1
|
Fernando RJ, Coleman SR, Alghanem F, Sanders J, Kothari P, Vanneman MW, Ochieng PO, Augoustides JG. The Year in Aortic Surgery: Selected Highlights From 2023. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00312-4. [PMID: 38960802 DOI: 10.1053/j.jvca.2024.05.002] [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: 05/01/2024] [Accepted: 05/02/2024] [Indexed: 07/05/2024]
Abstract
This article reviews the recent and relevant literature to the field of aortic surgery. Specific areas highlighted include outcomes of Stanford type A dissection, management of acute aortic syndromes, management of aortic aneurysms, and traumatic aortic injury. Although the focus was on articles from 2023, literature from prior years also was included, given that this article is the first of a series. Notably, the pertinent sections from the 2022 American College of Cardiology/American Heart Association Guidelines for the Diagnosis and Management Aortic Disease are discussed.
Collapse
Affiliation(s)
- Rohesh J Fernando
- Department of Anesthesiology, Cardiothoracic Section, Wake Forest University School of Medicine, Winston Salem, NC.
| | - Scott R Coleman
- Department of Anesthesiology, Cardiothoracic Section, Wake Forest University School of Medicine, Winston Salem, NC
| | - Fares Alghanem
- Department of Anesthesiology, Pain Management & Perioperative Medicine, Henry Ford Health, Detroit, MI
| | - Joseph Sanders
- Department of Anesthesiology, Pain Management & Perioperative Medicine, Henry Ford Health, Detroit, MI
| | - Perin Kothari
- Division of Cardiovascular & Thoracic Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Matthew W Vanneman
- Division of Cardiovascular & Thoracic Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Peter O Ochieng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - John G Augoustides
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
2
|
Naito N, Takagi H. Optimal Timing of Pre-emptive Thoracic Endovascular Aortic Repair in Uncomplicated Type B Aortic Dissection: A Network Meta-Analysis. J Endovasc Ther 2024:15266028241245282. [PMID: 38590280 DOI: 10.1177/15266028241245282] [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: 04/10/2024]
Abstract
BACKGROUND This network meta-analysis compares outcomes of optimal medical therapy (OMT) and pre-emptive thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection at different phases of chronicity. METHODS MEDLINE and EMBASE were searched through November 2023. Pooled short-term outcomes (short-term mortality, perioperative complications) and long-term outcomes (all-cause mortality, aortic-related mortality, aortic re-intervention rates) were calculated. RESULTS Systematic review identified 17 studies (2 randomized controlled trials, 3 propensity score matching, and 2 inverse probability weighting). Subacute-phase intervention had lower short-term mortality than the acute-phase (hazard ratio [HR] [95% confidence interval [CI]]=0.60 [0.38-0.94], p=0.027). No significant differences were observed in aortic rupture and paraplegia. Acute-phase TEVAR had a higher stroke incidence than subacute-phase intervention (HR [95% CI]=2.63 [1.36-5.09], p=0.042), chronic (HR [95% CI]=2.5 [1.03-6.2], p=0.043), and OMT (HR [95% CI]=1.57 [1.12-2.18], p=0.008). Acute-phase TEVAR had higher long-term all-cause mortality than subacute-phase intervention (HR [95% CI]=1.34 [1.03-1.74], p=0.03). Optimal medical therapy had elevated long-term all-cause mortality compared with subacute-phase TEVAR (HR [95% CI]=1.67 [1.25-2.33], p<0.001) and increased long-term aortic-related mortality vs acute-phase (HR [95% CI]=2.08 [1.31-3.31], p=0.002) and subacute-phase (HR [95% CI]=2.6 [1.62-4.18], p<0.01) interventions. No significant differences were observed in aortic re-intervention rates. CONCLUSIONS Pre-emptive TEVAR may offer lower all-cause mortality and aortic-related mortality than OMT. Considering lower short-term mortality, perioperative stroke rate, and long-term mortality, our findings support pre-emptive TEVAR during the subacute phase. CLINICAL IMPACT The optimal timing of pre-emptive thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection remains uncertain. This network meta-analysis suggests that the subacute phase (14-90 days from symptom onset) emerges as the optimal timing for pre-emptive TEVAR. This window is associated with lower rates of short-term complications and higher long-term survival rates compared with alternative strategies.
Collapse
Affiliation(s)
- Noritsugu Naito
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| |
Collapse
|
3
|
Luthra S, Miskolczi S, Velissaris T, De Silva RJ, Luehr M, Kempfert J, Moon MC. Hybrid noncovered open stents in repair of DeBakey type 1 acute aortic dissections. Eur J Cardiothorac Surg 2024; 65:ezae154. [PMID: 38598445 DOI: 10.1093/ejcts/ezae154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 03/22/2024] [Accepted: 04/08/2024] [Indexed: 04/12/2024] Open
Abstract
OBJECTIVES The indications for use, evidence base and experience with the novel noncovered open hybrid surgical stents for acute type A aortic dissection repair for concurrent stabilization of the 'downstream' aorta remains limited. We review the evidence base and the development of these stents. METHODS Data were collected from Pubmed/Medline literature search to develop and review the evidence base for safety and efficacy of non-covered surgical stents. Existing guidelines for use and developments were reviewed. RESULTS A single randomized control trial and 4 single-centre studies were included in the review with a total worldwide experience of 241 patients. The deployment was easy and did not add significantly to the primary operation. The mortality and new stroke ranged from 6.3-18.7%. Safe and complete deployment was accomplished in 92-100%. There was no device-related reintervention. There was a significant improvement in malperfusion in over 90% of the cases with varying degrees of remodelling (60-90%) of the downstream aorta. CONCLUSIONS Open noncovered stent grafts represent a major technical advancement as an adjunct procedure for acute dissection repairs, e.g. hemiarch repair. It has potential for wider use by non-aortic surgeons due to simplicity of technique. Limited safety and efficacy data confirm the device to be safe, feasible and reproducible with potential for wider adoption. However, long-term trial and registry data are required before recommendations for standard use outside of high-volume experienced aortic centres.
Collapse
Affiliation(s)
- Suvitesh Luthra
- Wessex Cardiothoracic Centre, Division of Cardiac Surgery, University Hospital Southampton, Southampton, UK
- Academic Unit of Human Development and Health, University of Southampton, Southampton, UK
| | - Szabolcs Miskolczi
- Wessex Cardiothoracic Centre, Division of Cardiac Surgery, University Hospital Southampton, Southampton, UK
| | - Theodore Velissaris
- Wessex Cardiothoracic Centre, Division of Cardiac Surgery, University Hospital Southampton, Southampton, UK
| | - Ravi J De Silva
- Division of Cardiac Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Maximilian Luehr
- Department of Cardio-Thoracic Surgery, Heart Center of the University of Cologne, Cologne, Germany
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany
| | - Michael C Moon
- Division of Cardiac Surgery, Mazankowski Alberta Heart Institute, Alberta, Canada
| |
Collapse
|
4
|
Zheng H, Lin D, Cheng Y, Yan C, Yu S, Li J, Cheng W. Systematic review of the effect of cerebrospinal fluid drainage on outcomes after endovascular type B aortic dissection repair. J Cardiothorac Surg 2024; 19:116. [PMID: 38475763 PMCID: PMC10935911 DOI: 10.1186/s13019-024-02603-3] [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: 08/10/2023] [Accepted: 03/05/2024] [Indexed: 03/14/2024] Open
Abstract
OBJECTIVE The aim of the present systematic review was to determine whether prophylactic use of cerebrospinal fluid drainage (CSFD) contributes to a lower rate of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD). METHODS PubMed, Embase, Web of Science and Cochrane Library databases were systematically searched to identify all relevant studies reported before May 7, 2023. A systematic review was conducted in accordance with PRISMA guidelines (PROSPERO registration no. CRD42023441392). The primary outcome was permanent SCI. Secondary outcomes were temporary SCI and 30-day/in-hospital mortality. The data were presented as the pooled event rates (ERs) and 95% confidence intervals (CIs). RESULTS A total of 1008 studies were screened, of which 34 studies with 2749 patients were included in the present analysis. The mean Downs and Black quality assessment score was 8.71 (range, 5-12). The pooled rate of permanent SCI with prophylactic CSFD was identical to that without prophylactic CSFD (2.0%; 95% CI, 1.0-3.0; P = 0.445). No statistically significant difference was found between the rates of permanent SCI with routine vs. selective prophylactic CSFD (P = 0.596). The pooled rate of temporary SCI was 1.0% (95% CI, 0.00-1.0%). The pooled rate for 30-day or in-hospital mortality was not significantly different (P = 0.525) in patients with prophylactic CSFD (4.0, 95% CI 2.0-6.0) or without prophylactic CSFD (5.0, 95% CI 2.0-7.0). CONCLUSIONS The systematic review has shown that prophylactic CSFD was not associated with a lower rate of permanent SCI and 30-day or in-hospital mortality after TEVAR for TBAD.
Collapse
Affiliation(s)
- Huajie Zheng
- Department of Cardiac Surgery, Southwest Hospital, Third Military Medical University (Army Medical University, No. 30, Gaotanyan Road, Shapingba District, Chongqing, 400038, P.R. China
| | - Deqing Lin
- Department of Cardiac Surgery, Southwest Hospital, Third Military Medical University (Army Medical University, No. 30, Gaotanyan Road, Shapingba District, Chongqing, 400038, P.R. China
| | - Yongbo Cheng
- Department of Cardiac Surgery, Southwest Hospital, Third Military Medical University (Army Medical University, No. 30, Gaotanyan Road, Shapingba District, Chongqing, 400038, P.R. China
| | - Chaojun Yan
- Department of Cardiac Surgery, Southwest Hospital, Third Military Medical University (Army Medical University, No. 30, Gaotanyan Road, Shapingba District, Chongqing, 400038, P.R. China
| | - Sanjiu Yu
- Department of Cardiac Surgery, Southwest Hospital, Third Military Medical University (Army Medical University, No. 30, Gaotanyan Road, Shapingba District, Chongqing, 400038, P.R. China
| | - Jun Li
- Department of Cardiac Surgery, Southwest Hospital, Third Military Medical University (Army Medical University, No. 30, Gaotanyan Road, Shapingba District, Chongqing, 400038, P.R. China.
| | - Wei Cheng
- Department of Cardiac Surgery, Southwest Hospital, Third Military Medical University (Army Medical University, No. 30, Gaotanyan Road, Shapingba District, Chongqing, 400038, P.R. China.
| |
Collapse
|
5
|
Matsushita A, Tabata M, Hattori T, Mihara W, Sato Y. Surgical treatment in the chronic phase for uncomplicated Stanford type B aortic dissection. PLoS One 2024; 19:e0298644. [PMID: 38394249 PMCID: PMC10890721 DOI: 10.1371/journal.pone.0298644] [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: 08/17/2023] [Accepted: 01/23/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND The most appropriate surgical method for patients with uncomplicated type B aortic dissection (UTBAD) in the chronic phase remains controversial. This study evaluated the outcomes of patients with UTBAD who needed aortic treatment as well as the impact of the treatment method or indication criteria on their prognosis. METHODS This retrospective review of 106 consecutive patients with aortic events in the chronic phase who underwent initial treatment for UTBAD between 2004 and 2021 comprised three groups: 19 patients who underwent endovascular repair (TEVAR), 38 who underwent open aortic repair and the medication group that included 49 patients. Aortic events were defined as a late operation or indication for operation for dissected aorta, aortic diameter (AD) ≥ 55 mm, rapid aortic enlargement (≥5 mm/6 months), and saccular aneurysmal change. The endpoint was all-cause death. We assessed the association between treatment methods or surgical indication criteria and mortality using a Cox regression analysis. RESULTS The 5-year actuarial mortality rates were 27.1% in the TEVAR group, 19.6% in the open aortic repair group, and 38.4% in the medication group (p = 0.86). Moreover, the 5-year actuarial mortality rates in patients who had AD ≥ 55 mm were significantly higher than those patients with other surgical indication criteria (41.2% vs. 18.7%, p < 0.01). Multivariable analysis revealed a significant difference in AD ≥ 55 mm (hazard ratio [HR]: 2.88, 95% confidence interval [CI] 1.38-6.02, p < 0.01) and age (HR: 1.09, 95% CI 1.05-1.13, p < 0.01). CONCLUSIONS Under the existing surgical indication criteria, there was no difference in mortality rates among patients with UTBAD based on their surgical treatment.
Collapse
Affiliation(s)
- Akihito Matsushita
- Department of Cardiovascular Surgery, Teikyo University Chiba Medical Center, Chiba, Japan
- Department of Cardiovascular Surgery, Seikeikai Chiba Medical Center, Chiba, Japan
| | - Minoru Tabata
- Department of Cardiovascular Surgery, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Takashi Hattori
- Department of Cardiovascular Surgery, Seikeikai Chiba Medical Center, Chiba, Japan
| | - Wahei Mihara
- Department of Cardiovascular Surgery, Seikeikai Chiba Medical Center, Chiba, Japan
| | - Yasunori Sato
- Department of Biostatistics, Keio University School of Medicine, Tokyo, Japan
| |
Collapse
|
6
|
Tang QH, Chen J, Long Z, Su XA, Wang YL, Qiu JY, Qin Z, Yang H, Li Q, Hu M, Qin X. Long-term survival and risk analysis of thoracic endovascular aortic repair for type B aortic dissection. iScience 2023; 26:108359. [PMID: 38034350 PMCID: PMC10682288 DOI: 10.1016/j.isci.2023.108359] [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: 07/19/2023] [Revised: 09/26/2023] [Accepted: 10/25/2023] [Indexed: 12/02/2023] Open
Abstract
To explore the safety and efficacy of thoracic endovascular aortic repair (TEVAR) in the treatment of patients with type B aortic dissection, and to evaluate the risk factors for long-term mortality. Our study retrospectively evaluated 729 patients with type B aortic dissection, who were divided into the thoracic endovascular aortic repair group and the optimal medical treatment group according to their treatment. In-hospital mortality, death within 30 days, and aortic-related mortality were lower in the thoracic endovascular aortic repair group than in the optimal medical treatment group (p < 0.05). The cumulative overall survival rates for the thoracic endovascular aortic repair group at 1 year, 5 years, and 10 years were 92.5%, 84.1%, and 73.5%, respectively. The Cox analysis found that TEVAR was beneficial in reducing mortality and that a vertical length of the dissection exceeding 150 mm was a risk factor for mortality.
Collapse
Affiliation(s)
- Qian-hui Tang
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| | - Jing Chen
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| | - Zhen Long
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| | - Xuan-an Su
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| | - Yu-Lin Wang
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| | - Jian-ye Qiu
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| | - Zhong Qin
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| | - Han Yang
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| | - Que Li
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| | - Ming Hu
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| | - Xiao Qin
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| |
Collapse
|
7
|
Trimarchi S, Gleason TG, Brinster DR, Bismuth J, Bossone E, Sundt TM, Montgomery DG, Pai CW, Bissacco D, de Beaufort HWL, Bavaria JE, Mussa F, Bekeredjian R, Schermerhorn M, Pacini D, Myrmel T, Ouzounian M, Korach A, Chen EP, Coselli JS, Eagle KA, Patel HJ. Editor's Choice - Trends in Management and Outcomes of Type B Aortic Dissection: A Report From the International Registry of Aortic Dissection. Eur J Vasc Endovasc Surg 2023; 66:775-782. [PMID: 37201718 DOI: 10.1016/j.ejvs.2023.05.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 04/21/2023] [Accepted: 05/11/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVE To describe the trends in management and outcomes of patients with acute type B aortic dissection in the International Registry of Acute Aortic Dissection. METHODS From 1996 - 2022, 3 908 patients were divided into similar sized quartiles (T1, T2, T3, and T4). In hospital outcomes were analysed for each quartile. Survival rates following admission were compared using Kaplan-Meier analyses with Mantel-Cox Log rank tests. RESULTS Endovascular treatment increased from 19.1% in T1 to 37.2% in T4 (ptrend < .001). Correspondingly, medical therapy decreased from 65.7% in T1 to 54.0% in T4 (ptrend < .001), and open surgery from 14.8% in T1 to 7.0% in T4 (ptrend < .001). In hospital mortality decreased in the overall cohort from 10.7% in T1 to 6.1% in T4 (ptrend < .001), as well as in medically, endovascularly and surgically treated patients (ptrend = .017, .033, and .011, respectively). Overall post-admission survival at three years increased (T1: 74.8% vs. T4: 77.3%; p = .006). CONCLUSION Considerable changes in the management of acute type B aortic dissection were observed over time, with a significant increase in the use of endovascular treatment and a corresponding reduction in open surgery and medical management. These changes were associated with a decreased overall in hospital and three year post-admission mortality rate among quartiles.
Collapse
Affiliation(s)
- Santi Trimarchi
- Department of Clinical and Community Sciences, University of Milan, Milan, Italy; Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milan, Italy.
| | - Tom G Gleason
- Department of Surgery, Brigham & Women's Hospital, Boston, MA, USA
| | - Derek R Brinster
- Department of Cardiac Surgery, Northwell Health, New York City, NY, USA
| | - Jean Bismuth
- DeBakey Heart & Vascular Centre, Methodist Hospital System, Houston, TX, USA
| | - Eduardo Bossone
- Department of Public Health, University "Federico II", Naples, Italy
| | - Thoralf M Sundt
- Thoracic Aortic Centre, Massachusetts General Hospital, Boston, MA, USA
| | | | - Chih-Wen Pai
- Cardiovascular Centre, University of Michigan, Ann Arbor, MI, USA
| | - Daniele Bissacco
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milan, Italy
| | | | - Joseph E Bavaria
- Division of Cardiothoracic Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Firas Mussa
- Department of Cardiac Surgery, Northwell Health, New York City, NY, USA
| | | | - Marc Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - Davide Pacini
- Department of Cardiac Surgery, University Hospital S. Orsola, Bologna, Italy
| | - Truls Myrmel
- Department of Thoracic and Cardiovascular Surgery, Tromsø University Hospital, Tromsø, Norway
| | - Maral Ouzounian
- Division of Cardiac Surgery, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Amit Korach
- Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Centre, Jerusalem, Israel
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Duke University, Durham, NC, USA
| | - Joseph S Coselli
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Kim A Eagle
- Cardiovascular Centre, University of Michigan, Ann Arbor, MI, USA
| | - Himanshu J Patel
- Cardiovascular Centre, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
8
|
Sá MP, Jacquemyn X, Van den Eynde J, Chu D, Serna-Gallegos D, Singh MJ, Chaer RA, Sultan I. Midterm Outcomes of Endovascular vs. Medical Therapy for Uncomplicated Type B Aortic Dissection: Meta-Analysis of Reconstructed Time to Event Data. Eur J Vasc Endovasc Surg 2023; 66:609-619. [PMID: 37422209 DOI: 10.1016/j.ejvs.2023.07.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/16/2023] [Accepted: 07/03/2023] [Indexed: 07/10/2023]
Abstract
OBJECTIVE To evaluate outcomes of thoracic endovascular aortic repair (TEVAR) vs. medical therapy in uncomplicated type B aortic dissections (TBAD). DATA SOURCES PubMed/MEDLINE, EMBASE, SciELO, LILACS, CENTRAL/CCTR, Google Scholar, and reference lists of relevant articles. REVIEW METHODS This was a pooled meta-analysis of time to event data extracted from studies published by December 2022 for the following outcomes: all cause mortality, aortic related mortality, and late aortic interventions. Certainty of evidence was evaluated through the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool. RESULTS Ten studies met the eligibility criteria (eight observational; two randomised trials), comprising 17 906 patients (2 332 patients in the TEVAR groups and 15 574 patients in the medical therapy group). Compared with patients who received medical therapy, patients who underwent TEVAR had a statistically significantly lower risk of all cause death (HR 0.79, 95% CI 0.72 - 0.87, p < .001; GRADE certainty: low) and lower risk of aortic related death (HR 0.43, 95% CI 0.30 - 0.62, p < .001; GRADE certainty: low) without statistically significant difference in the risk of late aortic interventions (HR 1.05, 95% CI 0.88 - 1.26, p = .56; GRADE certainty: low). In the subgroup analyses, TEVAR was associated with lower risk of all cause death when randomised controlled trials only were pooled (HR 0.44, 95% CI 0.23 - 0.83, p = .012; GRADE certainty: moderate), younger patients only (HR 0.56, 95% CI 0.47 - 0.67, p < .001; GRADE certainty: low), Western populations only (HR 0.85, 95% CI 0.77 - 0.93, p = .001; GRADE certainty: low) and non-Western populations only (HR 0.47, 95% CI 0.35 - 0.62, p < .001; GRADE certainty: low). For all cause mortality and aortic related mortality, restricted mean survival time was overall 396 days and 398 days longer with TEVAR (p < .001), respectively, which means that TEVAR was associated with lifetime gain. CONCLUSION TEVAR may be associated with better midterm survival and lower risk of aortic related death in the follow up of patients treated for uncomplicated TBAD compared with medical therapy; however, randomised controlled trials with larger sample sizes and longer follow up are still warranted.
Collapse
Affiliation(s)
- Michel Pompeu Sá
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA.
| | - Xander Jacquemyn
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | | | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
| | - Derek Serna-Gallegos
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
| | - Michael J Singh
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA; Division of Vascular Surgery, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
| | - Rabih A Chaer
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA; Division of Vascular Surgery, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA. https://twitter.com/IbrahimSultanMD
| |
Collapse
|
9
|
Cho NY, Chervu N, Verma A, Ebrahimian S, Kim S, Rollo J, Benharash P. National Trends and Clinical Outcomes of Type B Aortic Dissection Management at Safety-Net Hospitals. Am Surg 2023; 89:4105-4110. [PMID: 37212236 DOI: 10.1177/00031348231177928] [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: 05/23/2023]
Abstract
INTRODUCTION Patients with type B aortic dissection (TBAD) are often underinsured and urgently admitted for open or thoracic endovascular aortic repair (TEVAR). The present study evaluated the association of safety-net status with outcomes among patients with TBAD. METHODS The 2012-2019 National Inpatient Sample was queried to identify all adults admitted with type B aortic dissection. Safety-net hospitals (SNHs) were defined as institutions in the top 33% for the annual proportion of uninsured or Medicaid patients. Multivariable regression models were utilized to assess the association of SNH with in-hospital mortality, perioperative complications, length of stay (LOS), hospitalization cost, and non-home discharge. RESULTS Of an estimated 172 595 patients, 61 000 (35.3%) were managed at SNH. Compared to others, patients admitted to SNH were younger, more commonly non-white, and more frequently non-electively admitted. From 2012 to 2019, the annual incidence of type B aortic dissection increased in the overall cohort. Additionally, utilization of TEVAR at non-SNH increased significantly (2012: 6.5% vs 2019: 9.8%), while that of SNH remained similar (2012: 7.4% vs 2019: 7.9%). Patients undergoing open repair had higher mortality at both SNH (12.4 vs 7.8%, P < .001) and non-SNH (13.1 vs 6.1%, P < .001) compared to those receiving TEVAR. After risk adjustment, compared to non-SNH, SNH status was associated with greater odds of mortality, perioperative complications and non-home discharge. CONCLUSIONS Our finding suggests that SNH have inferior clinical outcomes for TBAD as well as reduced adoption of endovascular management strategies. Future studies to identify barriers to optimal aortic repair and ameliorate disparities at SNH are warranted.
Collapse
Affiliation(s)
- Nam Yong Cho
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Shayan Ebrahimian
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Shineui Kim
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jonathan Rollo
- Division of Vascular and Endovascular Surgery at UCLA, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| |
Collapse
|
10
|
Bicknell C, Bell R. Urgent priorities for patients with type B aortic dissection. Br J Surg 2023; 110:1023-1024. [PMID: 37368995 DOI: 10.1093/bjs/znad196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023]
Affiliation(s)
- Colin Bicknell
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust and Department of Surgery and Cancer, Imperial College London, London, UK
| | - Rachel Bell
- Vascular Society of Great Britain and Ireland, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| |
Collapse
|
11
|
Bashir M, Tan SZ, Jubouri M, Coselli J, Chen EP, Mohammed I, Velayudhan B, Sadeghipour P, Nienaber C, Awad WI, Slisatkorn W, Wong R, Piffaretti G, Mariscalco G, Bailey DM, Williams I. Uncomplicated Type B Aortic Dissection: Challenges in Diagnosis and Categorisation. Ann Vasc Surg 2023:S0890-5096(23)00223-6. [PMID: 37075834 DOI: 10.1016/j.avsg.2023.04.006] [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: 03/06/2023] [Revised: 04/06/2023] [Accepted: 04/06/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Acute type B aortic dissection (TBAD) is a rare disease that is likely under-diagnosed in the UK. As a progressive, dynamic clinical entity, many patients initially diagnosed with uncomplicated TBAD deteriorate, developing end-organ malperfusion and aortic rupture (complicated TBAD). An evaluation of the binary approach to the diagnosis and categorisation of TBAD is needed. METHODS A narrative review of the risk factors predisposing patients to progression from unTBAD to coTBAD was undertaken. RESULTS Key high-risk features predispose the development of complicated TBAD, such as maximal aortic diameter > 40 mm and partial false lumen thrombosis. CONCLUSION An appreciation of the factors that predispose to complicated TBAD would aid clinical decision-making surrounding TBAD.
Collapse
Affiliation(s)
- Mohamad Bashir
- Vascular and Endovascular Surgery, Health Education and Improvement Wales, Velindre University NHS Trust, Wales, UK.
| | - Sven Zcp Tan
- Barts and The London School of Medicine, Queen Mary University of London, UK
| | | | - Joseph Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University, Durham, North Carolina
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders, SRM Institutes for Medical Sciences, SIMS Hospital, Chennai, India
| | - Bashi Velayudhan
- Institute of Cardiac and Aortic Disorders, SRM Institutes for Medical Sciences, SIMS Hospital, Chennai, India
| | - Parham Sadeghipour
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Christoph Nienaber
- Cardiology and Aortic Centre, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Wael I Awad
- Department of Cardiothoracic Surgery, Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Worawong Slisatkorn
- Division of Cardio-Thoracic Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Randolph Wong
- Department of Surgery, Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
| | - Gabrielle Piffaretti
- Vascular Surgery - Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Giovanni Mariscalco
- Department of Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, UK
| | - Ian Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| |
Collapse
|
12
|
Ahmad W, Brunkwall J, Bunck AC, Dorweiler B, Mylonas S. Favorable Remodeling After TEVAR in Uncomplicated Acute and Subacute Type B Aortic Dissection in Comparison to Conservative Treatment: A Midterm Analysis. J Endovasc Ther 2023:15266028231158971. [PMID: 36891635 DOI: 10.1177/15266028231158971] [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: 03/10/2023]
Abstract
PURPOSE The purpose of the study was to evaluate the midterm and long-term outcomes of patients who underwent thoracic endovascular aortic repair (TEVAR) procedure to treat an uncomplicated acute and subacute type B aortic dissection (uATBAD) with high risk for subsequent aortic complications compared with the group of patients who received a conservative treatment protocol during the same period. MATERIALS AND METHODS Between 2008 and 2019, 35 patients who had TEVAR due to uATBAD and those with conservative procedure (n=18) were included in a retrospective analysis and follow-up study. The primary endpoints were false lumen thrombosis/perfusion, true lumen diameter, and aortic dilatation. The aortic-related mortality, reintervention, and long-term survival were the secondary endpoints. RESULTS In the study period, 53 patients (22 females) with a mean age of 61.1±13 years were included. No 30-day and in-hospital mortality was recorded. Permanent neurological deficits occurred in 2 patients (5.7%). In the TEVAR group (n=35) and in a median follow-up period of 34 months, a significant reduction of maximum aortic and false lumen diameter as well as a significant increase of true lumen diameter were detected (p<0.001 each). Complete false lumen thrombosis increased from 6% preoperatively to 60% at follow-up. The median difference in aortic, false lumen, and true lumen diameter was -5 mm (interquartile range [IQR]=-28 to 8 mm), -11 mm (IQR=-53 to 10 mm), and 7 mm (IQR=-13 to 17 mm), respectively. In 3 patients (8.6%), a reintervention was needed. Two patients (1 aortic-related) died during follow-up. The estimated survival according to Kaplan-Meyer analysis was 94.1% after 3 years and 87.5% after 5 years. Similar to the TEVAR group, no 30-day or in-hospital mortality was recorded in the conservative group. During follow-up, 2 patients died and 5 patients underwent conversion-TEVAR (28%). In a median follow-up period of 26 months (range=150), a significant increase of maximum aortic diameter (p=0.006) and a tendency to augmentation of the false lumen (p=0.06) were noted. No significant reduction of the true lumen was seen. CONCLUSIONS Thoracic endovascular aortic repair in patients at high risk of subsequent aortic complications in uncomplicated acute and subacute type B aortic dissection is safe and is associated with favorable midterm outcomes regarding aortic remodeling. CLINICAL IMPACT In a retrospective, single center analysis of prospectively collected data with follow-up, we compared 35 patients with high-risk features who recieved TEVAR in acute and sub-acute uncomplicated type B aortic dissection to a control-group (n=18). The TEVAR group showed a significant positive remoduling (reduction of max. aortic and false lumen diameter and increase of true lumen diameter (p<0.001 each)) during follow-up with an estimated survival of 94.1% after 3 years and 87.5% after 5 years.
Collapse
Affiliation(s)
- Wael Ahmad
- Department of Vascular and Endovascular Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jan Brunkwall
- Department of Vascular and Endovascular Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Alexander C Bunck
- Department of Radiology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Bernhard Dorweiler
- Department of Vascular and Endovascular Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Spyridon Mylonas
- Department of Vascular and Endovascular Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| |
Collapse
|
13
|
Luthra S, Tsang GM. Concurrent stabilization of "downstream" aorta during acute type A aortic dissection repair. J Thorac Cardiovasc Surg 2023; 165:586-588. [PMID: 34226050 DOI: 10.1016/j.jtcvs.2021.06.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 01/18/2023]
Affiliation(s)
- Suvitesh Luthra
- Division of Cardiac Surgery, Wessex Cardiothoracic Centre, Southampton University Hospital NHS Trust, Southampton, United Kingdom; UK Aortic Surgery Group (UKAS), United Kingdom.
| | - Geoffrey M Tsang
- Division of Cardiac Surgery, Wessex Cardiothoracic Centre, Southampton University Hospital NHS Trust, Southampton, United Kingdom; UK Aortic Surgery Group (UKAS), United Kingdom
| |
Collapse
|
14
|
Oberhuber A, Raddatz A, Betge S, Ploenes C, Ito W, Janosi RA, Ott C, Langheim E, Czerny M, Puls R, Maßmann A, Zeyer K, Schelzig H. Interdisciplinary German clinical practice guidelines on the management of type B aortic dissection. GEFASSCHIRURGIE 2023; 28:1-28. [PMCID: PMC10123596 DOI: 10.1007/s00772-023-00995-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 08/13/2023]
Affiliation(s)
- A. Oberhuber
- German Society of Vascular Surgery and Vascular Medicine (DGG); Department of Vascular and Endovascular Surgery, University Hospital of Münster, Münster, Germany
| | - A. Raddatz
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI); Department of Anaesthesiology, Critical Care and Pain Medicine, Saarland University Hospital, Homburg, Germany
| | - S. Betge
- German Society of Angiology and Vascular Medicine (DGG); Department of Internal Medicine and Angiology, Helios Hospital Salzgitter, Salzgitter, Germany
| | - C. Ploenes
- German Society of Geriatrics (DGG); Department of Angiology, Schön Klinik Düsseldorf, Düsseldorf, Germany
| | - W. Ito
- German Society of Internal Medicine (GSIM) (DGIM); cardiovascular center Oberallgäu Kempten, Hospital Kempten, Kempten, Germany
| | - R. A. Janosi
- German Cardiac Society (DGK); Department of Cardiology and Angiology, University Hospital Essen, Essen, Germany
| | - C. Ott
- German Society of Nephrology (DGfN); Department of Nephrology and Hypertension, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
- Department of Nephrology and Hypertension, Paracelsus Medical University, Nürnberg, Germany
| | - E. Langheim
- German Society of prevention and rehabilitation of cardiovascular diseaese (DGPR), Reha Center Seehof, Teltow, Germany
| | - M. Czerny
- German Society of Thoracic and Cardiovascular Surgery (DGTHG), Department University Heart Center Freiburg – Bad Krozingen, Freiburg, Germany
- Albert Ludwigs University Freiburg, Freiburg, Germany
| | - R. Puls
- German Radiologic Society (DRG); Institute of Diagnostic an Interventional Radiology and Neuroradiology, Helios Klinikum Erfurt, Erfurt, Germany
| | - A. Maßmann
- German Society of Interventional Radiology (DeGIR); Department of Diagnostic an Interventional Radiology, Saarland University Hospital, Homburg, Germany
| | - K. Zeyer
- Marfanhilfe e. V., Weiden, Germany
| | - H. Schelzig
- German Society of Surgery (DGCH); Department of Vascular and Endovascular Surgery, University Hospital of Düsseldorf, Düsseldorf, Germany
| |
Collapse
|
15
|
Smedberg C, Hultgren R, Leander K, Steuer J. Pharmacological treatment in patients with aortic dissection. Open Heart 2022; 9:openhrt-2022-002082. [PMID: 36396295 PMCID: PMC9677041 DOI: 10.1136/openhrt-2022-002082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/03/2022] [Indexed: 11/19/2022] Open
Abstract
Objectives To describe medical management in aortic dissection (AD) and to analyse the possible associations between antihypertensive, antithrombotic, anticoagulant and statin agents, respectively, and long-term survival. Methods From Swedish medical registers, all patients diagnosed with AD in 2006–2015 were identified. Filled prescriptions prior to admission and within 1 year from discharge in patients discharged and alive at 30 days were registered. Associations between pharmacological treatment and long-term survival were analysed using Cox proportional hazards models. Results Of 3951 patients hospitalised with acute AD, 3046 (77%) were discharged and alive at 30 days. In hospitalised patients, mean age was 66 years (SD 13), and 36% (n=1098) were women. Within 1 year from discharge, 96% (n=2939) had at least one antihypertensive drug. Beta blocker was the most commonly used drug type (90%, n=2741). Statin treatment (47%, n=1418) was associated with higher long-term survival; HR 0.74 (95% CI 0.63 to 0.87, p<0.001). The positive association between statins and long-term survival remained, in subgroup analysis, in medically managed patients (HR 0.72 (95% CI 0.60 to 0.86, p<0.001)), but not in patients undergoing surgical repair (HR 0.82 (95% CI 0.58 to 1.14, p=0.230)). Beta blockers were associated with favourable long-term survival in surgically managed patients (HR 0.58 (95% CI 0.35 to 0.97, p=0.038)) but not in medically managed patients (HR 0.93 (95% CI 0.72 to 1.12, p=0.057)). Neither antiplatelet therapy nor anticoagulants were associated with long-term survival. Conclusions Statin treatment was associated with favourable long-term outcome in medically managed AD patients, whereas treatment with beta blocker was associated with higher survival only in surgically managed AD patients. Statin use as well as optimal antihypertensive therapy in the chronic stage of the disease need to be further analysed, preferably in randomised controlled trials.
Collapse
Affiliation(s)
- Christian Smedberg
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Södersjukhuset, Stockholm, Sweden
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Karin Leander
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Johnny Steuer
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Södersjukhuset, Stockholm, Sweden
| |
Collapse
|
16
|
Roselli EE, Atkins MD, Brinkman W, Coselli J, Desai N, Estrera A, Johnston DR, Patel H, Preventza O, Vargo PR, Fleischman F, Taylor BS, Reardon MJ. ARISE: First-In-Human Evaluation of a Novel Stent Graft to Treat Ascending Aortic Dissection. J Endovasc Ther 2022:15266028221095018. [PMID: 35587698 DOI: 10.1177/15266028221095018] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Operative mortality for type A aortic dissection is still 10-20% at centers of excellence. Additionally, 10-20% are not considered as viable candidates for open surgical repair and not offered life-saving emergency surgery. ARISE is a multicenter investigation evaluating the novel GORE® Ascending Stent Graft (ASG; Flagstaff, AZ). OBJECTIVE The purpose of this study is to assess early feasibility of using these investigational devices to treat ascending aortic dissection. METHODS This a prospective, multicenter, non-randomized, single-arm study that enrolls patients at high surgical risk with appropriate anatomical requirements based on computed tomography imaging at 7 of 9 US sites. Devices are delivered transfemorally under fluoroscopic guidance. Primary endpoint is all-cause mortality at 30 days. Secondary endpoints include major adverse cardiovascular and cerebrovascular events (MACCE) at 30 days, 6 months, and 12 months. RESULTS Nineteen patients were enrolled with a mean age of 75.7 years (range 47-91) and 11 (57.9%) were female. Ten (52.6%) had DeBakey type I disease, and the rest were type II. Sixteen (84.2%) of the patients were acute. Patients were treated with safe access, (7/19 (36.8%) percutaneous, 10/19 (52.6%) transfemoral, 2/19 (10.5%) iliac conduit), delivery, and deployment completed in all cases. Median procedure time was 154 mins (range 52-392) and median contrast used was 111 mL (range 75-200). MACCE at 30 days occurred in 5 patients including mortality 3/19 (15.8%), disabling stroke in 1/19 (5.3%), and myocardial infarction in 1/19 (5.3%). CONCLUSION Results from the ARISE early feasibility study of a specific ascending stent graft device to treat ascending aortic dissection are promising.
Collapse
Affiliation(s)
- Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Aortic Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | | | - Nimesh Desai
- University of Pennsylvania, Philadelphia, PA, USA
| | | | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Aortic Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Himanshu Patel
- University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA
| | | | - Patrick R Vargo
- Department of Thoracic and Cardiovascular Surgery, Aortic Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | | |
Collapse
|
17
|
Yang Y, Zhang XH, Chen ZG, Diao YP, Wu ZY, Li YJ. Acute or Subacute, the Optimal Timing for Uncomplicated Type B Aortic Dissection: A Systematic Review and Meta-Analysis. Front Surg 2022; 9:852628. [PMID: 35592122 PMCID: PMC9110682 DOI: 10.3389/fsurg.2022.852628] [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: 01/11/2022] [Accepted: 03/08/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To evaluate the optimal timing (acute or subacute) of thoracic endovascular aortic repair (TEVAR) for uncomplicated B aortic dissection (uTBAD) through a systematic review and meta-analysis. Method A comprehensive literature search was undertaken across three major databases (EMBASE/Medline, PubMed, and Cochrane Library) and was assessed until November 2021 to identify studies reporting the outcomes of TEVAR utilized to treat patients with uTBAD. The continuous variables were compared between the two groups using t-test and the categorical variables were compared using the χ2-test. A meta-analysis was used to produce pooled odds ratios for early and follow-up outcomes. The random effects models were applied. A statistical analysis was performed using R software v.4.1. Result A comprehensive literature search found 490 citations published within the predetermined time span of the analysis. Three studies including 1,193 patients (acute group 718, subacute group 475) were finally included for downstream meta-analysis. An acute uTBAD group presented with higher rates both in 30-day complications (20.5 vs. 13.7%; p = 0.014) and mortality (4.6 vs. 1.3%; p = 0.004) than subacute group. The respiratory complications were significantly higher in the acute group than in the subacute group (10.8 vs. 5.0%; p = 0.015). The procedure success rate (90.8 vs. 93.6%; p = 0.329), the follow-up mortality (7.7 vs. 7.6%; p = 1) and dissection-related late mortality (3.9 vs. 5.3%; p = 0.603) showed no significant difference. Conclusion Our meta-analysis suggested that despite significantly higher 30-day complications and 30-day mortality in the acute uTBAD group, there was no significant difference in the follow-up mortality between the two groups. Systematic Review Registration PROSPERO, identifier: CRD42021247609.
Collapse
Affiliation(s)
| | | | | | | | | | - Yong-Jun Li
- Department of Vascular Surgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| |
Collapse
|
18
|
Panpho P, Yang Y, Davies HA, Nawaytou O, Harky A, Torella F, Field M, Madine J, Akhtar R. Time-dependent mechanical behaviour of the aortic chronic dissection flap. Interact Cardiovasc Thorac Surg 2022; 34:892-901. [PMID: 35141757 PMCID: PMC9070530 DOI: 10.1093/icvts/ivac029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 01/19/2022] [Accepted: 01/25/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The transition of aortic dissection from acute to chronic is poorly understood. We examined time-dependent mechanical behaviour and biochemical properties of chronic dissection tissues. METHODS Aorta samples were obtained from 14 patients with mixed aetiology who were undergoing elective surgery for chronic dissected aneurysms, ranging from 3 months to 15 years post-dissection. The tissue elastic modulus and tissue deformation following application of loading for 5 h were measured for the false lumen (FL), true lumen (TL) and flap (FP) tissues with a custom-indentation technique. Collagen, elastin and glycosaminoglycan levels were determined with established biochemical assays. Elastin fragmentation was graded from histological sections. The number of tissues characterized was as follows: FP (n = 10), TL (n = 5 for biomechanical testing, n = 8 for biochemical analysis, n = 8 for histological assessment) and FL (n = 4). RESULTS Tissues stiffness was highest in FP [59.8 (14.8) kPa] as compared with TL [50.7 (6.2) kPa] and FL [40.5 (4.7) kPa] (P = 0.023 and P = 0.006, respectively). FP [0.5 (0.08) mm] also exhibited reduced deformation relative to TL [0.7 (0.02) mm] and FL [0.9 (0.08) mm] (P = 0.003 and P = 0.006, respectively), lowest collagen concentration [FP: 40.1 (19.6) µg/mg, TL: 59.9 (19.5) µg/mg, P = 0.008; FL: 79.1 (32.0) µg/mg, P = 0.006] and the lowest collagen: elastin ratio [0.4 (0.1)] relative to the other tissues [TL; 0.6 (0.3), P = 0.006, FL; 1.5 (0.4); P = 0.003]. Significant elastin loss was evident in the FL-stained tissue sections whereas highly aligned, long fibres were visible in the FP and TL. A linear relationship was found between the stiffness, deformation and the time from the dissection event to surgical intervention for the FP. All data are presented as median (interquartile range). CONCLUSIONS FP exhibited reduced time-dependent deformation and distinct biochemical properties relative to TL and FL irrespective of connective tissue disorder or the anatomical region of the dissection.
Collapse
Affiliation(s)
- Phakakorn Panpho
- Faculty of Science and Technology, Pibulsongkram Rajabhat University, Phitsanulok, Thailand
- Department of Mechanical, Materials and Aerospace Engineering, School of Engineering, University of Liverpool, Liverpool, UK
| | - Ying Yang
- School of Pharmacy and Bioengineering, Keele University, Stoke-on-Trent, UK
| | - Hannah A Davies
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, Liverpool, UK
| | - Omar Nawaytou
- Liverpool Centre for Cardiovascular Science, Liverpool, UK
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Amer Harky
- Liverpool Centre for Cardiovascular Science, Liverpool, UK
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Francesco Torella
- Liverpool Centre for Cardiovascular Science, Liverpool, UK
- Liverpool Vascular & Endovascular Service, Liverpool, UK
| | - Mark Field
- Liverpool Centre for Cardiovascular Science, Liverpool, UK
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Jillian Madine
- Liverpool Centre for Cardiovascular Science, Liverpool, UK
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Riaz Akhtar
- Department of Mechanical, Materials and Aerospace Engineering, School of Engineering, University of Liverpool, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, Liverpool, UK
| |
Collapse
|
19
|
Wang J, Jin T, Chen B, Pan Y, Shao C. Systematic review and meta-analysis of current evidences in endograft therapy versus medical treatment for uncomplicated type B aortic dissection. J Vasc Surg 2022; 76:1099-1108.e3. [PMID: 35390485 DOI: 10.1016/j.jvs.2022.03.876] [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] [Received: 10/13/2021] [Accepted: 03/26/2022] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Best medical therapy (BMT) should be recommended for treating uncomplicated Stanford type B aortic dissection (uSTBAD), whereas thoracic aortic endovascular repair (TEVAR) has been controversial for uSTBAD. METHODS In this paper, a meta-analysis was conducted on all available randomized controlled trials and observational studies that evaluated the relative benefits and harms of TEVAR and BMT for the management of patients suffering from uSTBAD. Primary endpoints consisted of early adverse events, long-term adverse events and aortic remodeling. In addition, Risk difference (RD) or Odds ratios (OR) with 95% confidence intervals (CI) were estimated. The random effects model or the fixed-effects model was used in accordance with the 50% heterogeneity threshold. RESULTS Seven observational studies and two RCT studies from 11 articles that contained 15066 patients suffering from uSTBAD (1518 TEVARs) met the inclusion criteria. For early outcomes, no significant differences were found between the TEVAR group and the BMT group in aortic rupture, retrograde dissection, paraplegia/paraparesis, reintervention, aorta-related death and all caused death. In the long run, the TEVAR group was found to have a significantly lower incidence of adverse events, which included aortic rupture (OR:0.26, CI:0.16∼0.42, P<0.05; heterogeneity: P=0.90, I2=0%), reintervention (OR:0.45, CI:0.26∼0.75, P<0.05; heterogeneity: P=0.17, I2=41%), aorta-related death (OR:0.27, CI:0.18∼0.42, P<0.05; heterogeneity: P=0.61, I2=0%) and all caused death (OR:0.52, CI:0.42∼0.66, P<0.05; heterogeneity: P=0.05, I2=53%) as compared with the BMT group. Moreover, in compared with BMT, TEVAR was found to significantly contribute to the complete thrombosis of thoracic false lumen (OR:55.34, CI:34.32∼89.21, P<0.05; heterogeneity: P=0.97, I2=0%) and aortic regression (true lumen expansion and false lumen shrinkage). CONCLUSIONS Although early endovascular repair of uSTBAD does not outperform BMT, its implementation is found to be necessary to facilitate the long-term prognosis. Accordingly, if early TEVAR is to be deferred, close follow-up is critical to allow for timely reintervention.
Collapse
Affiliation(s)
- Jian Wang
- The Second Affiliated Hospital of Zhejiang University's Medical College, Department of Vascular Surgery, Hangzhou 310051, Zhejiang, China.
| | - Tao Jin
- The West China Medical School of Sichuan University, Chengdu 610041, Sichuan, China
| | - Bing Chen
- The Second Affiliated Hospital of Zhejiang University's Medical College, Department of Vascular Surgery, Hangzhou 310051, Zhejiang, China.
| | - Yifeng Pan
- The Second Affiliated Hospital of Zhejiang University's Medical College, Department of Vascular Surgery, Hangzhou 310051, Zhejiang, China
| | - Changming Shao
- The Second Affiliated Hospital of Zhejiang University's Medical College, Department of Vascular Surgery, Hangzhou 310051, Zhejiang, China
| |
Collapse
|
20
|
Jubouri M, Al-Tawil M, Yip HCA, Bashir A, Tan SZCP, Bashir M, Anderson R, Bailey D, Nienaber CA, Coselli JS, Williams I. Mid- and long-term outcomes of thoracic endovascular aortic repair in acute and subacute uncomplicated type B aortic dissection. J Card Surg 2022; 37:1328-1339. [PMID: 35191082 DOI: 10.1111/jocs.16349] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 01/28/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Uncomplicated type B aortic dissection (un-TBAD) has been managed conservatively with medical therapy to control the heart rate and blood pressure to limit disease progression, in addition to radiological follow-up. However, several trials and observational studies have investigated the use of thoracic endovascular aortic repair (TEVAR) in un-TBAD and suggested that TEVAR provides a survival benefit over medical therapy. Outcomes of TEVAR have also been linked with the timing of intervention. AIMS The scope of this review is to collate and summarize all the evidence in the literature on the mid- and long-term outcomes of TEVAR in un-TBAD, confirming its superiority. We also aimed to investigate the relationship between the timing of TEVAR intervention and results. METHODS We carried out a comprehensive literature search on multiple electronic databases including PubMed, Scopus, and EMBASE to collate and summarize all research evidence on the mid- and long-term outcomes of TEVAR in un-TBAD, as well as its relationship with intervention timing. RESULTS TEVAR has proven to be a safe and effective tool in un-TBAD, offering superior mid- and long-term outcomes including all-cause and aorta-related mortality, aortic-specific adverse events, aortic remodeling, and need for reintervention. Additionally, performing TEVAR during the subacute phase of dissection seems to yield optimal results. CONCLUSION The evidence demonstrating a survival advantage in favor TEVAR over medical therapy in un-TBAD means that with further research, particular trials and observational studies, TEVAR could become the gold-standard treatment option for un-TBAD patients.
Collapse
Affiliation(s)
- Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | | | | | - Ali Bashir
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Sven Z C P Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mohamad Bashir
- Vascular and Endovascular Surgery, Velindre University NHS Trust, Health Education & Improvement Wales (HEIW), Cardiff, Wales, UK
| | - Richard Anderson
- Department of Cardiology, University Hospital of Wales, Cardiff, Wales, UK
| | - Damian Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, Wales, UK
| | - Christoph A Nienaber
- Cardiology and Aortic Centre, Royal Brompton and Harefield Hospital NHS Foundation Trust, London, UK
| | - Joseph S Coselli
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA.,Department of Cardiovascular Surgery, CHI St Luke's-Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Ian Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, Wales, UK
| |
Collapse
|
21
|
Singh S, Palanca JA, Austin NJ, Tan SZCP, Jubouri M, Bailey DM, Williams IM, Nienaber CA, Coselli JS, Bashir M. Criteria for endovascular intervention in type B aortic dissection. J Card Surg 2022; 37:987-992. [PMID: 35083781 DOI: 10.1111/jocs.16267] [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] [Received: 01/06/2022] [Accepted: 01/10/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The use of thoracic endovascular aortic repair (TEVAR) for the management of uncomplicated type B aortic dissection (un-TBAD) remains controversial. There is a lack of consensus over whether pre-emptive TEVAR should be carried out in patients with un-TBAD at risk of progression to complicated TBAD. We present a review of current evidence and seek to suggest criteria where endovascular intervention in un-TBAD may prove beneficial relative to pharmacotherapy alone. METHODS AND MATERIALS PubMed and Cochrane databases were searched using terms including: type B aortic dissection, risk factors, medical therapy, TEVAR, false lumen (FL) expansion, and mortality. Papers were selected based on title and abstract. RESULTS Optimal medical therapy remains the mainstay treatment for patients with un-TBAD, however, patients with un-TBAD present with varying degrees of disease progression risk. Factors such as age, aortic morphology, history of connective tissue disorders, FL thrombosis, and aortic branch involvement may potentiate progression from un-TBAD to complicated TBAD. Short- and long-term outcomes associated with TEVAR for TBAD remain promising. CONCLUSION Pre-emptive TEVAR may be beneficial in patients with un-TBAD presenting with the above factors, however, further prospective research into the optimal timing for TEVAR in un-TBAD is required.
Collapse
Affiliation(s)
- Sidhant Singh
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Joaquin A Palanca
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Natasha J Austin
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sven Z C P Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | | | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Mohamad Bashir
- Department of Vascular and Endovascular Surgery, Velindre University NHS Trust, Health Education and Improvement Wales, Wales, UK
| |
Collapse
|
22
|
OUP accepted manuscript. Br J Surg 2022; 109:810-811. [DOI: 10.1093/bjs/znac165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 04/27/2022] [Indexed: 11/14/2022]
|
23
|
Jubouri M, Bashir M, Tan SZCP, Bailey D, Anderson R, Nienaber CA, Coselli JS, Williams I. What is the optimal timing for thoracic endovascular aortic repair in uncomplicated Type B aortic dissection? J Card Surg 2021; 37:993-1001. [PMID: 34967980 DOI: 10.1111/jocs.16190] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 11/16/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Uncomplicated Stanford Type B aortic dissection (un-TBAD) is characterized by a tear in the aorta distal to the left subclavian artery without ascending aorta and arch involvement. Optimized cardiovascular control (blood pressure and heart rate) is the current gold standard treatment according to current international guidelines. However, emerging evidence indicates that thoracic endovascular aortic repair (TEVAR) is both safe and effective in the treatment of un-TBAD with improved long-term survival outcomes in combination with optimal medical therapy (OMT) relative to OMT alone. However, the optimal timeframe for intervention is not entirely clarified. AIMS This review critically addresses current state-of-the-art comparing TEVAR with OMT and corresponding clinical outcomes for un-TBAD based on timing of intervention. METHODS We carried out a comprehensive literature search on multiple electronic databases including PUBMED and Scopus to collate all research evidence on timing of TEVAR in uncomplicated Type B aortic dissection. RESULTS TEVAR has proven to be a safe and effective treatment for un-TBAD in combination with OMT through comparable survival outcomes, improved aortic remodeling, and relatively low periprocedural added risks. Though the timing of intervention remains controversial, it is becoming clear that performing TEVAR during the subacute phase of un-TBAD yields better outcomes compared to earlier and delayed (>90 days) intervention. CONCLUSIONS Further research is required into both short- and long-term outcomes of TEVAR in addition to its optimal therapeutic window for un-TBAD. With stronger evidence, TEVAR is likely to be adopted as the gold-standard intervention for un-TBAD with definitive timeframe guidelines.
Collapse
Affiliation(s)
- Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Mohamad Bashir
- Vascular & Endovascular Surgery, Velindre University NHS Trust, Health Education & Improvement Wales, Cardiff, Wales, UK
| | - Sven Z C P Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Damian Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Richard Anderson
- Department of Cardiology, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Christoph A Nienaber
- Cardiology and Aortic Centre, Royal Brompton and Harefield Hospital NHS Foundation Trust, London, UK
| | - Joseph S Coselli
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Division of Cardiothoracic Surgery, Houston, Texas, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA.,CHI St Luke's-Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Ian Williams
- Department of Vascular Surgery, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
| |
Collapse
|
24
|
Augoustides JG. Commentary: Acute type B aortic dissection: Navigating new horizons. J Thorac Cardiovasc Surg 2021; 164:1066-1067. [PMID: 33985801 DOI: 10.1016/j.jtcvs.2021.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 04/05/2021] [Accepted: 04/06/2021] [Indexed: 11/29/2022]
Affiliation(s)
- John G Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
| |
Collapse
|
25
|
Meta-analysis of outcomes after intentional coverage of celiac artery in thoracic endovascular aortic repair. J Vasc Surg 2021; 74:1732-1739.e3. [PMID: 33592296 DOI: 10.1016/j.jvs.2021.01.053] [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: 08/19/2020] [Accepted: 01/08/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The aim of the present study was to demonstrate the clinical outcomes of intentional coverage of the celiac artery (CA) during thoracic endovascular aneurysm repair (TEVAR). METHODS The MEDLINE, EMBASE, and Cochrane Library databases were searched for studies reporting coverage of CA during TEVAR. The methodologic quality of the included studies was assessed using the Moga score and Newcastle-Ottawa scale. A random effects model was used to pool the estimates. A meta-analysis was performed with investigation of the following outcomes: visceral ischemia, spinal cord ischemia (SCI), stroke, endoleak, reintervention, 30-day mortality, and 1-year mortality. RESULTS A total of 10 studies with 171 patients were included. The summary estimate rate of visceral ischemia events was 4.2% (95% confidence interval [CI], 0.9-8.9%; I2 = 4.1%). The incidence of stroke and SCI was 0.2% (95% CI, 0%-3.4%; I2 = 0%) and 3% (95% CI, 0.3%-7.4%; I2 = 6.1%). The rate of endoleak during the follow-up period was 24.1% (95% CI, 14.3%-35.1%; I2 = 20.0%). The reintervention rate was 13.6% (95% CI, 4.4%-25.7%; I2 = 66.0%). The 30-day and 1-year mortality were 2.9% (95% CI, 0.3%-7.2%; I2 = 6.2%) and 15.2% (95% CI, 7.8%-23.9%; I2 = 0%). CONCLUSIONS Among the patients with complex thoracic aortic pathologies deemed at high risk for open reconstruction, TEVAR with intentional coverage of the CA is a safe and feasible option to extend the distal sealing zone with acceptable rates of visceral ischemia, SCI, type II endoleak from the CA, and 30-day mortality.
Collapse
|
26
|
Abstract
Aortic dissection (AD) causes more deaths each year in the United Kingdom than road traffic collisions. Yet the incidence of AD is not known. The management of acute type B AD (TBAD) is changing, with the greater use of thoracic aortic stent grafts (TEVAR) in treatment and fewer open surgical procedures performed. The study’s aim is to review the worldwide, English language published, literature on acute TBAD incidence and treatment, to report on its strengths and limitations, and better understand changes in incidence over time and between countries. Thirty-one studies were identified that focus on the epidemiology and treatment of TBAD. Eight of these studies report the incidence of acute TBAD as between of 0.5–6.3 per 100,000 person years. Hospital admissions for aortic dissection are reported to be increasing in six studies and stable in one study. The proportion of patients with TBAD operated on varies between studies (range 13% to 76%). Studies identify patient age (median 51–77 years), gender (range 48%–81% male) and prevalence of cardio-vascular risk factors, specifically hypertension, in the populations studied as independent factors influencing aortic dissection incidence. Treatment of acute TBAD remains largely conservative with analgesia, hypertension control and serial cross-sectional imaging (range 24%–87% TBAD medically treated). The use of TEVAR to treat acute AD is increasing worldwide (range 13%–76% TBAD treated with TEVAR). The incidence of TBAD is under-reported due to out of hospital deaths, variable clinical presentation (miss-diagnosis) and coding errors. Importantly for research, the single International Classification of Diseases (ICD) code for aortic dissection, I17.0, does not distinguish between acute, chronic, type A or type B dissection types. Similarly, the OPCS Classification of Interventions and Procedures version 4 (OPCS-4) codes for TEVAR, L27.4 and L28.4, do not distinguish between acute and chronic AD presentation, unlike the codes for open thoracic aortic replacement. Standardised reporting of aortic dissection type, and the urgency of both the initial presentation (acute or chronic) and treatment (emergency, urgent or planned) in future studies would allow more meaningful comparisons between populations.
Collapse
|
27
|
Jen JP, Malik A, Lewis G, Holloway B. Non-traumatic thoracic aortic emergencies: imaging diagnosis and management. Br J Hosp Med (Lond) 2020; 81:1-12. [PMID: 33135923 DOI: 10.12968/hmed.2020.0344] [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: 01/16/2023]
Abstract
The major component of non-traumatic thoracic aortic emergencies is the acute aortic syndromes. These include acute aortic dissection, intramural haematoma and penetrating atherosclerotic ulcer, grouped together because they are indistinguishable clinically and highly fatal. All three entities involve disruption to the tunica intima and media and may be complicated by rupture, end-organ ischaemia or aneurysmal transformation. Early diagnosis is vital to allow timely and appropriate management. Paired unenhanced and electrocardiogram-gated computed tomography angiography of the chest, extending more distally if required, is recommended for diagnosis. Specific computed tomography features of all three entities are reviewed, with a focus on morphological features associated with complications. Those with type A pathology are usually managed with open surgery because this has a high risk of complication. Patients with uncomplicated type B pathology are usually managed with best medical therapy whereas those with complicated type B pathology are usually offered either surgery or thoracic endovascular aortic repair. The limited evidence regarding the use of thoracic endovascular aortic repair in patients with subacute uncomplicated type B pathology is briefly discussed.
Collapse
Affiliation(s)
- Jian Ping Jen
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Akif Malik
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Gareth Lewis
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Benjamin Holloway
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| |
Collapse
|
28
|
Abstract
Acute aortic dissection has an incidence of approximately half that of symptomatic abdominal and thoracic aneurysm of the aorta and more than twice the mortality of population-based controls. While urgent undelayed open surgery is the strategy of choice in proximal dissection, medical management has been the mainstay of treatment for uncomplicated distal or type B aortic dissection, but endovascular intervention is now considered a potential treatment option for all type B dissection due to its success in complicated cases. Endovascular repair can be technically demanding in aortic dissection, and timing of the repair can have a significant influence on anatomical and clinical outcome. Observational reports of feasibility and reasonable safety are flanked by only two randomised trials; the Acute Dissection Stent Grafting or Best Medical Treatment (ADSORB) trial demonstrated improved remodelling in acute dissection and the INvestigation of STEnt grafts in patients with type B Aortic Dissections (INSTEAD) trial showed better long-term survival in patients treated endovascularly in the subacute phase. Meta-analyses and other large clinical studies have demonstrated mixed results. Due to some risks associated endovascular repair and the requirement of specialist aortic care (which is not always available), a pragmatic approach for current management could involve high intensity serial imaging in the acute phase of a type B aortic dissection, thereby identifying complicated cases for early intervention and selection of patients at high risk of disease progression for deferred endovascular management in the subacute phase within 90 days.
Collapse
|