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Nana P, Spanos K, Brotis A, Fabre D, Mastracci T, Haulon S. Effect of Sarcopenia on Mortality and Spinal Cord Ischaemia After Complex Aortic Aneurysm Repair: Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2023; 65:503-512. [PMID: 36657704 DOI: 10.1016/j.ejvs.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 12/21/2022] [Accepted: 01/11/2023] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Sarcopenia has been related to higher mortality rates after abdominal aortic aneurysm repair. This analysis aimed to assess sarcopenia related mortality and spinal cord ischaemia (SCI) at 30 days, and mortality during the available follow up, in patients with complex aortic aneurysms, managed with open or endovascular interventions. DATA SOURCES A search of the English literature, via Ovid, using Medline, EMBASE, and CENTRAL up to 15 June 2022 was done. REVIEW METHODS This meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines and preregistered in PROSPERO (CRD42022338079). Observational studies (2000 - 2022), with five or more patients, reporting on sarcopenia related mortality and SCI at 30 days, and midterm mortality after thoraco-abdominal aneurysm repair (open or endovascular), were eligible. The ROBINS-I tool (Risk Of Bias In Non-Randomised Studies of Interventions) was used for risk of bias, and GRADE (Grading of Recommendations, Assessment, Development and Evaluation) for the assessment of evidence quality. The primary outcome was 30 day and midterm mortality, and the secondary outcome was SCI at 30 days, in sarcopenic and non-sarcopenic patients. The outcomes were summarised as odds ratio (OR) with 95% confidence intervals (CIs). RESULTS Four retrospective studies (1 092 patients; 40.0% sarcopenic) were included. Thirty day mortality was similar, with low certainty between groups (6% [95% CI 1 - 11] in sarcopenic vs. 5% [95% CI 1 - 9] non-sarcopenic patients [OR 0.30, 95% CI -0.21 - 0.81; p = .94, Ι2 = 0%). The estimated midterm mortality was statistically significantly higher (very low certainty) in sarcopenic patients (25% [95% CI 0.19 - 0.31] vs. 13% [95% CI -0.03 - 0.29] in non-sarcopenic patients (1.11 OR 0.95, 95% CI -0.21 - 2.44; p < .001, Ι2 = 88.32%). SCI was significantly higher (very low certainty) in sarcopenic patients (19%, 95% CI 4 - 34) vs. 7% (95% CI 5 - 20) in non-sarcopenic patients (OR 1.80, 95% CI -0.17 - 3.78; Ι2 = 82.4%), despite an equal distribution of aneurysm type between the groups. CONCLUSION Early mortality does not appear to be affected by sarcopenia in patients treated for thoraco-abdominal aneurysms. However, sarcopenia may be associated with higher peri-operative SCI and midterm mortality rates.
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Affiliation(s)
- Petroula Nana
- Aortic Centre, Marie Lannelongue Hospital, Le Plessis-Robinson, Paris Saclay University, Paris, France.
| | - Konstantinos Spanos
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Alexandros Brotis
- Department of Neurosurgery, Larissa University Hospital, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Dominique Fabre
- Aortic Centre, Marie Lannelongue Hospital, Le Plessis-Robinson, Paris Saclay University, Paris, France
| | - Tara Mastracci
- Department of Cardiothoracic surgery, St. Bartholomew's Hospital London and University College London, London UK
| | - Stephan Haulon
- Aortic Centre, Marie Lannelongue Hospital, Le Plessis-Robinson, Paris Saclay University, Paris, France
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Results of open thoracoabdominal aneurysm repair with left partial cardiopulmonary bypass in a low-volume center. ANGIOLOGIA 2022. [DOI: 10.20960/angiologia.00400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Sorber R, Bowen CJ, Hicks CW, Black JH. Connective tissue disease type mediates branch patency of grafts in open thoracoabdominal aortic reconstruction. J Vasc Surg 2022; 75:90-98. [PMID: 34186165 PMCID: PMC8710179 DOI: 10.1016/j.jvs.2021.05.062] [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: 12/26/2020] [Accepted: 05/24/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Despite a shared degenerative vascular phenotype, Marfan syndrome (MFS), Loeys-Dietz syndrome (LDS), and other genetically distinct connective tissue diseases (CTDs) have unique extravascular pathologies that impact the outcomes of aortic replacement. The aim of our study was to investigate the association of CTD genotype with postoperative outcomes and branch patency following open thoracoabdominal aortic replacement in a large institutional cohort. METHODS All patients undergoing open branched thoracoabdominal aortic replacement at a single academic center from 2006 to 2020 were included and classified as CTD or non-CTD based on the presence of genotypic documentation. Outcomes were compared using analysis of variance and χ2 testing for continuous and discrete variables, respectively. Kaplan-Meier curves were utilized to examine patency of graft branches over time. RESULTS Overall, 172 patients were included, with a mean follow-up of 30.5 ± 34.9 months. CTD was present in 45 patients (26%); specifically, 32 had MFS, five had LDS, and eight had another CTD. Patients with CTDs had more extent II thoracoabdominal aneurysms (40% vs 15%), more reconstructed branches (3.5 vs 1.8), more frequently reconstructed visceral branches (86.7% vs 22.7%), and higher intraoperative blood loss (13.3 vs 6.8 L; all P < .05) compared with non-CTD patients. Patients with MFS were more frequently systemically anticoagulated preoperatively (50% vs 5%) and demonstrated higher rates of postoperative deep vein thrombosis/pulmonary embolism compared with non-CTD patients (9% vs 2%; both P < .05). Five-year renal branch patency was decreased among all patients compared with visceral branches (87.3% vs 95.6%; P = .05), but there were no individual branch patency differences between patients with and without CTDs (P = .086). Overall branch patency at 1 and 5 years was significantly higher in patients with MFS than in non-CTD patients (98.9% vs 89.1% at 5 years); there were no significant patency differences between non-CTD patients and any other CTD subgroup, mostly due to early patency loss. CONCLUSIONS Open thoracoabdominal reconstruction in patients with CTD is technically challenging and associated with increased transfusion and postoperative thromboembolic events when compared with non-CTD patients. Technical outcomes of the procedure are excellent and are differentially associated with genotype, with patients with MFS experiencing significantly improved branch patency over both non-CTD patients and patients with other CTDs, a finding which has multifactorial drivers.
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Affiliation(s)
- Rebecca Sorber
- Department of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Hospital,Department of Genetic Medicine, Johns Hopkins University School of Medicine
| | - Caitlin J. Bowen
- Department of Genetic Medicine, Johns Hopkins University School of Medicine
| | - Caitlin W. Hicks
- Department of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Hospital,Johns Hopkins Surgery Center For Outcomes Research (JSCOR),Johns Hopkins University School of Medicine
| | - James H. Black
- Department of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Hospital
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Tenorio ER, Dias-Neto MF, Lima GBB, Estrera AL, Oderich GS. Endovascular repair for thoracoabdominal aortic aneurysms: current status and future challenges. Ann Cardiothorac Surg 2021; 10:744-767. [PMID: 34926178 PMCID: PMC8640886 DOI: 10.21037/acs-2021-taes-24] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/26/2021] [Indexed: 12/23/2022]
Abstract
Open surgical repair has been the gold standard for treatment of thoracoabdominal aortic aneurysms (TAAA). Currently, open surgical repair has been reserved mostly for young and fit patients with connective tissue disorders, using separate branch vessel reconstructions instead of 'island' patches, and distal perfusion instead of a 'clamp and go' technique. Endovascular repair has gained widespread acceptance because of its potential to significantly decrease morbidity and mortality. Several large aortic centers have developed dedicated clinical programs to advance techniques of fenestrated-branched endovascular aortic repair (FB-EVAR) using patient-specific and off-the-shelf devices, which offers a less-invasive alternative to open repair. Although FB-EVAR was initially considered an option for older and frail patients, many centers have expanded its indications to any patient with suitable anatomy and no evidence of connective tissue disorders, independent of their clinical risk. In this article, we review current techniques and outcomes of endovascular TAAA repair.
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Affiliation(s)
- Emanuel R Tenorio
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Marina F Dias-Neto
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Guilherme Baumgardt Barbosa Lima
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Anthony L Estrera
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Gustavo S Oderich
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
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Akhmerov A, Shah AS, Gupta N, Tulloch AW, Gewertz B, Azizzadeh A. Thoracic Endovascular Aortic Repair in Octogenarians and Nonagenarians. Ann Vasc Surg 2020; 68:299-304. [PMID: 32439524 DOI: 10.1016/j.avsg.2020.04.066] [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: 06/28/2019] [Revised: 04/16/2020] [Accepted: 04/21/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The oldest segments of the population are expanding rapidly, and the number of thoracic endovascular aortic repairs (TEVARs) performed in the elderly parallels this trend. We describe our institutional TEVAR experience in octogenarians and nonagenarians. METHODS All patients 80 years and older undergoing TEVAR at a single institution were reviewed using a prospectively maintained database. Baselines demographics, operative details, and outcomes were retrospectively analyzed. RESULTS Twenty-five octogenarians and nonagenarians (age, 84.8 ± 3.7 years; 64% male) underwent TEVAR between January 2014 and January 2019. The most common preoperative comorbidities were hypertension (n = 24; 96%) and tobacco use (n = 18; 72%), and the mean modified frailty index was 0.32 ± 0.17. Degenerative aneurysms constituted the majority of aortic pathologies (60%), and most patients were symptomatic (64%), with a mean maximal aortic diameter of 62.7 ± 15.6 mm. Endoleaks were noted in 3 (12%) patients. Intensive care unit length of stay was 2.0 (1.5, 3.0) days, and the total length of stay was 5.0 (3.0, 7.0) days. In-hospital mortality was 12% (n = 3), while the overall 30-day mortality was 16% (n = 4). The median follow-up was 469.0 (76.0, 586.0) days. On univariate analysis, the presence of a postoperative complication was associated with a significantly increased risk of 30-day mortality (P < 0.01). CONCLUSIONS Despite the inherently elevated operative risk among the elderly, this study demonstrates reasonable success rates for TEVAR in octogenarian and nonagenarian patients. In properly selected patients, advanced age alone should not be a prohibitive factor for TEVAR.
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Affiliation(s)
- Akbarshakh Akhmerov
- Department of Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Aamir S Shah
- Department of Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA; Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Navyash Gupta
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Allan W Tulloch
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Bruce Gewertz
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Ali Azizzadeh
- Department of Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA; Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
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Kolarczyk LM, Arora H, Manning MW, Zvara DA, Isaak RS. Defining Value-Based Care in Cardiac and Vascular Anesthesiology: The Past, Present, and Future of Perioperative Cardiovascular Care. J Cardiothorac Vasc Anesth 2018; 32:512-521. [DOI: 10.1053/j.jvca.2017.09.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Indexed: 12/22/2022]
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Bakaeen FG, Roselli EE, Johnston DR, Soltesz EG, Tong MZ, Svensson LG. Thoracoabdominal aortic aneurysm repair: big case, big risk, big center! J Surg Res 2016; 206:I-II. [PMID: 27712829 DOI: 10.1016/j.jss.2016.09.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 09/21/2016] [Accepted: 09/22/2016] [Indexed: 11/24/2022]
Affiliation(s)
- Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael Z Tong
- Department of Thoracic and Cardiovascular Surgery, Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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