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Gibello L, Antonello M, Civilini E, Pellenc Q, Bellosta R, Carbonari L, Bonardelli S, Freyrie A, Riambau V, Varetto G, Verzini F. Multicentre experience of antegrade thoracic endovascular aortic repair for the treatment of thoracic aortic diseases. Eur J Cardiothorac Surg 2024; 65:ezae185. [PMID: 38733578 DOI: 10.1093/ejcts/ezae185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/09/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024] Open
Abstract
OBJECTIVES The goal of this multicentre retrospective cohort study was to evaluate technical success and early and late outcomes of thoracic endovascular repair (TEVAR) with grafts deployed upside down through antegrade access, to treat thoracic aortic diseases. METHODS Antegrade TEVAR operations performed between January 2010 and December 2021 were collected and analysed. Both elective and urgent procedures were included. Exclusion criteria were endografts deployed in previous or concomitant surgical or endovascular repairs. RESULTS Fourteen patients were enrolled; 13 were males (94%) with a mean age of 71 years (interquartile range 62; 78). Five patients underwent urgent procedures (2 ruptured aortas and 3 symptomatic patients). Indications for treatment were 8 (57%) aneurysms/pseudoaneurysms, 3 (21%) dissections and 3 (21%) penetrating aortic ulcers. Technical success was achieved in all procedures. Early mortality occurred in 4 (28%) cases, all urgent procedures. Median follow-up was 13 months (interquartile range 1; 44). Late deaths occurred in 2 (20%) patients, both operated on in elective settings. The first died at 19 months of aortic-related reintervention; the second died at 34 months of a non-aortic-related cause. Two patients (14%) underwent aortic-related reinterventions for late type I endoleak. The survival rate of those having the elective procedures was 100%, 84% and 67% at 12, 24 and 36 months, respectively. Freedom from reintervention was 92%, 56% and 56% at 12, 24 and 36 months, respectively. CONCLUSIONS Antegrade TEVAR can seldom be considered an alternative when traditional retrograde approach is not feasible. Despite good technical success and few access-site complications, this study demonstrates high rates of late type I endoleak and aortic-related reinterventions.
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Affiliation(s)
- Lorenzo Gibello
- Unit of Vascular Surgery, Department of Surgical Sciences, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Michele Antonello
- Section of Vascular and Endovascular Surgery, Department of Cardiac Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Efrem Civilini
- Humanitas University Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Quentin Pellenc
- Department of Thoracic and Vascular Surgery, Marfan Syndrome National Referral Center, Bichat University Hospital, APHP, Paris, France
- Vascular and Endovascular Surgery Division, La Cote HealthCare Group, Morges, VD, Switzerland
| | - Raffaello Bellosta
- Vascular and Endovascular Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | | | - Stefano Bonardelli
- Vascular Surgery, Department of Surgery, Spedali Civili University Teaching Hospital, University of Brescia School of Medicine, Brescia, Italy
| | - Antonio Freyrie
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Vincent Riambau
- Department of Vascular Surgery, Cardiovascular Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Gianfranco Varetto
- Unit of Vascular Surgery, Department of Surgical Sciences, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Fabio Verzini
- Unit of Vascular Surgery, Department of Surgical Sciences, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy
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Karaolanis GI, Georgakarakos E, Karakosta A, Glantzounis GK, Moulakakis KG, Dorweiler B, Mylonas SN. Long-term outcomes of thoracic endovascular aortic repair for the treatment of descending thoracic aortic aneurysms: a systematic review and meta-analysis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:139-146. [PMID: 37335279 DOI: 10.23736/s0021-9509.23.12648-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
INTRODUCTION We undertook a systematic review of the currently published literature on TEVAR for DTAAs and we combined the eligible studies into a meta-analysis with the intention of evaluating the efficacy and the long-term durability of this treatment option. EVIDENCE ACQUISITION A systematic search of the literature from January 2015 up to December 2022 was performed according to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. For events during follow-up we calculated the incidence rates (IRs) with 95% confidence intervals (95% CIs) per 100 patient-years (p-ys) as the number of patients with outcome events occurring during the specific time period divided by the total number of p-ys. EVIDENCE SYNTHESIS A total of 4127 study titles were identified by the initial search strategy, of which 12 were considered eligible for inclusion in the meta-analysis. A Total of 1976 patients (62% male) were identified among the eligible studies. One-year survival was 90.1% (95% CI 86.3% to 93.0%), 3-year survival was estimated at 80.5% (95% CI 69.2% to 88.4%) and the 5-year survival was estimated at 73.2% (95%CI 64.3% to 80.5%) with significant heterogeneity among studies regarding these outcomes. Regarding freedom from reintervention analysis for 1 year and 5 years was 96.5% (95% CI 94.5% to 97.8%) and 85.4% (95% CI 56.7% to 96.3%) respectively. The pooled late complications IR per 100 p-ys was 55.0 (95% CI 39.1 to 70.9), whereas the pooled IR for late reinterventions per 100 p-ys was 21.2 (95% CI 26.0 to 87.5). Late type I endoleak was reported with a pooled IR of 26.7 per 100 p-ys (95% CI 19.8 to 33.6) and late type III endoleak with a pooled IR of 7.6 per 100 p-ys (95% CI 5.5 to 9.7). CONCLUSIONS TEVAR presents a safe and feasible solution for the treatment of DTAA with sustained long-term effectivity. Current evidence supports a satisfactory 5-year survival with low rates of reinterventions.
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Affiliation(s)
- Georgios I Karaolanis
- Vascular Unit, Department of Surgery, University Hospital of Ioannina and School of Medicine, Ioannina, Greece -
| | - Efstratios Georgakarakos
- Department of Vascular Surgery, "Democritus" University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Agathi Karakosta
- Department of Anesthesia and Postoperative Intensive Care, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Georgios K Glantzounis
- Department of Surgery, School of Health Sciences, University Hospital of Ioannina and Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | | | - Bernhard Dorweiler
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Germany
| | - Spyridon N Mylonas
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Germany
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Vervoort D, An KR, Deng MX, Elbatarny M, Fremes SE, Ouzounian M, Tarola C. The Call for the "Interventional/Hybrid" Aortic Surgeon: Open, Endovascular, and Hybrid Therapies of the Aortic Arch. Can J Cardiol 2024; 40:478-495. [PMID: 38052303 DOI: 10.1016/j.cjca.2023.11.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/29/2023] [Accepted: 11/29/2023] [Indexed: 12/07/2023] Open
Abstract
Aortic arch pathology is relatively rare but potentially highly fatal and associated with considerable comorbidity. Operative mortality and complication rates have improved over time but remain high. In response, aortic arch surgery is one of the most rapidly evolving areas of cardiac surgery in terms of surgical volume and improved outcomes. Moreover, there has been a surge in novel devices and techniques, many of which have been developed by or codeveloped with vascular surgeons and interventional radiologists. Nevertheless, the extent of arch surgery, the choice of nadir temperature, cannulation, and perfusion strategies, and the use of open, endovascular, or hybrid options vary according to country, centre, and surgeon. In this review article, we provide a technical overview of the surgical, total endovascular, and hybrid repair options for aortic arch pathology through historical developments and contemporary results. We highlight key information for surgeons, cardiologists, and trainees to understand the management of patients with aortic arch pathology. We conclude by discussing training paradigms, the role of aortic teams, and gaps in knowledge, arguing for the need for wire skills for the future "interventional aortic surgeon" and increased research into techniques and novel devices to continue improving outcomes for aortic arch surgery.
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Affiliation(s)
- Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kevin R An
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mimi X Deng
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Malak Elbatarny
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Tarola
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Al Tannir AH, Biesboer EA, Pokrzywa C, Golestani S, Kukushliev V, Jean X, Harding E, de Moya MA, Morris R, Kugler N, Schellenberg M, Murphy PB. Open versus endovascular repair of penetrating non-aortic arterial injuries: A systematic review and meta analysis. Injury 2024; 55:111368. [PMID: 38309083 DOI: 10.1016/j.injury.2024.111368] [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: 12/12/2023] [Revised: 01/15/2024] [Accepted: 01/17/2024] [Indexed: 02/05/2024]
Abstract
BACKGROUND Non-aortic arterial injuries are common and are associated with high morbidity and mortality. Historically, open surgical repair (OSR) was the conventional method of repair. With recent advancements in minimally invasive techniques, endovascular repair (ER) has gained popularity. We sought to compare outcomes in patients undergoing endovascular and open repairs of traumatic non-aortic penetrating arterial injuries. METHODS A systematic review and meta-analysis was conducted using MEDLINE (OVID), Web of Science, Cochrane Library, and Scopus Database from January 1st, 1990, to March 20th, 2023. Titles and abstracts were screened, followed by full text review. Articles assessing clinically important outcomes between OSR and ER in penetrating arterial injuries were included. Exclusion criteria included blunt injuries, aortic injuries, pediatric populations, review articles, and non-English articles. Odds ratios (OR) and Cohen's d ratios were used to quantify differences in morbidity and mortality. RESULTS A total of 3770 articles were identified, of which 8 met inclusion criteria and were included in the review. The articles comprised a total of 8369 patients of whom 90 % were male with a median age of 28 years. 85 % of patients were treated with OSR while 15 % underwent ER. With regards to injury characteristics, those who underwent ER were less likely to present with concurrent venous injuries (OR: 0.41; 95 %CI: 0.18, 0.94; p = 0.03). Regarding hospital outcomes, patients who underwent ER had a lower likelihood of in-hospital or 30-day mortality (OR: 0.72; 95 %CI: 0.55, 0.95; p = 0.02) and compartment syndrome (OR: 0.29, 95 %CI: 0.12, 0.71; p = 0.007). The overall risk of bias was moderate. CONCLUSION Endovascular repair of non-aortic penetrating arterial injuries is increasingly common, however open repair remains the most common approach. Compared to ER, OSR was associated with higher odds of compartment syndrome and mortality. Further prospective research is warranted to determine the patient populations and injury patterns that most significantly benefit from an endovascular approach. LEVEL OF EVIDENCE Level III, Systematic Reviews & Meta-Analyses.
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Affiliation(s)
- Abdul Hafiz Al Tannir
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Elise A Biesboer
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Courtney Pokrzywa
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Simin Golestani
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Vasil Kukushliev
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Xavier Jean
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Eric Harding
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Marc A de Moya
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rachel Morris
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Nathan Kugler
- Department of Surgery, Division of Vascular & Endovascular Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Morgan Schellenberg
- Department of Surgery, Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, USA
| | - Patrick B Murphy
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
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DiLosa K, Pozolo C, Heafner T, Humphries M, Kwong M, Maximus S. Early experience with the Gore TAG thoracic branch endoprosthesis for treatment of acute aortic pathology. J Vasc Surg Cases Innov Tech 2024; 10:101363. [PMID: 38130369 PMCID: PMC10731599 DOI: 10.1016/j.jvscit.2023.101363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 10/21/2023] [Indexed: 12/23/2023] Open
Abstract
The Gore TAG thoracic branch endoprosthesis (TBE) is the first Food and Drug Administration-approved device for zone 2 thoracic endovascular aortic repair, allowing for graft placement proximal to the left subclavian artery origin and maintaining vessel patency through a side branch. We describe our experience with the Gore TBE device in 20 patients for acute indications, including blunt thoracic aortic injuries, complicated dissections, and ruptured aneurysms. Technical success, with exclusion of pathology and left subclavian patency, was 100% without major complications within 30 days. Our early Gore TBE device experience demonstrates safe use in acute aortic pathology without an increased risk of complications.
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Affiliation(s)
- Kathryn DiLosa
- Division of Vascular Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA
| | - Cara Pozolo
- Division of Vascular Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA
| | - Thomas Heafner
- Division of Vascular Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA
| | - Misty Humphries
- Division of Vascular Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA
| | - Mimmie Kwong
- Division of Vascular Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA
| | - Steven Maximus
- Division of Vascular Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA
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Carter AW, Jayawardana S, Costa-Font J, Nasir K, Krumholz HM, Mossialos E. How to Use Quasi-Experimental Methods in Cardiovascular Research: A Review of Current Practice. Circ Cardiovasc Qual Outcomes 2024; 17:e010078. [PMID: 38362765 DOI: 10.1161/circoutcomes.123.010078] [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] [Indexed: 02/17/2024]
Abstract
BACKGROUND Quasi-experimental methods (QEMs) are a family of techniques used to estimate causal relationships when randomized controlled trials are unfeasible or unethical. They offer a powerful alternative to observational studies by introducing random assignment of individuals or groups into their design, thereby offering stronger means of establishing causation. The use of QEMs in cardiovascular research has not been systematically examined to determine steps toward improving and expanding their use. METHODS We identified 4 main techniques using a systematic search strategy from 2016 to 2021: instrumental variable analysis, interrupted time series analysis, difference-in-differences analysis, and regression discontinuity designs. QEMs are examined as alternatives to randomized controlled trials and traditional observational studies; as more observational data becomes available to researchers, there are more opportunities to apply these techniques. Eligible articles were selected based on publication in high-ranked journals. The quality of eligible articles was appraised using the Joanna Briggs Institute checklist for quasi-experimental studies. RESULTS Data from 380 studies were extracted based on our inclusion criteria. Forty-two of these studies were published in the top 10 medical or top 20 cardiovascular disease journals, and 25 studies were included after quality appraisal. The review identifies the main features and limitations associated with each technique, providing readers with practical guidance on how to apply these to their research. A graphical decision aid was developed to facilitate the routine use of QEMs. CONCLUSIONS The use of QEMs in cardiovascular research published in contemporary, high-impact articles was examined. Findings are biased toward this segment of literature, which represents the latest developments in this growing area of cardiovascular research. The decision aid is a novel schematic that researchers can adopt into practice.
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Affiliation(s)
- Alexander W Carter
- Department of Health Policy, The London School of Economics and Political Science, United Kingdom (A.W.C., S.J., J.C.-F., E.M.)
| | - Sahan Jayawardana
- Department of Health Policy, The London School of Economics and Political Science, United Kingdom (A.W.C., S.J., J.C.-F., E.M.)
| | - Joan Costa-Font
- Department of Health Policy, The London School of Economics and Political Science, United Kingdom (A.W.C., S.J., J.C.-F., E.M.)
| | - Khurram Nasir
- Division of Cardiology, Houston Methodist Hospital, TX (K.N.)
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (H.M.K.)
| | - Elias Mossialos
- Department of Health Policy, The London School of Economics and Political Science, United Kingdom (A.W.C., S.J., J.C.-F., E.M.)
- Centre for Health Policy, The Institute of Global Health Innovation, Imperial College London, United Kingdom (E.M.)
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Oh AR, Lim SK, Sung K, Lee SM, Lee JH. Outcomes of open repair for descending thoracic and thoracoabdominal aortic aneurysm in recent 10 years: experience of a high-volume centre in Korea. Eur J Cardiothorac Surg 2023; 64:ezad338. [PMID: 37847652 DOI: 10.1093/ejcts/ezad338] [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: 07/03/2023] [Revised: 09/13/2023] [Indexed: 10/19/2023] Open
Abstract
OBJECTIVES Although recent studies and guidelines suggest the preferred outcomes after surgical repair of thoracic aortic aneurysm (TAA) and thoracoabdominal aortic aneurysm (TAAA), published results are limited to those from high-volume hospitals and based on old data gathered before optimal management was established. Here, we analysed our outcomes over the previous 10 years from cases of open TAA and TAAA repair to offer updated and real-world results of those complex procedures performed in a high-volume centre. METHODS From November 2013 to April 2022, 212 consecutive adult patients who underwent open TAA and TAAA repair were enrolled. We analysed early and late outcomes after surgery, including postoperative complications and mortality. RESULTS There were 154 (73%) men, and the median age at surgery was 61 years. Intraoperative death occurred in 1 patient due to uncontrolled bleeding. Nine patients (4%) died during follow-up, and the survival estimates at 5 years were 94 ± 3% and 95 ± 3% after descending TAA and TAAA repair, respectively. Ten patients (4%) suffered from spinal cord ischaemic injury (9 with paraplegia and 1 with paresthesia), but permanent paraplegia persisted in only 1 case. CONCLUSIONS We report very low postoperative complication rates and excellent early and late survival rates after open TAA and TAAA repair from our recent 10-year data analysis. These findings may assist when choosing treatment options for these complicated diseases.
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Affiliation(s)
- Ah Ran Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Suk Kyung Lim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sangmin Maria Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Kumins NH, Ambani RN, Bose S, King AH, Cho JS, Colvard B, Kashyap VS. Anatomic Utility of Single Branched Thoracic Endograft During Thoracic Endovascular Aortic Repair. Vasc Endovascular Surg 2023; 57:680-688. [PMID: 36961838 DOI: 10.1177/15385744231165988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
INTRODUCTION Single branched thoracic endografts (SBTEs) have been designed for pathology requiring zone 2 seal during thoracic endovascular aortic repair (TEVAR). Numerous criteria must be met to allow for their implantation. Our aim was to analyze anatomic suitability for a next generation SBTE. METHODS We reviewed 150 TEVAR procedures between 2015 and 2019. Proximal seal was: zone 0 in 21 (16%), zone 1 in 4 (3%), zone 2 in 52 (40%), zone 3 in 45 (35%), and zone 4 or distal in 7 (5%). We analyzed the Zone 2 patient's angiograms and CT angiograms using centerline software to measure arterial diameters and length in relation to the left common carotid artery (LCCA), left subclavian artery (LSA) and proximal extent of aortic disease to determine if patients met anatomic criteria of a novel SBTE. RESULTS Zone 2 average age was 64.4 ± 16.3 years; 34 patients were male (65%). Indications for repair were aneurysm (N = 9, 17%), acute dissection (N = 14, 27%), chronic dissection with aneurysmal degeneration (N = 7, 13%), intramural hematoma (N = 9, 17%), penetrating aortic ulcer (N = 5, 10%), and blunt traumatic aortic injury (BTAI, N = 8, 15%). LSA revascularization occurred in 27 patients (52%). Overall, 20 (38.5%) of the zone 2 patients met anatomic criteria. Patients with dissection met anatomic criteria less frequently than aneurysm (33% [10 of 30] vs 64% [9 of 14]). Patients treated for BTAI rarely met the anatomic criteria (1 of 8, 13%). The main anatomic constraints were an inadequate distance from the LCCA to the LSA takeoff and from the LCCA to the start of the aortic disease process. CONCLUSION Less than half of patients who require seal in zone 2 met criteria for this SBTE. Patients with aneurysms met anatomic criteria more often than those with dissection. The device would have little applicability in treating patients with BTAI.
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Affiliation(s)
- Norman H Kumins
- Department of Vascular Surgery, The Heart and Vascular Institute, The Cleveland Clinic, Cleveland, OH, USA
| | - Ravi N Ambani
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Saideep Bose
- Division of Vascular and Endovascular Surgery, Department of Surgery, St Louis University, St Louis, MO, USA
| | - Alexander H King
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Benjamin Colvard
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Vikram S Kashyap
- Division of Vascular Surgery, Frederik Meijer Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI, USA
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Ahmad W, Liebezeit-Sievert M, Wegner M, Alokhina A, Wahlers T, Dorweiler B, Luehr M. Feasibility of Total Endovascular Repair of the Aorta in Patients with Acute Type A Aortic Dissection: Morphological Analysis of 119 Patients. J Clin Med 2023; 12:5615. [PMID: 37685682 PMCID: PMC10488701 DOI: 10.3390/jcm12175615] [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: 07/31/2023] [Revised: 08/16/2023] [Accepted: 08/27/2023] [Indexed: 09/10/2023] Open
Abstract
(1) Background: This study aimed to morphologically analyze acute type A aortic dissection (aTAAD) patients for potential endovascular treatment candidates. The objective was to specify requirements for aTAAD endovascular devices. (2) Methods: A single-center retrospective analysis included aTAAD patients who underwent open surgical repair between November 2005 and December 2020. Preoperative CTA scans were used for morphological analysis, assessing endovascular repair eligibility. Statistical tests were performed. (3) Results: A total of 129 patients with aTAAD were studied, with 119 included. Entry tear (ET) locations were identified, mainly in the aortic root, 20 mm above the sinotubular junction (STJ) and within the ascending aorta (20 mm above STJ to -20 mm before the brachiocephalic trunk). Endovascular treatment was deemed feasible for 36 patients, with suggested solutions for the aortic arch and descending aorta. Significant differences were observed between eligible and noneligible groups for aortic diameter, false lumen diameter, distance between STJ and entry tear, and more. Dissection extension showed no significant difference. (4) Conclusions: Morphological analysis identified potential aTAAD candidates for endovascular treatment, highlighting differences between eligible and noneligible morphologies. This study offers insights for implementing endovascular approaches in aTAAD treatment and emphasizes the need for research and standardized protocols.
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Affiliation(s)
- Wael Ahmad
- Department of Vascular and Endovascular Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany (B.D.)
| | - Mark Liebezeit-Sievert
- Department of Vascular and Endovascular Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany (B.D.)
| | - Moritz Wegner
- Department of Vascular and Endovascular Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany (B.D.)
| | - Anastasiia Alokhina
- Department of Cardiothoracic Surgery, Heart Centre, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany (M.L.)
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Centre, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany (M.L.)
| | - Bernhard Dorweiler
- Department of Vascular and Endovascular Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany (B.D.)
| | - Maximilian Luehr
- Department of Cardiothoracic Surgery, Heart Centre, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany (M.L.)
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Kawarai SI, Katahira S, Miyatake M, Itagaki K, Tsuruoka N, Haga Y, Saiki Y. Development of modified laser Doppler flowmetry device for real-time monitoring of esophageal mucosal blood flow: a preclinical assessment with an animal model. J Artif Organs 2023:10.1007/s10047-023-01408-w. [PMID: 37418161 DOI: 10.1007/s10047-023-01408-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 05/31/2023] [Indexed: 07/08/2023]
Abstract
This study aimed to modify a laser Doppler flowmeter designed and assembled at our institute. After measuring sensitivity evaluation in ex vivo experiments, we confirmed the efficacy of this new device for monitoring real-time esophageal mucosal blood flow changes after thoracic stent graft implantation by simulating various clinical situations in an animal model. Thoracic stent graft implantation was performed in a swine model (n = 8). Esophageal mucosal blood flow decreased significantly from baseline (34.1 ± 18.8 ml/min/100 g vs. 16.7 ± 6.6 ml/min/100 g, P < 0.05) in the lower esophagus (Th6-Th8) where the stent graft covered the aorta. In the hemorrhagic shock model (shock index ≥ 1.0), esophageal mucosal blood flow showed a remarkable change from baseline in the upper esophagus (Th1-Th3), where the stent graft did not cover the aorta (20.8 ± 9.8 ml/min/100 g vs. 12.9 ± 8.6 ml/min/100 g, P < 0.01); however, it returned to the baseline value within a 30-min period. Mucosal blood flow remained stable in the esophagus, where the stent graft did not cover the aorta. After elevating the mean blood pressure to > 70 mmHg with continuous intravenous noradrenaline infusion, esophageal mucosal blood flow increased significantly in both regions; however, the reaction was different between the two regions. Our newly developed laser Doppler flowmeter could measure real-time esophageal mucosal blood flow changes in various clinical situations during thoracic stent graft implantation in a swine model. Hence, this device can be applied in many medical fields by downsizing it.
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Affiliation(s)
- Shun-Ichi Kawarai
- Division of Cardiovascular Surgery, Hachinohe City Hospital, 3-1-1 Tamukai, Hachinohe, Aomori, 031-8555, Japan
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-Ku, Sendai, 980-8574, Japan
| | - Shintaro Katahira
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-Ku, Sendai, 980-8574, Japan.
| | - Midori Miyatake
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-Ku, Sendai, 980-8574, Japan
| | - Kota Itagaki
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-Ku, Sendai, 980-8574, Japan
| | - Noriko Tsuruoka
- Tohoku University Graduate School of Engineering, 6-6-12 Aoba, Aramaki, Aoba-Ku, Sendai, 980-8579, Japan
| | - Yoichi Haga
- Tohoku University Graduate School of Biomedical Engineering, 6-6-12 Aoba, Aramaki, Aoba-Ku, Sendai, 980-8579, Japan
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-Ku, Sendai, 980-8574, Japan
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11
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Rohlffs F, Grandi A, Panuccio G, Detter C, von Kodolitsch Y, Kölbel T. Endovascular Options for the Ascending Aorta and Aortic Arch - A Scoping Review. Ann Vasc Surg 2023:S0890-5096(23)00316-3. [PMID: 37328096 DOI: 10.1016/j.avsg.2023.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/02/2023] [Accepted: 06/06/2023] [Indexed: 06/18/2023]
Abstract
The gold standard for aneurysmal repair of the ascending aorta and the aortic arch has been open surgery with an established track record of good results in suitable patients. In recent years, with innovations in the endovascular field alternative endovascular solutions for pathologies of the aortic arch and ascending aorta became available. At first reserved only for highly selected patients unfit for open surgery, endovascular aortic arch repair is now being offered to patients with suitable anatomy in high volume referral centers after discussion in an interdisciplinary team. The present scoping review aims at providing an overview on indications, available devices, technical aspects and feasibility studies of endovascular arch repair both in elective and emergent situations, including also experiences and considerations from our center.
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Affiliation(s)
- Fiona Rohlffs
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany.
| | - Alessandro Grandi
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Christian Detter
- Cardiothoracic Surgery, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Yskert von Kodolitsch
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
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12
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Alhussaini M, Falasa MP, Jeng EI, Martin T, Becker TK, Arnaoutakis GJ, Fillion A, Neal D, Beaver TM. Application of deep hypothermic circulatory arrest in open left chest aortic aneurysm repair. J Thorac Cardiovasc Surg 2023; 165:1275-1280. [PMID: 33934896 DOI: 10.1016/j.jtcvs.2021.03.080] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 03/15/2021] [Accepted: 03/20/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Deep hypothermic circulatory arrest (DHCA) is often required for patients undergoing repair of descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm via left thoracotomy when proximal crossclamping is not feasible or when aneurysmal disease extends into the transverse aortic arch. Historical literature suggests higher complications rates due to the technical complexity of this approach; we examined outcomes with this approach at our center. METHODS Between January 2008 and May 2018, 84 patients with DTAA or Crawford extent I thoracoabdominal aortic aneurysm underwent open repair. DHCA was employed in 46 of 84 (55%) patients, of which 33 (72%) required repair of distal arch and DTAA, and 13 (28%) required repair of the distal arch and extent I thoracoabdominal aortic aneurysm. Patients who underwent DHCA had more chronic dissections than those in the non-DHCA group (70% vs 34%; P ≤ .05). RESULTS Major adverse outcomes for the DHCA group versus non-DHCA group were as follows: early mortality 3 out of 46 (7%) versus 4 out of 38 (11%) (P = .70), stroke 3 out of 46 (7%) versus 1 out of 38 (3%) (P = .62), permanent spinal cord deficit 2 out of 46 (4%) versus 3 out of 38 (8%) (P = .65), permanent renal failure necessitating dialysis 1 out of 46 (2%) versus 2 out of 38 (5%) (P = .59). Freedom from major adverse outcomes was 38 out of 46 (83%) versus 31 out of 38 (82%) for DHCA versus non-DHCA (P = 1). CONCLUSIONS DHCA can be employed via left thoracotomy for combined arch and DTAA or extent I thoracoabdominal aortic aneurysm open repair.
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Affiliation(s)
| | - Matheus P Falasa
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Eric I Jeng
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Tomas Martin
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Torben K Becker
- Department of Emergency Medicine, University of Florida, Gainesville, Fla
| | - George J Arnaoutakis
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Amber Fillion
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Dan Neal
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla.
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13
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Milam AJ, Hung P, Bradley AS, Herrera-Quiroz D, Soh I, Ramakrishna H. Open Versus Endovascular Repair of Descending Thoracic Aneurysms: Analysis of Outcomes. J Cardiothorac Vasc Anesth 2023; 37:483-492. [PMID: 36522256 DOI: 10.1053/j.jvca.2022.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 11/16/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Adam J Milam
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ
| | - Penny Hung
- Medical Student, Mayo Clinic Alix School of Medicine, Scottsdale, AZ
| | - A Steven Bradley
- Department of Anesthesiology, Uniformed Services University of Health Sciences, Bethesda, MD
| | | | - Ina Soh
- Division of Vascular Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ
| | - Harish Ramakrishna
- Division of Cardiovascular Anesthesia, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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14
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Vacirca A, Tenorio ER, Mesnard T, Sulzer T, Baghbani-Oskouei A, Mirza AK, Huang Y, Oderich GS. Technical tips and clinical experience with the Gore Thoracic Branch Endoprosthesis®. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:18-25. [PMID: 36534126 DOI: 10.23736/s0021-9509.22.12564-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Thoracic endovascular aortic repair (TEVAR) has been widely accepted as a treatment option in patients with thoracic aortic aneurysms and dissections who have suitable anatomy. It is estimated that up to 60% of patients treated by TEVAR require extension of the repair into the distal aortic arch across Ishimaru zone 2. In these patients, coverage of the left subclavian artery (LSA) without revascularization has been associated with increased risk of arm ischemia, stroke, and spinal cord injury. The Gore Thoracic Branch Endoprosthesis (TBE, WL Gore, Flagstaff, AZ, USA) is the first off-the-shelf thoracic branch stent-graft approved by the Federal Drug Administration for treatment of distal aortic arch lesions requiring extension of the proximal seal into zone 2. This article summarizes the technical pitfalls and clinical outcomes of the TBE® device in zone 2.
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Affiliation(s)
- Andrea Vacirca
- Advanced Aortic Research Program, McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Memorial Hermann Medical Plaza, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Emanuel R Tenorio
- Advanced Aortic Research Program, McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Memorial Hermann Medical Plaza, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Thomas Mesnard
- Advanced Aortic Research Program, McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Memorial Hermann Medical Plaza, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Titia Sulzer
- Advanced Aortic Research Program, McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Memorial Hermann Medical Plaza, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Aidin Baghbani-Oskouei
- Advanced Aortic Research Program, McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Memorial Hermann Medical Plaza, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Aleem K Mirza
- Advanced Aortic Research Program, McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Memorial Hermann Medical Plaza, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Ying Huang
- Advanced Aortic Research Program, McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Memorial Hermann Medical Plaza, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Gustavo S Oderich
- Advanced Aortic Research Program, McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Memorial Hermann Medical Plaza, University of Texas Health Science Center at Houston, Houston, TX, USA -
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15
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Goh JHF, Hwang NC. Stent Graft-Induced Aortic Wall Injury-Anesthesia Pitfalls and Pearls for the Thoracic Endovascular Aortic Repair Procedure. J Cardiothorac Vasc Anesth 2023; 37:683-686. [PMID: 36822890 DOI: 10.1053/j.jvca.2023.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 01/16/2023] [Indexed: 01/22/2023]
Affiliation(s)
- Jacqueline Hui Fen Goh
- Department of Anaesthesiology, Singapore General Hospital, Singapore, Singapore; Department of Cardiothoracic Anesthesia, National Heart Centre, Singapore, Singapore
| | - Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, Singapore, Singapore; Department of Cardiothoracic Anesthesia, National Heart Centre, Singapore, Singapore.
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16
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Current status of adult cardiac surgery-part 2. Curr Probl Surg 2023; 60:101245. [PMID: 36642488 DOI: 10.1016/j.cpsurg.2022.101245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 10/13/2022] [Indexed: 12/13/2022]
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17
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Zhao K, Zhu H, Ma J, Zhao Z, Zhang L, Zeng Z, Du P, Sun Y, Yang Q, Zhou J, Jing Z. Peripheral Eosinophil Count Is Associated With the Prognosis of Patients With Type B Aortic Dissection Undergoing Endovascular Aortic Repair: A Retrospective Cohort Study. J Am Heart Assoc 2022; 11:e027339. [PMID: 36416154 PMCID: PMC9851444 DOI: 10.1161/jaha.122.027339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Eosinophil count (EOS) has been proposed to provide prognostic information in multiple cardiovascular disorders. However, few researchers have investigated the predictive value of EOS for patients with type B aortic dissection who had thoracic endovascular repair. Methods and Results The authors reviewed the records of 912 patients with type B aortic dissection who were treated with thoracic endovascular repair in Changhai Hospital, Shanghai. By using receiver operating characteristic curve analysis, patients were divided into 2 groups based on the admission EOS cutoff value (<7.4×106/L [n=505] and ≥7.4×106/L [n=407]). To reduce selection bias, propensity score matching was applied. Multivariable regression analysis and Kaplan-Meier curves were performed to assess the association between EOS and long-term outcomes. Furthermore, we investigated nonlinear correlations between EOS and outcomes using general additive models with restricted cubic splines. In the matched population, lower EOS was associated with significantly higher 30-day mortality (4.1% vs 0%, P=0.007). There was no statistically difference in 30-day adverse events between the 2 groups (all P>0.05). Kaplan-Meier analysis revealed that patients with an EOS <7.4×106/L had a higher incidence of 1-year all-cause death (7.95% vs. 2.34%, P=0.008) and aortic-related death (5.98% vs 1.81%, P=0.023) than those with higher EOS. Multivariable Cox analysis showed that continuous EOS was independently associated with 1-year mortality (hazard ratio, 3.23 [95% CI, 1.20-8.33], P=0.019). In addition, we discovered a nonlinear association between EOS and 1-year outcomes. Conclusions Lower admission EOS values predict higher short- and long-term mortality after thoracic endovascular repair.
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Affiliation(s)
- Kaiwen Zhao
- Department of Vascular Surgerythe First Affiliated Hospital of the Navy Medical UniversityShanghaiChina
| | - Hongqiao Zhu
- Department of Vascular Surgerythe First Affiliated Hospital of the Navy Medical UniversityShanghaiChina
| | - Jiqing Ma
- Department of Vascular Surgerythe First Affiliated Hospital of the Navy Medical UniversityShanghaiChina
| | - Zhiqing Zhao
- Department of Vascular Surgerythe First Affiliated Hospital of the Navy Medical UniversityShanghaiChina
| | - Lei Zhang
- Department of Vascular Surgerythe First Affiliated Hospital of the Navy Medical UniversityShanghaiChina
| | - Zan Zeng
- Department of Vascular Surgerythe First Affiliated Hospital of the Navy Medical UniversityShanghaiChina
| | - Pengcheng Du
- Department of Vascular Surgerythe First Affiliated Hospital of the Navy Medical UniversityShanghaiChina
| | - Yudong Sun
- Depaertment of General surgery, Jinling HospitalMedical School of Nanjing UniversityNanjingChina
| | - Qin Yang
- Department of CardiologyJinan Hospital of Integrated Traditional Chinese and Western MedicineJinanShandongChina
| | - Jian Zhou
- Department of Vascular Surgerythe First Affiliated Hospital of the Navy Medical UniversityShanghaiChina
| | - Zaiping Jing
- Department of Vascular Surgerythe First Affiliated Hospital of the Navy Medical UniversityShanghaiChina
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18
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Keegan A, Hicks CW. Surgical Decision-Making and Outcomes in Open Versus Endovascular Repair for Various Vascular Diseases. Anesthesiol Clin 2022; 40:627-644. [PMID: 36328619 PMCID: PMC9833286 DOI: 10.1016/j.anclin.2022.08.008] [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] [Indexed: 11/05/2022]
Abstract
Today's vascular surgeon must navigate their practice through a field of ever-advancing technology while maintaining knowledge of open techniques that remain equally important in the care of their patients. In this article, the authors provide insight into the perioperative decision-making that goes into choosing a surgical plan for each patient based on their disease process, anatomy, nonmodifiable risk factors, and other comorbidities.
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Affiliation(s)
- Alana Keegan
- General Surgery, Sinai Hospital of Baltimore, 2435 West Belvedere Avenue, Suite 42, Baltimore, MD 21215, USA
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins School of Medicine, 600 North Wolfe Street, Halsted 668, Baltimore, MD 21287, USA.
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19
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Huang X, Wang Z, Shen Z, Lei F, Liu YM, Chen Z, Qin JJ, Liu H, Ji YX, Zhang P, Zhang XJ, Yang J, Cai J, She ZG, Li H. Projection of global burden and risk factors for aortic aneurysm - timely warning for greater emphasis on managing blood pressure. Ann Med 2022; 54:553-564. [PMID: 35139697 PMCID: PMC8843207 DOI: 10.1080/07853890.2022.2034932] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
RATIONALE Aortic aneurysm (AA) is a serious condition that largely increases the risk of aortic dissection and sudden death. Exploring the global burden of disease and changes in risk factors for AA is essential for public health policy development. OBJECTIVE To project the death burden from AA and its attributable risk factors in the following decade based on the epidemiological data over the past 30 years. METHODS AND RESULTS We analysed the death burden of AA and trends of four risk factors from 1990-2019 using the updated 2019 Global Burden of Disease study database by Joinpoint regression analysis. Furthermore, we project the AA-related death burden for the next decade using the Bayesian age-period-cohort model. This study discovered that the global burden of death attributable to AA began to increase after decreasing for two decades. This upward trend will continue in the subsequent decade (average annual percent change: 0.318%, 95% CI: 0.288 to 0.348). Meanwhile, the disease burdens in all economic regions except high-middle socio-demographic index (SDI) regions will continuously increase in the next decade, with the fastest acceleration in the low-middle SDI region (average annual percent change: 1.183%, 95% CI: 1.166 to 1.200). Notably, high systolic blood pressure will surpass the contribution of smoking to become the most important risk factor for mortality due to AA. CONCLUSION This study discovered a rebounding trend in the aortic aneurysm-related death burden globally. High systolic blood pressure will be the top risk factor attributed to death from AA. Therefore, it should be considered as the first-degree risk factor in the guidance of AA management and criteria for population-based screening programs.Key messagesThe death burden of aortic aneurysms is beginning to rebound globally, and the trend will continue for the next decade.High systolic blood pressure will replace smoking as the most important risk factor associated with aortic aneurysm death.
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Affiliation(s)
- Xuewei Huang
- Department of Cardiology, Renmin Hospital, School of Basic Medical Science, Wuhan University, Wuhan, China.,Institute of Model Animal, Wuhan University, Wuhan, China
| | - Zhouxiang Wang
- Institute of Model Animal, Wuhan University, Wuhan, China.,Medical Science Research Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zhengjun Shen
- Huanggang Institute of Translation Medicine, Huanggang, China.,Department of Cardiology, Center Hospital of Huanggang, Huanggang, China
| | - Fang Lei
- Department of Cardiology, Renmin Hospital, School of Basic Medical Science, Wuhan University, Wuhan, China.,Institute of Model Animal, Wuhan University, Wuhan, China
| | - Ye-Mao Liu
- Institute of Model Animal, Wuhan University, Wuhan, China.,Department of Cardiology, Center Hospital of Huanggang, Huanggang, China
| | - Ze Chen
- Institute of Model Animal, Wuhan University, Wuhan, China.,Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Juan-Juan Qin
- Department of Cardiology, Renmin Hospital, School of Basic Medical Science, Wuhan University, Wuhan, China.,Institute of Model Animal, Wuhan University, Wuhan, China
| | - Hui Liu
- Department of Cardiology, Renmin Hospital, School of Basic Medical Science, Wuhan University, Wuhan, China.,Department of Gastroenterology, Tongren Hospital of Wuhan University & Wuhan Third Hospital, Wuhan, China
| | - Yan-Xiao Ji
- Institute of Model Animal, Wuhan University, Wuhan, China.,Medical Science Research Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Peng Zhang
- Department of Cardiology, Renmin Hospital, School of Basic Medical Science, Wuhan University, Wuhan, China.,Institute of Model Animal, Wuhan University, Wuhan, China
| | - Xiao-Jing Zhang
- Department of Cardiology, Renmin Hospital, School of Basic Medical Science, Wuhan University, Wuhan, China.,Institute of Model Animal, Wuhan University, Wuhan, China
| | - Juan Yang
- Department of Cardiology, Renmin Hospital, School of Basic Medical Science, Wuhan University, Wuhan, China.,Institute of Model Animal, Wuhan University, Wuhan, China
| | - Jingjing Cai
- Institute of Model Animal, Wuhan University, Wuhan, China.,Department of Cardiology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Zhi-Gang She
- Department of Cardiology, Renmin Hospital, School of Basic Medical Science, Wuhan University, Wuhan, China.,Institute of Model Animal, Wuhan University, Wuhan, China
| | - Hongliang Li
- Department of Cardiology, Renmin Hospital, School of Basic Medical Science, Wuhan University, Wuhan, China.,Institute of Model Animal, Wuhan University, Wuhan, China.,Medical Science Research Center, Zhongnan Hospital of Wuhan University, Wuhan, China.,Huanggang Institute of Translation Medicine, Huanggang, China
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20
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Trends in thoracic aortic aneurysm hospital admissions, interventions and mortality in England between 1998 to 2020: An observational study. Eur J Vasc Endovasc Surg 2022; 64:340-348. [PMID: 35842176 DOI: 10.1016/j.ejvs.2022.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 06/01/2022] [Accepted: 07/10/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess trends in thoracic aortic aneurysm (TAA) hospital admissions, interventions, and aneurysm-related mortality (ARM) in England and examine the impact of endovascular repair on mortality for the years 1998 to 2020. METHODS Hospital admission and operative approach (thoracic endovascular aortic repair, TEVAR or open surgical repair, OSR) using Hospital Episodes Statistics (HES), and ARM data from the Office for National Statistics for England (ONS) standardised to the 2013 European Standard Population were analysed using linear regression and Joinpoint regression analyses. ARM was compared between the pre-endovascular era (1998-2008) and the endovascular era (2009-2019). RESULTS A rising trend in in-hospital admission incidence was observed, mainly due non-ruptured admissions (4.11 per 100,000 in 1998 [95% CI 3.71 to 4.50 per 100,000] to 12.61 per 100,000 in 2020 [95% CI 12.00 to 13.21 per 100,000] in 2020; r2 = 0.98; p < .001). Operative interventions increased mainly due to an increase in TEVAR (2.15 per 100,000 [95% CI 1.91 to 2.41 per 100,000] in 2020 vs 0.26 per 100,000 [95% CI 0.16 to 0.36 per 100,000] in 2006; r2 = 0.90; p < .001). Reductions in ARM from TAA were observed for males and females, irrespective of age and rupture status. The greatest reduction in ARM in the endovascular era was observed in females > 80 years, with ruptured disease 15.26 deaths per 100,000 versus 9.50 deaths per 100,000, p < .0001). CONCLUSION A significant increase in hospital admissions for non-ruptured TAA was observed in the last 23 years in England, paralleled by a shift towards endovascular repair, and significant declining trends in ARM irrespective of gender and age. The significant reductions in ASDR from ruptured and non-ruptured TAA in the endovascular era, particularly for females >80 years with ruptured disease affirm the positive impact of an endovascular approach to TAA.
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21
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Torsello GF. [Update on thoracic endovascular aneurysm repair : New stent graft designs]. RADIOLOGIE (HEIDELBERG, GERMANY) 2022; 62:551-555. [PMID: 35759018 DOI: 10.1007/s00117-022-01032-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/31/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND In the last decade, new stent graft designs have evolved to tackle challenges in thoracic endovascular aortic repair. A specific focus on access vessel issues has led to the introduction of new low-profile endograft designs for most of the major products. OBJECTIVE The main objective of this article is to provide an overview of the available publications on new stent graft designs. MATERIALS AND METHODS Assessing recent publications on the major reiterations of thoracic endografts, benefits and drawbacks are discussed. RESULTS Recent reiterations of major endografts for thoracic aortic endovascular repair have focused mainly on the development of low-profile devices. Through alterations on graft fabric as well as stent material and design, delivery systems were reduced in profile, thus, reducing access vessel complications or enabling an endovascular procedure altogether. Long-term data are already available for one endoprosthesis. Other refinements include in situ adaptation of the stent graft to the aortic arch curvature as well as the option of staged deployment to allow more precision and reduce manipulation close to supra-aortic branches. CONCLUSIONS Especially in the case of low-profile endografts, preliminary and long-term results of access vessel complications are promising. In order to draw final conclusions as to how durable the results of aneurysm exclusion are, more long-term studies are warranted.
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Affiliation(s)
- Giovanni Federico Torsello
- Ärztliche Leitung Angiographie/Interventionsradiologie CCM, Klinik für Radiologie - Arbeitsbereich Interventionelle Radiologie, Campus Charité Mitte, Campus Virchow-Klinikum, CC 06 Diagnostische und Interventionelle Radiologie und Nuklearmedizin, Charité - Universitätsmedizin Berlin, Berlin, Deutschland.
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22
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Mezzetto L, Mastrorilli D, Bravo G, Scorsone L, Gennai S, Leone N, D'Oria M, Veraldi E, Veraldi GF. Celiac Artery Coverage After Thoracic Endovascular Aortic Procedure: A Meta-Analysis of Early and Late Results. J Endovasc Ther 2022:15266028221090443. [PMID: 35466769 DOI: 10.1177/15266028221090443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND/AIM Clinical outcomes of celiac artery (CA) coverage during aortic procedures are often contradicting and the fate of this additional maneuver is still unclear. This study summarizes the results of available literature and aims to clarify the impact of CA coverage during thoracic endovascular aneurysm repair (TEVAR) in patients with inadequate distal sealing zone. METHODS Prospective and retrospective, observational original articles focused on CA coverage during elective/urgent TEVAR for descending thoracic aortic pathology (DTAP) were included. PubMed/MEDLINE, Embase, and Cochrane Central Register of Controlled Trials database were examined to identify articles published from January 2007 to December 2020, according to PRISMA guidelines. Early and late visceral (any sign or symptom reported) and neurological (both transient and permanent) complications were considered as primary outcomes. Onset of any endoleak, type IB endoleak, need of reintervention, and TEVAR-related mortality were considered as secondary outcomes. RESULTS A total of 5618 articles were extracted for analysis and 13 studies were finally included in the synthesis. A total of 178 CAs were covered during 2653 TEVAR (7%). Spinal cord ischemia was 8% (95% CI, 5-14%, I2 0%) Any endoleak and type IB endoleak was observed in 12% (95% CI, 6-21%, I2 17%) and 5% (95% CI, 2-11%, I2 0%), respectively. Thoracic endovascular aneurysm repair-related reoperation was necessary in 8% (95% CI, 4-14%, I2 0%), the majority of which (14/18, 78%) performed for distal sealing failure; mortality rate was 9% (95% CI, 5-14%, I2 0%). Out of 178 patients, 168 (94%) were available for follow-up, ranged 12 to 42 months. Visceral complications, any endoleak, and type IB endoleak were identified in 15% (95% CI, 10-23%, I2 45%), 20% (95% CI, 13-29%, I2 8%), and 8% (95% CI, 4-15%, I2 0%), respectively. Thoracic endovascular aneurysm repair-related reintervention was required in 8% (95% CI, 4-14%, I2 0%). Mortality rate was 17% (95% CI, 12-25%, I2 4%). CONCLUSIONS Celiac artery coverage in DTAP should be regarded as a "bailout" procedure especially in urgent/emergent settings but requires caution in elective cases. Even if transient visceral ischemia is frequent, life-threatening complications are rare. Early and late mortality rates are similar to standard TEVAR although the risk of type IB endoleak and reintervention may be an issue.
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Affiliation(s)
- Luca Mezzetto
- Vascular Surgery, Integrated University Hospital of Verona, Verona, Italy
| | - Davide Mastrorilli
- Vascular Surgery, Integrated University Hospital of Verona, Verona, Italy
| | - Giulia Bravo
- Department of Medicine, University of Udine, Udine, Italy
| | - Lorenzo Scorsone
- Vascular Surgery, Integrated University Hospital of Verona, Verona, Italy
| | - Stefano Gennai
- Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicola Leone
- Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Mario D'Oria
- Vascular and Endovascular Surgery, Trieste University Hospital, Trieste, Italy
| | - Edoardo Veraldi
- Vascular Surgery, Integrated University Hospital of Verona, Verona, Italy
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Muncan B, Sangari A, Liu SH, Price LZ. Midterm Outcomes of Endovascular versus Open Surgical Repair of Intact Descending Thoracic Aneurysms in Patients with Connective Tissue Disorders. Ann Vasc Surg 2022; 87:40-46. [PMID: 35460854 DOI: 10.1016/j.avsg.2022.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/07/2022] [Accepted: 04/07/2022] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Data on the efficacy of endovascular (TEVAR) vs open surgical repair for chronic aortic pathology in patients with connective tissue disorders are limited. In particular, few studies have examined outcomes of TEVAR vs. open repair for intact aneurysms of the descending thoracic aorta (DTAAs) in this subset of patients beyond index hospitalization. Therefore, we investigate and five-year outcomes of TEVAR and open surgical repair of intact DTAAs in patients with known connective tissue disorders. METHODS Using the TriNetX Data Network, a global federated database of over 75 million patients, we conducted a retrospective cohort study of patients with connective tissue disorders and intact DTAAs, treated initially with either TEVAR or open surgery. Eligible patients were 1:1 propensity score-matched for several preoperative covariates including demographics, surgical history, and comorbidities. We calculated and compared five-year cumulative incidence and hazard of death, reintervention, aortic dissection, renal failure, stroke, intracranial hemorrhage, paraplegia and limb ischemia using the Kaplan-Meier method and Cox proportional hazards models. RESULTS We identified 55 patients treated with TEVAR and 200 treated with open surgery. After matching, we compared 46 patients in each cohort. After matching, only incidence of reintervention via endovascular approach was significantly higher among patients in the TEVAR cohort (27.1% vs. 4.8%, p = 0.009). Rates and hazards of other outcomes were higher in the TEVAR group, however differences were not statistically significant. CONCLUSION Patients treated with TEVAR had numerically higher rates of adverse outcomes compared to open surgical patients, however only the difference in reintervention rate was statistically significant. Given the evolving landscape of endovascular intervention, greater-powered studies are needed to determine the safety and efficacy of TEVAR for intact DTAAs in a select subset of connective tissue disorder patients.
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Affiliation(s)
- Brandon Muncan
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA.
| | - Ayush Sangari
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Steven H Liu
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Lucyna Z Price
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
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24
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Impact of Female Sex on Outcomes of Patients Undergoing Thoracic Endovascular Aortic Aneurysm Repair: A Ten-Year Retrospective Nationwide Study in France. J Clin Med 2022; 11:jcm11082253. [PMID: 35456346 PMCID: PMC9029404 DOI: 10.3390/jcm11082253] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/06/2022] [Accepted: 04/12/2022] [Indexed: 12/04/2022] Open
Abstract
The impact of sex on the outcomes of patients with cardiovascular disease is still incompletely understood. The aim of this nationwide multicenter observational study was to investigate the impact of sex on post-operative outcomes in patients undergoing thoracic endovascular aortic repair (TEVAR) for intact thoracic aortic aneurysm (iTAA). The French National Health Insurance Information System was searched to identify these patients over a ten-year retrospective period. Post-operative outcomes, 30-day and overall mortality were recorded. Among the 7383 patients included (5521 men and 1862 women), females were significantly older than males (66.8 vs. 64.8 years, p < 0.001). They were less frequently diagnosed with cardiovascular comorbidities. Post-operatively, women had less frequently respiratory (10.9 vs. 13.7%, p = 0.002) as well as cardiac complications (34.3 vs. 37.3%, p = 0.023), but they had more frequently arterial complications (52.8 vs. 49.8%, p = 0.024). There was no significant difference on overall mortality for a mean follow-up of 2.2 years (26.9 vs. 27.6%, p = 0.58). In the multivariable regression model, female sex was not associated with 30-day or overall mortality. Although women had a favorable comorbidity profile, the short-term and long-term survival was similar. The significantly higher rate of arterial complications suggests that women may be at higher risk of access-vessel-related complications.
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25
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Rastogi V, Stefens SJM, Houwaart J, Verhagen HJM, de Bruin JL, van der Pluijm I, Essers J. Molecular Imaging of Aortic Aneurysm and Its Translational Power for Clinical Risk Assessment. Front Med (Lausanne) 2022; 9:814123. [PMID: 35492343 PMCID: PMC9051391 DOI: 10.3389/fmed.2022.814123] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/21/2022] [Indexed: 01/03/2023] Open
Abstract
Aortic aneurysms (AAs) are dilations of the aorta, that are often fatal upon rupture. Diagnostic radiological techniques such as ultrasound (US), magnetic resonance imaging (MRI), and computed tomography (CT) are currently used in clinical practice for early diagnosis as well as clinical follow-up for preemptive surgery of AA and prevention of rupture. However, the contemporary imaging-based risk prediction of aneurysm enlargement or life-threatening aneurysm-rupture remains limited as these are restricted to visual parameters which fail to provide a personalized risk assessment. Therefore, new insights into early diagnostic approaches to detect AA and therefore to prevent aneurysm-rupture are crucial. Multiple new techniques are developed to obtain a more accurate understanding of the biological processes and pathological alterations at a (micro)structural and molecular level of aortic degeneration. Advanced anatomical imaging combined with molecular imaging, such as molecular MRI, or positron emission tomography (PET)/CT provides novel diagnostic approaches for in vivo visualization of targeted biomarkers. This will aid in the understanding of aortic aneurysm disease pathogenesis and insight into the pathways involved, and will thus facilitate early diagnostic analysis of aneurysmal disease. In this study, we reviewed these molecular imaging modalities and their association with aneurysm growth and/or rupture risk and their limitations. Furthermore, we outline recent pre-clinical and clinical developments in molecular imaging of AA and provide future perspectives based on the advancements made within the field. Within the vastness of pre-clinical markers that have been studied in mice, molecular imaging targets such as elastin/collagen, albumin, matrix metalloproteinases and immune cells demonstrate promising results regarding rupture risk assessment within the pre-clinical setting. Subsequently, these markers hold potential as a future diagnosticum of clinical AA assessment. However currently, clinical translation of molecular imaging is still at the onset. Future human trials are required to assess the effectivity of potentially viable molecular markers with various imaging modalities for clinical rupture risk assessment.
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Affiliation(s)
- Vinamr Rastogi
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Sanne J. M. Stefens
- Department of Molecular Genetics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Judith Houwaart
- Department of Molecular Genetics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Hence J. M. Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Jorg L. de Bruin
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Ingrid van der Pluijm
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Molecular Genetics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Jeroen Essers
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Molecular Genetics, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Radiation Oncology, Erasmus University Medical Center, Rotterdam, Netherlands
- *Correspondence: Jeroen Essers
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26
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Ouchi T, Kato N, Kato H, Higashigawa T, Ito H, Nakajima K, Chino S, Tokui T, Oue K, Mizumoto T, Sakuma H. Utility of psoas muscle area in selecting older patients feasible for thoracic endovascular aortic repair. Ann Thorac Surg 2022; 114:750-756. [PMID: 35216989 DOI: 10.1016/j.athoracsur.2022.01.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 01/04/2022] [Accepted: 01/26/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND The impact of psoas muscle mass index (PMI) on overall survival is unknown in older patients undergoing elective thoracic endovascular aortic repair (TEVAR). METHODS We retrospectively reviewed 105 patients 75 years and older who underwent elective TEVAR for descending thoracic aortic aneurysm between January 2010 and December 2019. Psoas muscle area was measured at the L3 level with preoperative computed tomography and adjusted by height2 to derive PMI. The patients were stratified into two groups, Sarcopenia and Non-sarcopenia. Sarcopenia was defined as a PMI < 5.40 cm2/m2 for male and < 3.56 cm2/m2 for female. The overall survival was compared with the age- and sex-matched general population using the one-sample log-rank test. The propensity score adjusted-Cox proportional-hazard model was applied to determine the hazard ratio for all-cause mortality. RESULTS Twenty-three patients died during the follow-up period (median, 3.0 years). Thirty-eight (36%) patients were classified as Sarcopenia. The 5-year overall survival rate was 46% (95% confidence interval, 29-73) in Sarcopenia and 84% (95% confidence interval, 74-94) in Non-sarcopenia. The overall survival was significantly lower in Sarcopenia than in its matched general population (P = .004). Whereas, no statistically significant difference in overall survival was found between Non-sarcopenia and its matched general population (P = .417). Sarcopenia was an independent risk factor for all-cause mortality (adjusted hazard ratio, 2.64; 95% confidence interval, 1.02- 6.82; P = .045). CONCLUSIONS PMI may be a good predictor of mortality in older patients undergoing elective TEVAR for descending thoracic aortic aneurysm.
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Affiliation(s)
- Takafumi Ouchi
- Department of Radiology, Mie University Hospital, Tsu, Mie, Japan
| | - Noriyuki Kato
- Department of Radiology, Mie University Hospital, Tsu, Mie, Japan.
| | - Hiroaki Kato
- Department of Radiology, Mie University Hospital, Tsu, Mie, Japan
| | | | - Hisato Ito
- Department of Thoracic and Cardiovascular Surgery, Mie University Hospital, Tsu, Mie, Japan
| | - Ken Nakajima
- Department of Radiology, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Shuji Chino
- Department of Radiology, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Toshiya Tokui
- Department of Thoracic Surgery, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Kensuke Oue
- Department of Cardiovascular Surgery, Kochi Health Sciences Center, Kochi, Kochi, Japan
| | - Toru Mizumoto
- Department of Cardiovascular Surgery, Anjo Kosei Hospital, Anjo, Aichi, Japan
| | - Hajime Sakuma
- Department of Radiology, Mie University Hospital, Tsu, Mie, Japan
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27
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Rajapandian J, Periyanarkunan M, Swamiappan E, Chinnasamy G. Penetrating atherosclerotic aortic ulcer with pseudoaneurysm: Role of hybrid procedure with d-TEVAR. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2022. [DOI: 10.4103/ijves.ijves_134_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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28
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Bissacco D, Domanin M, Weaver FA, Azizzadeh A, Miller CC, Gable DR, Piffaretti G, Lomazzi C, Trimarchi S. Differences in Mid-Term Outcomes Between Patients Undergoing Thoracic Endovascular Aortic Repair for Aneurysm or Acute Aortic Syndromes: Report From the Global Registry for Endovascular Aortic Treatment. J Endovasc Ther 2021; 29:731-738. [PMID: 34911391 DOI: 10.1177/15266028211064819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To analyze differences in baseline characteristics, overall mortality, device-related mortality, and re-intervention rates in patients who underwent thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm (DTAA) with atherosclerotic/degenerative cause or acute aortic syndrome (AAS), using the Global Registry For Endovascular Aortic Treatment (GREAT). MATERIALS AND METHODS Patients submitted to TEVAR for AAS or DTAA, included in GREAT, were eligible for this analysis. Primary outcome was 30-day all-cause mortality rate. Secondary outcomes were 30-day aorta-related mortality and re-intervention rate, 1-year and 3-year all-cause mortality, aorta-related mortality and re-intervention rate. RESULTS Five-hundred and seventy-five patients were analyzed (305 DTAA and 270 AAS). Thirty-day mortality rate was 1.3% and 1.8% for DTAA and AAS, respectively (p=0.741). One-year and 3-year mortality rates were 6.2% versus 9.3 and 17.3% versus 15.9% for DTAA and AAS, respectively (p=0.209 and p=0.655, respectively). Aorta-related mortality rates at 30 days, 1 year and 3 years were 1.3%, 1.3%, and 2.6% for DTAA, 1.8%, 4.2%, and 4.2% for AAS (p=ns). Re-intervention rates at 30 days, 1 year, and 3 years were 1.3%, 4.3%, and 7.5% for DTAA, 3.3%, 8.1%, and 10.7% for AAS (p=ns). Furthermore, a specific analysis with similar outcomes was performed dividing follow-up in 3 periods (1-30 days, 31-365 days, 366-1096 days) and describing mutual differences between 2 groups and temporal trends in each group. CONCLUSION Patients who underwent TEVAR for DTAA or AAS experienced different mortality and re-intervention rates among years during mid-term follow-up. Although all-cause related deaths within 30 days were TEVAR-related, aorta-related deaths were more common for AAS patients within 1 year. A greater re-intervention rate was described for AAS patients, although only 1 year after TEVAR.
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Affiliation(s)
- Daniele Bissacco
- Vascular Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Domanin
- Vascular Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Fred A Weaver
- Division of Vascular Surgery and Endovascular Therapy, University of Southern California, Los Angeles, CA, USA
| | - Ali Azizzadeh
- Division of Vascular Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Charles C Miller
- McGovern Medical School, Department of Cardiothoracic & Vascular Surgery, University of Texas Health Science Center, Houston, TX, USA
| | - Dennis R Gable
- Division of Vascular and Endovascular Surgery, Baylor Scott & White Heart Hospital, Plano, TX, USA
| | - Gabriele Piffaretti
- Vascular Surgery Unit, ASST Sette Laghi, Varese, Italy.,Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Chiara Lomazzi
- Vascular Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Santi Trimarchi
- Vascular Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical and Community Sciences, University of Milan, Milan, Italy
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Hamwi T, Tsilimparis N, Stana J, Fenelli C, Benfor B, Prendes CF. The "Skewer Technique" for Stentgraft Delivery in the Aortic Arch: Advancing the Dilatator in The Innominate Artery Over a Right Femoro-Brachial Through-And-Through Wire. Ann Vasc Surg 2021; 80:397.e1-397.e6. [PMID: 34808261 DOI: 10.1016/j.avsg.2021.10.058] [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: 04/21/2021] [Revised: 07/28/2021] [Accepted: 10/27/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) is the preferred treatment for different aortic pathologies, because it has reduced mortality and morbidity rates. However, TEVAR is not feasible in all cases due to aortic angulations, the hemodynamics of the aortic arch and narrow or tortuous iliofemoral access. Therefore, different adjuvant techniques, such as iliac percutaneous transluminal angioplasty, iliathrough-and-through guidewires and external transapical guidewires have been previously reported. Herein we describe the Skewer Technique for successful TEVAR delivery, through a right-brachial-femoral through-and-through guidewire and advancement of the delivery system into the innominate artery. METHODS A 38-year-old male presented with a symptomatic 11.5cm thoracic aneurysm with involvement of the left-subclavian artery ostium. The patient underwent left carotid-subclavian bypass and a TEVAR. Due to the huge size of the aneurysm a left-brachial-right femoral artery through-and-through guidewire was established. However, the achievement of a stable position for the deployment of the stentgraft was not possible. Eventually, the exclusion of the aneurysm was done with a right brachio-femoral through-and-through wire, inserting the proximal part of the delivery system into the innominate artery. CONCLUSIONS The use of adjuvant techniques such as a through-and-through right brachial-femoral guidewire with advancement of the endograft delivery system in the innominate artery (Skewer Technique) represents a useful alternative option in cases where the angulations of the aortic arch impede the deployment of the stent graft using conventional techniques.
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Affiliation(s)
- Tarek Hamwi
- Department of Vascular Surgery, Ludwig Maximilians University Hospital, Munich, Germany.
| | - Nikolaos Tsilimparis
- Department of Vascular Surgery, Ludwig Maximilians University Hospital, Munich, Germany
| | - Jan Stana
- Department of Vascular Surgery, Ludwig Maximilians University Hospital, Munich, Germany
| | - Cecilia Fenelli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Policlinico Sant'Orsola-Malpighi, Bologna, Italy
| | - Bright Benfor
- Department of Vascular Surgery, Ludwig Maximilians University Hospital, Munich, Germany
| | - Carlota F Prendes
- Department of Vascular Surgery, Ludwig Maximilians University Hospital, Munich, Germany
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30
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Zhang B, Wei Y, Liu Y, Lin H, Liang S, Dun Y, Yu C, Qian X, Guo H, Sun X. Safety and durability of single-stage type I hybrid total aortic arch repair for extensive aortic arch disease: early- and long-term clinical outcomes from a single center and our 10-year of experience. J Thorac Dis 2021; 13:6230-6239. [PMID: 34992803 PMCID: PMC8662513 DOI: 10.21037/jtd-20-3479] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/24/2021] [Indexed: 11/10/2022]
Abstract
Background Single-stage type I hybrid total aortic arch repair is a surgical treatment for extensive aortic arch disease, but the clinical outcomes were distinguishing. The purposes of this study were to share our experience and evaluate the perioperative safety and long-term durability. Methods Thirty-six patients who underwent single-stage type I hybrid total aortic arch repair in Fuwai Hospital between January 2010 and June 2020 were respectively reviewed. Early primary endpoint was defined as early composite adverse events, including mortality, multiple organ dysfunction syndrome (MODS), unplanned reoperation, stroke, paraplegia, acute renal failure (ARF) necessitating continuous renal replacement therapy (CRRT), respiratory failure and stents related complications. Long-term endpoints included late mortality, late aortic related reintervention and late adverse aortic events. When evaluating the early- and long-term outcomes, all patients were stratified into two subgroups by age (65 years). Results All patients acquired technical success. Early composite adverse events rate was 11.1% (4/36), in-hospital mortality was 8.3% (3/36). Average follow-up period was 48.0±35.3 months. Overall survival rate was 83.3% and 51.9% at 5 and 10 years respectively. Late aortic related reintervention occurred at one (3.0%, 1/33) patient and this patient died after reintervention. Overall freedom from adverse aortic events was 79.2% and 47.5% at 5 and 10 years respectively. Significant difference was not observed between the elderly and young subgroups, no matter in early- and long-term outcomes. Conclusions Single-stage type I hybrid total aortic arch repair has achieved desirable outcomes in our center, which does not increase perioperative risk in the elderly patients, meanwhile, also acquire acceptable durability in the young patients. In conclusion, this surgery is a practical mini-invasive treatment for extensive aortic arch disease with strict and limited indications.
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Affiliation(s)
- Bowen Zhang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yizhen Wei
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanxiang Liu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hao Lin
- Department of Cardiovascular Surgery, Shandong Provincial Hospital affiliated to Shandong First Medical University, Jinan, China
| | - Shenghua Liang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yaojun Dun
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Cuntao Yu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiangyang Qian
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongwei Guo
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaogang Sun
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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31
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Gennai S, Leone N, Karelis A, Xodo A, Mezzetto L, Fargion A, Antonello M, Veraldi GF, Dias NV, Sonesson B, Pratesi C, Silingardi R. Distal landing zone outcomes in thoracic endovascular aortic aneurysm repair with challenging morphology: a propensity-matched comparison of distal active fixation versus standard stent-graft. INT ANGIOL 2021; 41:24-32. [PMID: 34636507 DOI: 10.23736/s0392-9590.21.04718-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND To evaluate the distal landing zone (LZ) outcomes in adverse morphology after thoracic endovascular repair (TEVAR) with distal active fixation (DAF) stent-grafts compared with standard endografts. METHODS between 2006 and the 31st December 2020, sixty-nine DAFs (study group) and sixty-nine standard stent-grafts (control group) were enrolled in a multi-center, retrospective, case-control study. The primary outcomes were the distal endoleak and reintervention. The secondary outcomes were: distal segment migration, wedge apposition and related complications. A univariate and multivariate logistic regression followed by a propensity-scored model (1:1) were performed. RESULTS The results were reported for the DAF vs control group. The mean follow-up was 3.3 ± 2.1 vs 3.7 ± 3.4 years. The distal endoleak rate was 7.3% vs 27.5% (P=0.011). The freedom from distal endoleak was 95%, 95% and 91% vs 85%, 76%, and 73% at 1, 3 and 5 years respectively (Log-rank P=0.011). Tortuosity index and distal thoracic aorta angulation were predictors of endoleak (P=0.012 and P=0.029 respectively). The distal reinterventions rate was 7.3% vs 20.3% (P=0.026). The freedom from distal reinterventions was 95%, 95% and 91% vs 92%, 75% and 75% at 1, 3 and 5 years respectively (Log-rank P=0.041). The wedge apposition was 5.8 vs 13.0-mm (P<0.000). The distal segment migration was upward directed in all cases and was significant (>10- mm) in 13.0% vs 39.1% (P=0.000). CONCLUSIONS The DAF stent-graft showed a significant reduction of the distal endoleak rates and other specific outcomes of the distal LZ in patients with an adverse anatomy.
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Affiliation(s)
- Stefano Gennai
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicola Leone
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy -
| | - Angelos Karelis
- Vascular Center, Department of Thoracic Surgery and Vascular Diseases, Vascular Center, Skåne University Hospital, Malmö, Sweden
| | - Andrea Xodo
- Vascular and Endovascular Surgery Unit, Department of Cardiac, Thoracic, and Vascular Sciences, University of Padua, Padua, Italy
| | - Luca Mezzetto
- Vascular Surgery, University Hospital of Verona, Verona, Italy
| | - Aaron Fargion
- Department of Vascular Surgery, University of Florence, Florence, Italy
| | - Michele Antonello
- Vascular and Endovascular Surgery Unit, Department of Cardiac, Thoracic, and Vascular Sciences, University of Padua, Padua, Italy
| | | | - Nuno V Dias
- Vascular Center, Department of Thoracic Surgery and Vascular Diseases, Vascular Center, Skåne University Hospital, Malmö, Sweden
| | - Björn Sonesson
- Vascular Center, Department of Thoracic Surgery and Vascular Diseases, Vascular Center, Skåne University Hospital, Malmö, Sweden
| | - Carlo Pratesi
- Department of Vascular Surgery, University of Florence, Florence, Italy
| | - Roberto Silingardi
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
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Umegaki T, Kunisawa S, Nishimoto K, Nakajima Y, Kamibayashi T, Imanaka Y. Paraplegia After Open Surgical Repair Versus Thoracic Endovascular Aortic Repair for Thoracic Aortic Disease: A Retrospective Analysis of Japanese Administrative Data. J Cardiothorac Vasc Anesth 2021; 36:1021-1028. [PMID: 34446324 DOI: 10.1053/j.jvca.2021.07.043] [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: 05/07/2021] [Revised: 07/15/2021] [Accepted: 07/25/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To comparatively examine the risk of postoperative paraplegia between open surgical descending aortic repair and thoracic endovascular aortic repair (TEVAR) among patients with thoracic aortic disease. DESIGN Retrospective cohort study. SETTING Acute-care hospitals in Japan. PARTICIPANTS A total of 6,202 patients diagnosed with thoracic aortic disease. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The main outcome of this study was the incidence of postoperative paraplegia. Multiple logistic regression models, using inverse probability of treatment weighting and an instrumental variable (ratio of TEVAR use to open surgical repair and TEVAR uses), showed that the odds ratios of paraplegia for TEVAR (relative to open surgical descending aortic repair) were 0.81 (95% confidence interval: 0.42-1.59; p = 0.55) in the inverse probability of treatment-weighted model and 0.88 (0.42-1.86; p = 0.75) in the instrumental-variable model. CONCLUSIONS There were no statistical differences in the risk of paraplegia between open surgical repair and TEVAR in patients with thoracic aortic disease. Improved perioperative management for open surgical repair may have contributed to the similarly low incidence of paraplegia in these two surgery types.
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Affiliation(s)
- Takeshi Umegaki
- Department of Anesthesiology, Kansai Medical University Hospital, Osaka, Japan
| | - Susumu Kunisawa
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kota Nishimoto
- Department of Anesthesiology, Kansai Medical University Hospital, Osaka, Japan
| | - Yasufumi Nakajima
- Department of Anesthesiology, Kansai Medical University Hospital, Osaka, Japan
| | | | - Yuichi Imanaka
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
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Mahboub-Ahari A, Sadeghi-Ghyassi F, Heidari F. Effectiveness of endovascular versus open surgical repair for thoracic aortic aneurysm: a systematic review and meta-analysis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 63:25-36. [PMID: 34235903 DOI: 10.23736/s0021-9509.21.11894-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Since the approval, the TEVAR is widely used for the repair of thoracic aortic aneurysm. However, the long-term mortality and re-intervention rates compared to OSR are unclear. We aimed to compare the effectiveness of the thoracic endovascular aortic repair (TEVAR) with open surgical repair (OSR) specifically for thoracic aortic aneurysms. EVIDENCE ACQUISITION We conducted a comprehensive search in MEDLINE, PubMed, EMBASE, CINAHL, PROSPERO, Centre for Reviews and Dissemination, and the Cochrane Library up to November 2020. The main outcomes were early mortality, mid-to-long-term survival, and re-intervention. The quality of the evidence was assessed using the GRADE methodology. All analyses were performed using RevMan with the random effect model and Comprehensive Meta-Analysis software. EVIDENCE SYNTHESIS One systematic review and 15 individual studies were included. Pooled analysis showed that 30-day mortality, stroke, renal failure, and pulmonary complications were significantly lower in TEVAR vs. open surgery. The pooled rate of re-intervention significantly favored the OSR. The long-term survival and mortality favored TEVAR and OSR in one and two studies, respectively, but was non-significant in 7 analyzes. CONCLUSIONS Early clinical outcomes including the 30-day mortality, stroke, renal failure, and pulmonary complications significantly favored the TEVAR. However, the mid-to-long-term re-intervention rate favored the OSR and long-term survival was inconsistent among the studies. The quality of evidence was very low. More studies with longer follow-ups are needed. The use of TEVAR should be decided by taking into account other factors including patient characteristics and preferences, cost, and surgeon expertise.
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Affiliation(s)
- Alireza Mahboub-Ahari
- Tabriz Health Services Management Research Center, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran.,National Institute of Health Research, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Sadeghi-Ghyassi
- Research Center for Evidence-Based Medicine: A JBI Centre of Excellence, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fariba Heidari
- Research Center for Evidence-Based Medicine: A JBI Centre of Excellence, Tabriz University of Medical Sciences, Tabriz, Iran -
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Miller LK, Patel VI, Wagener G. Spinal Cord Protection for Thoracoabdominal Aortic Surgery. J Cardiothorac Vasc Anesth 2021; 36:577-586. [PMID: 34366215 DOI: 10.1053/j.jvca.2021.06.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/15/2021] [Accepted: 06/20/2021] [Indexed: 01/06/2023]
Abstract
Open and endovascular repairs of the descending thoracic and thoracoabdominal aorta are associated with a substantial risk of spinal cord injury, namely paraplegia. Endovascular repairs seem to have a lower incidence of spinal cord injury, but there have been no randomized trials comparing outcomes of open and endovascular repairs. Paraplegia occurs when collateral blood supply to the anterior spinal artery is impaired. The risk of spinal cord injury can be mitigated with perioperative protocols that include drainage of cerebrospinal fluid, avoidance of hypotension and anemia, intraoperative neurophysiologic monitoring, and advanced surgical techniques. Drainage of cerebrospinal fluid using a spinal drain decreases the risk of spinal cord ischemia by improving spinal cord perfusion pressure. However, cerebrospinal fluid drainage has risks including neuraxial and intracranial bleeding, and these risks need to be carefully weighed against its potential benefit. This review discusses current surgical management of descending thoracic and thoracoabdominal aortic disease, incidence of and risk factors for spinal cord injury, and elements of spinal cord protection protocols that pertain to anesthesiologists, with a focus on cerebrospinal fluid drainage.
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Affiliation(s)
- Lydia K Miller
- Department of Anesthesiology, Columbia University, New York, NY
| | | | - Gebhard Wagener
- Department of Anesthesiology, Columbia University, New York, NY.
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Iyengar A, Goel NJ, Kelly JJ, Han J, Brown CR, Khurshan F, Chen Z, Desai ND. Predictors of 30-day readmission and resource utilization after thoracic endovascular aortic repair. Eur J Cardiothorac Surg 2021; 58:574-582. [PMID: 32386207 DOI: 10.1093/ejcts/ezaa128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 02/01/2020] [Accepted: 02/04/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The introduction and expansion of thoracic endovascular aortic repair (TEVAR) have revolutionized the treatment of a variety of thoracic aortic diseases. We sought to evaluate the incidence, causes, predictors and costs associated with 30-day readmission after TEVAR in a nationally representative cohort. METHODS Adult patients undergoing isolated TEVAR were identified in the National Readmissions Database from 2010 to 2014. Hospital costs were estimated by converting individual hospital charge data adjusted to 2014 consumer price indices. Multivariable logistic regression was utilized to determine hospital- and patient-level factors associated with readmissions. RESULTS A total of 24 983 TEVARs were noted during the study period; the average age of the patients was 65 ± 16 years; 40% were women. The most common indication was an intact thoracic aneurysm (43.5%), followed by aortic dissection (30.5%). The average cost of the index admission was $63 644 ± $52 312; the average hospital stay was 11 ± 14 days; the index mortality rate was 6.7%. Readmissions within 30 days occurred in 17.4% of patients. Indications for readmission were varied; the most common aetiologies were cardiac (17.8%), infectious (16.0%) and pulmonary (12.1%). On multivariable analysis, the strongest predictor of readmission was the diagnosis, with a ruptured thoraco-abdominal aneurysm having the highest readmission burden (adjusted odds ratio 2.23, 1.17-4.24; P = 0.015). Notably, hospital volume did not predict index hospital length of stay, costs or 30-day readmissions (all P > 0.10). CONCLUSIONS Annual TEVAR volume was not associated with any of the outcomes assessed. Rather, indication for TEVAR was the strongest predictor for many outcomes. As TEVAR becomes increasingly utilized, a focus on cardiac and vascular diseases may reduce readmissions and improve quality of care.
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Affiliation(s)
- Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Nicholas J Goel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - John J Kelly
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Jason Han
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Chase R Brown
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Fabliha Khurshan
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Zehang Chen
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Tong MZ, Eagleton MJ, Roselli EE, Blackstone EH, Xiang F, Ibrahim M, Johnston DR, Soltesz EG, Bakaeen FG, Lyden SP, Toth AJ, Liu H, Svensson LG. Outcomes of Open v. Endovascular Repair of Descending Thoracic and Thoracoabdominal Aortic Aneurysms. Ann Thorac Surg 2021; 113:1144-1152. [PMID: 34048754 DOI: 10.1016/j.athoracsur.2021.04.100] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 04/26/2021] [Accepted: 04/30/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Open repair is the standard of care for patients with descending thoracic and thoracoabdominal aortic aneurysms. Although effective, surgery carries a high risk of morbidity and mortality. Endovascular stent-grafts were introduced to treat these aneurysms in patients considered too high risk for open repair. Early results are promising, but later results are incompletely known. Therefore, we sought to compare short- and intermediate-term outcomes of open versus endovascular repair for these aneurysms. METHODS From 2000-2010, 1,053 patients underwent open (n=457) or endovascular (n=596) repair of descending thoracic and thoracoabdominal aortic aneurysms at Cleveland Clinic. To balance patient characteristics between these groups, propensity-score matching was performed, yielding 278 well-matched pairs (61% of possible pairs). Endpoints included short- and long-term outcomes. RESULTS In matched patients, compared with endovascular stenting, open repair achieved similar in-hospital mortality (n=23/8.3% vs n=21/7.6%, P=.8) and occurrence of paralysis and stroke (n=10/3.6% vs n=6/2.2%, P=.3), despite longer postoperative stay (median 11 vs 6 days), more dialysis-dependent acute renal failure (n=24/8.6% vs n=9/3.3%, P=.008), and prolonged ventilation (n=106/46% vs n=17/6.3%, P<.0001). Open repair resulted in better 10-year survival than endovascular repair (52% vs 33%, P<.0001), and aortic reintervention was less frequent (4% vs 21%, P<.0001). Despite a decrease in the first postoperative year, average aneurysm size did not recover to normal range after endovascular stenting. CONCLUSIONS Open repair of descending thoracic and thoracoabdominal aneurysms can achieve acceptable short-term outcomes with better intermediate-term outcomes than endovascular repair.
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Affiliation(s)
- Michael Z Tong
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
| | | | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Fei Xiang
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Currently at the Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Mudathir Ibrahim
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Sean P Lyden
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Andrew J Toth
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Huan Liu
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Currently at ZhongShan Hospital, Shanghai, China
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
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Jordan WD, Desai N, Letter AJ, Matsumura JS. Long-term outcomes of the conformable TAG thoracic endoprosthesis in a prospective multicenter trial. J Vasc Surg 2021; 74:1491-1498. [PMID: 34022380 DOI: 10.1016/j.jvs.2021.04.063] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 04/22/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Gore conformable TAG thoracic endoprosthesis (CTAG) was engineered to enhance conformability in the thoracic aorta and has demonstrated greater deployment accuracy and wall apposition than the original TAG device. The Food and Drug Administration approved the CTAG in 2011 based on the 1-year results of the pivotal trial for the CTAG device. In the present report, we have documented the outcomes for those patients through 5 years. METHODS The CTAG aneurysm study was a prospective, multicenter trial that assessed the safety and effectiveness of the CTAG device as treatment of descending thoracic aortic aneurysms. Follow-up imaging assessments consisted of radiographs and computed tomography at annual intervals through 5 years. A core imaging laboratory was used to assess the aneurysm size, device integrity, and endoleaks. RESULTS A total of 66 patients were enrolled (51 pivotal arm patients and 15 continued access patients) from October 2009 through September 2011. The baseline characteristics, procedural characteristics, and outcomes through 2 years were reported previously. Through 5 years, five patients (7.6%) had required device-related reintervention (one type Ia endoleak or contained rupture of the descending thoracic aorta, one type Ib endoleak, two indeterminate endoleaks, and one thoracic aortic pseudoaneurysm). Four patients (6.1%) had died of aneurysm-related causes, with one death occurring within 30 days of the index procedure. A total of 24 patients (36.3%) had died during the 5-year study period. Seven patients (10.6%) had experienced stroke or transient ischemic attack through 5 years, with one early stroke (postoperative day 28). Prosthesis or intercomponent migration was observed in six patients (9.1%) through 5 years; however, no patient had developed a type III junctional endoleak. No stent-graft fracture or compression was observed through 5 years. At 5 years, 14 patients (50.0%) showed sac regression, 5 (17.9%) showed sac expansion, and 9 (32.1%) showed sac stability using on a 5-mm threshold for change. CONCLUSIONS Thoracic endovascular aortic repair with the CTAG device was associated with low rates of aneurysm-related mortality and reintervention through 5 years. Proximal endoleak was rare, and most patients showed sac regression or stability at 5 years after the initial thoracic endovascular aortic repair.
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Affiliation(s)
- William D Jordan
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga.
| | - Nimesh Desai
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pa
| | | | - Jon S Matsumura
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wis
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Novak Z, Zaky A, Spangler EL, McFarland GE, Tolwani A, Beck AW. Incidence and predictors of early and delayed renal function decline after aortic aneurysm repair in the Vascular Quality Initiative database. J Vasc Surg 2021; 74:1537-1547. [PMID: 34019992 DOI: 10.1016/j.jvs.2021.04.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 04/16/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Postoperative acute kidney injury (AKI) may complicate both open and endovascular aortic aneurysm repair (EVAR) and is associated with substantial morbidity, mortality, and health care expense. We aim to evaluate the incidence of postoperative AKI and factors associated with its occurrence and the effects of postoperative AKI on long-term renal function and mortality after open and EVAR in the Society for Vascular Surgery Vascular Quality Initiative registry. METHODS Elective aneurysm cases were identified including thoracic endovascular aortic aneurysm repair (TEVAR) and complex endovascular aortic aneurysm repair (cEVAR), infrarenal endovascular repair (EVAR) and infrarenal open repair (OAR) from 2003 to 2019. The preoperative estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease formula and stratified based on chronic kidney disease (CKD) grades. Postoperative AKI was defined per the Vascular Quality Initiative definition as a creatinine increase of 0.5 mg/dL or if postoperative dialysis was required. Patients on preprocedural hemodialysis and those with previous renal transplant were excluded. Demographics and procedural factors were evaluated for predicting in-hospital postoperative AKI (all approaches) and at 9 to 21 months of long-term follow-up (EVAR only) using logistic regression modeling. RESULTS We identified a total of 2813 cEVAR, 2995 TEVAR, 39,945 EVAR, and 8143 OAR patients. Of those, postoperative AKI occurred in 377 cEVAR (13.5%), 199 TEVAR (6.7%), 1099 EVAR (2.8%), and 1249 OAR (15.5%). Risk factors for postoperative AKI across all groups were worse preoperative eGFR, total number of blood transfusions, perioperative anemia, reinterventions, and postoperative respiratory complications. Additional procedure-specific risk factors of postoperative AKI were preoperative hemoglobin of less than 10 and contrast volume of 125 to 150 mL, hypertension, a low ejection fraction, and a history of percutaneous revascularization for EVAR; for both EVAR/cEVAR, renal artery coverage was a risk factor, whereas for OAR, male sex, non-White race, hypertension, suprarenal aortic cross-clamp, and increased renal ischemic time were risk factors. Among 8133 EVAR patients with long-term follow-up, a decrease in kidney function occurred in 56.7% of patients with postoperative AKI vs 19.9% without postoperative AKI (P < .001). The following risk factors were associated with a decrease in renal function at long-term follow-up: postoperative AKI, a preoperative eGFR of less than 90, and hypertension. A preoperative hemoglobin of greater than 12 was protective. Postoperative AKI was associated with significantly lower survival compared with no postoperative AKI across all procedures (log rank <0.001). CONCLUSIONS Postoperative AKI occurs more often in patients with worse preoperative renal function, lower preoperative hemoglobin, and in open surgeries with inter-renal or suprarenal cross-clamping. Importantly, postoperative AKI is associated with increased mortality across all types of aortic repair. Given the long-term impact of postoperative AKI on outcomes for all aortic repairs and the limitations of current insensitive functional indices, there is a need to seek more sensitive indicators of decreases in early renal structural in this population.
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Affiliation(s)
- Zdenek Novak
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Ahmed Zaky
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Ala.
| | - Emily L Spangler
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Graeme E McFarland
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Ashita Tolwani
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Ala
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
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Nadeswaran P, Ding L, Singh N, Plotkin A, Magee GA, Han SM, Garg PK. Functional performance status and risk of cardiovascular events and mortality following endovascular repair of thoracic and abdominal aortic pathology. Vascular 2021; 30:206-216. [PMID: 33900842 DOI: 10.1177/17085381211010545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To characterize the association of preoperative functional performance status based on Eastern Cooperative Oncology Group (ECOG) scoring with the risk of adverse cardiovascular events, vascular events, and mortality in patients undergoing EVAR and TEVAR. METHODS Retrospective review of the Society for Vascular Surgery Vascular Quality Initiative, a large, multi-center, registry database was performed. All individuals undergoing EVAR (n = 18,730) and TEVAR (n = 6595) for non-ruptured aortic pathologies between 2014 and 2018 were eligible for analysis. Multivariable logistic regression was used to determine the association of pre-procedure ECOG functional performance status on risk of in-hospital adverse cardiovascular events, vascular events, and mortality. RESULTS The number of operations complicated by adverse cardiovascular and vascular events was 480 (2.6%) and 190 (1.0%) for EVAR and 733 (11.1%) and 219 (3.3%) for TEVAR, respectively. There were 118 (0.6%) and 240 (3.6%) in-hospital deaths following EVAR and TEVAR, respectively. Patients with ECOG grades 3 or 4 undergoing EVAR were at increased risk of cardiovascular events (OR = 1.62; 95% CI = 1.09, 2.41) and one-year mortality (HR = 2.62; 95% CI = 1.92, 3.57) compared to those with ECOG grade 0. Patients undergoing TEVAR with ECOG grade 3 or 4 were at increased risk for both inpatient death (OR = 2.77; 95% CI = 1.56, 4.9) and one-year mortality (HR = 3.27, 95% CI = 2.06, 5.21). ECOG status was not associated with an increased risk of adverse vascular events following either EVAR or TEVAR. CONCLUSIONS Poor preoperative functional status as assessed by ECOG score is associated with an increased risk of adverse postoperative cardiovascular events following EVAR and a higher mortality risk following both EVAR and TEVAR. Functional status assessment may be useful for risk stratification and determining procedural candidacy prior to EVAR and TEVAR.
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Affiliation(s)
- Pradeep Nadeswaran
- Division of Cardiology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Li Ding
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Nikhil Singh
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Anastasia Plotkin
- Division of Vascular Surgery and Endovascular Therapy, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Sukgu M Han
- Division of Vascular Surgery and Endovascular Therapy, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Parveen K Garg
- Division of Cardiology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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Banno H, Mutsuga M, Sugimoto M, Tokuda Y, Kodama A, Usui A, Komori K. Midterm Outcomes of Zone 0 Antegrade Endograft Implantation During Type I Hybrid Aortic Arch Repair. Eur J Vasc Endovasc Surg 2021; 61:938-944. [PMID: 33773906 DOI: 10.1016/j.ejvs.2021.02.044] [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] [Received: 11/02/2020] [Revised: 02/05/2021] [Accepted: 02/22/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Type I hybrid arch repair has become popular as a procedure that is less invasive than total arch replacement. The major advantage of this technique is that antegrade endograft implantation can be performed during the procedure, thereby avoiding the complications of introducing the endograft from the groin. The aim of this study was to assess the midterm outcomes of type I hybrid aortic arch repair with antegrade endograft implantation. METHODS Thirty consecutive patients who underwent type I hybrid repair with antegrade endograft implantation from 2009 to 2015 were reviewed retrospectively. Patient demographics, and peri-operative and late results were collected from a prospective database and analysed. RESULTS Four patients (13%) were female and the median age was 78 years. Median aneurysm size was 64 mm. Six patients (20%) developed stroke, and the 30 day mortality rate was 3%. Two patients suffered aortic dissection at the site of debranching anastomosis. The median follow up was 5.2 years. All aneurysms remained stable or had decreased in size at three years, and 82% were stable at five years. Overall survival was 79% at three years and 71% at five years. The rates of freedom from aorta related death were 86% at three and five years, respectively. During the follow up period, three additional left subclavian artery embolisations and one endograft relining due to type IIIb endoleak were required. CONCLUSION Midterm outcomes of type I hybrid aortic arch repair with antegrade endograft implantation for aortic arch aneurysms are reported. Although the incidence of peri-operative stroke was high, late sac behaviour was acceptable.
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Affiliation(s)
- Hiroshi Banno
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Masato Mutsuga
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masayuki Sugimoto
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshiyuki Tokuda
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akio Kodama
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kimihiro Komori
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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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: 2] [Impact Index Per Article: 0.7] [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.
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Upchurch GR, Escobar GA, Azizzadeh A, Beck AW, Conrad MF, Matsumura JS, Murad MH, Perry RJ, Singh MJ, Veeraswamy RK, Wang GJ. Society for Vascular Surgery clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms. J Vasc Surg 2021; 73:55S-83S. [DOI: 10.1016/j.jvs.2020.05.076] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 12/17/2022]
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Qu JZ, Kao LW, Smith JE, Kuo A, Xue A, Iyer MH, Essandoh MK, Dalia AA. Brain Protection in Aortic Arch Surgery: An Evolving Field. J Cardiothorac Vasc Anesth 2020; 35:1176-1188. [PMID: 33309497 DOI: 10.1053/j.jvca.2020.11.035] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/10/2020] [Accepted: 11/16/2020] [Indexed: 12/11/2022]
Abstract
Despite advances in cardiac surgery and anesthesia, the rates of brain injury remain high in aortic arch surgery requiring circulatory arrest. The mechanisms of brain injury, including permanent and temporary neurologic dysfunction, are multifactorial, but intraoperative brain ischemia is likely a major contributor. Maintaining optimal cerebral perfusion during cardiopulmonary bypass and circulatory arrest is the key component of intraoperative management for aortic arch surgery. Various brain monitoring modalities provide different information to improve cerebral protection. Electroencephalography gives crucial data to ensure minimal cerebral metabolism during deep hypothermic circulatory arrest, transcranial Doppler directly measures cerebral arterial blood flow, and near-infrared spectroscopy monitors regional cerebral oxygen saturation. Various brain protection techniques, including hypothermia, cerebral perfusion, pharmacologic protection, and blood gas management, have been used during interruption of systemic circulation, but the optimal strategy remains elusive. Although deep hypothermic circulatory arrest and retrograde cerebral perfusion have their merits, there have been increasing reports about the use of antegrade cerebral perfusion, obviating the need for deep hypothermia. With controversy and variability of surgical practices, moderate hypothermia, when combined with unilateral antegrade cerebral perfusion, is considered safe for brain protection in aortic arch surgery performed with circulatory arrest. The neurologic outcomes of brain protection in aortic arch surgery largely depend on the following three major components: cerebral temperature, circulatory arrest time, and cerebral perfusion during circulatory arrest. The optimal brain protection strategy should be individualized based on comprehensive monitoring and stems from well-executed techniques that balance the major components contributing to brain injury.
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Affiliation(s)
- Jason Z Qu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lee-Wei Kao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jennifer E Smith
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Alexander Kuo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Albert Xue
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Nanjing, China
| | - Manoj H Iyer
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH
| | - Michael K Essandoh
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH
| | - Adam A Dalia
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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Banno H, Kawai Y, Sato T, Tsuruoka T, Sugimoto M, Kodama A, Komori K. Low-density vulnerable thrombus/plaque volume on preoperative computed tomography predicts for spinal cord ischemia after endovascular repair for thoracic aortic aneurysm. J Vasc Surg 2020; 73:1557-1565.e1. [PMID: 33068765 DOI: 10.1016/j.jvs.2020.09.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Similar to open surgical repair, thoracic endovascular aortic repair (TEVAR) carries a risk of spinal cord ischemia (SCI). However, the generally lower incidence of SCI after TEVAR compared with that after open surgical repair, despite the inability to preserve the intercostal arteries, indicates different pathophysiologic mechanisms with the two procedures. We hypothesized that a microembolism from an aortic mural thrombus is the main cause of SCI. Thus, we evaluated the association between the density of a mural thrombus in the descending thoracic aorta and the development of SCI. METHODS A retrospective review of a prospectively assembled database was performed for all patients who had undergone surgery at a single institution from October 2008 to December 2018. Patient demographics and procedure-related variables were collected. The volume and Hounsfield unit (HU) value of mural thrombi in the whole descending thoracic aorta were estimated on preoperative computed tomography using a three-dimensional workstation. Logistic regression analysis was performed to identify the risk factors for SCI development. RESULTS Of the 367 patients who had undergone TEVAR during the study period, 155 were excluded because of previous arch surgery (n = 59), previous descending thoracic aortic surgery (n = 6), previous TEVAR (n = 6), unavailability of optimal preoperative computed tomography data (n = 17), double-barreled dissection (n = 40), and other reasons. The mean ± standard deviation age of the remaining 212 patients was 75.8 ± 6.4 years, and 42 (19.8%) were women. Of the 212 patients, 14 (6.6%) developed SCI after TEVAR. The low mean density of the mural thrombus, total thrombus volume, low-density (≥-100 HU but <30 HU) thrombus volume, intermediate-density (≥30 HU but <150 HU) thrombus volume, treatment length, urgent surgery, and baseline dialysis differed significantly between patients with and without SCI. Although subsequent multivariate analysis could not be performed owing to the small number of SCI events, vulnerable low-density thrombus/plaque was a stronger predictor among the aneurysm-related factors of SCI after TEVAR on univariate analysis. Well-known risk factors, such as distal coverage between T8 and L1, left subclavian artery coverage, previous abdominal aortic surgery, and prophylactic spinal drainage, did not show significant differences. CONCLUSIONS The results from the present study have demonstrated that among aneurysm-related factors, a lower density mural thrombus/plaque in the descending thoracic aorta is a predictor of SCI development after TEVAR. These results suggest that microembolism is one of the important mechanisms of SCI after TEVAR, which might change the prophylactic strategy.
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Affiliation(s)
- Hiroshi Banno
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Yohei Kawai
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomohiro Sato
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takuya Tsuruoka
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masayuki Sugimoto
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akio Kodama
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kimihiro Komori
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Ho VT, Itoga NK, Tran K, Lee JT, Stern JR. Mid-Term Survival after Thoracic Endovascular Aortic Repair by Indication in the Medicare Population. J Am Coll Surg 2020; 232:46-53.e2. [PMID: 33022404 DOI: 10.1016/j.jamcollsurg.2020.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/18/2020] [Accepted: 09/10/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) is indicated for treatment of aneurysms, dissections, and traumatic injury. We describe mid-term mortality and reintervention rates in Medicare beneficiaries undergoing TEVAR. STUDY DESIGN Patients who underwent TEVAR between 2006 and 2014 were identified by CPT codes in a 20% Medicare sample. Indication for aortic repair (aneurysm, dissection, trauma) was ascertained via ICD-9 codes. Follow-up was evaluated until 2015. Kaplan-Meier survival analysis and Cox regression were used to compare mortality, with reintervention and mortality rates expressed as a composite outcome in a hazard ratio with 95% confidence interval (hazard ratio [HR] 95% CI). RESULTS There were 3,095 patients who underwent TEVAR during the study period: 1,465 (47%) for aneurysm, 1,448 (47%) for dissection, and 182 (5.9%) for trauma. Mean patient age was 74.4 years, and 44.5% were female. Median follow-up was 2.7 years. The overall 30-day, 1-year, and 5-year, and 8-year survival rates were 93%, 78%, 49%, and 33%, respectively. Thirty-day mortality was highest in traumatic indications, but overall mortality was highest in patients undergoing TEVAR for aneurysm. Freedom from combined reintervention and mortality at 30 days, 1 year, 5 years, and 8 years was 89%, 73%, 43%, and 29%, respectively. Reintervention was highest in patients undergoing TEVAR for dissection (12.8%), followed by aneurysm (10.0%) and trauma (5.5%). Advanced age (HR 1.03 per year, 95% CI 1.02-1.03), congestive heart failure (CHF) (HR 1.48, 95% CI 1.33-1.65), dementia (HR 1.40, 95% CI 1.14-1.28), and rupture (HR 1.38, 95% CI 1.24-1.54) were associated with mortality. CONCLUSIONS Midterm survival is lower in patients who undergo TEVAR for dissection and aneurysm compared with trauma. Aneurysmal disease, advanced age, CHF, dementia, and aortic rupture are associated with mortality and reintervention in TEVAR.
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Affiliation(s)
- Vy T Ho
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Nathan K Itoga
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Kenneth Tran
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jason T Lee
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jordan R Stern
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA.
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Yadav A, Shrestha UK, Shrestha KR, Gurung D. Thoracic aortic aneurysm causing aorto-esophageal fistula-our experience with a rare disease. J Surg Case Rep 2020; 2020:rjaa242. [PMID: 32728417 PMCID: PMC7378018 DOI: 10.1093/jscr/rjaa242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/14/2020] [Accepted: 06/22/2020] [Indexed: 12/15/2022] Open
Abstract
Aorto-esophageal fistula is a life-threatening condition, accounting for a small number of cases of upper gastrointestinal bleeding where patients present with one or more features of Chiari's triad. We present the case of a 43-year-old woman, referred to us with symptoms of central chest pain, sudden onset dysphagia followed by massive hemoptysis. She was diagnosed with an aorto-esophageal fistula due to a ruptured thoracic aortic aneurysm and rushed for an emergency endovascular thoracic aortic stent and feeding jejunostomy with intravenous antibiotics and supportive care. After 6 weeks of surgery, the patient was re-evaluated to plan for an esophageal stent if required. The purpose of this presentation is to make the surgical fraternity aware of the gravity of this disease and novel techniques to manage it.
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Affiliation(s)
- Aakriti Yadav
- Department of General Surgery, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
| | - Uttam Krishna Shrestha
- Department of Vascular Surgery, Manmohan Cardio Thoracic Vascular and Transplant Center, Institute of Medicine, Kathmandu, Nepal
| | - Kajan Raj Shrestha
- Department of Vascular Surgery, Manmohan Cardio Thoracic Vascular and Transplant Center, Institute of Medicine, Kathmandu, Nepal
| | - Dinesh Gurung
- Department of Vascular Surgery, Manmohan Cardio Thoracic Vascular and Transplant Center, Institute of Medicine, Kathmandu, Nepal
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DuBois BG, Houben IB, Khaja MS, Yang B, Kim KM, van Herwaarden JA, Williams DM, Patel HJ. Thoracic Endovascular Aortic Repair in the Setting of Compromised Distal Landing Zones. Ann Thorac Surg 2020; 111:237-245. [PMID: 32645338 DOI: 10.1016/j.athoracsur.2020.05.074] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/13/2020] [Accepted: 05/08/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The short-term and intermediate-term outcomes of two distinct approaches to thoracic endovascular aortic repair (TEVAR) for descending aortic aneurysms in patients with compromised distal landing zones are reported. METHODS Fifty-one patients (38 female, average age 72 ± 9 years) underwent 55 TEVARs (2008 to 2018) for aneurysmal disease. Inclusion criteria consisted of TEVAR in a compromised distal landing zone, defined as follows: diameter 3.5 cm or greater; cross-sectional thrombus 50% or greater; or 25% or greater circumferential mural calcification in the 2 cm supraceliac aorta; or tortuosity index of 1.1 or more over the 10 cm supraceliac aorta. Treatment cohorts were (1) TEVAR alone (n = 29), and (2) TEVAR with adjunct consisting of visceral snorkel graft with distal stent extension (n = 20) or EndoAnchors (Medtronic, Minneapolis, MN [n = 6]). RESULTS Perioperative complication rate was 20%. Thirty-day mortality was 5% including one access-site related intraoperative death and one postoperative death from embolic mesenteric ischemia. Median clinical follow-up was 2.2 years. Intermediate-term outcomes include type 1B endoleaks, 35%; 0.5 cm or more per year maximal aortic diameter growth, 9%; reintervention, 15%; and all-cause mortality, 25%. The distal landing zone diameter increased by 0.3 cm per year in the TEVAR alone cohort; however, it decreased by 0.1 cm per year in the adjunct cohort ( P = .04). CONCLUSIONS Thoracic endovascular aortic repair is a viable alternative for the treatment of thoracoabdominal aortic aneurysms in patients with compromised distal landing zones, although these patients may benefit significantly from the development of branched thoracoabdominal devices. In the interim, the use of TEVAR adjuncts may limit progressive degeneration of the distal landing zone in this patient population.
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Affiliation(s)
- Byron G DuBois
- Department of Radiology, Michigan Medicine, Ann Arbor, Michigan
| | - Ignas B Houben
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Minhaj S Khaja
- Department of Radiology, Michigan Medicine, Ann Arbor, Michigan; Department of Radiology, University of Virginia Medical Center, Charlottesville, Virginia.
| | - Bo Yang
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Karen M Kim
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | | | | | - Himanshu J Patel
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
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Townsley MM, Soh IY, Ramakrishna H. Endovascular Versus Open Aortic Reconstruction: A Comparison of Outcomes. J Cardiothorac Vasc Anesth 2020; 35:1875-1883. [PMID: 32741610 DOI: 10.1053/j.jvca.2020.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Matthew M Townsley
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Ina Y Soh
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Phoenix, AZ
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Miletic KG, Kindzelski BA, Hodges KE, Beach J, Tong MZ, Bakaeen F, Johnston DR, Desai M, Lyden S, Roselli EE. Impact of Endovascular False Lumen Embolization on Thoracic Aortic Remodeling in Chronic Dissection. Ann Thorac Surg 2020; 111:495-501. [PMID: 32525030 DOI: 10.1016/j.athoracsur.2020.04.093] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 03/14/2020] [Accepted: 04/13/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Retrograde false lumen (FL) perfusion after thoracic endovascular aortic repair (TEVAR) for chronic dissection is a mode of treatment failure. Thrombosis of the FL is associated with favorable reverse remodeling. Objectives are to describe FL embolization (FLE) strategy and assess aortic remodeling and survival. METHODS From January 2009 to December 2017, 51 patients with chronic dissection underwent FLE, most after previous TEVAR. Devices included a combination of iliac plug (29 patients), coils (19 patients), or nitinol plug (3 patients). Computed tomography was performed before discharge, at 3 months, and annually (median follow-up 2 years [range, 1 month to 7 years]). RESULTS After FLE, mean maximum aortic diameter decreased (64.2 ± 12 mm to 61.0 ± 13 mm; P = .03), true lumen diameter increased (24.7 ± 10 mm to 33.7 ± 8 mm; P < .001), and FL diameter decreased (36.7 ± 12 mm to 25.6 ± 15 mm, P < .001). For reverse remodeling, FL thrombosis with ≥10% decrease in diameter and ≥10% increase in true lumen diameter was achieved in 20 (39.2%; 16 primarily, 4 secondarily). Nine patients progressed after the first FLE: persistent FL flow with increase in aortic diameter and underwent repeat FLE with complete thrombosis (n = 4) or open thoracoabdominal completion (n = 5). A total of 26 patients had indeterminate response (FL thrombosis without change in maximum diameter), and none have required reoperation. Six patients had complete obliteration of the entire FL. At last follow-up, 42 (82%) patients were alive. Three deaths were related to aortic pathology. CONCLUSIONS FLE is an important endovascular adjunct to TEVAR promoting reverse aortic remodeling in select patients with chronic aortic dissection and persistent retrograde FL perfusion.
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Affiliation(s)
- Kyle G Miletic
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bogdan A Kindzelski
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kevin E Hodges
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jocelyn Beach
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael Z Tong
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Faisal Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Milind Desai
- Aorta Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Cardiology, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sean Lyden
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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50
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Thoracic Endovascular Aneurysm Repair Trends and Outcomes in Over 27,000 Medicare Patients for Descending Thoracic Aneurysms. Ann Thorac Surg 2020; 109:1757-1764. [DOI: 10.1016/j.athoracsur.2019.12.054] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 10/21/2019] [Accepted: 12/19/2019] [Indexed: 11/19/2022]
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