1
|
Alanezi T, Altoijry A, AlSheikh S, Al-Mubarak H, Alhamzah M, Alomran F, Abdulrahim O, Aljabri B, Greco E, Hussain MA, Al-Omran M. Predicting the need for subclavian artery revascularization in thoracic endovascular aortic repair: A systematic review and meta-analysis. J Vasc Surg 2024; 80:922-936.e5. [PMID: 38621636 DOI: 10.1016/j.jvs.2024.04.023] [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: 02/06/2024] [Revised: 03/21/2024] [Accepted: 04/09/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVE This systematic review and meta-analysis aims to investigate the effectiveness of left subclavian artery revascularization compared with non-revascularization in thoracic endovascular aortic repair, and to summarize the current evidence on its indications. METHODS A computerized search was conducted across multiple databases, including MEDLINE, SCOPUS, Cochrane Library, and Web of Science, for studies published up to November 2023. Study selection, data abstraction, and quality assessment (using the Newcastle-Ottawa Scale) were independently conducted by two reviewers, with a third author resolving discrepancies. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models and publication bias was assessed using funnel plots. RESULTS In the 76 included studies, left subclavian artery revascularization was associated with reduced risks of stroke (OR, 0.67; 95% CI, 0.45-0.98; n = 15,331), spinal cord ischemia (OR, 0.75; 95% CI, 0.56-0.99; n = 11,995), and arm ischemia (OR, 0.09; 95% CI, 0.01-0.59; n = 8438). No significant reduction in paraplegia (OR, 0.56; 95% CI, 0.21-1.47; n = 1802) or mortality (OR, 0.77; 95% CI, 0.53-1.12; n = 11,831) was observed. Moreover, the risk of endoleak was comparable in both groups (OR, 1.25; 95% CI, 0.55-2.84; P = .60; n = 793), whereas the risk of reintervention was significantly higher in the revascularization group (OR, 1.98; 95% CI, 1.03-3.83; P = .04; n = 272). Both groups had similar risks of major (OR, 0.45; 95% CI, 0.19-1.09; P = .08; n = 1113), minor (OR, 0.21; 95% CI, 0.01-3.45; P = .27; n = 183), renal (OR, 0.61; 95% CI, 0.12-3.06; P = .55; n = 310), and pulmonary (OR, 0.59; 95% CI, 0.16-2.15; P = .42; n = 8083) complications. The most frequent indications for left subclavian artery revascularization were primary prevention of spinal cord ischemia, augmentation of the landing zone, and primary stroke prevention. CONCLUSIONS Left subclavian artery revascularization in thoracic endovascular aortic repair was associated with reduced neurological complications but was not found to impact mortality. The study highlights important indications for revascularization as well as significant predictors of complications, providing a basis for clinical decision-making and future research.
Collapse
Affiliation(s)
- Tariq Alanezi
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulmajeed Altoijry
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Sultan AlSheikh
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Husain Al-Mubarak
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Musaad Alhamzah
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Faris Alomran
- Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Omer Abdulrahim
- Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Badr Aljabri
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Elisa Greco
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Mohamad A Hussain
- Harvard Medical School, Boston, MA; Division of Vascular and Endovascular Surgery and the Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston
| | - Mohammed Al-Omran
- Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
| |
Collapse
|
2
|
Shi M, Fang H, Wu Y, Li H, Sheng C, Li S, Zhou Q. Optimal antiplatelet therapy after revascularization of left subclavian artery during TEVAR. J Cardiothorac Surg 2024; 19:402. [PMID: 38937841 PMCID: PMC11212403 DOI: 10.1186/s13019-024-02932-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 06/15/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) is a minimally invasive technique used to treat type B aortic dissections. Left subclavian artery (LSA) reconstruction is required when treating patients with involvement of LSA. The best antiplatelet therapy after LSA reconstruction is presently uncertain. METHODS This study retrospectively analyzed 245 type B aortic dissection patients who underwent left subclavian artery revascularization during TEVAR. Out of 245 patients, 159 (64.9%) were in the single antiplatelet therapy (SAPT) group, receiving only aspirin, and 86 (35.1%) were in the dual antiplatelet therapy (DAPT) group, receiving aspirin combined with clopidogrel. During the 6-month follow-up, primary endpoints included hemorrhagic events (general bleeding and hemorrhagic strokes), while secondary endpoints comprised ischemic events (left upper limb ischemia, ischemic stroke, and thrombotic events), as well as death and leakage events. Both univariate and multivariate Cox regression analyses were performed on hemorrhagic and ischemic events, with the Kaplan-Meier method used to generate the survival curve. RESULTS During the six-month follow-up, the incidence of hemorrhagic events in the DAPT group was higher (8.2% vs. 30.2%, P < 0.001). No significant differences were observed in ischemic events, death, or leakage events among the different antiplatelet treatment schemes. Multivariate Cox regression analysis showed that DAPT (HR: 2.22, 95% CI: 1.07-4.60, P = 0.032) and previous chronic conditions (HR:3.88, 95% CI: 1.24-12.14, P = 0.020) significantly affected the occurrence of hemorrhagic events. Chronic conditions in this study encompassed depression, vitiligo, and cholecystolithiasis. Carotid subclavian bypass (CSB) group (HR:0.29, 95% CI: 0.12-0.68, P = 0.004) and single-branched stent graft (SBSG) group (HR:0.26, 95% CI: 0.13-0.50, P < 0.001) had a lower rate of ischemic events than fenestration TEVAR (F-TEVAR). Survival analysis over 6 months revealed a lower risk of bleeding associated with SAPT during hemorrhagic events (P = 0.043). CONCLUSIONS In type B aortic dissection patients undergoing LSA blood flow reconstruction after synchronous TEVAR, the bleeding risk significantly decreases with the SAPT regimen, and there is no apparent ischemic compensation within 6 months. Patients with previous chronic conditions have a higher risk of bleeding. The CSB group and SBSG group have less ischemic risk compared to F-TEVAR group.
Collapse
Affiliation(s)
- Mengxiao Shi
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Number 321 Zhong-shan Road, Nanjing, Jiangsu, 210008, China
| | - Hong Fang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Number 321 Zhong-shan Road, Nanjing, Jiangsu, 210008, China
| | - Ying Wu
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Number 321 Zhong-shan Road, Nanjing, Jiangsu, 210008, China
| | - Han Li
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Nanjing, China
| | - Chong Sheng
- Department of Cardio-Thoracic Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Shuchun Li
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Nanjing, China.
| | - Qing Zhou
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Number 321 Zhong-shan Road, Nanjing, Jiangsu, 210008, China.
- Department of Cardio-Thoracic Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China.
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Nanjing, China.
| |
Collapse
|
3
|
Mandigers TJ, Allievi S, Jabbour G, Gomez-Mayorga JL, Caron E, Giles KA, Wang GJ, van Herwaarden JA, Trimarchi S, Scali ST, Schermerhorn ML. Comparison of open and endovascular left subclavian artery revascularization for zone 2 thoracic endovascular aortic repair. J Vasc Surg 2024:S0741-5214(24)01278-3. [PMID: 38880180 DOI: 10.1016/j.jvs.2024.06.018] [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: 03/08/2024] [Revised: 05/27/2024] [Accepted: 06/09/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVE In patients undergoing elective thoracic endovascular aortic repair (TEVAR) and left subclavian artery (LSA) coverage, routine preoperative LSA revascularization is recommended. However, in the current endovascular era, the optimal surgical approach is debated. We compared baseline characteristics, procedural details, and perioperative outcomes of patients undergoing open or endovascular LSA revascularization in the setting of TEVAR. METHODS Adult patients undergoing TEVAR with zone 2 proximal landing and LSA revascularization between 2013 and 2023 were identified in the Vascular Quality Initiative. We excluded patients with traumatic aortic injury, aortic thrombus, or ruptured presentations, and stratified based on revascularization type (open vs any endovascular). Open LSA revascularization included surgical bypass or transposition. Endovascular LSA revascularization included single-branch, fenestration, or parallel stent grafting. Primary outcomes were stroke, spinal cord ischemia (SCI), and perioperative mortality (Pearson's χ2 test). Multivariable logistic regression was used to evaluate associations between revascularization type and primary outcomes. Secondarily, we studied other in-hospital complications and 5-year mortality (Kaplan-Meier, multivariable Cox regression). Sensitivity analyses were performed in patients undergoing concomitant LSA revascularization to TEVAR. RESULTS Of 2489 patients, 1842 (74%) underwent open and 647 (26%) endovascular LSA revascularization. Demographics and comorbidities were similar between open and endovascular cohorts. Compared with open, endovascular revascularization had shorter procedure times (median, 135 minutes vs 174 minutes; P < .001), longer fluoroscopy times (median, 23 minutes vs 16 minutes; P < .001), lower estimated blood loss (median, 100 mL vs 123 mL; P < .001), and less preoperative spinal drain use (40% vs 49%; P < .001). Patients undergoing endovascular revascularization were more likely to present urgently (24% vs 19%) or emergently (7.4% vs 3.4%) (P < .001). Compared with open, endovascular patients experienced lower stroke rates (2.6% vs 4.8%; P = .026; adjusted odds ratio [aOR], 0.50 [95% confidence interval (CI), 0.25-0.90]), but had comparable SCI (2.9% vs 3.5%; P = .60; aOR, 0.64 [95% CI, 0.31-1.22]) and perioperative mortality (3.1% vs 3.3%; P = .94; aOR, 0.71 [95% CI, 0.34-1.37]). Compared with open, endovascular LSA revascularization had lower rates of overall composite in-hospital complications (20% vs 27%; P < .001; aOR, 0.64 [95% CI, 0.49-0.83]) and shorter overall hospital stay (7 vs 8 days; P < .001). After adjustment, 5-year mortality was similar among groups (adjusted hazard ratio, 0.85; 95% CI, 0.64-1.13). Sensitivity analyses supported the primary analysis with similar outcomes. CONCLUSIONS In patients undergoing TEVAR starting in zone 2, endovascular LSA revascularization had lower rates of postoperative stroke and overall composite in-hospital complications, but similar SCI, perioperative mortality, and 5-year mortality rates compared with open LSA revascularization. Future comparative studies are needed to evaluate the mid- to long-term safety of endovascular LSA revascularization and assess differences between specific endovascular techniques.
Collapse
Affiliation(s)
- Tim J Mandigers
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Section of Vascular Surgery, Cardio Thoracic Vascular Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Sara Allievi
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Gabriel Jabbour
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jorge L Gomez-Mayorga
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Elisa Caron
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kristina A Giles
- Division of Vascular and Endovascular Surgery, Maine Medical Center, Portland, ME
| | - Grace J Wang
- Division of Vascular and Endovascular Therapy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Joost A van Herwaarden
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Santi Trimarchi
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| |
Collapse
|
4
|
Oishi Y, Kumamaru H, Kato M, Ohki T, Shiose A, Motomura N, Shimizu H. Open Versus Zone 0/1 Endovascular Aortic Repair for Arch Aneurysm: A Propensity Score-Matched Study from the National Clinical Database in Japan. Ann Vasc Surg 2024; 100:128-137. [PMID: 38122978 DOI: 10.1016/j.avsg.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/22/2023] [Accepted: 10/13/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Although open surgical repair (OSR) is the gold standard for treating arch aneurysms, thoracic endovascular aortic repair (TEVAR) may be a less invasive alternative. However, it remains unclear which of the 2 methods yields better outcomes. In this study, we compared the perioperative outcomes of both procedures for arch aneurysms using a nationwide surgical database. METHODS Data of patients who underwent elective aortic repair for true arch aneurysms were extracted from the National Clinical Database of Japan. Patients who underwent OSR and Zone 0/1 TEVAR were matched in a 1:1 ratio using propensity scores and their mortality and morbidity rates were compared. RESULTS A total of 2,815 and 1,125 patients underwent OSR and Zone 0/1 TEVAR, respectively. After propensity score matching, 1,058 patients were included in both groups. Compared with OSR, Zone 0/1 TEVAR was associated with a significantly higher incidence of stroke (5.8 vs. 10.0%, P < 0.001) and paraplegia/paraparesis (1.6 vs. 4.4%, P < 0.001). However, there were no significant differences in the 30-day and operative mortality rates between the 2 groups (2.2 vs. 2.7% and 4.5 vs. 5.4%, respectively). In the Zone 0/1 TEVAR group, postoperative computed tomography was performed in 92.4% of patients, and types I and III endoleaks were identified in 6.4% and 1.1% of patients, respectively. CONCLUSIONS Zone 0/1 TEVAR has higher incidences of stroke and paraplegia/paraparesis than OSR, with a risk of postoperative endoleaks. Resolving these problems is the key for expanding the application of Zone 0/1 TEVAR and in the meantime OSR remains the gold standard for surgically fit patients.
Collapse
Affiliation(s)
- Yasuhisa Oishi
- Advanced Aortic Therapeutics, Faculty of Medicine, Kyushu University Graduate School of Medicine, Fukuoka, Japan.
| | - Hiraku Kumamaru
- Department of Health Care Quality Assessment, The University Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital, Osaka, Japan; Japan Cardiovascular Surgery Database, Tokyo, Japan; Japan Stent Graft Committee for Stentgraft Management, Tokyo, Japan
| | - Takao Ohki
- Japan Stent Graft Committee for Stentgraft Management, Tokyo, Japan; Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Akira Shiose
- Department of Cardiovascular Surgery, Faculty of Medicine, Kyushu University Graduate School of Medicine, Fukuoka, Japan
| | - Noboru Motomura
- Japan Cardiovascular Surgery Database, Tokyo, Japan; Department of Cardiovascular Surgery, Toho University Sakura Medical Center, Chiba, Japan
| | - Hideyuki Shimizu
- Japan Stent Graft Committee for Stentgraft Management, Tokyo, Japan; Department of Cardiovascular Surgery, Keio University School of Medicine, Tokyo, Japan
| |
Collapse
|
5
|
Bonvini S, Spadoni N, Tasselli S. Endovascular repair of an intrathoracic subclavian artery aneurysm with a single-branched thoracic endograft in a hostile anatomy. Vascular 2024; 32:42-47. [PMID: 36120869 DOI: 10.1177/17085381221128058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2024]
Abstract
OBJECTIVE Subclavian artery aneurysms (SAA) are rare and usually involve the proximal segment of the artery. In this setting traditional surgical treatment or hybrid procedures are associated with significative morbidity rate so that new endovascular solutions are preferred. METHODS Authors report a case of a patient with an intrathoracic left SAA involving the aortic arch's outer curve. Patient's comorbidities contraindicated open surgical treatment while anatomical issues were not favourable to hybrid or standard endovascular solutions. Thus a single-branched custom-made thoracic stent-graft (Castor, MicroPort Medical, Shanghai, China) was implanted. RESULTS Technical success was achieved with no intra-operative complications and technical steps of the procedure are accurately described.A pre-discharge CT scan showed the correct position of the endograft, complete aneurysm exclusion and branch patency. CONCLUSION Single-branched thoracic stentgrafts could be a good option in unfavourable anatomies with supra-aortic vessels disease involving the aortic arch, with good results in terms of morbidity and early outcomes.
Collapse
Affiliation(s)
- Stefano Bonvini
- Department of Vascular Surgery, Santa Chiara Hospital, Trento, Italy
| | - Nicola Spadoni
- Department of Vascular Surgery, Santa Chiara Hospital, Trento, Italy
| | | |
Collapse
|
6
|
Piffaretti G, Franchin M, Gnesutta A, Gatta T, Piacentino F, Rivolta N, Lomazzi C, Bissacco D, Fontana F, Trimarchi S. Anatomic Feasibility of In-Situ Fenestration for Isolate Left Subclavian Artery Preservation during Thoracic Endovascular Aortic Repair Using an Adjustable Needle Puncturing System. J Clin Med 2023; 13:162. [PMID: 38202169 PMCID: PMC10779778 DOI: 10.3390/jcm13010162] [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: 10/24/2023] [Revised: 12/14/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
OBJECTIVES To evaluate the feasibility of thoracic endovascular aortic repair (TEVAR) using the Ankura™ device (Lifetech Scientific, Shenzhen, China) with left subclavian artery (LSA) in-situ fenestration (ISF) using an adjustable puncture device system. METHODS It is a single center, retrospective, financially unsupported cohort study of TEVAR performed from 16 February 2007 to 10 January 2023. Inclusion criteria were isolate LSA revascularization for elective or urgent/emergent "zone 2" TEVAR, and the availability of the preoperative computed tomography angiography. RESULTS Post-hoc analysis identified 52 TEVARs. There were 39 (75.0%) males, and 13 (25.0%) females: median age was 74.5 years (IQR, 65.5-78). Index TEVAR was performed for atherosclerotic aneurysm in 27 (51.9%) cases, dissection-related diseases in 18 (34.6%), penetrating aortic ulcer in 5 (9.6%), and blunt traumatic aortic injury in 2 (3.8%). Access-vessel feasibility rate of TEVAR using the Ankura™ device would have been 98.1% (51/52). Considering the morphology of the aortic arch, ISF TEVAR feasibility would have been 61.5% (32/52). Binary logistic regression analysis identified LSA angulation (OR: 1.1, 95%CI: 1.03-1.14, p = 0.003) to be associated with ISF feasibility using this endograft and a self-centering adjustable needle-based puncture device. CONCLUSIONS Potential feasibility of TEVAR using the Ankura™ endograft with ISF using a self-centering adjustable needle system was 61.5%. Left subclavian artery angulation seems to be the most important and limiting anatomical constraint.
Collapse
Affiliation(s)
- Gabriele Piffaretti
- Vascular Surgery—Department of Medicine and Surgery, University of Insubria School of Medicine, 21100 Varese, Italy; (M.F.); (N.R.)
- ASST Settelaghi University Teaching Hospital, 21100 Varese, Italy
| | - Marco Franchin
- Vascular Surgery—Department of Medicine and Surgery, University of Insubria School of Medicine, 21100 Varese, Italy; (M.F.); (N.R.)
- ASST Settelaghi University Teaching Hospital, 21100 Varese, Italy
| | - Aroa Gnesutta
- ASST Settelaghi University Teaching Hospital, 21100 Varese, Italy
| | - Tonia Gatta
- ASST Settelaghi University Teaching Hospital, 21100 Varese, Italy
| | - Filippo Piacentino
- ASST Settelaghi University Teaching Hospital, 21100 Varese, Italy
- Interventional Radiology—Department of Medicine and Surgery, University of Insubria School of Medicine, ASST Settelaghi University Teaching Hospital, 21100 Varese, Italy
| | - Nicola Rivolta
- Vascular Surgery—Department of Medicine and Surgery, University of Insubria School of Medicine, 21100 Varese, Italy; (M.F.); (N.R.)
- ASST Settelaghi University Teaching Hospital, 21100 Varese, Italy
| | - Chiara Lomazzi
- Vascular Surgery, Cardio Thoracic Vascular Department, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy (S.T.)
| | - Daniele Bissacco
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Federico Fontana
- ASST Settelaghi University Teaching Hospital, 21100 Varese, Italy
| | - Santi Trimarchi
- Vascular Surgery, Cardio Thoracic Vascular Department, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy (S.T.)
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| |
Collapse
|
7
|
Lin F, He Z, Gao J, Huang X, Wang H, Han L, Zhu X, Zhan Y, Wang W. Comparison of surgical and endovascular left subclavian artery revascularization during thoracic aortic endovascular repair: a systematic review and meta-analysis. Front Cardiovasc Med 2023; 10:1274629. [PMID: 38028461 PMCID: PMC10658894 DOI: 10.3389/fcvm.2023.1274629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/20/2023] [Indexed: 12/01/2023] Open
Abstract
Objective The purpose of this systematic review and meta-analysis was to incorporate data from the latest clinical studies and compare the safety and efficacy of surgical left subclavian artery (LSA) revascularization and endovascular LSA revascularization during thoracic endovascular aortic repair (TEVAR). Methods This study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered with the PROSPERO database on 16 April 2023 (CRD42023414579). The Embase, MEDLINE (PubMed), and the Cochrane Library databases were searched from January 2000 to May 2023. Results A total of 14 retrospective cohort studies with a total of 1,695 patients, were included for review. The peri-operative stroke rates of the surgical and endovascular LSA revascularization groups were 3.8% and 2.6%, respectively (P = 0.97). The peri-operative technical success rates for the surgical and endovascular LSA revascularization groups were 95.6% and 93.0%, respectively (P = 0.24). The peri-operative spinal cord ischemia rates were 1.6% (n = 18) and 1.9% (n = 7) in the surgical and endovascular LSA revascularization groups, respectively (P = 0.90). The peri-operative type Ⅰ endoleak rates for the surgical and endovascular LSA revascularization groups were 6.6% and 23.2%, respectively (P = 0.25). The subgroup analysis showed that the incidence of peri-operative type I endoleak in the parallel stent group was significantly higher than that in the surgical LSA revascularization group (P < 0.0001). The peri-operative left upper limb ischemia rates for the surgical and endovascular LSA revascularization groups were 1.2% and 0.6%, respectively (P = 0.96). The peri-operative mortality rates of the surgical and endovascular LSA revascularization groups were 2.0% and 2.0%, respectively (P = 0.88). Conclusion There was no significant difference in the terms of short-term outcomes when comparing the two revascularization techniques. The quality of evidence assessed by GRADE scale was low to very-low. Surgical and endovascular LSA revascularization during TEVAR were both safe and effective. Compared with surgical LSA revascularization techniques, parallel stent revascularization of LSA significantly increased the rate of type I endoleak.
Collapse
Affiliation(s)
- Feng Lin
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of General Surgery, Anhui Public Health Clinical Center, Hefei, China
| | - Zhipeng He
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Junpeng Gao
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xiaoci Huang
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Haoran Wang
- Department of Vascular Surgery, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Long Han
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of General Surgery, Anhui Public Health Clinical Center, Hefei, China
| | - Xingyang Zhu
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of General Surgery, Anhui Public Health Clinical Center, Hefei, China
| | - Yanqing Zhan
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of General Surgery, Anhui Public Health Clinical Center, Hefei, China
| | - Wenbin Wang
- Department of General Surgery, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of Vascular Surgery, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| |
Collapse
|
8
|
Xodo A, de Kort JF, Trimarchi S, Piffaretti G. A 'semi-custom' unibody single-branch endograft to preserve the left subclavian artery during thoracic endovascular aortic repair in zone 2: the answer to any question? Eur J Cardiothorac Surg 2023; 64:ezad328. [PMID: 37740310 DOI: 10.1093/ejcts/ezad328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 09/21/2023] [Indexed: 09/24/2023] Open
Affiliation(s)
- Andrea Xodo
- Vascular and Endovascular Surgery Division, "San Bortolo" Hospital, AULSS8 Berica, Vicenza, Italy
| | - Jasper F de Kort
- Department of Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Santi Trimarchi
- Department of Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Clinical and Community Sciences Department, Università degli Studi di Milano, Milan, Italy
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| |
Collapse
|
9
|
Kumins NH, Ambani RN, Bose S, King AH, Cho JS, Colvard B, Kashyap VS. Anatomic Utility of Single Branched Thoracic Endograft During Thoracic Endovascular Aortic Repair. Vasc Endovascular Surg 2023; 57:680-688. [PMID: 36961838 DOI: 10.1177/15385744231165988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
INTRODUCTION Single branched thoracic endografts (SBTEs) have been designed for pathology requiring zone 2 seal during thoracic endovascular aortic repair (TEVAR). Numerous criteria must be met to allow for their implantation. Our aim was to analyze anatomic suitability for a next generation SBTE. METHODS We reviewed 150 TEVAR procedures between 2015 and 2019. Proximal seal was: zone 0 in 21 (16%), zone 1 in 4 (3%), zone 2 in 52 (40%), zone 3 in 45 (35%), and zone 4 or distal in 7 (5%). We analyzed the Zone 2 patient's angiograms and CT angiograms using centerline software to measure arterial diameters and length in relation to the left common carotid artery (LCCA), left subclavian artery (LSA) and proximal extent of aortic disease to determine if patients met anatomic criteria of a novel SBTE. RESULTS Zone 2 average age was 64.4 ± 16.3 years; 34 patients were male (65%). Indications for repair were aneurysm (N = 9, 17%), acute dissection (N = 14, 27%), chronic dissection with aneurysmal degeneration (N = 7, 13%), intramural hematoma (N = 9, 17%), penetrating aortic ulcer (N = 5, 10%), and blunt traumatic aortic injury (BTAI, N = 8, 15%). LSA revascularization occurred in 27 patients (52%). Overall, 20 (38.5%) of the zone 2 patients met anatomic criteria. Patients with dissection met anatomic criteria less frequently than aneurysm (33% [10 of 30] vs 64% [9 of 14]). Patients treated for BTAI rarely met the anatomic criteria (1 of 8, 13%). The main anatomic constraints were an inadequate distance from the LCCA to the LSA takeoff and from the LCCA to the start of the aortic disease process. CONCLUSION Less than half of patients who require seal in zone 2 met criteria for this SBTE. Patients with aneurysms met anatomic criteria more often than those with dissection. The device would have little applicability in treating patients with BTAI.
Collapse
Affiliation(s)
- Norman H Kumins
- Department of Vascular Surgery, The Heart and Vascular Institute, The Cleveland Clinic, Cleveland, OH, USA
| | - Ravi N Ambani
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Saideep Bose
- Division of Vascular and Endovascular Surgery, Department of Surgery, St Louis University, St Louis, MO, USA
| | - Alexander H King
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Benjamin Colvard
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Vikram S Kashyap
- Division of Vascular Surgery, Frederik Meijer Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI, USA
| |
Collapse
|
10
|
Amabile A, Lewis E, Costa V, Tadros RO, Han DK, Di Luozzo G. Spinal cord protection in open and endovascular approaches to thoracoabdominal aortic aneurysms. Vascular 2023; 31:874-883. [PMID: 35507464 DOI: 10.1177/17085381221094411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite advancements in surgical and postoperative management, spinal cord injury has been a persistent complication of both open and endovascular repair of thoracoabdominal and descending thoracic aortic aneurysm. Spinal cord injury can be explained with an ischemia-infarction model which results in local edema of the spinal cord, damaging its structure and leading to reversible or irreversible loss of its function. Perfusion of the spinal cord during aortic procedures can be enhanced by several adjuncts which have been described with a broad variety of evidence in their support. These adjuncts include systemic hypothermia, cerebrospinal fluid drainage, extracorporeal circulation and distal aortic perfusion, segmental arteries reimplantation, left subclavian artery revascularization, and staged aortic repair. The Authors here reviewed and discussed the role of such adjuncts in preventing spinal cord injury from occurring, pinpointing current evidence and outlining future perspectives.
Collapse
Affiliation(s)
- Andrea Amabile
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Erin Lewis
- Department of Surgery, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Victor Costa
- Department of Surgery, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Rami O Tadros
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniel K Han
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gabriele Di Luozzo
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
11
|
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: 14] [Impact Index Per Article: 14.0] [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
| | | |
Collapse
|
12
|
Leonard S, Vernier B, Keyhani K, Keyhani A, Tanaka A, Wang SK. Gore cTAG sleeve-associated maldeployment for traumatic aortic injury with aberrant right subclavian artery. J Vasc Surg Cases Innov Tech 2023; 9:101216. [PMID: 37408950 PMCID: PMC10319308 DOI: 10.1016/j.jvscit.2023.101216] [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: 02/11/2023] [Accepted: 04/26/2023] [Indexed: 07/07/2023] Open
Abstract
A 30-year-old woman presented following a motor vehicle collision with a grade III blunt thoracic aortic injury and an aberrant right subclavian artery. Using intraoperative ultrasound and diagnostic subtraction angiography, we deployed an aortic endograft (cTAG; W.L. Gore & Associates), excluding the injury and aberrant right subclavian artery. The patient immediately lost arterial waveforms in her left arm, confirming incidental coverage of the left subclavian artery, likely due to the polytetrafluoroethylene sheath of the endograft. Her pulses returned after placement of a left subclavian chimney via retrograde brachial artery access.
Collapse
Affiliation(s)
| | | | | | | | | | - S. Keisin Wang
- Correspondence: S. Keisin Wang, MD, Department of Cardiothoracic and Vascular Surgery, John P. and Kathrine G. McGovern Medical School at UTHealth Houston, 1631 North Loop West, Ste 610, Houston, TX 77008
| |
Collapse
|
13
|
Gouveia E Melo R, Fernández Prendes C, Khanafer A, Wanhainen A, Mani K, Rouhani G, Chao V, Tay KH, Chong TT, Adam D, Dias N, Agaev A, Tsilimparis N. Common Designs of Custom-Made Fenestrated Arch Devices and Applicability of an Off-the-Shelf Design. J Endovasc Ther 2023:15266028231179593. [PMID: 37300282 DOI: 10.1177/15266028231179593] [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: 06/12/2023]
Abstract
OBJECTIVES To analyze device designs, similarities and overlaps of custom-made fenestrated arch endografts intended for mid/distal arch thoracic endovascular aortic repair. MATERIALS AND METHODS A multicenter cross-sectional study analyzing custom-made anonymized graft plans was performed. Graft plans were included from a cohort of mid/distal aortic arch repairs using custom-made fenestrated aortic endografts treated at 8 centers. Grafts targeting >2 arteries were excluded. No patient/clinical data were analyzed. A descriptive analysis was performed followed by an analysis of overlap of the designs to reach a common design in which the greatest number of grafts would overlap. RESULTS One hundred thirty-one graft plans were included. All grafts were custom-made grafts from the COOK Medical Fenestrated arch platform. Ninety-four (71.8%) had a scallop-and-single-fenestration design, 33 (25.2%) had a single fenestration and 4 (4.3%) a single scallop. For analysis purposes, these latter 4 grafts were excluded. Two main graft plans (Plans 1 and 2) were proposed after analysis with similar configuration (1 scallop with 30 mm width, 20 mm height, 12:00 position; 1 preloaded fenestration with 8 mm diameter, 26 mm from the top of the graft and 12:00 position; tapered, with a 193 mm length and 32 mm distal diameter) but with 2 different proximal diameters of 38 mm (Plan 1) and 44 mm (Plan 2), reaching an overall feasibility of 85.8% (n=109), being 47.2% (n=60) and 38.6% (n=49) for each design, respectively. CONCLUSION The degree of overlap between the studied fenestrated and/or scalloped thoracic endovascular aneurysm repair (TEVAR) graft designs was high. Future studies analyzing these designs in a real-world cohort of patients are needed to further address off-the-shelf feasibility. CLINICAL IMPACT In a multicenter study analyzing 127 fenestrated aortic arch endograft plans from 9 aortic centers, we found that the degree of overlap between the studied fenestrated and/or scalloped arch graft designs was high and that 2 proposed graft designs would be theoretically applicable in 85.8% of cases. Future studies analyzing these designs in a real-world cohort of patients are needed to further address off-the-shelf feasibility.
Collapse
Affiliation(s)
- Ryan Gouveia E Melo
- Department of Vascular Surgery, Ludwig Maximilian University Hospital, Munich, Germany
| | | | - Adib Khanafer
- University of Otago, Christchurch, Christchurch Hospital, Christchurch, New Zealand
| | - Anders Wanhainen
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Kevin Mani
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Guido Rouhani
- Section of Vascular Surgery, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | | | | | | | - Donald Adam
- Department of Vascular and Endovascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Nuno Dias
- Vascular Center Malmö, Department of Thoracic Surgery and Vascular Diseases, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden
| | - Arzou Agaev
- Department of Vascular Surgery, Cardiovascular Center Bad Neustadt, Bad Neustadt, Germany
| | - Nikolaos Tsilimparis
- Department of Vascular Surgery, Ludwig Maximilian University Hospital, Munich, Germany
| |
Collapse
|
14
|
Liu Y, Fang K, Luo MY, Xiao ZH, Yang P, Lu C, Zhang Y, Wang HY, Xie Y, Xu ZY, Zhang HW, Shu C, Hu J. Single-Center Preliminary Experience with Gutter-Plugging Chimney Stent-Graft for Aortic Dissection. Cardiovasc Intervent Radiol 2023:10.1007/s00270-023-03444-8. [PMID: 37198293 DOI: 10.1007/s00270-023-03444-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 04/06/2023] [Indexed: 05/19/2023]
Abstract
PURPOSE To report the early 2-year results and experience of a novel gutter-plugging chimney stent-graft in a single center that participated in the clinical trial of Prospective Study for Aortic Arch Therapy with stENt-graft for Chimney technology. MATERIALS AND METHODS Patients diagnosed with aortic dissection were treated with the novel chimney stent-grafts named Longuette™ for the left subclavian artery revascularization. Primary study outcomes were the incidence of freedom from major adverse events within 30 days and success rate of the operation over 12 months. RESULTS A total of 34 patients were enrolled between September 2019 and December 2020. The immediate technical success rate (stent-grafts successfully deployed without fast-flow type Ia or type III endoleak intraoperatively) was 100%, and there were no conversions to open repair. Type Ia and type II endoleaks were noted in three patients (8.8%) and one patient (2.9%) at discharge, respectively. One patient (2.9%) with type Ia endoleak underwent coil embolization at 12 months because of false lumen dilation, and one (2.9%) case of type Ia endoleak resolved spontaneously at 24 months. One chimney stent (2.9%) was revealed with stenosis at discharge and occluded with thrombosis at 6 months postoperatively. During the 2-year follow-up, there was no death, rupture, stroke, paraplegia, left arm ischemia, retrograde dissection, stent-graft induced new entry, or stent migration. CONCLUSION The initial results of the Longuette™ stent-graft for revascularization of the left subclavian artery are encouraging with a high technical success rate. Further multicenter follow-up outcomes are required to assess the long-term durability. LEVEL OF EVIDENCE Level 4, Case Series.
Collapse
Affiliation(s)
- Yu Liu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Kun Fang
- National Center for Cardiovascular Diseases, Fuwai Hospital, CAMS & PUMC, Beijing, China
| | - Ming-Yao Luo
- National Center for Cardiovascular Diseases, Fuwai Hospital, CAMS & PUMC, Beijing, China
| | - Zheng-Hua Xiao
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Peng Yang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Chen Lu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Yu Zhang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Hai-Yue Wang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Yi Xie
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Zhen-Yuan Xu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Hong-Wei Zhang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Chang Shu
- National Center for Cardiovascular Diseases, Fuwai Hospital, CAMS & PUMC, Beijing, China.
| | - Jia Hu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China.
- Department of Cardiovascular SurgeryWest China Guang'an Hospital, Sichuan University, Guang'an, 638000, Sichuan, China.
| |
Collapse
|
15
|
Cheng Z, Liu Y, Ma X. Comparative Analysis of Endovascular Repair of Single-Branched Stent-Graft and Hybrid Procedure for Patients With Type B Acute Aortic Dissection Involving the Left Subclavian Artery. J Endovasc Ther 2023:15266028221149920. [PMID: 36945730 DOI: 10.1177/15266028221149920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
PURPOSE Thoracic endovascular aortic repair (TEVAR) with left subclavian artery (LSA) revascularization has been used in patients with type B aortic dissection (TBAD), with inadequate proximal landing zone (PLZ). The outcomes of comparisons between TEVAR and hybrid procedure on patients with TBAD, with inadequate PLZ, are rarely reported. This study sought to compare and clarify the early and midterm outcomes between TEVAR and hybrid procedure in patients with TBAD, with inadequate PLZ. MATERIALS AND METHODS Between January 2019 and December 2021, 93 patients with TBAD, with inadequate PLZ, who underwent TEVAR or hybrid procedure, were retrospectively evaluated in Beijing Anzhen hospital. Demographics, comorbidities, preoperative imaging features, periprocedural details, and follow-up outcomes were analyzed. Survival was analyzed according to Kaplan-Meier method. RESULTS TEVAR procedures were performed on 41 patients (TEVAR group) and hybrid procedures on 52 patients (hybrid group). Early events, 30 day mortality, and all-cause mortality, were not significantly different between the 2 groups. However, patients receiving TEVAR had significantly shorter procedure time (p<0.001), hospital stay (p<0.001), and intensive care unit (ICU) stay (p=0.001) compared with those in the hybrid group. Patients receiving TEVAR had significantly lower midterm events (p=0.014) and re-intervention (p=0.015) compared with those in the hybrid group. CONCLUSION The study indicated that TEVAR with LSA revascularization for TBAD with inadequate PLZ is associated with a trend toward lower rates of midterm events, while the early and midterm mortalities were comparable with those in hybrid procedure. CLINICAL IMPACT This study is novel as it compared the outcomes between thoracic endovascular aortic repair (TEVAR) and hybrid procedure in patients with type B aortic dissection (TBAD), with inadequate proximal landing zone, which has been rarely reported previously. We believe that our study makes a significant contribution to the literature because it is clinically relevant as it demonstrated that TEVAR with left subclavian artery (LSA) revascularization for TBAD with inadequate proximal landing zone is associated with a trend toward lower rates of mid-term events, while the early and mid-term mortalities were comparable with those in the hybrid procedure.
Collapse
Affiliation(s)
- Zhang Cheng
- Department of Interventional Diagnosis and Treatment, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yongmin Liu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaohai Ma
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
16
|
Carrel T, Sundt TM, von Kodolitsch Y, Czerny M. Acute aortic dissection. Lancet 2023; 401:773-788. [PMID: 36640801 DOI: 10.1016/s0140-6736(22)01970-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/04/2022] [Accepted: 09/27/2022] [Indexed: 01/13/2023]
Abstract
Although substantial progress has been made in the prevention, diagnosis, and treatment of acute aortic dissection, it remains a complex cardiovascular event, with a high immediate mortality and substantial morbidity in individuals surviving the acute period. The past decade has allowed a leap forward in understanding the pathophysiology of this disease; the existing classifications have been challenged, and the scientific community moves towards a nomenclature that is likely to unify the current definitions according to morphology and function. The most important pathophysiological pathway, namely the location and extension of the initial intimal tear, which causes a disruption of the media layer of the aortic wall, together with the size of the affected aortic segments, determines whether the patient should undergo emergency surgery, an endovascular intervention, or receive optimal medical treatment. The scientific evidence for the management and follow-up of acute aortic dissection continues to evolve. This Seminar provides a clinically relevant overview of potential prevention, diagnosis, and management of acute aortic dissection, which is the most severe acute aortic syndrome.
Collapse
Affiliation(s)
- Thierry Carrel
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland.
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts' General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yskert von Kodolitsch
- Department of Vascular Medicine, German Aortic Center, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Germany; Faculty of Medicine, Albert Ludwig University Freiburg, Freiburg, Germany
| |
Collapse
|
17
|
MANAGEMENT OF LEFT SUBCLAVIAN ARTERY IN TYPE-B AORTIC DISSECTION TREATED WITH THORACIC ENDOVASCULAR AORTA REPAIR. J Vasc Surg 2022; 77:1553-1561.e2. [PMID: 36272506 DOI: 10.1016/j.jvs.2022.10.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 09/21/2022] [Accepted: 10/06/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Thoracic endovascular aortic repair (TEVAR) has been the favored approach for the treatment of type B aortic dissection (TBAD). To obtain an adequate proximal landing zone, coverage of the left subclavian artery (LSA) will often be necessary. The occurrence of possible neurologic complications has continued to be debated. We investigated the management of the LSA in patients with TBAD undergoing endovascular repair. METHODS We searched the PubMed and MEDLINE databases to October 2020 for studies of TEVAR for TBAD. Data on the study design, demographics, endograft details, LSA coverage and revascularization, mortality, complications, and follow-up were extracted and analyzed. The effects of LSA coverage and revascularization on neurologic complications and outcomes were investigated. RESULTS A total of 26 reports (24 retrospective and 2 prospective) were deemed eligible for our study. A total of 1483 patients (mean age, 56.9 ± 6.2 years) had undergone TEVAR for acute (n = 932; 62.9%), subacute (n = 36; 2.4%), or chronic (n = 515; 34.7%) TBAD, with a success rate of 97.8% and hospital mortality of 4.9%. The LSA origin had been covered for 707 patients (47.7%), and 326 had undergone LSA revascularization (surgical, n = 96; endovascular, n = 170; unspecified or not reported, n = 60). LSA revascularization was concomitant for 68.1% of cases, after TEVAR for 1.8%, and not reported for 30.1%. Of 1146 patients, 10 (0.9%) had experienced left arm claudication, and the overall stroke rate was 3.3% (2.7% for the LSA group and 1% for the uncovered LSA group; P = .0815). Of the patients with stroke and a covered LSA, 1% (2 of 203) had undergone LSA revascularization and 4.8% (5 of 105) had not (P = .0478). Twenty-six patients (1.9%) had developed paraplegia: 0.7% (3 of 433) with a covered LSA, 1.4% (7 of 491) with an uncovered LSA (P = .3508), and not reported for 16 patients. Endoleak was present in 138 patients (13.4%) at a mean follow-up of 32.1 ± 25.6 months. CONCLUSIONS Our review has shown that LSA coverage during endovascular repair for complicated TBAD will does not significantly increase the risk of neurologic complications; however, revascularization of the LSA should be always recommended.
Collapse
|
18
|
Singh S, Pupovac SS, Assi R, Vallabhajosyula P. Comprehensive review of hybrid aortic arch repair with focus on zone 0 TEVAR and our institutional experience. Front Cardiovasc Med 2022; 9:991824. [PMID: 36187018 PMCID: PMC9520124 DOI: 10.3389/fcvm.2022.991824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/25/2022] [Indexed: 11/24/2022] Open
Abstract
Even with increasing operator experience and a better understanding of the disease and the operation, intervention for aortic arch pathologies continues to struggle with relatively higher mortality, reintervention, and neurologic complications. The hybrid aortic arch repair was introduced to simplify the procedure and improve the outcome. With recent industry-driven advances, hybrid repairs are not only offered to poor surgical candidates but have become mainstream. This review discusses the evolution of hybrid repair, terminology pertinent to this technique, and results. In addition, we aim to provide a pervasive review of hybrid aortic arch repairs with reference to relevant literature for a detailed understanding. We have also discussed our institutional experience with hybrid repairs.
Collapse
|
19
|
Hu J, Li F, Qiu P, Wu X, Pu H, Zhao Z, Qin J, Liu G, Jin S, Lu X, Liu X. Clinical Validation of the Impact of Branch Stent Extension on Hemodynamics in ISF-TEVAR Involving LSA Reconstruction. Front Cardiovasc Med 2022; 9:911934. [PMID: 35770224 PMCID: PMC9234204 DOI: 10.3389/fcvm.2022.911934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 05/13/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe study of hemodynamics regarding thoracic endovascular aortic repair (TEVAR) is helpful to improve the surgical efficacy.ObjectiveCorrelations between hemodynamic changes and branch stent extension length and interference factors for branch stent extension length of in situ fenestration TEVAR (ISF-TEVAR) involving the left subclavian artery (LSA) were evaluated.Materials and MethodsThis study retrospectively analyzed 196 patients with Stanford type B aortic dissection who received in situ laser fenestrated thoracic endovascular aortic repair with LSA fenestration from April 2014 to March 2021. Branch stent extension to the main stent graft was evaluated by the computed tomographic angiography (CTA). Hemodynamic change of LSA was defined as a 20 mmHg interbrachial systolic pressure difference. The factors affecting the extension of the branch stent were also evaluated.ResultsAll patients underwent ISF-TEVAR with LSA fenestration, and there was no recurrence during the follow-up. The mean length of the branch stent extension was 10.37 ± 0.34 mm, which was used to divide the patients into long and short groups. Asymptomatic hemodynamic changes (defined as a 20 mmHg interbrachial systolic pressure difference) in LSA were observed in 61 patients undergoing ISF-TEVAR involving LSA fenestration. The Spearman correlation analysis showed extension length of a branch stent >1.5 cm elevated the risk of hemodynamic changes.ConclusionOverall, we conclude that branch stent extension length >1.5 cm induced LSA hemodynamic changes. Appropriate shortening of the stent extension length can improve the curative effect of ISF-TEVAR, especially when faced with a type II/III aortic arch and stent angles of <30 degrees.
Collapse
Affiliation(s)
- Jiateng Hu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
| | - Fengshi Li
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
| | - Peng Qiu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoyu Wu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
| | - Hongji Pu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
| | - Zhen Zhao
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
| | - Jinbao Qin
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
| | - Guang Liu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
| | - Shanliang Jin
- Department of Anesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Shanliang Jin
| | - Xinwu Lu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
- Xinwu Lu
| | - Xiaobing Liu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
- Xiaobing Liu
| |
Collapse
|
20
|
Batubara EAD, Nugraha RA, Amshar M, Taofan, Indriani S, Adiarto S. Ischemic Complications Following Thoracic Endovascular Aortic Repair with and without Revascularization of Left Subclavian Artery: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2022; 86:417-427. [DOI: 10.1016/j.avsg.2022.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 11/01/2022]
|
21
|
MacGillivray TE, Gleason TG, Patel HJ, Aldea GS, Bavaria JE, Beaver TM, Chen EP, Czerny M, Estrera AL, Firestone S, Fischbein MP, Hughes GC, Hui DS, Kissoon K, Lawton JS, Pacini D, Reece TB, Roselli EE, Stulak J. The Society of Thoracic Surgeons/American Association for Thoracic Surgery clinical practice guidelines on the management of type B aortic dissection. J Thorac Cardiovasc Surg 2022; 163:1231-1249. [PMID: 35090765 DOI: 10.1016/j.jtcvs.2021.11.091] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 01/16/2023]
Affiliation(s)
| | - Thomas G Gleason
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | | | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Md
| | - Davide Pacini
- Department of Cardiac Surgery, University of Bologna, Bologna, Italy
| | - T Brett Reece
- Department of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| |
Collapse
|
22
|
Hauck SR, Kupferthaler A, Kern M, Rousseau H, Ferrer C, Iwakoshi S, Sakaguchi S, Stelzmüller ME, Ehrlich M, Loewe C, Funovics MA. Branched versus fenestrated thoracic endovascular aortic repair in the aortic arch: A multicenter comparison. J Thorac Cardiovasc Surg 2022; 164:1379-1389.e1. [DOI: 10.1016/j.jtcvs.2022.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/15/2022] [Accepted: 03/24/2022] [Indexed: 12/18/2022]
|
23
|
MacGillivray TE, Gleason TG, Patel HJ, Aldea GS, Bavaria JE, Beaver TM, Chen EP, Czerny M, Estrera AL, Firestone S, Fischbein MP, Hughes GC, Hui DS, Kissoon K, Lawton JS, Pacini D, Reece TB, Roselli EE, Stulak J. The Society of Thoracic Surgeons/American Association for Thoracic Surgery Clinical Practice Guidelines on the Management of Type B Aortic Dissection. Ann Thorac Surg 2022; 113:1073-1092. [PMID: 35090687 DOI: 10.1016/j.athoracsur.2021.11.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 02/07/2023]
Affiliation(s)
| | - Thomas G Gleason
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Florida
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Texas
| | | | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, California
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Davide Pacini
- Department of Cardiac Surgery, University of Bologna, Bologna, Italy
| | - T Brett Reece
- Department of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
24
|
Hanna L, Lam K, Agbeko AE, Amoako JK, Ashrafian H, Sounderajah V, Abdullah A. Coverage of the coeliac artery during thoracic endovascular aortic repair: A systematic review and meta-analysis. Eur J Vasc Endovasc Surg 2022; 63:828-837. [DOI: 10.1016/j.ejvs.2022.02.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 02/07/2022] [Accepted: 02/20/2022] [Indexed: 11/16/2022]
|
25
|
Ghanem M, Meyer F, Halloul Z. Covering/Overstenting of the left subclavian artery (LSA) in thoracic endovascular repair (TEVAR) to treat various thoracic/thoracoabdominal aortic lesions: Is revascularization of the left arm a must?
(A retrospective cohort study with 12 years of experience to describe the real-world situation of daily clinical practice and the literature review). POLISH JOURNAL OF SURGERY 2022. [DOI: 10.5604/01.3001.0015.7090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Pathologies of the descending thoracic aorta inwardly extended towards the aortic arch actually shorten the proximal landing zone for aortic prosthesis. This, in turn, worsens the feasibility of the aorta for endovascular therapeutic options of those pathologies.
Objective: This work considers the blockage of the left subclavian artery (LSA) through endovascular treatment of the pathologies of the descending aorta as a main work question, which is based on the hypothesis that there is no necessity for primary standard revascularization of the LSA in TEVAR with LSA covering. The researchers have 12 years of experience in treatment of different thoracic aortic lesions. Their experience will also be reviewed in this paper.
Design: Retrospective unicenter cohort study in consecutive patients order to describe the real-world situation of daily clinical practice
Material: All the patients who had undergone endovascular, hybrid, or open operative therapy of variant pathologies of descending aorta were included in this study.
Methods: Various parameters were investigated, including therapeutic procedures such as i) pure endovascular vs. hybrid; ii) year of therapy; iii) symptomatic vs. asymptomatic status of the patients; iv) variant epidemiological factors (age, sex, risk factors, mortality, and follow up); v) overstenting/blocking of the LSA; vi) complications of applied therapies; vii) further operations/interventions to treat such complications; viii) radiologic aortic measurements (such as lumen extensions, false lumen measurements, distance to the supra-aortic and visceral vessels); and ix) multiple other pathological features. Different statistical parameters were also examined. Survival was analysed by the Kaplan–Meier assessment in the group of whole patients vs. the group of over-stented patients. Here the analysis of variance is performed for the independent parameters for the revascularized patients—not the revascularized patients—who had undergone LSA coverage. For statistical approval, U-test was used. The p-value < 0.05 was considered significantly different. The literature review was achieved by a search in PubMed, Google scholar, Research Gate, ScienceDirect, and Cochrane library by using the following terms endovascular, TEVAR, revascularization, stroke, and left-subclavian-artery ischemia. The literature is classified accordingly in relation to the main topic. In fact, the literature undergoes further analysis if it goes with or against our hypothesis.
Results: Overall, 112 patients were enrolled in the study. There was no significant difference comparing the not-revascularized vs. the revascularized group of patients, considering the consequences on cerebrovascular blood circulation (in particular, n=1 case [4.8 %] vs. no case [0 %]; p=1) or the spinal cord ischemia (n=2 [9.5 %] vs. n=1 [7.1 %]; p=1). As the main result, there was no case of manifest left arm ischemia and deaths (mortality, 0). Survival was in both groups as follows: 22 [95% CI, 14.154–29.904] months vs. 43 [95% CI, 33.655–51.921] months with no significant statistical difference (p>0.05) . The only statistically significant risk factor found was renal insufficiency (p, 0.028), but this too is considered a trend by the urgency of revascularization. Postoperatively, pneumonia showed a trend of higher frequency (p=0.058) in the revascularized cases (n=0 in the not-revascularized vs. n=3 [21.4 %] in the revascularized cases). There was no significant difference in the occurance of postoperative neurovascular complications (such as cerebrovascular accidents, spinal cord ischemia, or left arm ischemia) by comparing the groups of not-revascularized and revascularized patients.
Conclusion: The revascularization of the overstented LSA due to TEVAR should be limited to certain indications, including i) the inadequate intracerebral circle of Willis; ii) the predominantly perfused left vertebral artery with inadequate blood perfusion via the right vertebral artery (e.g., by stenosis), iii) anatomic variance such as the left vertebral artery originating directly from the aortic arch (and must be blocked by TEVAR); iv) the need of an adequate left internal thoracic artery for coronary-artery-bypass grafting (CABG); v) the need of patent LSA for the dialysis shunt of the left arm. However, there is no appropriate evidence as yet based on sufficient study results achieved in trials with an advanced design (such as [double-]blind, multicenter randomized study) that appears to be urgently required.
Collapse
Affiliation(s)
- Mohammad Ghanem
- Division of Vascular Surgery; Department of General, Abdominal, Vascular and Transplant Surgery; Otto-von-Guericke University with University Hospital; Magdeburg, Germany
| | - Frank Meyer
- Dept. of General, Abdominal and Vascular Surgery, University Hospital at Magdeburg, Magdeburg (Germany)
| | - Zuhir Halloul
- Division of Vascular Surgery; Department of General, Abdominal, Vascular and Transplant Surgery; Otto-von-Guericke University with University Hospital; Magdeburg, Germany
| |
Collapse
|
26
|
Sun M, Wang Y, Zhou T, Liu X, Jing Q, Liu H, Wang X. Safety of Left Subclavian Artery Selective Coverage without Revascularization in Thoracic Endovascular Aortic Repair for Type B Aortic Dissections. Ann Thorac Cardiovasc Surg 2022; 29:70-77. [PMID: 36476816 PMCID: PMC10126769 DOI: 10.5761/atcs.oa.22-00146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Whether to proceed left subclavian artery (LSA) revascularization in patients with LSA coverage due to insufficient proximal landing zone (PLZ) during thoracic endovascular aortic repair (TEVAR) remains controversial. METHODS A total of 903 patients who received TEVAR were retrospectively analyzed. LSA could be covered if the PLZ was less than 15 mm accompanied with 1) a dominant or balanced right vertebral artery, 2) a complete circle of Willis, and 3) a left vertebral artery with a diameter ≥3 mm and without severe stenosis. RESULTS LSA selective coverage was necessary for 35.0% (316/903) of the patients to extend the PLZ. Patients presented with weakness, pain, cooling and discoloration of the left upper extremity (LUE), and pulselessness of the left brachial artery were more in the LSA-covered group. The ischemia of LUE occurred more often in patients with LSA covered completely than in those with LSA covered partially. Functional arm status showed no significant difference in the arm, shoulder, and hand questionnaire scores at 12 months postoperative between the LSA-covered group and LSA-uncovered group, or between the LSA-covered completely group and LSA-covered partially group. CONCLUSION It was safe to cover the LSA origin without revascularization if the PLZ was less than 15 mm accompanied with careful evaluation (description in method).
Collapse
Affiliation(s)
- Mingyu Sun
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| | - Yasong Wang
- The General Hospital of Northern Theater Command Training Base for Graduate, China Medical University, Shenyang, Liaoning, China
| | - Tienan Zhou
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| | - Xuanze Liu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| | - Quanmin Jing
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| | - Haiwei Liu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| | - Xiaozeng Wang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| |
Collapse
|
27
|
Brusa J, Lutz E, Schoenhoff FS, Weiss S, Schmidli J, Makaloski V. One-year outcome of postoperative stroke and nerve injury after supraclavicular revascularization of the left subclavian artery for proximal landing zone extension in thoracic endovascular aortic repair. Ann Vasc Surg 2021; 83:265-274. [PMID: 34954037 DOI: 10.1016/j.avsg.2021.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 11/22/2021] [Accepted: 12/04/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess the outcome of stroke and nerve injury after supraclavicular revascularization of the left subclavian artery for proximal landing zone extension in thoracic endovascular aortic repair (TEVAR). METHODS Retrospective analysis of all patients undergoing left-sided carotid-subclavian bypass (CSB) and subclavian-carotid transposition (SCT) with simultaneous or staged TEVAR between January 2010 and June 2019. Endpoints were perioperative cerebrovascular events and nerve injuries, patency and re-intervention due to the debranching, and mortality at 30 days and during follow-up. RESULTS Forty-eight patients (median age 66 years, 81 % male) had 25 (52%) CSB and 23 (48%) SCT. TEVAR was performed simultaneously in 39 (81%) patients, eleven (23%) of them in an emergent setting. There were seven (15%) re-interventions within 30 days: three due to local hematoma, one for bypass occlusion, two for stenosis (of which one was not confirmed intraoperatively), and one after initially abandoned SCT with subsequent CSB on the next day. Thirty-day mortality was 2%; one patient died on the first postoperative day after emergency coronary artery bypass surgery and multiorgan failure. Four (8%) patients suffered postoperative strokes; three occurred after simultaneous emergency procedures and none was fatal. There were nine (19%) left neck nerve injuries in eight patients, five patients had SCT and three CSB. During a median follow-up of 37.5 months (IQR 23-83) with a Follow-up Index of 0.77, there were no reinterventions or occlusions, and no graft infections. Primary patency was 90% and primary assisted patency 98% during follow-up. Eight patients died during follow-up, all of them with patent cervical debranching. CONCLUSION Supraclavicular LSA revascularization for proximal landing zone extension in TEVAR is safe with an acceptable rate of early re-interventions. There is higher risk for perioperative stroke during concomitant emergency LSA revascularization and TEVAR. Left neck nerve injuries are common complications but resolve completely in vast majority of the cases during first postoperative year. During follow-up, excellent patency could be expected.
Collapse
Affiliation(s)
- Juliette Brusa
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Eric Lutz
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Florian S Schoenhoff
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Salome Weiss
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Juerg Schmidli
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Vladimir Makaloski
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland.
| |
Collapse
|
28
|
Dueppers P, Meuli L, Reutersberg B, Hofmann M, Messmer F, Zimmermann A. Early and Mid-Term Outcomes of Open versus Endovascular Left Subclavian Artery Debranching for Thoracic Aortic Diseases. Ann Thorac Cardiovasc Surg 2021; 28:193-203. [PMID: 34937820 PMCID: PMC9209886 DOI: 10.5761/atcs.oa.21-00206] [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] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Purpose: To compare open versus endovascular left subclavian artery debranching for thoracic endovascular aortic repair of thoracic aortic pathologies. Methods: This is a retrospective study of patients receiving left subclavian artery debranching in our institution from October 2009 to January 2020. The primary outcome was freedom from aortic reintervention. Secondary outcomes were type I endoleaks, left subclavian artery (LSA) debranching failure, stroke, technical or clinical success, procedure-related reintervention, as well as 30-day or overall all-cause and aorta-related mortality. Results: Forty-eight patients received parallel graft-based (n = 24, ENDO; median age 75 years [70–80 years]) or open (n = 24, OPEN; median age 71 years [59–75 years]) debranching for type B aortic dissection (n = 25), degenerative aneurysm (n = 12), type IA endoleak (n = 6), suture-associated (n = 3) or ostial LSA aneurysm (n = 1), or penetrating aortic ulcer (n = 1). The median follow-up was 36 months (13–61 months). After 16 months, aortic reintervention-free survival in groups OPEN and ENDO was 91% (95% confidence interval [CI]: 79 to 100%) and 86% (73 to 100%) (p = 0.71), respectively. After 36 months, all-cause survival in groups OPEN and ENDO was 74% (95% CI: 55 to 99%) and 79% (95% CI: 64 to 97%) (p = 0.74), respectively; freedom from aorta-related mortality was 81% (95% CI: 62 to 100%) and 91% (95% CI: 80 to 100%) (p = 0.78), respectively. Group OPEN presented less type I endoleaks (OPEN/ENDO = 3/19, p <0.001) and higher technical (OPEN/ENDO = 81/36%, p = 0.003) and clinical success rates (OPEN/ENDO = 67/36%, p = 0.047). No statistical differences were found for other outcomes. Conclusion: Both strategies achieved comparable reintervention and mortality rates, but open debranching should be preferred due to its higher technical and clinical success and less type I endoleaks.
Collapse
Affiliation(s)
- Philip Dueppers
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Lorenz Meuli
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | | | - Michael Hofmann
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Florian Messmer
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | | |
Collapse
|
29
|
Zhang B, Wei Y, Liu Y, Lin H, Liang S, Dun Y, Yu C, Qian X, Guo H, Sun X. Safety and durability of single-stage type I hybrid total aortic arch repair for extensive aortic arch disease: early- and long-term clinical outcomes from a single center and our 10-year of experience. J Thorac Dis 2021; 13:6230-6239. [PMID: 34992803 PMCID: PMC8662513 DOI: 10.21037/jtd-20-3479] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/24/2021] [Indexed: 11/10/2022]
Abstract
Background Single-stage type I hybrid total aortic arch repair is a surgical treatment for extensive aortic arch disease, but the clinical outcomes were distinguishing. The purposes of this study were to share our experience and evaluate the perioperative safety and long-term durability. Methods Thirty-six patients who underwent single-stage type I hybrid total aortic arch repair in Fuwai Hospital between January 2010 and June 2020 were respectively reviewed. Early primary endpoint was defined as early composite adverse events, including mortality, multiple organ dysfunction syndrome (MODS), unplanned reoperation, stroke, paraplegia, acute renal failure (ARF) necessitating continuous renal replacement therapy (CRRT), respiratory failure and stents related complications. Long-term endpoints included late mortality, late aortic related reintervention and late adverse aortic events. When evaluating the early- and long-term outcomes, all patients were stratified into two subgroups by age (65 years). Results All patients acquired technical success. Early composite adverse events rate was 11.1% (4/36), in-hospital mortality was 8.3% (3/36). Average follow-up period was 48.0±35.3 months. Overall survival rate was 83.3% and 51.9% at 5 and 10 years respectively. Late aortic related reintervention occurred at one (3.0%, 1/33) patient and this patient died after reintervention. Overall freedom from adverse aortic events was 79.2% and 47.5% at 5 and 10 years respectively. Significant difference was not observed between the elderly and young subgroups, no matter in early- and long-term outcomes. Conclusions Single-stage type I hybrid total aortic arch repair has achieved desirable outcomes in our center, which does not increase perioperative risk in the elderly patients, meanwhile, also acquire acceptable durability in the young patients. In conclusion, this surgery is a practical mini-invasive treatment for extensive aortic arch disease with strict and limited indications.
Collapse
Affiliation(s)
- Bowen Zhang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yizhen Wei
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanxiang Liu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hao Lin
- Department of Cardiovascular Surgery, Shandong Provincial Hospital affiliated to Shandong First Medical University, Jinan, China
| | - Shenghua Liang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yaojun Dun
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Cuntao Yu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiangyang Qian
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongwei Guo
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaogang Sun
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
30
|
Technical Note: Left Subclavian Artery Scallop Endografts to Facilitate a Proximal Landing Zone and Upper Extremity Access for Branched Endovascular Aortic Repair of Type II Thoracoabdominal Aortic Aneurysms. Cardiovasc Intervent Radiol 2021; 44:1657-1662. [PMID: 34272588 PMCID: PMC8478747 DOI: 10.1007/s00270-021-02909-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 06/22/2021] [Indexed: 11/02/2022]
Abstract
PURPOSE To describe the dual purpose of left subclavian artery (LSA) scallop endografts to create the proximal landing zone (PLZ) and facilitate antegrade left-sided upper extremity access for branched endovascular aortic repair (BEVAR) of Type II thoracoabdominal aneurysms (TAAA) with a short PLZ. TECHNIQUE Three patients with an inadequate (< 20 mm) PLZ underwent a 2-stage repair of Type II TAAA. Following femoral cut-down, a custom-made LSA scallop endograft was deployed into zone 2 to create the PLZ and maintain perfusion to the LSA. In a second procedure 36-96 days after insertion of the scalloped thoracic stent-graft, a branched abdominal stent-graft was subsequently deployed to dock into the proximal scallop endograft as the second stage. Via a left axillary conduit, a 12Fr sheath was used to cannulate the LSA scallop to facilitate selective catheterisation of antegrade branch cuffs and renovisceral target vessels, and insertion and deployment of bridging stents. The LSA scallop was also used to selectively catheterise and stent the perfusion branches via left-sided brachial puncture that were left open in each of the three cases 8-14 days after the second procedure to minimise the risk of spinal cord ischaemia. There were no neurological or endoleak complications. CONCLUSION LSA scallop endografts are a feasible and useful adjunct to create the PLZ and to provide antegrade access for visceral stenting of branches and target vessels through the LSA scallop in branched endovascular repair of Type II TAAA with short PLZ.
Collapse
|
31
|
Mesar T, Alie-Cusson FS, Rathore A, Dexter DJ, Stokes GK, Panneton JM. A more proximal landing zone is preferred for thoracic endovascular repair of acute type B aortic dissections. J Vasc Surg 2021; 75:38-46. [PMID: 34197944 DOI: 10.1016/j.jvs.2021.06.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 06/21/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Thoracic endovascular aortic repair (TEVAR) has become first line therapy for complicated acute type B aortic dissection (aTBAD). However, the strategy for optimal proximal landing zone remains to be determined. We compared early outcomes and late aortic-related adverse events in patients undergoing TEVAR for complicated aTBAD with endograft deployment in proximal landing zone 2 versus 3. METHODS We performed a retrospective chart review of adult patients undergoing TEVAR for complicated aTBAD within 6 weeks of diagnosis from 1/2008 to 12/2018. We excluded patients with connective tissue disorders and prior type A repair. Patients were divided into landing zone 2 TEVAR (Z2T) and zone 3 TEVAR (Z3T) groups. Z2 patients were divided between left subclavian artery (LSA) revascularization (Z2R) versus LSA coverage without revascularization (Z2C). Groups were compared for need for aortic re-intervention within 36 months of initial admission and freedom from aortic related adverse events and mortality (AREM), defined as need for aortic re-intervention, aortic-related death or rupture. RESULTS Eighty-three patients underwent TEVAR for complicated aTBAD within a mean of 4.1±7.8 days. 89.5% of patients had less than 2 cm of healthy proximal descending thoracic aorta. Landing zone was Z3T in 35 patients and 48 underwent Z2T: 10 Z2C and 38 Z2R. There were no differences between Z2T and Z3T in time from diagnosis to TEVAR, demographics, comorbidities and diameter aortic measurements. 30-day survival was 87.8%: 89.5% for Z2R, 88.6% for Z3 and 80.0 % for Z2C (p=0.610). Post-operative spinal cord ischemia rate was 3.7%: 2.7 % for Z2R, 0% for Z3T and 20.0% for Z2C (p=0.012). Post-operative thoracic aortic rupture was 2.2% in Z2 and 0 in Z3. Need for aortic re-intervention at 36 months post-TEVAR was lower for Z2T (10.4%) vs. Z3T (31.4%), p=0.025. Freedom from AREM at 36 months was higher in Z2T vs. Z3T - 87.5% vs. 68.6%, p= 0.048. Freedom from proximal re-intervention was higher in Z2T (95.8%) compared to Z3T (80.0%), p=0.019. Z3T deployment was predictive for AREM (OR:3.648,95%CI:1.161-11.465,p=0.027) and need for proximal re-intervention (OR: 5.542,95%CI:1.062-28.927,p=0.042). CONCLUSION Most patients with aTBAD have less than 2 cm of proximal healthy descending thoracic aorta. In patients treated for complicated aTBAD, zone 2 TEVAR is associated with a lower need for aortic re-intervention and aortic-related adverse events than zone 3 TEVAR. Patients may benefit from a more aggressive proximal landing zone with similar perioperative morbidity when zone 2 TEVAR is done with LSA revascularization.
Collapse
Affiliation(s)
- Tomaz Mesar
- Eastern Virginia Medical School, Division of Vascular Surgery, Norfolk, VA, USA.
| | - Fanny S Alie-Cusson
- Eastern Virginia Medical School, Division of Vascular Surgery, Norfolk, VA, USA
| | - Animesh Rathore
- Eastern Virginia Medical School, Division of Vascular Surgery, Norfolk, VA, USA
| | - David J Dexter
- Eastern Virginia Medical School, Division of Vascular Surgery, Norfolk, VA, USA
| | - Gordon K Stokes
- Eastern Virginia Medical School, Division of Vascular Surgery, Norfolk, VA, USA
| | - Jean M Panneton
- Eastern Virginia Medical School, Division of Vascular Surgery, Norfolk, VA, USA
| |
Collapse
|
32
|
Combined fenestrated/chimney thoracic endovascular repair for the treatment of blunt traumatic aortic injury: A case report. Chin J Traumatol 2021; 24:140-143. [PMID: 33678538 PMCID: PMC8173584 DOI: 10.1016/j.cjtee.2021.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 12/24/2020] [Accepted: 01/20/2021] [Indexed: 02/04/2023] Open
Abstract
Blunt traumatic thoracic aortic injury (BTAI) is an extremely serious medical condition with a high rate of associated mortality. Recent advances in techniques such as thoracic endovascular repair offer new opportunities to manage the critical BTAI patients in an efficacious yet less invasive manner. A 65 year-old-male suffered from multiple injuries after a fall, including BTAI in the aortic arch, which resulted in dissection of the descending thoracic-abdominal aorta and iliac artery, development of an intimal flap in the left common carotid artery, and dissection of the left subclavian artery. Based on the imaging information of this patient and our clinical experience, the combined treatment of fenestrated thoracic endovascular repair and a chimney technique was immediately planned to fully repair these dissections and moreover prevent further dissection of the branching vessels, additionally to ensure sufficient blood flow in the left subclavian artery and left common carotid artery. The intervention yielded satisfactory early outcomes. Follow-up assessment at six months reported no symptoms or complications associated with the stent-graft. Computed tomography angiography further confirmed adequate stent-graft coverage of the aortic injury.
Collapse
|
33
|
Protocolized Based Management of Cerebrospinal Fluid Drains in Thoracic Endovascular Aortic Aneurysm Repair Procedures. Ann Vasc Surg 2021; 72:409-418. [DOI: 10.1016/j.avsg.2020.08.134] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 08/12/2020] [Accepted: 08/17/2020] [Indexed: 01/04/2023]
|
34
|
Li F, Wu X, Zhang X, Qin J, Zhao Z, Ye K, Yin M, Lu X, Liu G, Liu X. Clinical Outcomes of Distal Tapered Restrictive Covered Stent Applied in Endovascular Treatment of Aortic Dissection Involving Zone 0. Eur J Vasc Endovasc Surg 2021; 61:413-421. [PMID: 33422438 DOI: 10.1016/j.ejvs.2020.11.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 10/28/2020] [Accepted: 11/20/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The safety and efficacy of a distal tapered restrictive covered stent (RCS) applied in the endovascular treatment of aortic dissection involving Zone 0 was evaluated. METHODS This study retrospectively analysed 43 patients with acute aortic dissection involving Zone 0 who received in situ laser fenestrated thoracic endovascular aortic repair with distal tapered RCS from January 2015 to February 2019. The indication for the distal tapered RCS procedure was an inappropriate distal size of the main stent graft. Technical success, aortic remodelling, and clinical outcomes were evaluated. RESULTS Technical success was achieved in all patients. The 30 day post-operative mortality rate was 0%. All patients had complete false lumen thrombosis in the stent coverage segment. True lumen volume increased significantly (p < .001) with an average change of 87.0% ± 34.3%, while false lumen volume decreased significantly (p < .001) with an average change of -71.0% ± 13.5% between baseline and 12 months. During the follow up period (mean 28.7 months, range 12-63 months), no distal stent graft induced new entry (SINE) was observed. The average distance between the distal end of the RCS and the coeliac trunk was 57.5 mm. Two (4.7%) patients had spinal cord ischaemia (SCI) and recovered without permanent paraplegia after undergoing conservative treatment. CONCLUSION The distal tapered RCS applied in the endovascular treatment of aortic dissection involving Zone 0 is considered to be a feasible and effective approach along with satisfactory aortic remodelling, a low risk of SINE, and SCI. The favourable results are partly explained by selection. No patients had an entry tear near the coronary artery, nor were the coronary arteries, pericardium, or aortic valve involved at the time of repair.
Collapse
Affiliation(s)
- Fengshi Li
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoyu Wu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
| | - Xing Zhang
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
| | - Jinbao Qin
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
| | - Zhen Zhao
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
| | - Kaichuang Ye
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
| | - Minyi Yin
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Vascular Centre of Shanghai Jiao Tong University, Shanghai, China
| | - Xinwu Lu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Vascular Centre of Shanghai Jiao Tong University, Shanghai, China.
| | - Guang Liu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Vascular Centre of Shanghai Jiao Tong University, Shanghai, China.
| | - Xiaobing Liu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Vascular Centre of Shanghai Jiao Tong University, Shanghai, China.
| |
Collapse
|
35
|
Perioperative Outcomes of Carotid–Subclavian Bypass or Transposition versus Endovascular Techniques for Left Subclavian Artery Revascularization during Nontraumatic Zone 2 Thoracic Endovascular Aortic Repair in the Vascular Quality Initiative. Ann Vasc Surg 2020; 69:17-26. [DOI: 10.1016/j.avsg.2020.05.062] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/19/2020] [Accepted: 05/20/2020] [Indexed: 12/31/2022]
|
36
|
Bartos O, Mustafi M, Andic M, Grözinger G, Artzner C, Schlensak C, Lescan M. Carotid-axillary bypass as an alternative revascularization method for zone II thoracic endovascular aortic repair. J Vasc Surg 2020; 72:1229-1236. [DOI: 10.1016/j.jvs.2019.11.053] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 11/26/2019] [Indexed: 12/17/2022]
|
37
|
Permissive Hypertension and Collateral Revascularization May Allow Avoidance of Cerebrospinal Fluid Drainage in Thoracic Endovascular Aortic Repair. Ann Thorac Surg 2020; 110:1469-1474. [PMID: 32535042 DOI: 10.1016/j.athoracsur.2020.04.101] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 04/04/2020] [Accepted: 04/17/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The utility of cerebrospinal fluid drainage (CSFD) for prevention of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) remains unclear. We previously published our institutional algorithm restricting preoperative CSFD to patients deemed high risk for SCI. Since that publication, our algorithm has evolved with preoperative CSFD avoided in all patients undergoing isolated descending TEVAR with or without arch involvement (+/- arch TEVAR). This study evaluated the updated algorithm in a contemporary cohort. METHODS Patients who underwent TEVAR for descending aortic +/-arch pathology between February 2012 and September 2018 at a single center were identified from an institutional aortic surgery database. The algorithm includes left subclavian artery (LSA) revascularization in cases of coverage with no preservation of antegrade flow, permissive hypertension, and use of evoked potential monitoring. The primary end points were SCI or postoperative CSFD. RESULTS During the study interval, 225 patients underwent descending +/- arch TEVAR. CSFD was used before TEVAR in 2 patients (0.9%) in violation of the algorithm, and they were excluded from the study cohort. Endograft coverage below T6 occurred in 81%. The LSA was fully covered in 100 patients (47%), all of whom underwent LSA revascularization. Following the updated algorithm, the incidence of temporary or permanent SCI was 0%. No patient required postoperative CSFD. CONCLUSIONS A restrictive lumbar CSFD algorithm, including permissive hypertension and LSA revascularization in the setting of descending +/- arch TEVAR, appears safe, with a 0% incidence of SCI in 223 consecutive patients treated during a 6.5-year interval. We recommend consideration of further prospective study to evaluate this algorithm.
Collapse
|
38
|
Tsilimparis N, Law Y, Rohlffs F, Spanos K, Debus ES, Kölbel T. Fenestrated endovascular repair for diseases involving the aortic arch. J Vasc Surg 2020; 71:1464-1471. [DOI: 10.1016/j.jvs.2019.06.205] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 06/13/2019] [Indexed: 11/26/2022]
|
39
|
Chait J, Kibrik P, Alsheekh A, Marks N, Rajaee S, Hingorani A, Ascher E. Descending thoracic endovascular aortic repair does not require cardiothoracic surgery support. Vascular 2019; 27:448-450. [PMID: 30866752 DOI: 10.1177/1708538119836331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective Descending thoracic endovascular aneurysm repair (D-TEVAR) is often performed by vascular surgeons. At many institutions, cardiothoracic surgery support is required for an elective TEVAR to take place. Oftentimes, this means a dedicated cardiopulmonary bypass team must be available. This study aims to investigate that TEVAR is a safe procedure that does not require such a resource-intensive “back-up plan.” Methods This is a retrospective analysis of data collected from March 2014 to January 2018 of 18 patients who underwent TEVAR at a tertiary care facility with a level I trauma center. There were 11 males and 7 females with an average age of 68.8 years old (range 19–97; SD ± 19.52). The average body mass index (BMI) was 24.7 kg/m2 (range 16.8–35; SD ±4.67). Nine were never smokers, four were former smokers, and five were currently smoking at the time of the procedure. The most common presenting symptom prior to intervention was chest pain ( n = 10), followed by cough/dyspnea ( n = 5), back pain ( n = 3), and trauma ( n = 2). Results The average maximum diameter of the thoracic aortic aneurysms (TAA) treated with TEVAR was 5.49 cm ( n = 7; range 4.3–6.7; SD ± 0.855). Six patients had Stanford Type B aortic dissections. Two patients with TAAs had concomitant, rapidly expanding aortic ulcers. Two patients had traumatic pseudoaneurysms, one of which ruptured prior to TEVAR. One patient had an expanding 1.9 × 1.8 cm saccular pseudoaneurysm of the aortic arch. The mean follow-up time was 69.2 weeks ( n = 17; range 3–166; SD ± 62.67), and one patient did not follow up following their initial TEVAR procedure. Of the 18 patients who received TEVAR, there were no major complications. Two patients experienced a type II endoleak. No patients required conversion to an open procedure, nor did any patients necessitate intervention by cardiothoracic surgery or cardiopulmonary bypass support. Conclusion These data suggest that cardiothoracic surgery support is not required for descending thoracic endovascular aneurysm repair (D-TEVAR). Further research is warranted on the risk factors associated with open conversion during these procedures.
Collapse
Affiliation(s)
- Jesse Chait
- Division of Vascular Surgery, NYU Langone Hospital-Brooklyn, Brooklyn, NY, USA
| | - Pavel Kibrik
- Division of Vascular Surgery, NYU Langone Hospital-Brooklyn, Brooklyn, NY, USA
| | - Ahmad Alsheekh
- Division of Vascular Surgery, NYU Langone Hospital-Brooklyn, Brooklyn, NY, USA
| | - Natalie Marks
- Division of Vascular Surgery, NYU Langone Hospital-Brooklyn, Brooklyn, NY, USA
| | - Sareh Rajaee
- Division of Vascular Surgery, NYU Langone Hospital-Brooklyn, Brooklyn, NY, USA
| | - Anil Hingorani
- Division of Vascular Surgery, NYU Langone Hospital-Brooklyn, Brooklyn, NY, USA
| | - Enrico Ascher
- Division of Vascular Surgery, NYU Langone Hospital-Brooklyn, Brooklyn, NY, USA
| |
Collapse
|
40
|
D’Oria M, Chiarandini S, Pipitone M, Calvagna C, Ziani B. Coverage of visible intercostal and lumbar segmental arteries can predict the volume of cerebrospinal fluid drainage in elective endovascular repair of descending thoracic and thoracoabdominal aortic disease: a pilot study. Eur J Cardiothorac Surg 2018; 55:646-652. [DOI: 10.1093/ejcts/ezy371] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 09/23/2018] [Accepted: 09/26/2018] [Indexed: 12/22/2022] Open
Affiliation(s)
- Mario D’Oria
- Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
| | - Stefano Chiarandini
- Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
| | - Marco Pipitone
- Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
| | - Cristiano Calvagna
- Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
| | - Barbara Ziani
- Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
| |
Collapse
|
41
|
Oderich GS, Kärkkäinen JM, Reed NR, Tenorio ER, Sandri GA. Penetrating Aortic Ulcer and Intramural Hematoma. Cardiovasc Intervent Radiol 2018; 42:321-334. [DOI: 10.1007/s00270-018-2114-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 11/01/2018] [Indexed: 01/10/2023]
|