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Adam DJ, Juszczak M, Vezzosi M, Claridge M, Quinn D, Senanayake E, Clift P, Mascaro J. The Complementary Roles of Open and Endovascular Repair of Extent I - III Thoraco-abdominal Aortic Aneurysms in a United Kingdom Aortic Centre. Eur J Vasc Endovasc Surg 2024; 68:62-72. [PMID: 38403184 DOI: 10.1016/j.ejvs.2024.02.031] [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: 04/20/2023] [Revised: 02/07/2024] [Accepted: 02/22/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVE A multidisciplinary approach offering both open surgical repair (OSR) and complex endovascular aortic repair (cEVAR) is essential if patients with thoraco-abdominal aortic aneurysms (TAAAs) are to receive optimal care. This study reports early and midterm outcomes of elective and non-elective OSR and cEVAR for extent I - III TAAA in a UK aortic centre. METHODS Retrospective study of consecutive patients treated between January 2009 and December 2021. Primary endpoint was 30 day/in hospital mortality. Secondary endpoint was Kaplan-Meier estimates of midterm survival. Data are presented as median (interquartile range [IQR]). RESULTS In total, 296 patients (176 men; median age 71 years [IQR 65, 76]; median aneurysm diameter 66 mm [IQR 61, 75]) underwent repair (222 elective, 74 non-elective). OSR patients (n = 66) were significantly younger with a higher incidence of heritable disease and chronic dissection, while cEVAR patients (n = 230) had a significantly higher prevalence of coronary, pulmonary, and renal disease. Overall, in hospital mortality after elective and non-elective repair was 3.2% (n = 7) and 23.0% (n = 17), respectively, with no significant difference between treatment modalities (elective OSR 6.5% vs. cEVAR 2.3%, p = .14; non-elective OSR 25.0% vs. cEVAR 20.3%, p = .80). Major non-fatal complications occurred in 15.3% (33/215) after elective repair (OSR 39.5%, 17/43, vs. cEVAR 9.3%, 16/172; p < .001) and 14% (8/57) after non-elective repair (OSR 26.7%, 4/15, vs. cEVAR 9.5%, 4/42; p = .19). Median follow up was 52 months (IQR 23, 78). Estimated survival ± standard error at 1, 3, and 5 years for the entire cohort was 89.6 ± 2.0%, 76.6 ± 2.9%, and 69.0% ± 3.2% after elective repair, and 67.6 ± 5.4%, 52.1 ± 6.0%, and 41.0 ± 6.2% after non-elective repair. There was no difference in 5 year survival comparing modalities after elective repair for patients younger than 70 years and those with post-dissection aneurysms. CONCLUSION A multidisciplinary approach offering OSR and cEVAR can deliver comprehensive care for extent I - III TAAA with low early mortality and good midterm survival. Further studies are required to determine the optimal complementary roles of each treatment modality.
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Affiliation(s)
- Donald J Adam
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Maciej Juszczak
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Massimo Vezzosi
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Martin Claridge
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - David Quinn
- Department of Cardiac Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Eshan Senanayake
- Department of Cardiac Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Paul Clift
- Department of Cardiac Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jorge Mascaro
- Department of Cardiac Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Locatelli F, Nana P, Le Houérou T, Guirimand A, Nader M, Gaudin A, Bosse C, Fabre D, Haulon S. Spinal cord ischemia rates and prophylactic spinal drainage in patients treated with fenestrated/branched endovascular repair for thoracoabdominal aneurysms. J Vasc Surg 2023; 78:883-891.e1. [PMID: 37315908 DOI: 10.1016/j.jvs.2023.06.002] [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: 04/14/2023] [Revised: 06/01/2023] [Accepted: 06/03/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Spinal cord ischemia (SCI) is a devastating complication after thoracoabdominal aortic aneurysm (TAAA) repair. The benefit of prophylactic cerebrospinal fluid drainage (pCSFD) to prevent SCI is still under investigation. The aim of this study was to evaluate the SCI rate and the impact of pCSFD following complex endovascular repair (fenestrated or branched endovascular repair [F/BEVAR]) for type I to IV TAAA. METHODS The STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement was followed. A single-center retrospective study was conducted, including all consecutive patients, managed for TAAA type I to IV using F/BEVAR, between January 1, 2018, and November 1, 2022, for degenerative and post-dissection aneurysms. Patients with juxta- or pararenal aneurysms were excluded, as well as cases managed urgently for aortic rupture or acute dissection. After 2020, pCSFD in type I to III TAAAs was abandoned and replaced by therapeutic CSFD (tCSFD), performed only in patients presenting SCI. The primary outcome was the perioperative SCI rate for the entire cohort and the role of pCSFD for type I to III TAAAs. RESULTS In total, 198 patients were included (mean age, 71.1±3.4 years; 81.8% males), including 50.5% with type I to III TAAA. The primary technical success was 94.9%. The perioperative mortality was 2.5%. and the major adverse cardiovascular event (MACE) rate was 10.6%; 4.5% presented SCI of any type (2.5% paraplegia). When comparing the SCI group with the remaining cohort, patients with SCI presented higher MACE (66.7% vs 7.9%; P < .001) rate and longer intensive care unit stay (3.5 vs 1 day; P = .002). Following type I to III repair, similar SCI, paraplegia, and paraplegia with no recovery rates were reported in the pCSFD and tCSFD groups (7.3% vs 5.1%; P = .66; 4.8% vs 3.3%; P = .72; and 2% vs 0%; P = .37). CONCLUSIONS The incidence of SCI after TAAA I to IV endovascular repair was low. SCI was associated with significantly increased MACE and intensive care unit stay. The prophylactic use of CSFD in type I to III TAAAs was not associated with lower SCI rates and may not be justified routinely.
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Affiliation(s)
- Federica Locatelli
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris Saclay University, Paris, France
| | - Petroula Nana
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris Saclay University, Paris, France
| | - Thomas Le Houérou
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris Saclay University, Paris, France
| | - Avit Guirimand
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris Saclay University, Paris, France
| | - Marwan Nader
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris Saclay University, Paris, France
| | - Antoine Gaudin
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris Saclay University, Paris, France
| | - Côme Bosse
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris Saclay University, Paris, France
| | - Dominique Fabre
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris Saclay University, Paris, France
| | - Stéphan Haulon
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris Saclay University, Paris, France.
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Mehta V, Wooster M. Hypogastric artery thrombectomy for spinal cord ischemia following fenestrated endovascular aortic repair. J Vasc Surg Cases Innov Tech 2022; 8:413-416. [PMID: 35942496 PMCID: PMC9356088 DOI: 10.1016/j.jvscit.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 05/17/2022] [Indexed: 11/29/2022] Open
Abstract
Spinal cord ischemia can be a devastating complication after thoracoabdominal aortic surgery. We report a case of a 56-year-old woman who had undergone multiple prior thoracic aneurysm repairs with an increase of a visceral segment aneurysm to 6 cm. The aneurysm was repaired using a physician-modified four-vessel fenestrated graft and iliac branch device. Postoperatively, she developed weakness in her right leg. Computed tomography angiography showed an occluded right hypogastric artery. We proceeded with aspiration thrombectomy with complete resolution of her right leg weakness within hours postoperatively. Our findings have illustrated the important role of hypogastric arteries in the development of spinal cord ischemia.
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Affiliation(s)
- Veena Mehta
- Division of Vascular Surgery, Department of Surgery, Harbor UCLA Medical Center, Torrance
- Correspondence: Veena Mehta, MD, Division of Vascular Surgery, Department of Surgery, Harbor UCLA Medical Center, 1000 W Carson St, Torrance, CA 90502
| | - Mathew Wooster
- Division of Vascular Surgery, Department of Surgery, College of Medicine, Medical University of South Carolina, Charleston
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COELIAC INCORPORATION STRATEGY IMPACTS VISCERAL BRANCH VESSEL STABILITY IN FENESTRATED ENDOVASCULAR ANEURYSM REPAIR. Eur J Vasc Endovasc Surg 2022; 64:321-330. [PMID: 35764244 DOI: 10.1016/j.ejvs.2022.06.015] [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: 04/22/2021] [Revised: 05/30/2022] [Accepted: 06/19/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE During fenestrated endovascular repair (FEVAR), mesenteric vessels may be incorporated with a scallop or fenestration. The benefits/harms of techniques to incorporate the coeliac axis (CA) have not been assessed for their impact on procedural complexity versus perioperative and longer-term outcomes; this assessment may instruct a balanced operative strategy for the CA and complex FEVAR, minimizing adverse intra/perioperative events, and maximizing durability. DESIGN Retrospective Cohort MATERIALS AND METHODS: Patients undergoing fenestrated or scalloped CA incorporation during FEVAR for a juxtarenal/pararenal/suprarenal aortic aneurysm (January 2015-December 2019) were reviewed (n=159) for demographics, intra-procedural/perioperative outcomes, and reinterventions to 5 years. Mean follow-up for all groups was 3.28 years. The primary outcome of CA instability (occlusion/stenosis/endoleak/reintervention) was assessed. CA-specific reintervention, reintervention-free survival, and all-cause mortality were assessed against incorporation strategy. Secondarily, the harm of CA stenting, comprising intraoperative harms and perioperative adverse outcomes was interrogated. RESULTS The CA was incorporated with a stented fenestration (n=74), an unstented fenestration (n=59), and a minority with scallop (n=26). There were no between group differences in operative indication, or anatomic aneurysm/CA features. Fenestrated stented and unstented patients had longer aortic coverage but the same primary technical success. At follow-up, three CA endoleaks occurred in stented fenestrated patients, although scallop patients more often had type 3 endoleaks at the SMA and renal fenestrations (23%). Elevated CA instability in fenestrated unstented patients was driven by CA occlusion (16.9%), but not associated with CA reintervention, worse reintervention-free survival, or all-cause mortality. Regression analysis for visceral branch instability revealed significant predictors of CA non-stenting and diminished aortic coverage. CONCLUSION In our experience, the practice of not stenting a CA fenestration does not pose a perioperative or long-term clinical harm. At follow-up, not stenting the CA is associated with CA instability, however, both fenestration groups are preferable to a shorter (scalloped) endograft as increasing aortic coverage reduces non-CA branch vessel instability.
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Shalan A, Tenorio ER, Mascaro JG, Juszczak MT, Claridge MW, Melloni A, Bertoglio L, Chiesa R, Oderich GS, Adam DJ. Fenestrated-branched endovascular repair for distal thoraco-abdominal aortic pathology after total aortic arch replacement with frozen elephant trunk. J Vasc Surg 2022; 76:867-874. [PMID: 35697307 DOI: 10.1016/j.jvs.2022.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/04/2022] [Accepted: 04/08/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To report the outcomes of fenestrated-branched endovascular repair (FBEVAR) for thoracoabdominal aortic pathology after total aortic arch replacement with frozen elephant trunk (TAR+FET). METHODS Interrogation of prospectively-maintained databases from four high volume aortic centres identified consecutive patients treated with distal FBEVAR after prior TAR+FET between August 2013 and September 2020. Primary endpoint was 30-day/in-hospital mortality. Secondary end points were technical success, early clinical success, mid-term survival and freedom from re-intervention. Data are presented as median (IQR). RESULTS 39 patients [21 men; median age, 73 years (67-75)] with degenerative (n=22) and post-dissection TAAAs (n=17) [median diameter 71 mm (61-78)] were identified. Distal FBEVAR was intended in 27 patients [median interval 9.8 months (6.2-16.6)], anticipated in seven and unexpected in five. 31 patients had a two (n=24) or three (n=7) stage distal FBEVAR. Reno-visceral target vessel preservation was 99.3% (145 of 146). Early primary and secondary technical success was 92% and 97%, respectively. 30-day mortality was 2.6% [n=1; respiratory failure and spinal cord ischaemia (SCI)]. Six survivors also developed SCI which was associated with complete (n=4), or partial recovery (n=2) at hospital discharge. No patients required renal replacement therapy or suffered a stroke. Early clinical success was 95%. Median follow-up was 30.5 months (23.7-49.7). Eleven patients required 16 late re-interventions. Estimated 3-year survival and freedom from re-intervention were 84±6% and 63±10%, respectively. CONCLUSIONS Distal FBEVAR after prior TAR+FET is associated with high technical success and low early mortality. The risk of SCI is significant although the majority of patients demonstrate full or partial recovery before hospital discharge. Mid-term patient survival is favourable but there remains a high requirement for late re-intervention. FBEVAR represents an acceptable alternative to distal open TAAA repair.
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Affiliation(s)
- Ahmed Shalan
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Emanuel R Tenorio
- Mayo Clinic, Rochester, Minnesota and The University of Texas Health Sciences Centre at Houston, McGovern Medical School, Houston, Texas, USA
| | - Jorge G Mascaro
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Maciej T Juszczak
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Martin W Claridge
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andrea Melloni
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Gustavo S Oderich
- Mayo Clinic, Rochester, Minnesota and The University of Texas Health Sciences Centre at Houston, McGovern Medical School, Houston, Texas, USA
| | - Donald J Adam
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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Uijtterhaegen G, VAN Langenhove K, Moreels N, VAN Herzeele I, Vermassen F. Fenestrated and branched endovascular repair for juxtarenal and thoracoabdominal aortic aneurysms: analysis of the first 100 cases. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:317-327. [PMID: 35142459 DOI: 10.23736/s0021-9509.22.11964-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Endovascular aortic aneurysm repair (EVAR) has become the most popular technique to treat infrarenal abdominal aortic aneurysms. In aneurysms with unsuitable anatomy open surgical repair remains the golden standard but fenestrated EVAR (FEVAR) or branched EVAR (BEVAR) may be an alternative to treat juxtarenal or thoracoabdominal aneurysms. The aim of this study was to report our results and to evaluate its safety and feasibility. METHODS This is a single center cohort study analyzing all consecutive patients undergoing FEVAR or BEVAR. RESULTS One hundred patients underwent a procedure between June 2012 and December 2019. Forty-seven percent had a history of coronary artery disease and 31% of previous aortic repair. Sixty percent were treated for a juxtarenal and 40% for a TAAA. Primary technical success was 87%. Overall, thirty-day mortality was 6%, with 50% of the deaths resulting from a myocardial infarction. Four percent had a bowel resection for ischemia, 3% developed a stroke and 3% spinal cord ischemia. Mean follow-up was 33.6±22.4 months, freedom from all-cause mortality was 89.3±3.2% at one year and 66.4±7.6% at five years. Six intraoperative target vessel events were noted (1.7%), six early postoperative (1.7%) and three late (0.8%). A total of ten (10%) late procedure related secondary interventions were performed, among which six for endoleak. CONCLUSIONS This study confirms that fenestrated and branched endovascular repair is a safe and feasible treatment for juxtarenal and thoracoabdominal aortic aneurysms with acceptable complication rates. The perioperative cardiac mortality highlights the importance of preoperative risk assessment and patient selection.
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Affiliation(s)
- Gilles Uijtterhaegen
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium -
| | - Karen VAN Langenhove
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Nathalie Moreels
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Isabelle VAN Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Frank Vermassen
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
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Rinaldi E, Melloni A, Gallitto E, Fargion A, Isernia G, Kahlberg A, Bertoglio L, Faggioli G, Lenti M, Pratesi C, Gargiulo M, Melissano G, Chiesa R, Luigi B, Luca B, Roberto C, Gianluca F, Aaron F, Cecilia F, Enrico G, Mauro G, Giacomo I, Massimo L, Antonino L, Andrea K, Chiara M, Germano M, Andrea M, Rodolfo P, Carlo P, Enrico R, Gioele S, Sara S. Spinal Cord Ischemia After Thoracoabdominal Aortic Aneurysms Endovascular Repair: From the Italian Multicenter Fenestrated/Branched Endovascular Aneurysm Repair Registry. J Endovasc Ther 2022; 30:281-288. [PMID: 35236159 DOI: 10.1177/15266028221081074] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE The aim of this study is to report an Italian multicenter experience analyzing the incidence and the risk factors associated with spinal cord ischemia (SCI) in a large cohort of thoracoabdominal aortic aneurysms (TAAAs) treated by fenestrated-branched endovascular aneurysm repair (F-/B-EVAR). MATERIALS AND METHODS All consecutive patients undergoing F-/B-EVAR in 4 Italian university centers between 2008 and 2019 were prospectively recorded and retrospectively analyzed. Spinal cord ischemia, 30 day/in-hospital adverse events, and mortality were assessed as early outcomes. Risk factors for SCI were determined by multivariable analysis. RESULTS A total of 351 patients received F-/B-EVAR for a TAAA. Twenty-eight (8.0%) patients died within 30 postoperative days or during the hospitalization. Regarding SCI, 47 patients (13.4%) developed neurological symptoms related to spinal cord impaired perfusion. Among them, 17 (4.8%) had a major permanent impairment. The multivariable analysis identified that SCI was associated with Crawford extent I to III (odds ratio [OR]: 20.90, p=0.004, 95% confidence interval [CI]=2.69-162.57), and with endovascular procedures performed for ruptured TAAA (OR: 5.74, p=0.010, 95% CI=1.53-21.57). Spinal cord ischemia was also significantly associated with a grade 3 bleeding during the visceral stage (OR: 4.34, p=0.005, 95% CI=1.55-12.16) and a grade 2 renal insufficiency at 30 days (OR: 7.45, p=0.002, 95% CI=2.12-26.18). CONCLUSION The present study indicates that SCI is still an open issue after extent I to III TAAA endovascular repair, while its incidence in extent IV TAAA and pararenal/juxtarenal aneurysms is rare. Thoracoabdominal aortic aneurysms extension, urgent TAAA repair for rupture, severe bleeding, and 30 day renal insufficiency have been identified as significant risk factors for SCI. In the presence of such factors, adjunctive strategies may be considered to reduce SCI rates, while in low-risk patients invasive or potentially-risky maneuvers might not be justified.
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Affiliation(s)
- Enrico Rinaldi
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Melloni
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Enrico Gallitto
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Aaron Fargion
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Giacomo Isernia
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Andrea Kahlberg
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Massimo Lenti
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Carlo Pratesi
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Germano Melissano
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Baccani Luigi
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Bertoglio Luca
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Chiesa Roberto
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Faggioli Gianluca
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Fargion Aaron
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Fenelli Cecilia
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Gallitto Enrico
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Gargiulo Mauro
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Isernia Giacomo
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Lenti Massimo
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Logiacco Antonino
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Kahlberg Andrea
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Mascoli Chiara
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Melissano Germano
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Melloni Andrea
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Pini Rodolfo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Pratesi Carlo
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Rinaldi Enrico
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Simonte Gioele
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Speziali Sara
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
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Brown K, Cheng Y, Harley S, Allen C, Claridge M, Adam D, Lord JM, Nasr H, Juszczak M. Association of SARC-F Score and Rockwood Clinical Frailty Scale with CT-Derived Muscle Mass in Patients with Aortic Aneurysms. J Nutr Health Aging 2022; 26:792-798. [PMID: 35934824 DOI: 10.1007/s12603-022-1828-2] [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: 11/27/2022]
Abstract
OBJECTIVES Patients with aortic aneurysms (AA) are often co-morbid and susceptible to frailty. Low core muscle mass has been used as a surrogate marker of sarcopenia and indicator of frailty. This study aimed to assess association between core muscle mass with sarcopenia screening tool SARC-F and Clinical Frailty Scale (CFS) in patients with AA. METHODS Prospective audit of patients in pre-operative aortic clinic between 01/07/2019-31/01/2020 including frailty assessment using Rockwood CFS and sarcopenia screening using SARC-F questionnaire. Psoas and sartorius muscle area were measured on pre-operative CT scans and adjusted for height. Association was assessed using Spearman's rank correlation coefficient. RESULTS Of 84 patients assessed, median age was 75 years [72,82], 84.5% were men, 65.5% were multimorbid and 63.1% had polypharmacy. Nineteen percent were identified as frail (CFS score >3) and 6.1% positively screened for sarcopenia (SARC-F score 4 or more). Median psoas area (PMA) at L3 was 5.6cm2/m2 [4.8,6.6] and L4 was 7.4cm2/m2 [6.3,8.6]. Median sartorius area (SMA) was 1.8 cm2/m2 [1.5,2.2]. CFS demonstrated weak but statistically significant negative correlation with height-adjusted PMA at L3 (r=-0.25, p=0.034) but not at L4 (r=-0.23, p=0.051) or with SMA (r=-0.22, p=0.065). No association was observed between SARC-F score and PMA or SMA (L3 PMA r=-0.015, p=0.9; L4 PMA r=-0.0014, p= 0.99; SMA r=-0.051, p=0.67). CONCLUSION CFS showed higher association with CT-derived muscle mass than SARC-F. Comprehensive pre-operative risk-stratification tools which incorporate frailty assessment and body composition analysis may assist in decision making for surgery and allow opportunity for pre-habilitation.
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Affiliation(s)
- K Brown
- Kathryn Brown MBChB, Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, United Kingdom,
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Abisi S, Musto L, Lyons O, Carmichael M, Sallam M, Gkoutzios P, Zayed H, Puchakayala M. "Awake" Spinal Cord Monitoring Under Local Anesthesia and Conscious Sedation in Fenestrated and Branched Endovascular Aortic Repair. J Endovasc Ther 2021; 28:837-843. [PMID: 34180738 DOI: 10.1177/15266028211028207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Endovascular repair of thoracoabdominal aortic aneurysms carries a risk of spinal cord ischemia, the causes of which remain uncertain. We hypothesized that local anesthesia (LA) with conscious sedation could abrogate the potential suppressive cardiovascular effects of general anesthesia (GA) and facilitate intraoperative monitoring of neurological function. Here, we examine the feasibility of this technique during fenestrated (FEVAR) or branched endovascular aortic repair (BEVAR). MATERIALS AND METHODS Consecutive patients undergoing FEVAR or BEVAR under LA and conscious sedation by a team at a single center were analyzed. Patients received conscious sedation using intravenous remifentanil and propofol infusions in conjunction with a local anesthetic agent. No patient had a prophylactic spinal drain inserted. Outcome measures included conversion to GA, need for vasopressors and/or spinal drainage, length of stay, complications, and patient survival. RESULTS A total of 44 patients underwent FEVAR or BEVAR under LA and conscious sedation. The cohort included thoracoabdominal aortic aneurysms (n=41) and pararenal aneurysms treated with endografts covering the supraceliac segment (n=3). Four patients (9%) required conversion to GA at a median operative duration of 198 minutes (range 97-495 minutes). Vasopressors were required intraoperatively in 3 of the cases that were converted to GA. No patient developed spinal cord ischemia and none had insertion of a spinal drain. The median hospital length of stay was 4 days (range 2-41 days). Postoperative delirium and hospital-acquired pneumonia was seen in 7% of patients. All patients survived to 30 days, with 95% alive at a median follow-up of 15 months (range 3-26 months). CONCLUSION LA and conscious sedation is a feasible anesthetic technique for the endovascular repair of thoracoabdominal aortic aneurysms.
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Affiliation(s)
- Said Abisi
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Liam Musto
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Oliver Lyons
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Michelle Carmichael
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Morad Sallam
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Panos Gkoutzios
- Department of Radiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Hany Zayed
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
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10
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Lella SK, Waller HD, Pendleton A, Latz CA, Boitano LT, Dua A. A Systematic Review of Spinal Cord Ischemia Prevention and Management After Open and Endovascular Aortic Repair. J Vasc Surg 2021; 75:1091-1106. [PMID: 34740806 DOI: 10.1016/j.jvs.2021.10.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 10/24/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Spinal cord ischemia (SCI) is one of the most devastating complications after descending thoracic aortic (DTA) and thoracoabdominal aortic (TAA) repairs. Patients who develop SCI have a poor prognosis with mortality rates reaching 75% within the first year after surgery. Many factors have been shown to increase the risk of this complication, including extent of TAA repair, length of aortic and collateral network coverage, embolization, and reduced spinal cord perfusion pressure. As a result, a variety of treatment strategies have evolved. We aimed to provide an up-to-date review of SCI rates with associated treatment algorithms from open and endovascular DTA and TAA repairs. METHODS Using PRISMA guidelines, a literature review with the Medical Subject Headings (MeSH) terms "spinal cord ischemia; spinal cord ischemia prevention and mitigation strategies; spinal cord ischemia rates; spinal cord infarction" was performed in the Cochrane and PubMed databases to seek all peer-reviewed studies of DTA and TAA repairs with SCI complications, limited to 2012-2021 and the English language. MeSH subheadings including diagnosis, complications, physiopathology, surgery, mortality, and therapy were used to further restrict the articles. Studies were excluded if they were not in humans, not pertaining to SCI in DTA/TAA operative repairs, and if the study primarily discussed neuromonitoring techniques. Additionally, studies with <40 patients or limited information regarding SCI protection strategies were excluded. Each study was individually reviewed by two researchers to assess for type and extent of aortic pathology, operative technique, SCI protection or mitigation strategies, rates of overall and permanent SCI symptoms, associations with SCI on multivariate analysis, and mortality. RESULTS Of 450 studies returned by the MeSH search strategy, 41 met inclusion criteria and were included in the final analysis. For endovascular DTA repair patients, overall SCI rates ranged from 0-10.6% with permanent SCI symptoms ranging from 0-5.1%. Endovascular and open TAA repairs had rates of overall SCI of 0-35%. Permanent SCI symptom rate was reported by only one open study at 1.1% while endovascular TAA repairs had between 2-20.5%. CONCLUSION This review provides an up-to-date review of current rates of SCI as well as prevention and mitigation strategies for DTA and TAA repairs. We find that a multimodal approach, including a bundled institutional protocol, staging of multiple repairs, preservation of collateral blood flow network, augmented spinal cord perfusion, selective cerebrospinal fluid drainage, and distal aortic perfusion in open TAA repairs, appears to be important in reducing the risk of SCI.
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Affiliation(s)
- Srihari K Lella
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass.
| | - Harold D Waller
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Alaska Pendleton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Christopher A Latz
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
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11
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Pini R, Faggioli G, Paraskevas KI, Alaidroos M, Palermo S, Gallitto E, Gargiulo M. A systematic review and meta-analysis of the occurrence of spinal cord ischemia following endovascular repair of thoraco-abdominal aortic aneurysms. J Vasc Surg 2021; 75:1466-1477.e8. [PMID: 34736999 DOI: 10.1016/j.jvs.2021.10.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The rates of endovascular repair of thoracoabdominal aortic aneurysms (TAAA-ER) have increased considerably in the last years. While mortality and morbidity rates have improved, spinal cord ischemia (SCI) rates have not declined significantly. The aim of this systematic review and meta-analysis was to examine SCI rates with respect to the efficacy of the different approaches. METHODS Cohort studies and case series (>20 patients) reporting SCI rates after TAAA-ER were eligible for inclusion. The primary outcome was the evaluation of SCI. Moderators considered were primarily the staged/non-staged approach, the use of cerebrospinal fluid drainage (CSFD) and TAAA extension. Permanent SCI and mortality rates were extracted. RESULTS Twenty-seven studies (n=2333 patients) were included in the meta-analysis. The pooled estimate for SCI was 11% (95% confidence interval [CI]: 8%-15%; I2:80%). For extent I,II,III and V TAAA, the pooled SCI rate was 13% (95% CI: 10%-17%; I2=71%), while for extent IV TAAA it was 6% (95% CI: 3%-10%; I2=62%). A staged TAAA-ER approach was used in 18 studies and a non-staged approach in 6 (one study included both). A lower pooled SCI rate was identified following staged compared with non-staged TAAA-ER (9% vs. 18%, respectively; P=.02). Staging was accomplished in >1 month in 9 studies and ≤1 month in 2, leading to similar SCI rates (7% vs. 11%, respectively; P=.29). The method of staging (thoracic-endoprosthesis or temporary aortic sac perfusion) did not affect SCI rates. Symptomatic CSFD was associated with a similar pooled rate of SCI compared with prophylactic CSFD (10% vs. 10%, respectively; P=.95). Pooled permanent SCI was 5% (6% following extent I,II,III and V TAAA; 3% following extent IV TAAA). Prophylactic or symptomatic CSFD have a similar rate of SCI (10% vs. 10%, respectively; P=.89). The pooled rate of 30-day mortality was 7%, with a similar incidence for the staged and non-staged approaches (6% vs. 9%, respectively). The inter-stage mortality was reported in 10 studies, with a pooled estimate rate of 1.6%. CONCLUSIONS SCI occurs in 11% of TAAA-ER and half of these cases are permanent. A staged approach can reduce SCI rates independently from the timing and the method adopted. The overall mortality rate for staged TAAA-ER is 6%, with one fourth of deaths (1.6%) occurring between stages.
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Affiliation(s)
- Rodolfo Pini
- Department of Vascular Surgery, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
| | - Gianluca Faggioli
- Department of Vascular Surgery, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy.
| | | | - Moad Alaidroos
- Department of Vascular Surgery, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
| | - Sergio Palermo
- Department of Vascular Surgery, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
| | - Enrico Gallitto
- Department of Vascular Surgery, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy.
| | - Mauro Gargiulo
- Department of Vascular Surgery, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
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12
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Oderich GS. The quest to lower spinal cord injuries continues. J Vasc Surg 2021; 74:1079-1080. [PMID: 34598753 DOI: 10.1016/j.jvs.2021.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 03/25/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, Houston, Tex
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13
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Juszczak M, Vezzosi M, Nasr H, Claridge M, Adam DJ. Fenestrated-Branch Endovascular Repair After Prior Abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2021; 62:728-737. [PMID: 34474963 DOI: 10.1016/j.ejvs.2021.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 06/03/2021] [Accepted: 07/05/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To report the outcome of fenestrated and branch endovascular aortic repair (FEVAR-BEVAR) for asymptomatic and acute symptomatic proximal aortic pathology in patients with prior open (OSR) or endovascular (EVAR) abdominal aortic aneurysm (AAA) repair. METHODS This was a single centre retrospective study of consecutive patients with non-ruptured (asymptomatic and acute symptomatic) proximal aortic pathology after prior OSR or EVAR treated between December 2007 and February 2020. The primary endpoint was 30 day/in hospital mortality. Secondary endpoints were technical success, primary clinical success, and Kaplan-Meier estimates of medium term survival and freedom from re-intervention. Data are presented as median (interquartile range [IQR]). The effect of covariates on medium term survival was estimated using multivariable (Cox proportional hazards model) analysis. A p value < .05 was considered to be statistically significant. RESULTS Ninety-two patients (83 men; median age 75 years [IQR 71 - 80 years]; median diameter 73 mm [IQR 64 - 89 mm]; 82 elective, 10 acute) underwent FEVAR-BEVAR after prior OSR (n = 47) or EVAR (n = 45). Indications for intervention were aneurysmal degeneration with or without type 1a endoleak (n = 57; four juxtarenal [JR] AAA, 21 extent II/III, 32 extent IV thoraco-abdominal aortic aneurysms); type 1a endoleak alone (n = 27) and to create a more durable repair after acute infrarenal EVAR (n = 8; JRAAA). In total, 348 renovisceral vessels were targeted for preservation and 324 were stent grafted. Twenty-four unstented vessels comprised one bypass, 11 scallops and six fenestrations intentionally not stent grafted, two vessels occluded before graft implantation, and four vessels occluded intra-operatively. Primary technical success was 95.6%. The thirty day mortality rate was 1.1% and one patient each (1.1%) required permanent dialysis or developed temporary spinal cord ischaemia. Early primary clinical success was 94.6%. Median follow up was 36 months (IQR 23 - 64 months). Estimated overall survival (± standard error) at one, two, and three years was 86% ± 4%, 85% ± 4%, and 70% ± 5%, respectively. Multivariable analysis did not demonstrate any independent predictors of survival. Four target vessels occluded during follow up. Nineteen patients underwent 28 late re-interventions, with almost half performed for issues arising distal to the FEVAR-BEVAR. Patients treated with a cuff were statistically significantly more likely to require distal re-intervention compared with those treated by relining (9/49 vs. 1/43, p = .018 [odds ratio 9.3, 95% confidence interval 1.2 - 423]). In patients with prior EVAR alone, this did not reach statistical significance (cuff 7/25 vs. relining 1/20, p = .059 [odds ratio 7.1, 95% confidence interval 0.8 - 350]). Estimated freedom from re-intervention at one, two, and three years was 88% ± 3%, 81% ± 4%, and 81% ± 4%, respectively. CONCLUSION FEVAR-BEVAR after prior OSR or EVAR is associated with low peri-operative morbidity and mortality, and acceptable medium term survival and freedom from re-intervention. Treatment with a FEVAR-BEVAR cuff is associated with a higher requirement for distal re-intervention than relining of the original repair.
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Affiliation(s)
- Maciej Juszczak
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Massimo Vezzosi
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Hosaam Nasr
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Martin Claridge
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Donald J Adam
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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Karelis A, Haulon S, Sonesson B, Adam D, Kölbel T, Oderich G, Cieri E, Mesnard T, Verhoeven E, Dias N. Multicentre Outcomes of Redo Fenestrated/Branched Endovascular Aneurysm Repair to Rescue Failed Fenestrated Endografts. Eur J Vasc Endovasc Surg 2021; 62:738-745. [PMID: 34393056 DOI: 10.1016/j.ejvs.2021.06.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 06/02/2021] [Accepted: 06/30/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To report the outcomes of redo fenestrated and/or branched endovascular aortic repair (F/BEVAR in FEVAR) to rescue previous failed FEVAR. METHODS Retrospective review of all consecutive patients undergoing F/BEVAR in FEVAR at eight aortic centres including pre-, intra-, and post-operative data according to a pre-established protocol. Follow up consisted of at least yearly computed tomography angiography. Values are presented as median and interquartile range, and survival as estimate ± standard error in percentage. RESULTS 18 male patients (76 years old; range 69 - 78 years) receiving FEVAR involving two (two or three) target vessels between 2006 and 2016 underwent F/BEVAR in FEVAR between 2012 and 2019 (aneurysm diameter of 63 mm; range 56 - 69 mm). Median interval between the procedures was 53 (29 - 103) months. The indication for F/BEVAR in FEVAR was type Ia endoleak in 16 cases (eight isolated and eight combined with graft migration), one graft migration without endoleak and one migration with significant proximal aortic expansion. F/BEVAR in FEVAR involved all patent renovisceral arteries and had an operating time of 260 (204 - 344) minutes. Technical success was achieved in 15 (83%) cases. There was a failure to bridge one renal artery, one renal capsular bleed with the subsequent need for renal artery embolisation within 24 hours and one persistent type Ib endoleak despite iliac extension. There was no peri- or in hospital death. Two patients developed spinal cord ischaemia, one transient paraparesis and one permanent paraplegia. The latter occurred in a non-staged procedure where spinal drainage was used. During a follow up of 27 (7 - 39) months, three (17%) patients underwent late re-interventions. Overall survival at 24 months was 70 ± 11% with no aneurysm related death and a secondary clinical success at 24 months of 84 ± 11%. CONCLUSION F/BEVAR in FEVAR is a technically challenging but feasible solution to rescue failed FEVAR. The outcomes are promising in many aortic centres but need to be confirmed by further studies with longer follow up.
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Affiliation(s)
- Angelos Karelis
- Department of Thoracic Surgery and Vascular Diseases, Vascular Centre, Skåne University hospital, Malmö, Sweden.
| | - Stéphan Haulon
- Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint-Joseph, INSERM UMR_S 999, Université Paris Saclay, Paris, France
| | - Björn Sonesson
- Department of Thoracic Surgery and Vascular Diseases, Vascular Centre, Skåne University hospital, Malmö, Sweden
| | - Donald Adam
- Complex Aortic Team, Birmingham Heartlands Hospital and Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Centre, University Heart and Vascular Centre, Hamburg, Germany
| | - Gustavo Oderich
- Health Science Centre, University of Texas, Houston, TX, USA
| | - Enrico Cieri
- Unit of Vascular & Endovascular Surgery, S. Maria della Misericordia Hospital, Perugia, Italy
| | - Thomas Mesnard
- Aortic Centre, University of Lille, Inserm, CHU Lille, U1008, F-Lille, France
| | - Eric Verhoeven
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University, Nuremberg, Germany
| | - Nuno Dias
- Department of Thoracic Surgery and Vascular Diseases, Vascular Centre, Skåne University hospital, Malmö, Sweden
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15
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Editor's Choice - Fenestrated or Branched Endovascular versus Open Repair for Complex Aortic Aneurysms: Meta-Analysis of Time to Event Propensity Score Matched Data. Eur J Vasc Endovasc Surg 2020; 61:228-237. [PMID: 33288434 DOI: 10.1016/j.ejvs.2020.10.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/18/2020] [Accepted: 10/07/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The aim of this review was to investigate comparative outcomes of fenestrated or branched endovascular aneurysm repair (F/BEVAR) with open repair for juxta/para/suprarenal or thoraco-abdominal aortic aneurysms. METHODS Electronic bibliographic sources (MEDLINE and Embase) were interrogated using the Healthcare Databases Advanced Search interface. Eligible studies compared F/BEVAR with open repair for complex aortic aneurysms using propensity score or Cox regression modelling/multivariable logistic regression analysis. Pooled estimates of peri-operative outcomes were calculated using the odds ratio (OR) and 95% confidence interval (CI). The result of time to event analysis was reported as summary hazard ratio (HR) and 95% CI. Random effects models and the inverse variance method were applied. The quality of evidence was graded using the system developed by the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) working group. RESULTS Eleven studies published between 2014 and 2019 were selected for inclusion in qualitative and quantitative synthesis reporting a total of at least 7 061 patients. The odds of peri-operative mortality after F/BEVAR were lower, although not significantly, than after open repair (OR 0.56, 95% CI 0.28-1.12), whereas the hazard of overall mortality during follow up was higher following F/BEVAR, but, again, without reaching statistical significance (HR 1.25, 95% CI 0.93-1.67). The hazard of re-intervention was significantly higher after endovascular therapy (HR 2.11, 95% CI 1.39-3.18). The certainty for the body of evidence for peri-operative and overall mortality during follow up was judged to be very low and moderate, respectively, and for re-intervention it was judged to be high. CONCLUSION The evidence is uncertain about the effect of F/BEVAR on peri-operative mortality when compared with open repair. There is probably no difference in overall survival, but F/BEVAR results in an increased re-intervention hazard. There is a need for high level evidence to inform decision making and vascular/aortic service provision.
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16
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Kawajiri H, Tenorio ER, Khasawneh MA, Pochettino A, Mendes BC, Marcondes GB, Lima GBB, Oderich GS. Staged total arch replacement, followed by fenestrated-branched endovascular aortic repair, for patients with mega aortic syndrome. J Vasc Surg 2020; 73:1488-1497.e1. [PMID: 33189762 DOI: 10.1016/j.jvs.2020.09.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 09/22/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The aim of the present study was to review the clinical outcomes of a staged approach using total arch replacement (TAR) with an elephant trunk or a frozen elephant trunk, followed by fenestrated-branched endovascular aortic repair (F-BEVAR) for patients with mega aortic syndrome. METHODS We reviewed the clinical data and outcomes of 11 consecutive patients (8 men; mean age, 71 ± 7 years) treated by staged TAR and F-BEVAR from January 2014 to December 2018. The F-BEVAR procedures were performed under a prospective, nonrandomized, physician-sponsored investigational device exemption protocol. All patients had had mega aortic syndrome, defined by an ascending aorta, arch, and extent I-II thoracoabdominal aortic aneurysm. The endpoints were 30-day mortality, major adverse events (MAE), patient survival, freedom from reintervention, and freedom from target vessel instability. RESULTS Of the 11 patients, 6 had developed chronic postdissection aneurysms after previous Stanford A (three A11, two A10, one A9) dissection repair and 5 had had degenerative aneurysms with no suitable landing zone in the aortic arch. The thoracoabdominal aortic aneurysms were classified as extent I in four patients and extent II in seven. One patient had died within 30 days after TAR (9.0%). However, none of the remaining 10 patients who had undergone F-BEVAR had died. First-stage TAR resulted in MAE in three patients (27%), including one spinal cord injury. The mean length of stay was 12 ± 6 days. The mean interval between TAR and F-BEVAR was 245 ± 138 days with no aneurysm rupture during the interval. Second-stage F-BEVAR was associated with MAE in two patients (20%), including spinal cord injury in one patient from spinal hematoma due to placement of a cerebrospinal fluid drain. The mean follow-up period was 14 ± 10 months. At 2 years postoperatively, patient survival, primary patency, secondary patency, and freedom from renal-mesenteric target vessel instability was 80% ± 9%, 94% ± 6%, 100%, and 86% ± 8%, respectively. No aortic-related deaths occurred during the follow-up period. Four patients had required reintervention, all performed using an endovascular approach. CONCLUSIONS A staged approach to treatment of mega aortic syndrome using TAR and F-BEVAR is a feasible alternative for selected high-risk patients. Larger clinical experience and longer follow-up are needed.
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Affiliation(s)
- Hidetake Kawajiri
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn; Department of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Emanuel R Tenorio
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Tex
| | | | | | - Bernardo C Mendes
- Department of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Giulianna B Marcondes
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Tex
| | - Guilherme B B Lima
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Tex
| | - Gustavo S Oderich
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Tex.
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17
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Zeng Z, Zhao Y, Wu M, Bao X, Li T, Feng J, Feng R, Jing Z. Endovascular strategies for post-dissection aortic aneurysm (PDAA). J Cardiothorac Surg 2020; 15:287. [PMID: 33004048 PMCID: PMC7528487 DOI: 10.1186/s13019-020-01331-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 09/22/2020] [Indexed: 11/23/2022] Open
Abstract
Residual patent false lumen (FL) after type B aortic dissection (TBAD) repair is independently associated with poor long-term survival. Open surgery and endovascular repair result in good clinical outcomes in patients with AD. However, both treatments focus on proximal dissection but not distal dissection. About 13.4–62.5% of these patients present with different degrees of distal aneurysmal dilatation after primary repair. Although open surgery is the first-choice treatment for post-dissection aortic aneurysm (PDAA), there is a need for high technical demand since open surgery is associated with high mortality and morbidity. As a treatment strategy with minimal invasion, endovascular repair shows early benefits and low morbidity. For PDAA, the narrow true lumen (TL), rigid initial flap and branch arteries originating from FL have increased difficulties in operation. The aim of endovascular treatment is to promote FL thrombosis and aortic remodeling. Endovascular repair includes intervention from FL and TL sides. TL intervention techniques (parallel stent-graft, branched and fenestrated stent-graft among others) have been proven to be safe and effective in PDAA. Other FL intervention techniques that have been used in selected patients include FL embolization and candy-plug techniques. This article introduces available endovascular techniques and their outcomes for the treatment of PDAA.
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Affiliation(s)
- Zhaoxiang Zeng
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China
| | - Yuxi Zhao
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China
| | - Mingwei Wu
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China
| | - Xianhao Bao
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China
| | - Tao Li
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China
| | - Jiaxuan Feng
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China.
| | - Rui Feng
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China.
| | - Zaiping Jing
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China.
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18
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Juszczak MT, Vezzosi M, Khan M, Mascaro J, Claridge M, Adam D. Endovascular repair of acute juxtarenal and thoracoabdominal aortic aneurysms with surgeon-modified fenestrated endografts. J Vasc Surg 2020; 72:435-444. [DOI: 10.1016/j.jvs.2019.10.056] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 10/05/2019] [Indexed: 11/28/2022]
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19
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Mendes BC, Tenorio ER. Expanding the Anatomical Feasibility of Branched Stent-Grafts in Patients With Variant Visceral Vessel Anatomy. J Endovasc Ther 2020; 27:237-239. [DOI: 10.1177/1526602819899672] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Bernardo C. Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Emanuel R. Tenorio
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
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Liang NL, Mohapatra A, Avgerinos ED, Katsargyris A. Acute Kidney Injury after Complex Endovascular Aneurysm Repair. Curr Pharm Des 2020; 25:4686-4694. [DOI: 10.2174/1381612825666191129095829] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/25/2020] [Indexed: 11/22/2022]
Abstract
Background:
Complex endovascular repair of abdominal aortic aneurysm carries higher perioperative
morbidity than standard infrarenal endovascular repair.
Objective:
This study reviews the incidence and associated factors of acute kidney injury in complex aortic endovascular
repair of juxtarenal, pararenal, and thoracoabdominal aortic aneurysms.
Methods:
A literature review was performed for all studies on the endovascular repair of juxtarenal, pararenal,
and thoracoabdominal aneurysms that evaluated rates of acute kidney injury as an outcome. Outcomes were further
analyzed by the level of anatomic complexity and method of repair.
Results:
52 studies met inclusion criteria, with a total of 5454 individuals undergoing repair from 2004 to 2017.
The overall rate of acute kidney injury ranged widely from 0 to 41%, with a rate of hemodialysis from 0 to 19%
(temporary) and 0 to 14% (permanent). Increasing anatomic complexity was associated with higher rates of acute
kidney injury. Mode of endovascular repair, learning curve effect, and preoperative chronic renal insufficiency
did not demonstrate any associations with the outcome.
Conclusion:
Published rates of acute kidney injury in complex aortic aneurysm repair vary widely with few definitively
associated factors other than increasing anatomic complexity and operative time. Further study is
needed for the identification of predictors related to postoperative acute kidney injury.
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Affiliation(s)
- Nathan L. Liang
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh PA, Penn, United States
| | - Abhisekh Mohapatra
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh PA, Penn, United States
| | - Efthymios D. Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh PA, Penn, United States
| | - Athanasios Katsargyris
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University Nuremberg, General Hospital Nuremberg, Nuremberg, Germany
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Katsargyris A. Is it Really Time to Eliminate Prophylactic Cerebrospinal Fluid Drainage in TAAA Endovascular Repair? Eur J Vasc Endovasc Surg 2019; 57:649. [PMID: 30738733 DOI: 10.1016/j.ejvs.2019.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 01/07/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Athanasios Katsargyris
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University Nuremberg, General Hospital Nuremberg, Nuremberg, Germany.
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