion of the left subclavian artery was successfully performed. The patient was discharged in good physical condition without any complications. To our knowledge, this is the first reported case in the literature of successful Zone 0 TEVAR after ascending aorta wrapping and supra-aortic debranching with type A AAS associated with aortic arch aneurysm.
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Affiliation(s)
- Yoshihiro Suematsu
- 73582 Department of Cardiovascular Surgery, Tsukuba Memorial Hospital, Ibaraki, Japan
| | - Satoshi Nishi
- 73582 Tsukuba Memorial Hospital, Tsukuba, Ibaraki, Japan
| | - Daisuke Arima
- 73582 Tsukuba Memorial Hospital, Tsukuba, Ibaraki, Japan
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21
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Stepwise external wrapping procedure for type A intramural hematoma. J Thorac Cardiovasc Surg 2020; 164:31-38.e1. [DOI: 10.1016/j.jtcvs.2020.08.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 07/21/2020] [Accepted: 08/06/2020] [Indexed: 11/21/2022]
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22
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Wang M, Riambau V. Is TEVAR an Optimal Strategy for Retrograde Type A Intramural Haematoma? Eur J Vasc Endovasc Surg 2020; 60:394. [PMID: 32636063 DOI: 10.1016/j.ejvs.2020.05.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 05/21/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Mian Wang
- Vascular Surgery Division, Cardiovascular Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain; Department of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Vincent Riambau
- Vascular Surgery Division, Cardiovascular Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain.
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23
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Impact of center volume on outcomes of surgical repair for type A acute aortic dissections. Surgery 2020; 168:185-192. [PMID: 32507629 DOI: 10.1016/j.surg.2020.04.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 03/20/2020] [Accepted: 04/06/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND Acute type A aortic dissection is a cardiovascular emergency requiring operative intervention. Despite advancements in operative technique and increased specialization of cardiovascular care, operative mortality, and morbidity after repair of type A aortic dissection remain high. Our aim was to assess national trends in outcomes of type A aortic dissection repair and the impact of institutional thoracic aortic repair volume on clinical outcomes and resource use in the United States. METHODS Using the procedural and diagnostic codes of the International Classification of Diseases, Ninth Revision, we identified type A aortic dissection repairs from the 2005 to 2014 database of the National Inpatient Sample. Hospitals were classified into low-, medium- and high-volume tertiles based on annual incidence of thoracic aortic operations. Patient demographics and hospital characteristics, as well as outcomes including mortality, cost, and duration of stay, were evaluated using parametric tests for trends and the volume-outcome relationship. We used a multivariable-adjusted logistic regression model to identify factors associated with mortality. RESULTS An estimated 25,231 patients received type A aortic dissection repair with an increasing temporal trend in volume and concomitant decrease in mortality. When stratified by hospital volume, 10,115 (40.1%), 8,194 (32.4%), and 6,920 (27.4%) underwent type A aortic dissection at low-volume, medium-volume, and high-volume, respectively. The unadjusted mortality rate in high-volume was the least (21.5% vs 16.8% vs 11.6% for low-volume, medium-volume, and high-volume, respectively; P < .001). Multivariable analysis revealed older age, lesser household incomes and comorbidities, including congestive heart failure (adjusted odds ratio 1.44; P < .001) and coagulopathy (adjusted odds ratio 1.33; P = .01) as statistically significant predictors of mortality; however, the risk-adjusted duration of stay (adjusted odds ratio 0.88; P = .06) was not different between low-volume and high-volume hospitals. After adjusting for patient and hospital characteristics, type A aortic dissection repair at low-volume hospitals was associated with increased likelihood of mortality compared with high-volume hospitals (adjusted odds ratio 2.10; P < .001). Patients undergoing type A aortic dissection repair at low-volume hospitals had increased odds of all complications including stroke, and respiratory complications compared than those at high-volume hospitals (P = .02, P < .001, and P < .001, respectively). CONCLUSION The volume of open surgical repair for type A aortic dissection in the United States has increased over the past decade, while mortality has decreased. Hospital aortic operative volume is strongly associated with outcomes for type A aortic dissection repair. Protocols for expeditious transfer of patients to high volume aortic centers may serve to further decrease the acute mortality and complications of this procedure.
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24
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Harky A, Chan J, MacCarthy-Ofosu B. The future of stenting in patients with type A aortic dissection: a systematic review. J Int Med Res 2020; 48:300060519871372. [PMID: 31510840 PMCID: PMC7262859 DOI: 10.1177/0300060519871372] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 08/01/2019] [Indexed: 01/15/2023] Open
Abstract
Acute type A aortic dissection (ATAAD) carries high morbidity and mortality rates and is a clinical emergency. The reported mortality rate is 50% to 65% within the first 48 hours without surgical intervention. Open surgery therefore remains the gold standard management for ATAAD. However, in patients who are deemed unfit for surgery and where possible, endovascular repair offers a useful alternative to medical treatment alone or high-risk open surgical repair. Several case reports, case series, and retrospective studies have reported good outcomes following endovascular treatment. The endovascular option also has comparable early and late outcomes, favourable aortic remodelling, and satisfactory overall survival despite having a higher-risk patient cohort. However, stenting in patients with ATAAD undoubtedly still has several limitations and technical challenges.
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Affiliation(s)
- Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK
| | - Jeremy Chan
- Department of Cardiothoracic Surgery, Morriston Hospital, Wales, UK
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25
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Nissen AP, Ocasio L, Tjaden BL, Sandhu HK, Riascos RF, Safi HJ, Estrera AL, Charlton-Ouw KM. Imaging characteristics of acute type A aortic dissection and candidacy for repair with ascending aortic endografts. J Vasc Surg 2019; 70:1766-1775.e1. [DOI: 10.1016/j.jvs.2019.04.438] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 04/10/2019] [Indexed: 11/25/2022]
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26
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Zhang L, Li Z, Li S, Zhao Z, Bao J, Zhou J, Jing Z. Systematic review of endovascular repair of ascending aortic dissection. Catheter Cardiovasc Interv 2019; 94:1018-1025. [PMID: 31595660 DOI: 10.1002/ccd.28511] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/16/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Lei Zhang
- Department of Vascular SurgeryChanghai Hospital, Navy Medical University Shanghai China
| | - Zhenjiang Li
- Vascular Surgery Departmentthe First Affiliated Hospital of the Medical School of Zhejiang University Hangzhou Zhejiang
| | - Shuangshuang Li
- Department of Vascular SurgeryChanghai Hospital, Navy Medical University Shanghai China
| | - Zhiqing Zhao
- Department of SurgeryChanghai Hospital, Navy Medical University Shanghai China
| | - Junmin Bao
- Department of Vascular SurgeryChanghai Hospital, Navy Medical University Shanghai China
| | - Jian Zhou
- Department of Vascular SurgeryChanghai Hospital, Navy Medical University Shanghai China
| | - Zaiping Jing
- Department of Vascular SurgeryChanghai Hospital, Navy Medical University Shanghai China
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27
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Brescia AA, Patel HJ, Likosky DS, Watt TMF, Wu X, Strobel RJ, Kim KM, Fukuhara S, Yang B, Deeb GM, Thompson MP. Volume-Outcome Relationships in Surgical and Endovascular Repair of Aortic Dissection. Ann Thorac Surg 2019; 108:1299-1306. [PMID: 31400334 DOI: 10.1016/j.athoracsur.2019.06.047] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/22/2019] [Accepted: 06/05/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND As surgical mortality decreases and endovascular utilization increases, it is unknown whether volume-outcome relationships exist in thoracic aortic dissection repair. We characterized volume-outcome relationships for surgical and endovascular management of thoracic aortic dissection. METHODS Patients aged more than 18 years undergoing repair of thoracic aortic dissection in the United States between 2010 and 2014 were identified in seven all-payer state inpatient administrative databases. Patients were divided into groups based on type of repair: surgical repair of type A dissection (TAAD), surgical repair of type B dissection (TBAD), and endovascular repair (TEVAR). Hierarchical logistic regression models evaluated the association between hospital volume and in-hospital mortality. RESULTS Overall in-hospital mortality rate was 13.4% (890 of 6650), highest after TAAD (463 of 2918, 15.9%), followed by TBAD (270 of 1934, 14.0%) and TEVAR (157 of 1798, 8.7%). Volume-outcome relationships for adjusted in-hospital mortality were demonstrated for TAAD and TBAD (P-trend < .001), but not TEVAR (P-trend = .11). Adjusted in-hospital mortality differed most for TAAD (fewer than 3 cases per year: 21%, 95% confidence interval, 18% to 24%; vs 11 or more cases per year: 12%, 95% confidence interval, 8% to 16%; P < .001) and TBAD (fewer than 2 cases per year: 18%, 95% confidence interval, 15% to 22%; vs 11 or more cases per year: 9%, 95% confidence interval, 5% to 12%; P < .001), whereas TEVAR did not differ between quartiles. Adjusted mortality was lower at centers with 26 or more overall annual thoracic dissection repairs, compared with any of the three lower-volume quartiles (P < .001). CONCLUSIONS This study demonstrated lower mortality at high-volume hospitals for overall repair of aortic dissection, persisting separately for surgical repair of TAAD and TBAD, but not TEVAR. As endovascular technology advances and practice patterns consequently change, analyses should focus on understanding the balance between procedural volume, mortality, and access to care for thoracic aortic dissection.
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Affiliation(s)
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Donald S Likosky
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Tessa M F Watt
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Xiaoting Wu
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Raymond J Strobel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Karen M Kim
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Shinichi Fukuhara
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Bo Yang
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - G Michael Deeb
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Michael P Thompson
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
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Non-operative Management of Type A Acute Aortic Syndromes: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2019; 58:41-51. [DOI: 10.1016/j.ejvs.2018.10.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 10/12/2018] [Indexed: 01/16/2023]
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29
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Moriarty JM, Shah R, Hage AN, Srinivasa RN, Aboulhosn JA. Back-table Modified Aortic Endograft Deployed via "Innominate Bounce" Technique for Management of a Zone 0 Ascending Aortic Pseudoaneurysm. Ann Vasc Surg 2019; 59:307.e1-307.e5. [PMID: 31075458 DOI: 10.1016/j.avsg.2019.02.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 02/10/2019] [Accepted: 02/13/2019] [Indexed: 11/24/2022]
Abstract
Ascending aortic pseudoaneurysms pose a difficult therapeutic dilemma. Surgical repair carries high morbidity and mortality risk and may be challenging in patients with unfavorable anatomy or prior aortic surgery. Endovascular repair is difficult due to short landing zones, need for precise delivery, and the lack of adequately sized commercially available devices. This report describes a case of back-table modification of a thoracic aortic stent graft successfully deployed using an "innominate bounce" technique.
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Affiliation(s)
- John M Moriarty
- Department of Radiology, Division of Interventional Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Raj Shah
- University of Arizona College of Medicine, Tucson, AZ.
| | - Anthony N Hage
- Department of Radiology, Division of Interventional Radiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Ravi N Srinivasa
- Department of Radiology, Division of Interventional Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Jamil A Aboulhosn
- Department of Medicine, Division of Interventional Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
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30
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Abstract
Thoracic endovascular aortic repair (TEVAR) for thoracic aortic disease constitutes a paradigm shift in the treatment strategy of aortic dissection, as well as thoracic aortic aneurysms. Conventionally, most patients with Stanford type B acute aortic dissection are treated using conservative medical treatment during the acute phase. However, in patients with complicated type B aortic dissection who present with life-threatening complications, TEVAR has been introduced as a novel and less-invasive alternative and has shown better early results than those observed with conventional therapy. Recently, TEVAR was reported to be effective in not only promoting thrombosis of the false lumen but also in preventing aortic enlargement observed at long-term follow-up. TEVAR has been established as first-line therapy for complicated type B aortic dissection. In contrast, a considerable number of patients who received acute phase medical treatment required surgical intervention for chronic dissecting aortic aneurysms. With the increasing popularity of TEVAR for the treatment of complicated type B aortic dissection, prophylactic and pre-emptive TEVAR has been considered in patients with uncomplicated type B aortic dissection. However, supportive evidence for this strategy is limited, and reassessment is mandatory because it is continuously evolving. Although acute type A aortic dissection is a life-threatening condition, the results of open surgery continue to improve in the modern surgical era. Open surgical treatment is well established and recognized as a gold standard even in the endovascular era. Presently, the application of TEVAR for ascending aortic dissection has undergone a change, and TEVAR is considered a viable rescue option for patients with type A aortic dissection who are not eligible for open surgical repair. However, TEVAR for the descending aorta is well-established treatment for retrograde type A dissection. Several conceptual and technical issues remain unresolved, and technological advances would lead to the development of innovative disease-specific devices and solutions in the future for endovascular treatment of acute aortic dissection. (This is a translation of Jpn J Vasc Surg 2018; 27: 337–345.)
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Affiliation(s)
- Tetsuro Uchida
- Second Department of Surgery, Yamagata University Faculty of Medicine, Yamagata, Yamagata, Japan
| | - Mitsuaki Sadahiro
- Second Department of Surgery, Yamagata University Faculty of Medicine, Yamagata, Yamagata, Japan
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31
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Wu JL, Zhang L, Qiu JT, Yu CT. Morphological features of the thoracic aorta and supra-aortic branches in patients with acute Type A aortic dissection in China. Interact Cardiovasc Thorac Surg 2018; 27:555-560. [PMID: 29688450 DOI: 10.1093/icvts/ivy110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 03/12/2018] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES This study aimed to investigate the morphological characteristics of the dissected thoracic aorta and brachiocephalic arteries within the Chinese population. METHODS A retrospective analysis of computed tomography scans of 387 patients with acute Type A aortic dissection was carried out. The dimensions of the thoracic aorta at multiple levels and other imaging characteristics were studied. RESULTS The patients with a maximum diameter ≥55 mm accounted for less than one-third of the population. Among those without Marfan syndrome (MFS) (n = 349), only 114 (32.8%) patients had a maximal aortic diameter ≥ 55 mm, whereas among those with MFS (n = 38), 20 (78.9%) had a maximal aortic diameter ≥ 45 mm. The predicted maximum aortic diameter is 88.46 - 0.81 × height (cm) + 63.02 × body surface area (m2) + 5.50 × (if diabetes, 1, if not, 0) - 6.63 × (if hypertension, 1, if not, 0). A positive correlation was established between a circular false lumen and the probability that brachiocephalic arteries were involved by dissection. The size ratio of false lumen to true lumen was greater in the circumferential group when compared with the crescent group. The independent predictors for the circumferential false lumen were age, atherosclerosis and smoking. CONCLUSIONS Herein, the morphological characteristics of the thoracic aorta among Chinese patients with acute Type A aortic dissection were described. The currently recommended criteria for prophylactic aorta surgery were applied to most patients with MFS but not to those without MFS within the Chinese population. Furthermore, the shape of the false lumen was identified as a putative risk factor that might affect the prognosis of the patients.
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Affiliation(s)
- Jin-Lin Wu
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Liang Zhang
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jun-Tao Qiu
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Cun-Tao Yu
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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32
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Makaloski V, Tsilimparis N, Rohlffs F, Heidemann F, Debus ES, Kölbel T. Endovascular total arch replacement techniques and early results. Ann Cardiothorac Surg 2018; 7:380-388. [PMID: 30155417 DOI: 10.21037/acs.2018.04.02] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
During the last 20 years, a clear shift has been observed towards thoracic endovascular aortic repair for different aortic pathologies. However, total endovascular repair of the aortic arch remains technically demanding. Simultaneous perfusion of all supra-aortic arteries without longer cerebral ischemia time, whilst trying to avoid cerebral embolization, labels endovascular aortic arch repair with highest level of technical difficulty and surgical expertise. The aim of this article is to present an overview of the current technical options for endovascular aortic arch repair and their early results. Currently, early results are reported from four endovascular arch replacement techniques: hybrid repair, total endovascular approach, chimney grafts and in-situ fenestration. The early results of these different arch replacement techniques are promising, especially the total arch replacement with custom-made fenestrated or branched stent-grafts. Long-term results are unknown, and larger series results and comparative studies are needed to determine safety and efficacy.
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Affiliation(s)
- Vladimir Makaloski
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nikolaos Tsilimparis
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fiona Rohlffs
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franziska Heidemann
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eike Sebastian Debus
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
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33
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Gandet T, Seghrouchni A, Ozdemir BA, Captier G, Demaria R, Alric P, Albat B, Canaud L. Experimental evaluation of homemade distal stent graft fenestration for thoracic endovascular aortic repair of type A dissection by a transapical approach. J Vasc Surg 2018; 68:1217-1224. [PMID: 29680298 DOI: 10.1016/j.jvs.2017.08.095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 08/25/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The use of off-the-shelf stent grafts for thoracic endovascular aortic repair of type A dissections is limited by variability in both the length of the ascending aorta and the location of the proximal intimal tear. This experimental study aimed to assess the feasibility of using a physician-modified thoracic aortic stent graft to treat acute type A dissection by a transapical cardiac approach. METHODS The experiments were performed on six cadaveric human heart, ascending aorta, aortic arch, and descending aorta specimens. Fenestration was fashioned in each standard tubular Valiant thoracic stent graft (Valiant Captivia; Medtronic Vascular, Santa Rosa, Calif) to match the anatomy of each specimen. Stent grafts of sufficient length were selected to cover the entire ascending aorta and aortic arch. Stent graft diameters in proximal sealing zones were oversized by 5% to 10%. The length of the fenestration was the distance between the left subclavian artery and the proximal edge of the origin of the brachiocephalic trunk with an additional 10 mm. The diameter of the scallop was that of the brachiocephalic trunk with an additional 5 mm on all sides. The length of the covered portion of the stent graft was the distance between coronary arteries and the proximal edge of the origin of the brachiocephalic trunk. Two lateral radiopaque markers were positioned to delineate the distal and lateral edge of the scallop. Another 3-cm radiopaque marker was sutured onto the sheath to ensure accurate radiologic positioning of the scallop on the outer curve of the aorta. The left ventricle and the thoracic aorta were connected to a benchtop aortic pulsatile flow model. A 5-mm 30-degree lens was introduced through the left subclavian artery to monitor the procedure. The customized stent graft was deployed by a transapical approach under fluoroscopic control. RESULTS Median duration of stent graft modification was 21 minutes (range, 17-40 minutes). All attempts to deploy the homemade proximal scalloped stent graft by a transapical approach were successful. Completion angiography demonstrated patency of the supra-aortic trunks and of the coronary arteries in all cases. Macroscopic evaluation did not identify any deterioration of the customized stent graft. CONCLUSIONS The use of physician-modified stent grafts is feasible for thoracic endovascular aortic repair of type A dissection by a transapical approach in this model.
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Affiliation(s)
- Thomas Gandet
- Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.
| | - Anis Seghrouchni
- Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Baris Ata Ozdemir
- Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Guillaume Captier
- Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Roland Demaria
- Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Pierre Alric
- Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Bernard Albat
- Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Ludovic Canaud
- Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
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34
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Kreibich M, Rylski B, Kondov S, Morlock J, Scheumann J, Kari FA, Schröfel H, Siepe M, Beyersdorf F, Czerny M. Endovascular treatment of acute Type A aortic dissection-the Endo Bentall approach. J Vis Surg 2018; 4:69. [PMID: 29780715 DOI: 10.21037/jovs.2018.03.14] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 03/12/2018] [Indexed: 01/04/2023]
Abstract
Outcome after classical surgical repair of acute Type A aortic dissection has steadily improved over the years and several modifications in cannulation and perfusion added to this achievement. However, subgroups remain where results of classical surgical repair still have room for improvement, particularly patients with severe preoperative malperfusion as well as elderly patients with a limited physiological reserve. So far, only small case series or case reports have been published on the endovascular treatment of dissected ascending aortas. However, a tube alone is not sufficient to fix the entire complex underlying problem in the vast majority of patients with acute Type A aortic dissection. In addition, these published reports are either due to a favorable anatomy or due to very localized disease processes, which are the exception and not the rule. The concept of an endovascular valve-carrying conduit may significantly increase the number of patients suitable for endovascular therapy and it may soon be common practice.
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Affiliation(s)
- Maximilian Kreibich
- Department of Cardiovascular Surgery, Heart Center University Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Heart Center University Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, Heart Center University Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Julia Morlock
- Department of Cardiovascular Surgery, Heart Center University Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johannes Scheumann
- Department of Cardiovascular Surgery, Heart Center University Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Fabian A Kari
- Department of Cardiovascular Surgery, Heart Center University Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Holger Schröfel
- Department of Cardiovascular Surgery, Heart Center University Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, Heart Center University Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Heart Center University Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Heart Center University Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
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35
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Bonci G, Steigner ML, Hanley M, Braun AR, Desjardins B, Gaba RC, Gage KL, Matsumura JS, Roselli EE, Sella DM, Strax R, Verma N, Weiss CR, Dill KE. ACR Appropriateness Criteria® Thoracic Aorta Interventional Planning and Follow-Up. J Am Coll Radiol 2017; 14:S570-S583. [DOI: 10.1016/j.jacr.2017.08.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 08/14/2017] [Indexed: 12/11/2022]
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36
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Baikoussis NG, Antonopoulos CN, Papakonstantinou NA, Argiriou M, Geroulakos G. Endovascular stent grafting for ascending aorta diseases. J Vasc Surg 2017; 66:1587-1601. [DOI: 10.1016/j.jvs.2017.07.064] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/11/2017] [Indexed: 01/03/2023]
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37
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Affiliation(s)
- George Joseph
- Department of Cardiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Lars Lönn
- Department of Cardiovascular Radiology, Faculty of Health Sciences, The National Hospital and University of Copenhagen, Denmark
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38
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Nienaber CA, Sakalihasan N, Clough RE, Aboukoura M, Mancuso E, Yeh JS, Defraigne JO, Cheshire N, Rosendahl UP, Quarto C, Pepper J. Thoracic endovascular aortic repair (TEVAR) in proximal (type A) aortic dissection: Ready for a broader application? J Thorac Cardiovasc Surg 2017; 153:S3-S11. [DOI: 10.1016/j.jtcvs.2016.07.078] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 07/06/2016] [Accepted: 07/30/2016] [Indexed: 10/21/2022]
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39
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Fujimura N, Kawaguchi S, Obara H, Yoshitake A, Inoue M, Otsubo S, Kitagawa Y, Shimizu H. Anatomic Feasibility of Next-Generation Stent Grafts for the Management of Type A Aortic Dissection in Japanese Patients. Circ J 2017; 81:1388-1394. [DOI: 10.1253/circj.cj-17-0100] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Naoki Fujimura
- Department of Vascular Surgery, Saiseikai Central Hospital
- Department of Cardiovascular Surgery, Saiseikai Central Hospital
- Department of Surgery, Keio University School of Medicine
| | - Shinji Kawaguchi
- Department of Cadiovascular Surgery, Keio University School of Medicine
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine
| | - Akihiro Yoshitake
- Department of Cadiovascular Surgery, Keio University School of Medicine
| | - Masanori Inoue
- Department of Radiology, Keio University School of Medicine
| | - Satoshi Otsubo
- Department of Cardiovascular Surgery, Saiseikai Central Hospital
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine
| | - Hideyuki Shimizu
- Department of Cadiovascular Surgery, Keio University School of Medicine
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40
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Affiliation(s)
- George Joseph
- 1 Department of Cardiology, Christian Medical College, Vellore, India
| | - Ludovic Canaud
- 2 Service de Chirurgie Vasculaire et Thoracique, Hôpital A de Villeneuve, Montpellier, France
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41
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Li Z, Lu Q, Feng R, Zhou J, Zhao Z, Bao J, Feng X, Feng J, Pei Y, Song C, Jing Z. Outcomes of Endovascular Repair of Ascending Aortic Dissection in Patients Unsuitable for Direct Surgical Repair. J Am Coll Cardiol 2016; 68:1944-1954. [DOI: 10.1016/j.jacc.2016.08.031] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 06/21/2016] [Accepted: 07/22/2016] [Indexed: 10/20/2022]
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42
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Dake MD. On the Endovascular Climb to the Type A Dissection Summit, Reaching a New Base Camp ∗. J Am Coll Cardiol 2016; 68:1955-1957. [DOI: 10.1016/j.jacc.2016.07.772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 07/20/2016] [Indexed: 10/20/2022]
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43
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Shah A, Khoynezhad A. Thoracic endovascular repair for acute type A aortic dissection: operative technique. Ann Cardiothorac Surg 2016; 5:389-96. [PMID: 27563553 DOI: 10.21037/acs.2016.07.08] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Acute type A aortic dissection is a potentially lethal condition which requires immediate diagnostic and therapeutic intervention. Open surgical repair remains the standard of care as survival rates continue to improve in the modern surgical era. Unfortunately, up to twenty percent of patients are denied surgical therapy because they are deemed medically unfit to undergo open repair. The application of thoracic endovascular aortic repair (TEVAR) has changed the treatment paradigm for aortic disease involving the descending thoracic aorta and may be a viable rescue option for patients with type A dissection who are not eligible for open surgical repair. New endovascular devices and advanced image-guided procedures are continually evolving. This article summarizes the pathology of aortic dissection and focuses on currently available endovascular solutions for transapical and transfemoral stent graft deployment for acute aortic dissection involving the ascending aorta for selected patients who are ineligible for open surgical repair.
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Affiliation(s)
- Aamir Shah
- Division of Cardio-Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ali Khoynezhad
- Division of Cardio-Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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44
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Zhang Y, Tang H, Zhou J, Liu Z, Liu C, Qiao T, Zhou M. The imaging assessment and specific endograft design for the endovascular repair of ascending aortic dissection. Clin Interv Aging 2016; 11:933-40. [PMID: 27478370 PMCID: PMC4951051 DOI: 10.2147/cia.s104961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Endovascular option has been proposed for a very limited and selected number of Stanford type A aortic dissection (TAAD) patients. We have performed a computed tomography (CT)-based TAAD study to explore appropriate endograft configurations for the ascending aortic pathology. Methods TAAD patients treated with optimal CT scans were retrospectively reviewed, and their entry tears (ETs) were identified using three-dimensional and multiplanar reconstructions in an EndoSize workstation. After generating a centerline of flow, measurements, including numerous morphologic characteristics of anatomy, were evaluated and a selected subset of patients were determined to be suitable for endovascular treatments. Proximal diameter and distal diameter of endograft were selected based on diameters measured at the ET level and at the innominate artery (IA) level, with 10% oversizing with respect to the true lumen, but not exceeding the original aortic diameter. The length of the endograft was determined by the distance from the sinotubular junction to IA. Results This study covered 126 TAAD patients with primary ET in ascending aorta, among which, according to the assumed criteria, 48 (38.1%) patients were deemed to be suitable for endovascular treatment. The diameters of ascending aorta from the sinotubular junction to the IA level presented a downward trend, and the proximal diameters differed significantly from distal diameters of the endograft for TAAD (39.9 versus 36.2 mm, P<0.01), implying that the conical endograft might be compatible with the ascending pathology. In the ascending aorta, lengths of the endograft should be 50, 60, 70, 80, and 90 mm in five (10.4%), 22 (45.9%), 13 (27.1%), six (12.5%), and two (4.2%) patients, respectively. Conclusion In this selected number of Chinese patients, the suitability of endovascular repair has been demonstrated based on the CT imaging. Shorter, larger, and bare spring-free conical endografts were preferred in the ascending aortic pathology.
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Affiliation(s)
- Yepeng Zhang
- Department of Vascular Surgery, The Affiliated Hospital of Nanjing University Medical School, Nanjing
| | - Hanfei Tang
- Department of Vascular Surgery, The Affiliated Hospital of Nanjing University Medical School, Nanjing
| | - JianPing Zhou
- Department of General Surgery, Yixin People's Hospital, Yixin, People's Republic of China
| | - Zhao Liu
- Department of Vascular Surgery, The Affiliated Hospital of Nanjing University Medical School, Nanjing
| | - Changjian Liu
- Department of Vascular Surgery, The Affiliated Hospital of Nanjing University Medical School, Nanjing
| | - Tong Qiao
- Department of Vascular Surgery, The Affiliated Hospital of Nanjing University Medical School, Nanjing
| | - Min Zhou
- Department of Vascular Surgery, The Affiliated Hospital of Nanjing University Medical School, Nanjing
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International experience with endovascular therapy of the ascending aorta with a dedicated endograft. J Vasc Surg 2016; 63:1476-82. [DOI: 10.1016/j.jvs.2015.12.027] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 12/15/2015] [Indexed: 11/23/2022]
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Piffaretti G, Galli M, Lomazzi C, Franchin M, Castelli P, Mariscalco G, Trimarchi S. Endograft repair for pseudoaneurysms and penetrating ulcers of the ascending aorta. J Thorac Cardiovasc Surg 2016; 151:1606-14. [DOI: 10.1016/j.jtcvs.2015.12.055] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 12/18/2015] [Accepted: 12/24/2015] [Indexed: 11/30/2022]
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Kim JS, Park KH, Lim C, Kim DJ, Jung Y, Shin YC, Choi SI, Chun EJ, Yoo JY. Prediction of Intimal Tear Site by Computed Tomography in Acute Aortic Dissection Type A. Korean Circ J 2016; 46:48-55. [PMID: 26798385 PMCID: PMC4720849 DOI: 10.4070/kcj.2016.46.1.48] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 07/27/2015] [Accepted: 08/17/2015] [Indexed: 11/12/2022] Open
Abstract
Background and Objectives Preoperative identification of intimal tear site in acute type A dissection will help procedural planning. The objective of this study was to determine the key findings of computed tomography (CT)-based prediction for tear site and compare the accuracy between radiologists and surgeons. Subjects and Methods Multi-detector CT (MDCT) images from 50 patients who underwent surgical repair of type A aortic dissection were retrospectively reviewed by 4 cardiac surgeons with limited experience or by 3 radiologists specialized in cardiovascular imaging. Surgical findings of intimal tear site were used as references. Results In surgical findings, the locations of intimal tear that were identified in 43 patients included aorta (n=25), ascending with arch (n=7), and arch only (n=11). The rest were retrograde dissections from the tear of descending aorta. Key CT findings that were most frequently found were defect in the intimal flap shadow (30.0±4.0 patients/reviewer, accuracy 87.0±11.7%) and differential filling of false lumen by phase and location (9.4±2.9 patients/reviewer, 84.8±10.4%). Surgeons predicted tear site (75.0±7.7% vs. 86.7±1.2%, p=0.055) and specified flap defect (80.5±10.3% vs. 95.7±7.4%, p=0.073) with lower accuracy than radiologists. Conclusions With MDCT imaging, well-educated surgeons could be accurate in three fourths of cases. There was room for improvement through experience. Considering the substantial possibility of inaccuracy, critical decisions on CT images should be made through thorough reviewing by as many experienced radiologists and surgeons as possible.
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Affiliation(s)
- Jun Sung Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kay-Hyun Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Cheong Lim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dong Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yochun Jung
- Department of Thoracic and Cardiovascular Surgery, Halla General Hospital, Jeju, Korea
| | - Yoon Cheol Shin
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang Il Choi
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Eun Ju Chun
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jin Young Yoo
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
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Horton JD, Kölbel T, Haulon S, Khoynezhad A, Green RM, Borger MA, Mussa FF. Endovascular Repair of Type A Aortic Dissection: Current Experience and Technical Considerations. Semin Thorac Cardiovasc Surg 2015; 28:312-317. [PMID: 28043436 DOI: 10.1053/j.semtcvs.2015.12.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2015] [Indexed: 02/06/2023]
Abstract
Dissection of the ascending aorta, type A aortic dissection (TAAD), represents a surgical emergency with high morbidity and mortality. Current open surgical techniques, although state-of-the-art procedures and having improved outcomes for patients with TAAD over the last decades, confer significant risk of complications and death. Recently, endovascular techniques for repair of both the abdominal and thoracic aorta have gained acceptance within the vascular and cardiovascular surgical communities as a useful tool in select pathologies and patient populations. As development of endovascular technology proceeds ever closer to the aortic valve, thoracic endovascular repair for TAAD deserves special investigation. A comprehensive literature search for studies reporting outcomes of endovascular repair in the ascending aorta was performed. In this review, we compile the worldwide experience of thoracic endovascular repair for TAAD as well as imaging studies for patient selection and the use of hybrid (open plus endovascular) techniques. The authors discuss the remaining challenges that preclude its broader adoption in this role, namely patient selection and device specificity.
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Affiliation(s)
- Joshua D Horton
- Department of Surgery, New York University School of Medicine, New York, New York
| | - Tilo Kölbel
- University Heart Center Hamburg, Hamburg, Germany
| | - Stephan Haulon
- Aortic Center, Université Lille Nord de France, Lille, France
| | - Ali Khoynezhad
- Department of Cardio-thoracic Surgery, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Richard M Green
- Department of Surgery, Columbia University Medical Center Surgery, New York, New York
| | - Michael A Borger
- Department of Surgery, Columbia University Medical Center Surgery, New York, New York
| | - Firas F Mussa
- Department of Surgery, Columbia University Medical Center Surgery, New York, New York.
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Oderich GS, Pochettino A, Mendes BC, Roeder B, Pulido J, Gloviczki P. Endovascular Repair of Saccular Ascending Aortic Aneurysm After Orthotopic Heart Transplantation Using an Investigational Zenith Ascend Stent-Graft. J Endovasc Ther 2015; 22:650-654. [DOI: 10.1177/1526602815593537] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Purpose: To report the use of an investigational stent-graft to treat an ascending aortic aneurysm in a patient with a heart transplant. Case Report: A 48-year-old man presented with a 3.5×1.5-cm saccular aneurysm in the mid anterior ascending aorta, abutting the sternum. The patient’s history was notable for placement of a left ventricular assist device followed by orthotopic heart transplantation 2 years prior to treat end-stage familial dilated cardiomyopathy. Under compassionate use, a custom-designed ascending aortic stent-graft (Zenith Ascend) was successfully delivered via an 18-F system and deployed just distal to the origin of the left main coronary artery under pulmonary artery catheter–guided rapid ventricular pacing. The patient was discharged the next day, and 6-month follow-up was unremarkable. Imaging at 5 months showed an excluded aneurysm sac with no endoleak or migration. Conclusion: The ideal ascending aortic stent-graft should be low profile, conformable to the arch anatomy, with short tip delivery system and a stepwise deployment mechanism that allows precise placement relative to the ostia of the coronary arteries and the innominate artery. This case illustrates the advancement of endovascular techniques to the most challenging segment of the aorta to decrease morbidity and mortality in high-risk patients.
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Affiliation(s)
- Gustavo S. Oderich
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Bernardo C. Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Juan Pulido
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
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Huang C, Zhou M, Liu Z, Huang D, Ran F, Wang W, Zhang M, Liu C, Liu C, Qiao T, Liu C. Computed tomography-based study exploring the feasibility of endovascular treatment of type A aortic dissection in the Chinese population. J Endovasc Ther 2015; 21:707-13. [PMID: 25290800 DOI: 10.1583/14-4733mr.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE To characterize type A aortic dissection (TAAD) in the Chinese population using high-resolution computed tomography (CT) and explore potential candidacy for endovascular repair of TAAD. METHODS The imaging studies and medical records of all 302 patients presenting with TAAD at two Chinese hospitals from 2010 to 2013 were reviewed. Of these, 221 patients were excluded because of missing/inadequate preoperative CT scans. The remaining 91 patients (64 men; mean age 51.1±7.5 years) had CT data adequate to assess anatomical suitability for endovascular treatment. Entry tears were identified using multiplanar reconstructions, while morphological measurements were based on a centerline of flow (CLF) technique. Suitability for endovascular treatment was based on a proximal landing zone ≥20 mm long, a true lumen aortic diameter ≤38 mm, and a total aortic diameter ≤46 mm; no coronary bypass grafts originating from the ascending aorta; no malfunctioning aortic valve; and good cerebral and cardiac perfusion. RESULTS In the 91 patients, the precise location of the primary proximal entry tear could be identified in only 34 (37.4%) patients; in these patients, the identifiable intimal tears were located 36.4±41.0 mm distal to the closest coronary artery. The CLF was successfully generated in the CT scans of all patients; the mean lumen and total aortic lumen diameters at the entry tear level were 37.6±6.3 and 44.3±13.3 mm, respectively. Based on the CT measurements, stent-graft repair would have been anatomically feasible in 35 (38.5%) patients. No proximal landing zone (n=23), large aortic diameter (n=15), abnormal aortic valve (n=10), previous coronary bypass graft surgery (n=5), and poor cerebral and cardiac perfusion (n=3) were obstacles that affected the suitability for this treatment. CONCLUSION Based on high-resolution CT scans, our pilot study suggested that 38% of Chinese patients with TAAD could potentially be treated by stent-grafting based on the anatomical characteristics of the proximal dissection.
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Affiliation(s)
- Chen Huang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing, People's Republic of China
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