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Awiwi MO, Kandemirli VB, Kokash D, Hossain F, Gjoni M, Odisio E, Ocazionez D, Ferguson E, Hanna M, Duran C. Complications of thoracic endovascular aneurysm repair (TEVAR): A pictorial review. Curr Probl Diagn Radiol 2024; 53:648-661. [PMID: 38777715 DOI: 10.1067/j.cpradiol.2024.05.018] [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: 12/10/2023] [Revised: 05/06/2024] [Accepted: 05/06/2024] [Indexed: 05/25/2024]
Abstract
Thoracic endovascular aneurysm repair (TEVAR) has replaced open surgical repair as the treatment of choice for several aortic conditions. Despite its lower morbidity and mortality, several TEVAR-related complications can occur and some of which may necessitate surgical or endovascular re-intervention. The current article reviews common and rare complications of TEVAR procedure with emphasis on complications identifiable on cross-sectional imaging and potential pitfalls of pre-procedural planning.
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Affiliation(s)
- Muhammad O Awiwi
- Division of Diagnostic Imaging, The University of Texas Health Science Center at Houston, Texas, USA.
| | | | - Diana Kokash
- Division of Diagnostic Imaging, Dubai Academic Health Corporation, UAE
| | - Ferzana Hossain
- Division of Diagnostic Imaging, The University of Texas Health Science Center at Houston, Texas, USA
| | - Migena Gjoni
- Department of Medicine, Istanbul University-Cerrahpasa Hospital, Istanbul, Turkey
| | - Erika Odisio
- Division of Diagnostic Imaging, The University of Texas Health Science Center at Houston, Texas, USA
| | - Daniel Ocazionez
- Division of Diagnostic Imaging, The University of Texas Health Science Center at Houston, Texas, USA
| | - Emma Ferguson
- Division of Diagnostic Imaging, The University of Texas Health Science Center at Houston, Texas, USA
| | - Mina Hanna
- Division of Diagnostic Imaging, The University of Texas Health Science Center at Houston, Texas, USA
| | - Cihan Duran
- Division of Diagnostic Imaging, The University of Texas Health Science Center at Houston, Texas, USA
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Reutersberg B, Gleason T, Desai N, Ehrlich M, Evangelista A, Braverman A, Myrmel T, Chen EP, Estrera A, Schermerhorn M, Bossone E, Pai CW, Eagle K, Sundt T, Patel H, Trimarchi S, Eckstein HH. Neurological event rates and associated risk factors in acute type B aortic dissections treated by thoracic aortic endovascular repair. J Thorac Cardiovasc Surg 2024; 167:52-62.e5. [PMID: 35260280 DOI: 10.1016/j.jtcvs.2022.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 01/14/2022] [Accepted: 02/01/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Thoracic endovascular aortic repair is the method of choice in patients with complicated type B acute aortic dissection. However, thoracic endovascular aortic repair carries a risk of periprocedural neurological events including stroke and spinal cord ischemia. We aimed to look at procedure-related neurological complications within a large cohort of patients with type B acute aortic dissection treated by thoracic endovascular aortic repair. METHODS Between 1996 and 2021, the International Registry of Acute Aortic Dissection collected data on 3783 patients with type B acute aortic dissection. For this analysis, 648 patients with type B acute aortic dissection treated by thoracic endovascular aortic repair were included (69.4% male, mean age 62.7 ± 13.4 years). Patients were excluded who presented with a preexisting neurologic deficit or received adjunctive procedures. Demographics, clinical symptoms, and outcomes were analyzed. The primary end point was the periprocedural incidence of neurological events (defined as stroke, spinal cord ischemia, transient neurological deficit, or coma). Predictors for perioperative neurological events and follow-up outcomes were considered as secondary end points. RESULTS Periprocedure neurological events were noted in 72 patients (11.1%) and included strokes (n = 29, 4.6%), spinal cord ischemias (n = 21, 3.3%), transient neurological deficits (n = 16, 2.6%), or coma (n = 6, 1.0%). The group with neurological events had a significantly higher in-hospital mortality (20.8% vs 4.3%, P < .001). Patients with neurological events were more likely to be female (40.3% vs 29.3%, P = .077), and aortic rupture was more often cited as an indication for thoracic endovascular aortic repair (38.8% vs 16.5%, P < .001). In patients with neurological events, more stent grafts were used (2 vs 1 stent graft, P = .002). Multivariable logistic regression analysis showed that aortic rupture (odds ratio, 3.12, 95% confidence interval, 1.44-6.78, P = .004) and female sex (odds ratio, 1.984, 95% confidence interval, 1.031-3.817, P = .040) were significantly associated with perioperative neurological events. CONCLUSIONS In this highly selected group from dedicated aortic centers, more than 1 in 10 patients with type B acute aortic dissection treated by thoracic endovascular aortic repair had neurological events, in particular women. Further research is needed to identify the causes and presentation of these events after thoracic endovascular aortic repair, especially among women.
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Affiliation(s)
- Benedikt Reutersberg
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Thomas Gleason
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Nimesh Desai
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Marek Ehrlich
- Department of Cardiothoracic Surgery, University of Vienna, Vienna, Austria
| | | | - Alan Braverman
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St Louis, Mo
| | | | - Edward P Chen
- Division of Cardiovascular Surgery, Duke University School of Medicine, Durham, NC
| | - Anthony Estrera
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Tex
| | - Marc Schermerhorn
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Eduardo Bossone
- Department of Cardiology, San Giovanni e Ruggi, Salerno, Italy
| | - Chih-Wen Pai
- Department of Medicine and Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Mich
| | - Kim Eagle
- Department of Medicine and Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Mich
| | - Thoralf Sundt
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Himanshu Patel
- Cardiac Surgery, University of Michigan Health System, Ann Arbor, Mich
| | - Santi Trimarchi
- Department of Clinical and Community Sciences, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
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Liu YC, Sun YT, Yao YT. Anesthesia management of patients undergoing thoracic endovascular aortic repair: A retrospective analysis of single center. Medicine (Baltimore) 2023; 102:e34508. [PMID: 37565902 PMCID: PMC10419515 DOI: 10.1097/md.0000000000034508] [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: 05/10/2023] [Accepted: 07/05/2023] [Indexed: 08/12/2023] Open
Abstract
Thoracic endovascular aortic repair (TEVAR) is a new alternative surgical treatment for aortic pathologies, which is more minimally invasive. The aim of current study was to summarize the single-center experience of general anesthesia for patients undergoing TEVAR. In adult patients undergoing surgery for congenital heart disease, the strategy of "fast-track" anesthesia with early extubation in theater is associated with a shorter intensive care unit (ICU) stay, and lower health-care-related costs. Fast-track anesthesia has not been assessed in patients under TEVAR. Adult patients who received general anesthesia for TEVAR in our center from January 2020 to December 2020 were included. Baseline characteristics, airway management, anesthetic techniques and major complications were collected. A total of 204 (171 male, mean age 58.1 ± 11.5 years) patients met inclusion criteria for this study. The distribution of pathologies included 29 descending thoracic aneurysms, 87 type B dissections, and 88 intramural hematoma/perforating aortic ulcer. Etomidate was the induction agent in 190 (93.1%) patients, compared with propofol in 16 (7.8%). Cisatracurium was the muscle relaxant in 201 (98.5%), compared with rocuronium in 3 (1.5%). Midazolam (benzodiazepines) was given to 124 (60.8%) patients during anesthesia induction. General anesthesia was maintained with sevoflurane in 85.3% (174) patients, dexmedetomidine in 201 (98.5%) and propofol in 204 (100%). Postoperative length of stay (LOS) in the hospital was 6.0 (5.0-7.8) days. LOS in the ICU was 23.0 (20.0-27.8) hours. Overall neurologic event rate was 2.0% (n = 4) (spinal cord ischemia 1.5% [n = 3]; stroke 0.5% [n = 1]). After matching, patients who received "fast-track" anesthesia had a shorter LOS in ICUs (21.0 [18.0-24.0] vs 24.0 [20.0-44.0] hours; P = .005), and a shorter postoperative LOS in hospital (5.0 [4.0-7.0] vs 6.0 [5.0-8.0] days; P = .001). There were no in-hospital deaths. Fast-track anesthesia is feasible and safe in patients underwent TEVAR. This management strategy is associated with shorter LOS of ICU and total postoperative hospital stays. An early extubation strategy should be implemented for hemodynamically stable patients.
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Affiliation(s)
- Ying-chun Liu
- Department of Anesthesiology, Dongying People’s Hospital, Shandong, China
- Department of Anesthesiology, Anesthesia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yan-ting Sun
- Department of Anesthesiology, Anesthesia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Department of Anesthesiology, Baoji High-Tech Hospital, Shaanxi, China
| | - Yun-tai Yao
- Department of Anesthesiology, Anesthesia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Ali-Hasan-Al-Saegh S, Halloum N, Scali S, Kriege M, Abualia M, Stamenovic D, Bashar Izzat M, Bohan P, Kloeckner R, Oezkur M, Dorweiler B, Treede H, El Beyrouti H. A systematic review and meta-analysis of retrograde type A aortic dissection after thoracic endovascular aortic repair in patients with type B aortic dissection. Medicine (Baltimore) 2023; 102:e32944. [PMID: 37058052 PMCID: PMC10101253 DOI: 10.1097/md.0000000000032944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 01/23/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND Retrograde type A dissection (RTAD) is a devastating complication of thoracic endovascular repair (TEVAR) with low incidence but high mortality. The objective of this study is to report the incidence, mortality, potential risk factors, clinical manifestation and diagnostic modalities, and medical and surgical treatments. METHODS A systematic review and single-arm and two-arm meta-analyses evaluated all published reports of RTAD post-TEVAR through January 2021. All study types were included, except study protocols and animal studies, without time restrictions. Outcomes of interest were procedural data (implanted stent-grafts type, and proximal stent-graft oversizing), the incidence of RTAD, associated mortality rate, clinical manifestations, diagnostic workouts and therapeutic management. RESULTS RTAD occurred in 285 out of 10,600 patients: an estimated RTAD incidence of 2.3% (95% CI: 1.9-2.8); incidence of early RTAD was approximately 1.8 times higher than late. Wilcoxon signed-rank testing showed that the proportion of RTAD patients with acute type B aortic dissection (TBAD) was significantly higher than those with chronic TBAD (P = .008). Pooled meta-analysis showed that the incidence of RTAD with proximal bare stent TEVAR was 2.1-fold higher than with non-bare stents: risk ratio was 1.55 (95% CI: 0.87-2.75; P = .13). Single arm meta-analysis estimated a mortality rate of 42.2% (95% CI: 32.5-51.8), with an I2 heterogeneity of 70.11% (P < .001). CONCLUSION RTAD is rare after TEVAR but with high mortality, especially in the first month post-TEVAR with acute TBAD patients at greater risk as well as those treated with proximal bare stent endografts.
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Affiliation(s)
- Sadeq Ali-Hasan-Al-Saegh
- Department of Cardiac and Vascular Surgery, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Nancy Halloum
- Department of Cardiac and Vascular Surgery, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Salvatore Scali
- Division Vascular Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Marc Kriege
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Mohannad Abualia
- Department of Cardiac and Vascular Surgery, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Davor Stamenovic
- Division of Thoracic Surgery, Academic Thoracic Center Mainz, University Medical Center Mainz, Johannes Gutenberg University Mainz, Mainz, Germany
| | | | | | - Roman Kloeckner
- Department of Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Mehmet Oezkur
- Department of Cardiac and Vascular Surgery, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Bernhard Dorweiler
- Department of Vascular Surgery, Faculty of Medicine, University of Cologne, Koln, Germany
| | - Hendrik Treede
- Department of Cardiac and Vascular Surgery, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Hazem El Beyrouti
- Department of Cardiac and Vascular Surgery, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
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Panossian VS, Berro MM, Ismail AM, Takkoush SI, Chahrour MA, Fadlallah YA, Bahsoun AA, El Harati M, Jaffa MA, Hoballah JJ. General Versus Locoregional Anesthesia in TEVAR: An NSQIP Analysis. Ann Vasc Surg 2023; 90:109-118. [PMID: 36574571 DOI: 10.1016/j.avsg.2022.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/26/2022] [Accepted: 10/04/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Thoracic Endovascular Aortic Repair (TEVAR) is a minimally invasive surgery for repairing thoracic aneurysms and dissections. This study aims to compare postoperative outcomes of TEVAR performed under general versus locoregional anesthesia. METHODS Utilizing the 2008-2019 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, patients older than the age of 18 years who received TEVAR, were identified using the following current procedural terminology codes: 33,880, 33,881, 33,883, 33,884, or 33,886. Patients who underwent concomitant procedures, those with both thoracoabdominal and abdominal aortic pathologies, and trauma cases were excluded. Standard descriptive statistics, in addition to χ2, Fisher's exact test, and Mann-Whitney U-tests were used to compare patient baseline characteristics and postoperative outcomes between general and locoregional anesthesia groups as appropriate. Univariable and multivariable logistic regression analyses were performed to assess independent predictors of hospital length of stay (LOS) greater than 7 days. RESULTS Of the 1,028 patients included in the study, 86.5% received general anesthesia, and 13.5% received locoregional anesthesia, such as local anesthesia with monitored anesthesia care or regional anesthesia. No significant differences were found between patients receiving locoregional versus general anesthesia in mortality (3.6% vs. 7.9%, respectively, P = 0.071) and morbidity (18.7% and 24.8%, respectively, P = 0.121) within 30 days post-TEVAR, including any wound, pulmonary, thromboembolic, renal, septic, and cardiac arrest complications. Patients who received general anesthesia had significantly higher median LOS compared to those who received locoregional anesthesia [5 days (interquartile range (IQR): 3-10) versus 4 days (IQR: 2-7), P = 0.002], with 34.3% of the general anesthesia group having an LOS greater than 7 days compared to 21.6% of locoregional anesthesia group, P = 0.003. On multivariable logistic regression analysis, general anesthesia was found to be an independent predictor of prolonged LOS greater than 7 days (odds ratio (OR): 1.72, 95% confidence interval (CI): 1.05-2.81, P = 0.031). CONCLUSIONS Locoregional anesthesia results in significantly lower postoperative hospital LOS with similar postoperative mortality and morbidity compared to general anesthesia in patients undergoing TEVAR.
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Affiliation(s)
- Vahe S Panossian
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Moussa M Berro
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Ahmad M Ismail
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | | | - Mohamad A Chahrour
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon; Department of Surgery, University of Iowa, Iowa City, IA
| | | | - Aymen A Bahsoun
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Melhem El Harati
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Miran A Jaffa
- Epidemiology and Population Health Department, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Jamal J Hoballah
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon.
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Kamman AV, van Bakel PAJ, Yang B, Williams DM, Kim KM, Khaja MS, Moll FL, van Herwaarden JA, Trimarchi S, Eagle KA, Eliason JL, Patel HJ. Stroke Following Thoracic Endovascular Aortic Repair: Determinants, Short and Long Term Impact. Semin Thorac Cardiovasc Surg 2023; 35:19-30. [PMID: 35091051 DOI: 10.1053/j.semtcvs.2021.08.030] [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: 08/08/2021] [Accepted: 08/18/2021] [Indexed: 11/11/2022]
Abstract
We performed a contemporary assessment of clinical and radiographic factors of stroke after thoracic endovascular aortic repair (TEVAR). Patients undergoing TEVAR from 2006 to 2017 were identified. We assessed clinical and radiographic data, including preoperative head and neck computed tomography, Doppler ultrasonography, and intraoperative angiography. Our primary outcome was stroke after TEVAR. Four hundred seventy-nine patients underwent TEVAR, mean age 68.1 ± 19.5 years, 52.6% male. Indications for TEVAR included aneurysms (n = 238, 49.7%) or dissections (n = 152, 31.7%). Ishimaru landing zones were Zone 2 (n = 225, 47.0%), Zone 3 (n = 151, 31.5%), or Zone 4 (n = 103, 21.5%). Stroke occurred in 3.8% (n = 18) of patients, with 1.9% (8) major events (modified Rankin Scale >3). Pathophysiology was predominantly embolic (n = 14), and occurred in posterior (n = 6), anterior (n = 6), or combined circulation (n = 4), and in the left hemisphere (n = 10) or bilateral (n = 6). Univariate analysis suggested use of lumbar drain (33.3% versus 57.2%, P = 0.04), inability to revascularize the left subclavian artery (16.7% vs 5.2%, P = 0.04) and number of implanted components (2.5 ± 1.2 vs 2.0 ± 0.97, P = 0.03) were associated with stroke. Multivariable analysis identified number of implanted components (OR 1.7, 95%CI 1.17-2.67 P = 0.00) and inability to revascularize the left subclavian artery as independent predictors of stroke. Stroke was associated with a higher perioperative mortality (27.8% vs 3.9%, P < 0.01). Stroke after TEVAR is primarily embolic in nature and related to both anatomic and procedural factors. This may have important implications for device development in the era of endovascular arch repair.
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Affiliation(s)
- Arnoud V Kamman
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands; Thoracic Aortic Research Center, Policlinico San Donato IRCCS, San Donato Milanese, Italy; Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Pieter A J van Bakel
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Bo Yang
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - David M Williams
- Department of Radiology, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Karen M Kim
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Minhaj S Khaja
- Department of Radiology, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Frans L Moll
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Joost A van Herwaarden
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Santi Trimarchi
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, San Donato Milanese, Italy
| | - Kim A Eagle
- Department of Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Jonathan L Eliason
- Department of Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Himanshu J Patel
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan.
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Tan SZCP, Surkhi AO, Singh S, Jubouri M, Bailey DM, Williams IM, Bashir M. Favorable neurological outcomes in thoracic endovascular aortic repair with RELAY™ branched-An international perspective. J Card Surg 2022; 37:3556-3563. [PMID: 36124429 DOI: 10.1111/jocs.16957] [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] [Received: 08/09/2022] [Accepted: 08/19/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND While open surgical repair continues to be the mainstay option for aortic arch reconstruction, the associated mortality, morbidity, and high turn-down rates have led to a need for the development of minimally invasive options for aortic arch repair. Though RELAY™ Branched (Terumo Aortic, Inchinnan, UK) represents a promising option for complex endovascular aortic arch repair, neurological complications remain a pertinent risk. Herein we seek to present multicenter data from Europe documenting the neurological outcomes associated with RELAY™ Branched. METHODS Prospective data collected between January 2019 and January 2022 associated with patients treated with RELAY™ single-, double-, and triple-branched endoprostheses from centers across Europe was retrospectively analyzed with descriptive and distributive analysis. Follow-up data from 30 days and 6, 12, and 24 months postoperatively were included. Patient follow-up was evaluated for the onset of disabling stroke (DS) and non-disabling stroke (NDS). RESULTS Technical success was achieved in 147 (99.3%) cases. Over 24 months period, in total, six (4.1%) patients suffered DS, and eight (5.4%) patients suffered NDS after undergoing aortic arch repair with RELAY™. All patients that developed postoperative DS had been treated with the double-branched RELAY™ endoprosthesis. DISCUSSION The data presented herein demonstrates that RELAY™ Branched is associated with favorable neurological outcomes and excellent technical success rates. Key design features of the endoprosthesis and good perioperative management can contribute greatly to mitigating neurological complications following endovascular aortic arch repair.
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Affiliation(s)
- Sven Z C P Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Sidhant Singh
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Matti Jubouri
- Hull-York Medical School, University of York, Heslington, UK
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Newport, UK
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Newport, UK
| | - Mohamad Bashir
- Vascular and Endovascular Surgery, Velindre University NHS Trust, Health Education and Improvement Wales, Cardiff, UK
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8
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Branzan D, Geisler A, Steiner S, Lautenschlaeger T, Doss M, Matschuck M, Scheinert D, Schmidt A. Stroke rate after thoracic endovascular aortic repair using de-airing of stentgrafts with high-volume of saline solution. VASA 2021; 50:186-192. [PMID: 33559507 DOI: 10.1024/0301-1526/a000937] [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: 11/19/2022]
Abstract
Background: Our aim was to determine the rate of ischemic stroke following thoracic endovascular aortic repair (TEVAR) after reducing gas volume released during stentgraft deployment by de-airing of thoracic stentgrafts with high-volume of 0.9% heparinized saline solution. Patients and methods: A single center retrospective analysis of all consecutive patients undergoing TEVAR from 2014 to 2019 was performed. All thoracic stentgrafts were flushed with 120 ml 0.9% heparinized saline solution before implantation, according to our institutional protocol. Endpoints were in-hospital rates of ischemic stroke and spinal cord ischemia (SCI), and all-cause mortality. Results: One hundred and fifty-four patients (mean age: 66.8 ± 13.6 years, 64.9% males) were treated with TEVAR during the study period. Indications for treatment were thoracic aortic aneurysms (n = 75, 48.7%), acute type B aortic dissections (n = 46, 29.9%), aortic arch aneurysms and penetrating aortic ulcers (n = 28, 18.2%), and blunt traumatic aortic injuries (n = 5, 3.2%). Timing of procedure was urgent in 75 patients (48.7%). Proximal landing zone were zone 0-1-2 (n = 75, 48.7%), zone 3 (n = 66, 42.9%) and zone 4 (n = 13, 8.4%). Supra-aortic vessels were revascularized with custom-made fenestrated stentgrafts in 9 patients (5.8%), using chimney technique in 4 patients (2.6%), and with debranching procedures in 19 patients (12.3%). Left subclavian artery was covered without revascularization in 46 patients (29.9%). In-hospital stroke occurred in two patients (1.3%) and SCI in another two patients (1.3%). In-hospital mortality rate was 0.6%. No further in-hospital events were noted. Conclusions: De-airing of stentgrafts with high-volume of 0.9% heparinized saline solution seems to be safe and can be used as an adjunct to keep occurrence of neurological events after TEVAR as low as possible.
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Affiliation(s)
- Daniela Branzan
- Department of Vascular Surgery, University Hospital Leipzig, Germany
| | - Antonia Geisler
- Department of Vascular Surgery, University Hospital Leipzig, Germany
| | - Sabine Steiner
- Department of Interventional Angiology, University Hospital Leipzig, Germany
| | | | - Markus Doss
- Department of Vascular Surgery, University Hospital Leipzig, Germany
| | - Manuela Matschuck
- Department of Interventional Angiology, University Hospital Leipzig, Germany
| | - Dierk Scheinert
- Department of Interventional Angiology, University Hospital Leipzig, Germany
| | - Andrej Schmidt
- Department of Interventional Angiology, University Hospital Leipzig, Germany
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9
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Chavan A, Eldergash O, Thomas RP. Role of Endoluminal Techniques in the Management of Acute Type B Aortic Dissection and Intramural Haematoma. Cardiovasc Intervent Radiol 2020; 43:1798-1807. [PMID: 33000316 DOI: 10.1007/s00270-020-02652-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022]
Abstract
Twenty-five years ago, optimal medical management was the mainstay of treatment in acute type B aortic dissection (TBAD) and intramural haematoma (IMH), with surgery being reserved for cases with rupture or critical branch vessel ischaemia. Less invasive endoluminal management of TBAD and IMH has developed rapidly over the past two and a half decades, thus changing the treatment algorithm in these patients. Today the focus has shifted to primary management with a combination of endoluminal intervention and optimal medical treatment. The purpose of this article is to describe the various interventional techniques, discuss the indications for intervention, and present the results in the current literature regarding clinical (rupture, branch vessel ischaemia) as well as morphological response (aortic remodelling), complications, and morbidity/mortality associated with endoluminal intervention.
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Affiliation(s)
- Ajay Chavan
- Department of Diagnostic and Interventional Radiology, Christliches Krankenhaus Quakenbrück, Danziger Strasse 2, 49610, Quakenbrück, Germany.
| | - Osama Eldergash
- Institute of Diagnostic and Interventional Radiology, Klinikum Oldenburg, Oldenburg, Germany
| | - Rohit Philip Thomas
- Clinic for Diagnostic and Interventional Radiology, UKGM Marburg, Marburg, Germany
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10
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Usai MV, Nugroho NT, Oberhuber A, Asciutto G. Influence of TEVAR on blood pressure in subacute type B aortic dissection (TBAD) patients with refractory and non-refractory arterial hypertension. INT ANGIOL 2020; 40:60-66. [PMID: 32959641 DOI: 10.23736/s0392-9590.20.04433-8] [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 Aim of this study was to compare the modifications of systemic blood pressure in patients with subacute type b aortic dissection (TBAD) and refractory (rHTN) and non-refractory arterial hypertension (N-rHTN) treated by thoracic endovascular aortic repair (TEVAR). METHODS Patients were divided into two groups, rHTN defined as blood pressure >140/90 mmHg with ≥5 antihypertensive drugs and patients with N-rHTN. Primary endpoint was the variation of mean systolic, diastolic and overall pressure (MSP, MDP and MAP) before and after antihypertensive treatment or TEVAR. Secondary endpoints were the 30-days mortality. Fifty-seven patients were included in this study. RESULTS Of the 44 Patients of the TEVAR group 21 were included in the N-rHTN group. The MSP before and after surgery for the N-rHTN group was 130 (±10 SD) and 111 (±22 SD) mmHg, P=0.01. In the rHTN group 164 (±17 SD) and 118 (±17 SD) mmHg (P=0.01). The reduction of MSP was greater in the rHTN group (P=0.01). The MAP before and after the TEVAR for the N-rHTN group was 90 (±10 SD) and 74 (±12 SD) mmHg (P=0.01), in the rHTN group 111 (±14 SD) and 70 (±9 SD) mmHg (P=0.01). The overall mortality rate group was 2.2% (1/44). CONCLUSIONS TEVAR for TBAD appears to positively affect blood pressure in patients with rHTN and N-rHTN.
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Affiliation(s)
- Marco V Usai
- Department of Vascular and Endovascular Surgery, University Hospital of Münster, Münster, Germany -
| | - Nyityasmono T Nugroho
- Department of Vascular and Endovascular Surgery, University Hospital of Münster, Münster, Germany
| | - Alexander Oberhuber
- Department of Vascular and Endovascular Surgery, University Hospital of Münster, Münster, Germany
| | - Giuseppe Asciutto
- Department of Vascular and Endovascular Surgery, University Hospital of Münster, Münster, Germany
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11
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Intravascular Ultrasound-Assisted Endovascular Exclusion of Penetrating Aortic Ulcers. Ann Vasc Surg 2020; 70:467-473. [PMID: 32634558 DOI: 10.1016/j.avsg.2020.06.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Penetrating aortic ulcer (PAU) is an atherosclerotic lesion penetrating the elastic lamina and extending into the media of the aorta. It may evolve into intramural hematoma, focal dissection, pseudoaneurysm, and eventually rupture. The purpose of this study was to evaluate the effectiveness of a totally intravascular ultrasound (IVUS)-assisted endovascular exclusion of PAU. METHODS Thirteen consecutive patients (median age 66 years) underwent IVUS-assisted endovascular exclusion of PAU. The primary end points were fluoroscopy time, radiation dose, and occurrence of type I primary endoleak. Secondary end points were postoperative mortality and morbidity, arterial access complications, postoperative length of stay in the hospital, and occurrence of type II endoleaks. RESULTS The median fluoroscopy time was 4 min (4-5). The median radiation dose was 4.2 mGy (3.9-4.5). A proximal and distal landing zone of at least 2 cm could be obtained in all the patients. No patient presented a type I endoleak. No postoperative mortality, no morbidity, or arterial access complication was observed. The median length of postoperative stay in the hospital was 2 days (2-3). The median length of follow-up was 25 months (9.2-38.7). One late type II endoleak was observed (7.7%), because of reflux from the intercostal arteries, without the need for additional treatment. CONCLUSIONS IVUS-assisted endovascular treatment of PAU allows durable exclusion of PAU with a short fluoroscopy time and no need for injection of contrast media. Further series are needed to confirm the results of this preliminary study.
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12
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Massara M, Alberti A, Volpe P. Early and mid-term results of endovascular treatment of thoracic aorta diseases: a single-center experience. Semin Vasc Surg 2020; 32:111-116. [PMID: 32553123 DOI: 10.1053/j.semvascsurg.2020.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We conducted an analysis to assess early and mid-term outcomes of patients after thoracic endovascular aortic repair (TEVAR) for type B thoracic aorta dissection, descending thoracic aneurysm, or traumatic aortic transection. From January 2016 through December 2018, twenty-seven patients (23 male, 4 female, mean age of 57 years) affected by type B dissection (n = 13 [48.2%]), thoracic aneurysm (n = 9 [33.3%]), and post-traumatic aortic isthmus rupture (n = 5 [18.5%]) were treated using TEVAR with and without left subclavian artery revascularization. All procedures were performed in a hybrid operating room using general (n = 12) or regional (n = 15) anesthesia. A combined brachial artery and bilateral femoral artery access was used in all patients. To achieve adequate proximal thoracic aorta landing zone length, coverage of the left subclavian artery with proximal endovascular plug occlusion was performed in 17 patients (62.9%); including 4 patients undergoing carotid-subclavian artery bypass before TEVAR stent-graft deployment. Primary procedural success rate was 96.3%; 1 patient had a Type Ib endoleak that was treated by distal stent graft extension. Four adverse outcomes occurred in the immediate postoperative period, including 2 cases of left upper arm acute ischemia (7.4%), ischemic stroke (3.7%), and asymptomatic iliac artery dissection (3.7%). During a mean follow-up of 18 months, no graft-related deaths or endoleak occurred. One patient developed symptomatic subclavian steal syndrome 1 month after operation and underwent a left carotid-subclavian artery bypass with symptom resolution. One patient died 6 months after TEVAR due to neoplasm. Our experience indicates TEVAR is a safe and less invasive alternative to open surgery for a spectrum of thoracic aorta diseases, especially for urgent conditions and in patients with high-risk surgical comorbidities.
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Affiliation(s)
- Mafalda Massara
- Unit of Vascular and Endovascular Surgery, Grande Ospedale Metropolitano, Bianchi-Melacrino-Morelli, Via Giuseppe Melacrino 21-89124, Reggio Calabria, Italy.
| | - Antonino Alberti
- Unit of Vascular and Endovascular Surgery, Grande Ospedale Metropolitano, Bianchi-Melacrino-Morelli, Via Giuseppe Melacrino 21-89124, Reggio Calabria, Italy
| | - Pietro Volpe
- Unit of Vascular and Endovascular Surgery, Grande Ospedale Metropolitano, Bianchi-Melacrino-Morelli, Via Giuseppe Melacrino 21-89124, Reggio Calabria, Italy
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13
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Subbiah MM, Velayudhan BV. Spinal subarachnoid hemorrhage in type B aortic dissection: a rare presentation. Asian Cardiovasc Thorac Ann 2020; 28:175-178. [DOI: 10.1177/0218492320901935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Paraplegia is a common complication encountered during surgical and endovascular repair of aortic diseases. At times, it is also a presenting feature of aortic dissection. Involvement of more than one spinal blood supply system is the most common cause of spinal cord ischemia. Proper planning is needed to prevent and treat spinal cord ischemia. We report this rare case of acute type B aortic dissection that presented with paraplegia due to a spinal subarachnoid hemorrhage.
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Affiliation(s)
- Meenakshi M Subbiah
- Department of Cardiology, Institute of Cardiac and Vascular Diseases, Madras Medical Mission Hospital, Mogappair, Chennai, India
| | - Bashi V Velayudhan
- Institute of Cardiac and Advanced Aortic Disorders, SIMS Hospital, Chennai, India
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14
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Khaĭrutdinov AI, Iakubov RA, Sharafutdinov MR. [Treatment of a patient with Crawford type III thoracoabdominal aortic aneurysm]. ANGIOLOGIIA I SOSUDISTAIA KHIRURGIIA = ANGIOLOGY AND VASCULAR SURGERY 2020; 26:163-169. [PMID: 32597898 DOI: 10.33529/angio2020221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Presented herein is a clinical case report regarding hybrid techniques successfully used in a patient suffering from a Crawford type III thoracoabdominal aortic aneurysm and DeBakey type IIIB aortic dissection. The first stage consisted in endoprosthetic reconstruction of the descending portion of the thoracic aorta, with the second stage including visceral debranching with endoprosthetic reconstruction of the thoracoabdominal portion of the aorta. As the final stage, the patient was subjected to debranching of brachiocephalic arteries, followed by endoprosthetic repair of the aortic arch. The chosen approach made it possible to avoid the use of extracorporeal circulation, aortic occlusion, and, consequently, prolonged postoperative recovery.
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Affiliation(s)
- A I Khaĭrutdinov
- Cardiovascular Surgery Department, Emergency Hospital, Naberezhnye Chelny, Russia
| | - R A Iakubov
- Cardiovascular Surgery Department, Emergency Hospital, Naberezhnye Chelny, Russia
| | - M R Sharafutdinov
- Cardiovascular Surgery Department, Emergency Hospital, Naberezhnye Chelny, Russia
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15
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Zha B, Qiu P, Xie W, Zhang Z, Li Y, Chen Z, Zhu H. Surgical Outcomes And Postoperative Descending Aorta Morphologic Remodeling After Thoracic Endovascular Aortic Repair For Acute And Chronic Type B Aortic Dissection. Clin Interv Aging 2019; 14:1925-1935. [PMID: 31806948 PMCID: PMC6842900 DOI: 10.2147/cia.s225305] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/07/2019] [Indexed: 01/16/2023] Open
Abstract
Background This study aims to investigate the descending aortic morphological alterations caused by pathological changes in acute and chronic Type B aortic dissection (TBAD) and morphological remodeling after thoracic endovascular aortic repair (TEVAR). Patients and methods From February 2012 to January 2016, 86 TBAD patients undergoing TEVAR were divided into an acute group (n=63) and a chronic group (n=23). The areas of the true, false and maximal lumen and descending aorta morphological parameters, including the taper ratio (TR), oversizing ratio (OR), mismatch ratio (MR), radius of curvature (RoC) and tortuosity index (TI), were evaluated. Follow-ups were performed postoperatively before discharge, at 1 and 6 months, and yearly thereafter. Results Before TEVAR, the TR (0.57 (0.49) vs 0.74 (0.60); P < 0.05), OR (2.75 ± 1.89 vs 3.96 ± 2.27; P < 0.05) and TI (1.22 (1.19) vs 1.41 ± 0.17; P < 0.05) were significantly higher in the chronic group than in the acute group. The TEVAR technical success rate was 100%. No differences were found in 30-day and >30-day mortality between the two groups. Pathology-specific devices, such as tapered stent grafts and distal bare stents, were used more frequently in the chronic group than in the acute group (47.8% vs 23.8%, P = 0.03; 43.5% vs 12.7%, P = 0.002, respectively). The OR and TI changes that occurred after TEVAR were significantly higher in the chronic group than in the acute group (1.80 ± 0.86 vs 2.98 ± 1.85, P = 0.028; 0.00 ± 0.09 vs 0.09 ± 0.10, P < 0.001, respectively). Conclusion TEVAR is a safe and effective therapy for acute and chronic TBAD. Compared to acute TBAD, chronic TBAD resulted in an adverse preoperative descending aorta morphology. Pathology-specific devices may be a feasible treatment option for endovascular repair of chronic TBAD. A larger series of cases with longer follow-up are needed to draw definitive conclusions.
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Affiliation(s)
- Binshan Zha
- Department of Vascular and Thyroid Surgery, Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Anhui 230022, People's Republic of China
| | - Peng Qiu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Vascular Center of Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - Wentao Xie
- Department of Vascular and Thyroid Surgery, Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Anhui 230022, People's Republic of China
| | - Zhigong Zhang
- Department of Vascular and Thyroid Surgery, Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Anhui 230022, People's Republic of China
| | - Yongsheng Li
- Department of Vascular and Thyroid Surgery, Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Anhui 230022, People's Republic of China
| | - Zhiyong Chen
- Department of Vascular and Thyroid Surgery, Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Anhui 230022, People's Republic of China
| | - Huagang Zhu
- Department of Vascular and Thyroid Surgery, Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Anhui 230022, People's Republic of China
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16
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Piazza M, Squizzato F, Milan L, Miccoli T, Grego F, Antonello M. Incidence and Predictors of Neurological Complications Following Thoracic Endovascular Aneurysm Repair in the Global Registry for Endovascular Aortic Treatment. Eur J Vasc Endovasc Surg 2019; 58:512-519. [DOI: 10.1016/j.ejvs.2019.05.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 05/06/2019] [Accepted: 05/10/2019] [Indexed: 02/05/2023]
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17
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Late open conversion after thoracic endovascular aortic repair. J Vasc Surg 2019; 70:439-448.e1. [DOI: 10.1016/j.jvs.2018.11.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 11/05/2018] [Indexed: 11/17/2022]
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18
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Son SA, Hahm MH, Kim YE, Kim GJ. Fracture of the Bare Spring of a Thoracic Endograft for Type A Aortic Dissection: A Case Report. Vasc Specialist Int 2019; 35:39-43. [PMID: 30993107 PMCID: PMC6453602 DOI: 10.5758/vsi.2019.35.1.39] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Retrograde type A aortic dissection (RTAD) following thoracic endovascular aortic repair is a devastating complication associated with high mortality rates. In particular, a deployed endograft in a bird-beak formation in an acute curve of the aortic arch can induce injury to the fragile aortic wall, with the subsequent development of RTAD. Here, we describe an extremely rare case of RTAD caused by fracture of the bare spring of the thoracic endograft for type A aortic dissection.
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Affiliation(s)
- Shin-Ah Son
- Department of Thoracic and Cardiovascular Surgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Myong Hun Hahm
- Department of Radiology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Young Eun Kim
- Department of Thoracic and Cardiovascular Surgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Gun-Jik Kim
- Department of Thoracic and Cardiovascular Surgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
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19
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Geisbüsch S, Kuehnl A, Salvermoser M, Reutersberg B, Trenner M, Eckstein HH. Increasing Incidence of Thoracic Aortic Aneurysm Repair in Germany in the Endovascular Era: Secondary Data Analysis of the Nationwide German DRG Microdata. Eur J Vasc Endovasc Surg 2019; 57:499-509. [DOI: 10.1016/j.ejvs.2018.08.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 08/09/2018] [Indexed: 10/28/2022]
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20
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Yammine H, Krcelic D, Ballast JK, Briggs CS, Stanley G, Nussbaum T, Frederick JR, Arko FR. Cocaine use is associated with worse outcomes in patients treated with thoracic endovascular repair for type B aortic dissection. J Vasc Surg 2019; 70:60-66. [PMID: 30792056 DOI: 10.1016/j.jvs.2018.10.061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/14/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To describe and compare the clinical and anatomical characteristics and outcomes of patients with and without known cocaine use who underwent thoracic endovascular repair for type B aortic dissections. METHODS Between January 2012 and January 2017, 186 patients underwent thoracic endovascular repair for type B aortic dissection at our institution. Clinical data and anatomical characteristics were collected under an institutional review board-approved protocol. Survival, reintervention, complications, and characteristics of dissection were compared between patients with cocaine use (C+; n = 14) and those with no known cocaine use (C-; n = 172). RESULTS Cocaine users were more likely to be young African American males who smoked. They tended to present with more extensive dissections as evidenced by larger false lumen diameters. They also had higher rates of endoleaks and more reinterventions. CONCLUSIONS These results suggest that special care should be taken to provide close follow-up for these patients.
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Affiliation(s)
- Halim Yammine
- Sanger Heart & Vascular Institute, Atrium Health, Charlotte, NC
| | - Daniel Krcelic
- Sanger Heart & Vascular Institute, Atrium Health, Charlotte, NC
| | | | | | - Gregory Stanley
- Sanger Heart & Vascular Institute, Atrium Health, Charlotte, NC
| | - Tzvi Nussbaum
- Sanger Heart & Vascular Institute, Atrium Health, Charlotte, NC
| | | | - Frank R Arko
- Sanger Heart & Vascular Institute, Atrium Health, Charlotte, NC.
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21
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Zierler RE, Jordan WD, Lal BK, Mussa F, Leers S, Fulton J, Pevec W, Hill A, Murad MH. The Society for Vascular Surgery practice guidelines on follow-up after vascular surgery arterial procedures. J Vasc Surg 2018; 68:256-284. [PMID: 29937033 DOI: 10.1016/j.jvs.2018.04.018] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 04/11/2018] [Indexed: 12/20/2022]
Abstract
Although follow-up after open surgical and endovascular procedures is generally regarded as an important part of the care provided by vascular surgeons, there are no detailed or comprehensive guidelines that specify the optimal approaches with regard to testing methods, indications for reintervention, and follow-up intervals. To provide guidance to the vascular surgeon, the Clinical Practice Council of the Society for Vascular Surgery appointed an expert panel and a methodologist to review the current clinical evidence and to develop recommendations for follow-up after vascular surgery procedures. For those procedures for which high-quality evidence was not available, recommendations were based on observational studies, committee consensus, and indirect evidence. Recognizing that there are numerous published reports on the role of duplex ultrasound for surveillance of infrainguinal vein bypass grafts, the Society commissioned a systematic review and meta-analysis on this topic. The panel classified the strength of each recommendation and the corresponding quality of evidence on the basis of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system: recommendations were graded either strong or weak, and the quality of evidence was graded high, moderate, or low. The resulting recommendations represent a wide variety of open surgical and endovascular procedures involving the extracranial carotid artery, thoracic and abdominal aorta, mesenteric and renal arteries, and lower extremity arterial revascularization. The panel also identified many areas in which there was a lack of high-quality evidence to support their recommendations. This suggests that there are opportunities for further clinical research on testing methods, threshold criteria, and the role of surveillance as well as on the modes of failure and indications for reintervention after vascular surgery procedures.
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Affiliation(s)
| | | | - Brajesh K Lal
- Department of Surgery, University of Maryland, Baltimore, Md
| | - Firas Mussa
- Department of Surgery Palmetto Health/University of South Carolina School of Medicine, Columbia, SC
| | - Steven Leers
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Joseph Fulton
- Department of Surgery, Westchester Medical Center, Poughkeepsie, NY
| | - William Pevec
- Division of Vascular Surgery, University of California, Davis, Sacramento, Calif
| | - Andrew Hill
- Division of Vascular & Endovascular Surgery, The Ottawa Hospital & University of Ottawa, Ottawa, Ontario, Canada
| | - M Hassan Murad
- Division of Preventive Medicine, Mayo Clinic, Rochester, Minn
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22
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MDCT angiography before and after thoracic endovascular aortic repair (TEVAR) in patients with thoracic traumatic aortic injuries. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2018. [DOI: 10.1016/j.ejrnm.2017.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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23
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Kamman AV, Eliason JL, Williams DM, Yang B, Moll FL, Trimarchi S, Eagle KA, Patel HJ. Impact of Left Subclavian Artery Revascularization before Thoracic Endovascular Aortic Repair on Postoperative Cerebrovascular Hemodynamics. Ann Vasc Surg 2018. [DOI: 10.1016/j.avsg.2017.06.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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24
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Schoenhoff FS, Carrel TP. Re-interventions on the thoracic and thoracoabdominal aorta in patients with Marfan syndrome. Ann Cardiothorac Surg 2017; 6:662-671. [PMID: 29270378 DOI: 10.21037/acs.2017.09.14] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The advent of multi-gene panel genetic testing and the discovery of new syndromic and non-syndromic forms of connective tissue disorders have established thoracic aortic aneurysms as a genetically mediated disease. Surgical results in patients with Marfan syndrome (MFS) provide an important benchmark for this patient population. Prophylactic aortic root surgery prevents acute dissection and has contributed to the improved survival of MFS patients. In the majority of patients, re-interventions are driven by a history of dissection. Patients undergoing elective root repair have a low risk for re-interventions on the root itself. Experienced centers have results after valve-sparing procedures at 10 years comparable with those seen after a modified Bentall procedure. In patients where only the ascending aorta was replaced during the initial surgery, re-intervention rates are high as the root continues to dilate. The fate of the aortic arch in MFS patients presenting with dissection is strongly correlated with the extent of the initial surgery. Not replacing the entire ascending aorta and proximal aortic arch results in a high rate of re-interventions. Nevertheless, the additional burden of replacing the entire aortic arch during emergent proximal repair is not very well defined and makes comparisons with patients undergoing elective arch replacement difficult. Interestingly, replacing the entire aortic arch during initial surgery for acute dissection does not protect from re-interventions on downstream aortic segments. MFS patients suffering from type B dissection have a high risk for re-interventions ultimately leading up to replacement of the entire thoracoabdominal aorta even if the dissection was deemed uncomplicated by conventional criteria. While current guidelines do not recommend the implantation of stent grafts in MFS patients, implantation of a frozen-elephant-trunk to create a stable proximal landing zone for future endovascular or open procedures has emerged as a means to address aortic arch and descending aortic pathologies.
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Affiliation(s)
- Florian S Schoenhoff
- Department of Cardiovascular Surgery, University Hospital Bern, Bern, Switzerland
| | - Thierry P Carrel
- Department of Cardiovascular Surgery, University Hospital Bern, Bern, Switzerland
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25
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Chen Y, Zhang S, Liu L, Lu Q, Zhang T, Jing Z. Retrograde Type A Aortic Dissection After Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2017; 6:JAHA.116.004649. [PMID: 28939705 PMCID: PMC5634245 DOI: 10.1161/jaha.116.004649] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Retrograde type A aortic dissection (RTAD) is a potentially lethal complication after thoracic endovascular aortic repair (TEVAR). However, data are limited regarding the development of RTAD post‐TEVAR. This systematic review aims to define the incidence, mortality, and potential risk factors of RTAD post‐TEVAR. Methods and Results Multiple electronic searches were performed. Fifty publications with a total of 8969 patients were analyzed. Pooled estimates for incidence and mortality of RTAD were 2.5% (95% confidence interval [CI], 2.0–3.1) and 37.1% (95% CI, 23.7–51.6), respectively. Metaregression analysis evidenced that RTAD rate was associated with hypertension (P=0.043), history of vascular surgery (P=0.042), and American Surgical Association (P=0.044). The relative risk of RTAD was 1.81 (95% CI, 1.04–3.14) for acute dissection (relative to chronic dissection) and 5.33 (95% CI, 2.70–10.51) for aortic dissection (relative to a degenerative aneurysm). Incidence of RTAD was significantly different in patients with proximal bare stent and nonbare stent endografts (relative risk [RR]=2.06; 95% CI, 1.22–3.50). RTAD occurrence rate in zone 0 was higher than other landing zones. Conclusions The pooled RTAD rate after TEVAR was calculated at 2.5% with a high mortality rate (37.1%). Incidence of RTAD is significantly more frequent in patients treated for dissection than those with an aneurysm (especially for acute dissection), and when the proximal bare stent was used. Rate of RTAD after TEVAR varied significantly according to the proximal Ishimaru landing zone. The more‐experienced centers tend to have lower RTAD incidences.
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Affiliation(s)
- Yanqing Chen
- Division of Vascular Surgery, Changhai Hospital, Shanghai, China.,Military Institute of Vascular Disease, The First Affiliated Hospital of the Second Military Medical University, Shanghai, China
| | - Simeng Zhang
- Division of Vascular Surgery, Changhai Hospital, Shanghai, China.,Military Institute of Vascular Disease, The First Affiliated Hospital of the Second Military Medical University, Shanghai, China
| | - Lei Liu
- Division of Vascular Surgery, Changhai Hospital, Shanghai, China.,Military Institute of Vascular Disease, The First Affiliated Hospital of the Second Military Medical University, Shanghai, China
| | - Qingsheng Lu
- Division of Vascular Surgery, Changhai Hospital, Shanghai, China .,Military Institute of Vascular Disease, The First Affiliated Hospital of the Second Military Medical University, Shanghai, China
| | - Tianyi Zhang
- Department of statistics, The Second Military Medical University, Shanghai, China
| | - Zaiping Jing
- Division of Vascular Surgery, Changhai Hospital, Shanghai, China .,Military Institute of Vascular Disease, The First Affiliated Hospital of the Second Military Medical University, Shanghai, China
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26
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Results of the VALOR II trial of the Medtronic Valiant Thoracic Stent Graft. J Vasc Surg 2017; 66:335-342. [DOI: 10.1016/j.jvs.2016.12.136] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 12/05/2016] [Indexed: 11/17/2022]
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27
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Hu FY, Fang ZB, Leshnower BG, Duwayri Y, Jordan WD, Gillespie TW, Veeraswamy RK. Contemporary evaluation of mortality and stroke risk after thoracic endovascular aortic repair. J Vasc Surg 2017; 66:718-727.e5. [PMID: 28502542 DOI: 10.1016/j.jvs.2017.01.069] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 01/29/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE During the past decade, thoracic endovascular aortic repair (TEVAR) has increased as a treatment option for a variety of aortic pathologic processes. Despite this rise in the use of thoracic stent grafts, real-world outcomes from a robust, adjudicated, contemporary data set have yet to be reported. Previous studies have shown periprocedural mortality rates between 1.5% and 9.5% and procedure-related stroke rates of 2.3% to 8.2%. With advances in device engineering and increased experience of physicians, we hypothesized that the rates of these complications would be reduced in a more recent sample set. The purpose of this study was to determine current rates of mortality and stroke after TEVAR, to identify risk factors that contribute to 30-day mortality, and to develop a simple scoring system that allows risk stratification of patients undergoing TEVAR. METHODS We examined the 30-day mortality rate after TEVAR using the 2013 to 2014 American College of Surgeons National Surgical Quality Improvement Program database. Patients undergoing TEVAR for all aortic disease were identified using procedure codes. Bivariate analyses were performed to evaluate the association of preoperative, intraoperative, and postoperative variables with 30-day mortality, followed by multivariable logistic analysis using preoperative variables only, with P < .10 as the criterion for model entry. The predictive logistic model was internally validated by cross-validation. Variables included in the multivariable model were used to develop a risk score. RESULTS There were 826 patients included. The 30-day mortality and stroke rates were 7.63% (n = 63) and 4.5% (n = 37), respectively. In regression analysis, mortality was independently associated with age ≥80 years (odds ratio [OR], 2.32; 95% confidence interval [CI], 1.25-4.31), emergency case (OR, 2.61; 95% CI, 1.39-4.90), American Society of Anesthesiologists classification >3 (OR, 2.89; 95% CI, 1.34-6.24), transfusion >4 units in the 72 hours before surgery (OR, 2.86; 95% CI, 1.30-6.28), preoperative creatinine concentration ≥1.8 mg/dL (OR, 2.07; 95% CI, 1.05-4.08), and preoperative white blood cell count ≥12 × 109/L (OR, 2.65; 95% CI, 1.41-4.96). Incorporating these factors, a 6-point risk score was generated and demonstrated high predictability for overall 30-day mortality. CONCLUSIONS Recent data from a national, retrospective data set demonstrate that high perioperative mortality and stroke rates have persisted during the last decade. The risk score derived from this data set is simple and convenient and serves as a prognostic tool in the preoperative risk stratification of patients being evaluated for TEVAR.
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Affiliation(s)
- Frances Y Hu
- Division of Vascular and Endovascular Therapy, Department of Surgery, Emory University, Atlanta, Ga
| | - Zachary B Fang
- Division of Vascular and Endovascular Therapy, Department of Surgery, Emory University, Atlanta, Ga
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University, Atlanta, Ga
| | - Yazan Duwayri
- Division of Vascular and Endovascular Therapy, Department of Surgery, Emory University, Atlanta, Ga
| | - William D Jordan
- Division of Vascular and Endovascular Therapy, Department of Surgery, Emory University, Atlanta, Ga
| | - Theresa W Gillespie
- Department of Surgery and Department of Hematology & Medical Oncology, Emory University, Atlanta, Ga
| | - Ravi K Veeraswamy
- Division of Vascular Surgery, Department of Surgery, the Medical University of South Carolina, Charleston, SC.
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Nienaber CA, Sakalihasan N, Clough RE, Aboukoura M, Mancuso E, Yeh JS, Defraigne JO, Cheshire N, Rosendahl UP, Quarto C, Pepper J. Thoracic endovascular aortic repair (TEVAR) in proximal (type A) aortic dissection: Ready for a broader application? J Thorac Cardiovasc Surg 2017; 153:S3-S11. [DOI: 10.1016/j.jtcvs.2016.07.078] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 07/06/2016] [Accepted: 07/30/2016] [Indexed: 10/21/2022]
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Ahmed Z, McHugh SM, Elmallah A, Colgan MP, O'Callaghan A, O'Neill SM, Madhavan P, Martin Z. Emergency endovascular management of acute thoracic aortic pathology A safe and feasible option. Surgeon 2016; 15:325-328. [PMID: 28034631 DOI: 10.1016/j.surge.2016.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 10/16/2016] [Indexed: 11/19/2022]
Abstract
Endovascular repair has revolutionised the emergency treatment of thoracic aortic disease. We report our 10 year experience using this treatment in emergency cases. A prospectively maintained vascular database was analysed. Patients' medical records and CT images stored on the hospital PACS system were also reviewed. Statistical analysis was done using IBM SPSS V21. There were a total of 59 thoracic aortic stenting procedures of which 33 (60% males with a mean age of 58 yrs) were performed for emergency thoracic pathologies: traumatic transection (n = 10), ruptured aneurysm (n = 6), non-traumatic dissection (n = 8) and penetrating aortic ulcer (n = 9). All patients had self-expanding endografts implanted. Two patients required debranching procedures before the endovascular treatment. Thirty-day mortality was 12.1% (4/33). 70% of patients received a single device. There were 7 procedure related complications, 6 requiring re-intervention: thoracotomy and drainage in 2 patients, proximal graft extension in 2, open drainage of groin haematoma in 1 and open repair of a common femoral artery pseudo-aneurysm in one patient. In total 23 patients were transferred from 11 centres nationwide. There were no mortalities or other complications related to patient transfer from peripheral centres. Although acute thoracic aortic pathology is life threatening, appropriate blood pressure management and treatment of associated injuries can result in favourable outcomes. Endovascular repair is a safe and effective treatment option which enables patients to be treated with reduced morbidity and mortality. Transfer of patients with acute pathology to a tertiary centre can safely be performed.
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Affiliation(s)
- Z Ahmed
- St James's Vascular Institute, St James's Hospital, Dublin, Ireland.
| | - S M McHugh
- St James's Vascular Institute, St James's Hospital, Dublin, Ireland
| | - A Elmallah
- St James's Vascular Institute, St James's Hospital, Dublin, Ireland
| | - M P Colgan
- St James's Vascular Institute, St James's Hospital, Dublin, Ireland
| | - A O'Callaghan
- St James's Vascular Institute, St James's Hospital, Dublin, Ireland
| | - S M O'Neill
- St James's Vascular Institute, St James's Hospital, Dublin, Ireland
| | - P Madhavan
- St James's Vascular Institute, St James's Hospital, Dublin, Ireland
| | - Z Martin
- St James's Vascular Institute, St James's Hospital, Dublin, Ireland
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Kanaoka Y, Ohki T, Maeda K, Baba T. Analysis of Risk Factors for Early Type I Endoleaks After Thoracic Endovascular Aneurysm Repair. J Endovasc Ther 2016; 24:89-96. [DOI: 10.1177/1526602816673326] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Purpose: To evaluate risk factors for early (<30 days) type I endoleak following thoracic endovascular aortic repair (TEVAR). Methods: A retrospective study was conducted of 439 consecutive patients (mean age 74.0±10.0 years; 333 men) who underwent TEVAR at a single center between June 2006 and June 2013. Pathologies included 237 aortic arch aneurysms and 202 descending thoracic aortic aneurysms (dTAA). Maximum TAA diameter was 63.6±13.7 mm. Among the distal aortic arch aneurysms, 124 required coverage of the left subclavian artery (LSA), while the remaining 113 arch aneurysms had debranching (n=40), the chimney technique (n=52), and a branched stent-graft (n=13). Eight patients with dilatation of the ascending aorta underwent arch replacement with elephant trunk prior to TEVAR. Predictive factors for type I endoleak were explored in univariate analysis and examined for each outcome using logistic regression models; results are given as the odds ratio (OR) and 95% confidence interval (CI). Results: Among 439 TEVAR cases, 37 (8.4%) had type I endoleaks on imaging at 1 month; 31 were in the 237 arch cases (13.1%). Endoleak investigation by site indicated a low incidence (3.0%) for dTAAs and markedly low (1.4%) in zone 4. Significantly more endoleaks were observed in zones 0–2 than in zone 4 (p<0.001). On univariate analysis, significant associations were found between endoleak and LSA coverage (OR 5.8, 95% CI 2.4 to 14.4, p<0.001), operative time ≥240 minutes (OR 3.7, 95% CI 1.5 to 6.2, p=0.002), and ≥270 mL of contrast (OR 2.8, 95% CI 1.4 to 5.8, p=0.004). Among the aortic branch reconstruction procedures, the chimney technique was the only maneuver associated with a significant risk of endoleak (OR 5.3, 95% CI 2.3 to 11.2, p<0.001). Arch state was not correlated with endoleaks, but ≥38-mm proximal neck diameter (OR 3.6, 95% CI 1.2 to 10.8, p=0.023), stent-graft diameter ≥40 mm (OR 9.9, 95% CI 1.4 to 30.5, p=0.015), and excessively oversized (≥14%) stent-grafts (OR 3.5, 95% CI 1.2 to 10.3, p=0.020) were; the proximal neck length was not correlated with endoleaks if a proximal neck length >10 mm can be secured. Conclusion: Risks for early type I endoleaks after TEVAR for aneurysm were landing zone 0–2, LSA coverage, large proximal neck and stent-graft diameters, excessive oversizing, and the use of the chimney technique.
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Affiliation(s)
- Yuji Kanaoka
- Division of Vascular Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Koji Maeda
- Division of Vascular Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Takeshi Baba
- Division of Vascular Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
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Pantaleo A, Jafrancesco G, Buia F, Leone A, Lovato L, Russo V, Di Marco L, Di Bartolomeo R, Pacini D. Distal Stent Graft-Induced New Entry: An Emerging Complication of Endovascular Treatment in Aortic Dissection. Ann Thorac Surg 2016; 102:527-32. [DOI: 10.1016/j.athoracsur.2016.02.001] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 01/01/2016] [Accepted: 02/01/2016] [Indexed: 11/16/2022]
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Chen IM, Huang CY, Weng SH, Lin PY, Chen PL, Chen WY, Shih CC. Implantation sequence modification averts distal stent graft-induced new entry after endovascular repair of Stanford type B aortic dissection. J Vasc Surg 2016; 64:281-288. [DOI: 10.1016/j.jvs.2016.02.032] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 02/05/2016] [Indexed: 11/17/2022]
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Narita H, Komori K, Usui A, Yamamoto K, Banno H, Kodama A, Sugimoto M. Postoperative Outcomes of Hybrid Repair in the Treatment of Aortic Arch Aneurysms. Ann Vasc Surg 2016; 34:55-61. [DOI: 10.1016/j.avsg.2015.11.041] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 10/31/2015] [Accepted: 11/24/2015] [Indexed: 11/25/2022]
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Lin PH, El Sayed HF, Kougias P, Zhou W, LeMaire SA, Coselli JS. Endovascular Repair of Thoracic Aortic Disease: Overview of Current Devices and Clinical Results. Vascular 2016; 15:179-90. [PMID: 17714632 DOI: 10.2310/6670.2007.00041] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Endovascular repair of thoracic aortic aneurysm has become an important treatment modality in patients who are at increased risk for open surgical repair. Since the US Food and Drug Administration (FDA) approved the clinical application of this technology in the thoracic aorta in 2005, there has been a rapid growth in this treatment modality as numerous endovascular devices have been introduced in the application of thoracic aortic pathology. Although thoracic aortic aneurysm is the only FDA-approved treatment indication for endovascular repair, this technology may lead to a broader clinical applicability in other thoracic pathologies. This article reviews the current endovascular devices designed for the treatment of thoracic aortic pathology. These devices are described, and the current clinical results are discussed.
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Affiliation(s)
- Peter H Lin
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA.
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35
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Abraha I, Romagnoli C, Montedori A, Cirocchi R. Thoracic stent graft versus surgery for thoracic aneurysm. Cochrane Database Syst Rev 2016; 2016:CD006796. [PMID: 27265222 PMCID: PMC7388299 DOI: 10.1002/14651858.cd006796.pub4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Thoracic aortic aneurysm (TAA) is an uncommon disease with an incidence of 10.4 per 100,000 inhabitants. It occurs mainly in older individuals and is evenly distributed among both sexes. There are no signs or symptoms indicative of the presence of the disease. Progressive but unpredictable enlargement of the dilated aorta is the natural course of the disease and can lead to rupture. Open chest surgical repair using prosthetic graft interposition has been a conventional treatment for TAAs. Despite improvements in surgical procedures perioperative complications remain significant. The alternative option of thoracic endovascular aneurysm repair (TEVAR) is considered a less invasive and potentially safer technique, with lower morbidity and mortality compared with conventional treatment. Evidence is needed to support the use of TEVAR for these patients, rather than open surgery. This is an update of the review first published in 2009. OBJECTIVES This review aimed to assess the efficacy of TEVAR versus conventional open surgery in patients with thoracic aortic aneurysms. SEARCH METHODS For this update the Cochrane Vascular Information Specialist searched the Specialised Register (last searched January 2016) and CENTRAL (2015, Issue 12). SELECTION CRITERIA Randomised controlled trials in which patients with TAAs were randomly assigned to TEVAR or open surgical repair. DATA COLLECTION AND ANALYSIS Two review authors independently identified and evaluated potential trials for eligibility. Excluded studies were further checked by another author. We did not perform any statistical analyses as no randomised controlled trials were identified. MAIN RESULTS We did not find any published or unpublished randomised controlled trials comparing TEVAR with conventional open surgical repair for the treatment of thoracic aortic aneurysms. AUTHORS' CONCLUSIONS Stent grafting of the thoracic aorta is technically feasible and non-randomised studies suggest reduction of early outcomes such as paraplegia, mortality and hospital stay. High quality randomised controlled trials assessing all clinically relevant outcomes including open-conversion, aneurysm exclusion, endoleaks, and late mortality are needed.
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Affiliation(s)
- Iosief Abraha
- Health Planning Service, Regional Health Authority of UmbriaPerugiaItaly
| | | | - Alessandro Montedori
- Regional Health Authority of UmbriaHealth Planning ServiceVia Mario Angeloni 61PerugiaUmbriaItaly06124
| | - Roberto Cirocchi
- University of PerugiaDepartment of General SurgeryTerniItaly05100
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Zipfel B, Zaefferer P, Riambau V, Szeberin Z, Weigang E, Menéndez M, Funovics M, Hamady M, Zipfel B, Zaefferer P, Riambau V, Szeberin Z, Weigang E, Menéndez M, Funovics M, Hamady M, Rousseau H, Mariné L, Kiskinis D, Bonneville JF, Kratimenos T, Nano G, Kato M, Gasparini D, Teebken O, Mangialardi N, Coppi G, Hoksbergen A, Heijmen RH. Worldwide results from the RESTORE II on elective endografting of thoracic aneurysms and dissections. J Vasc Surg 2016; 63:1466-75. [DOI: 10.1016/j.jvs.2015.12.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 12/10/2015] [Indexed: 10/21/2022]
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Terzi F, Rocchi G, Fattori R. Current challenges in endovascular therapy for thoracic aneurysms. Expert Rev Cardiovasc Ther 2016; 14:599-607. [DOI: 10.1586/14779072.2016.1141677] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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38
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Murana G, Castrovinci S, Kloppenburg G, Yousif A, Kelder H, Schepens M, de Maat G, Sonker U, Morshuis W, Heijmen R. Open thoracoabdominal aortic aneurysm repair in the modern era: results from a 20-year single-centre experience. Eur J Cardiothorac Surg 2015; 49:1374-81. [DOI: 10.1093/ejcts/ezv415] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Accepted: 10/25/2015] [Indexed: 01/16/2023] Open
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Abstract
ResumoA intrincada anatomia tridimensional da irrigação medular é frequentemente explanada na literatura com diferentes nomenclaturas e devido a sua alta relevância no estudo da isquemia medular, o estudo da terminologia se faz necessário para melhor compreensão do tema. A artéria de Adamkiewicz, também chamada de artéria radicular magna, é a via principal. Foi realizada a revisão da literatura com equiparação das nomenclaturas utilizadas e elaboração de descrição acurada e sumarizada do conhecimento atual sobre a vascularização medular.
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40
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Open Surgery with Frozen Elephant Trunk for the Treatment of Proximal Stent Graft–Induced New Entry in Type B Aortic Dissection: A Case Report. Ann Vasc Surg 2015; 29:1316.e21-4. [DOI: 10.1016/j.avsg.2015.01.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Revised: 12/31/2014] [Accepted: 01/23/2015] [Indexed: 01/31/2023]
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Clinical Outcomes of Left Subclavian Artery Coverage on Morbidity and Mortality During Thoracic Endovascular Aortic Repair for Distal Arch Aneurysms. World J Surg 2015. [DOI: 10.1007/s00268-015-3166-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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42
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Goldfinger JZ, Halperin JL, Marin ML, Stewart AS, Eagle KA, Fuster V. Thoracic aortic aneurysm and dissection. J Am Coll Cardiol 2015; 64:1725-39. [PMID: 25323262 DOI: 10.1016/j.jacc.2014.08.025] [Citation(s) in RCA: 230] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 08/26/2014] [Accepted: 08/26/2014] [Indexed: 11/27/2022]
Abstract
Aortic dissection is the most devastating complication of thoracic aortic disease. In the more than 250 years since thoracic aortic dissection was first described, much has been learned about diseases of the thoracic aorta. In this review, we describe normal thoracic aortic size; risk factors for dissection, including genetic and inflammatory conditions; the underpinnings of genetic diseases associated with aneurysm and dissection, including Marfan syndrome and the role of transforming growth factor beta signaling; data on the role for medical therapies in aneurysmal disease, including beta-blockers, angiotensin receptor blockers, and angiotensin-converting enzyme inhibitors; prophylactic surgery for aneurysm; surgical techniques for the aortic root; and surgical and endovascular management of aneurysm and dissection for different aortic segments.
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Affiliation(s)
- Judith Z Goldfinger
- Department of Medicine, Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jonathan L Halperin
- Department of Medicine, Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael L Marin
- Department of Surgery, Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Allan S Stewart
- Department of Cardiothoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kim A Eagle
- Department of Medicine, Samuel and Jean A. Frankel Cardiovascular Center, University of Michigan Health System and Medical School, Ann Arbor, Michigan
| | - Valentin Fuster
- Department of Medicine, Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York.
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Matsuyama M, Nakamura K, Nagahama H, Nina K, Endou J, Kojima K, Nishimura M, Ishii H, Yokota A. Long-term results of endovascular repair for distal arch and descending thoracic aortic aneurysms treated by custom-made endografts: usefulness of fenestrated endografts. Ann Vasc Dis 2015; 7:383-92. [PMID: 25593623 DOI: 10.3400/avd.oa.14-00057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 08/14/2014] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE We evaluated early and long-term results of atherosclerotic aneurysm repair with custom-made endografts. MATERIALS AND METHODS Eighty-one consecutive patients underwent thoracic endovascular aortic repair with custom-made endografts. Fenestrated grafts were used in 37 patients (45.7%) to maintain blood flow of the neck and a landing zone for as long as possible for distal arch or proximal descending aneurysms. The rates of perioperative mortality, stroke, paraplegia, and primary endoleaks were assessed to evaluate in-hospital safety. The rates of endoleak development, survival, and freedom from aortic-related death were assessed to evaluate long-term efficiency. RESULTS Twenty-four patients (29.6%) underwent urgent operations, and 38 (46.9%) underwent distal arch or proximal descending aortic aneurysm repair. There was one case (1.2%) of in-hospital mortality and no cases of stroke. Permanent spinal injury occurred in one patient (1.2%). Early and late endoleaks occurred in one and 16 patients, respectively. The actuarial survival rates were 88.9%, 64.9%, and 51.7% at 1, 5, and 10 years, respectively. The actuarial rates of freedom from endoleaks were 90.1%, 81.3%, and 68.6% at 1, 5, and 10 years, respectively. CONCLUSION Early results of custom-made endografts were excellent, and fenestrated endografts were safe for distal arch and proximal descending aortic aneurysms.
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Affiliation(s)
- Masakazu Matsuyama
- Department of Cardiovascular, Thoracic and General Surgery, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Kunihide Nakamura
- Department of Cardiovascular, Thoracic and General Surgery, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Hiroyuki Nagahama
- Department of Cardiovascular, Thoracic and General Surgery, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Katsuhiko Nina
- Department of Cardiovascular Surgery, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Miyazaki, Japan
| | - Jouji Endou
- Department of Cardiovascular, Thoracic and General Surgery, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Kazushi Kojima
- Department of Cardiovascular Surgery, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Miyazaki, Japan
| | - Masanori Nishimura
- Department of Cardiovascular, Thoracic and General Surgery, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Hirohito Ishii
- Department of Cardiovascular, Thoracic and General Surgery, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Atsuko Yokota
- Department of Cardiovascular Surgery, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Miyazaki, Japan
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Massmann A, Kunihara T, Fries P, Schneider G, Buecker A, Schäfers HJ. Uncovered stent implantation in complicated acute aortic dissection type B. J Thorac Cardiovasc Surg 2014; 148:3003-11. [DOI: 10.1016/j.jtcvs.2014.07.053] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 06/24/2014] [Accepted: 07/08/2014] [Indexed: 12/01/2022]
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Silent Cerebral Ischemia After Thoracic Endovascular Aortic Repair: A Neuroimaging Study. Ann Thorac Surg 2014; 98:53-8. [DOI: 10.1016/j.athoracsur.2014.03.037] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 03/10/2014] [Accepted: 03/20/2014] [Indexed: 11/20/2022]
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Survival after endovascular therapy in patients with type B aortic dissection: a report from the International Registry of Acute Aortic Dissection (IRAD). JACC Cardiovasc Interv 2014; 6:876-82. [PMID: 23968705 DOI: 10.1016/j.jcin.2013.05.003] [Citation(s) in RCA: 308] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 04/26/2013] [Accepted: 05/09/2013] [Indexed: 12/19/2022]
Abstract
OBJECTIVES This study sought to evaluate long-term survival in type B aortic dissection patients treated with thoracic endovascular aortic repair (TEVAR) therapy. BACKGROUND Historical data have supported medical therapy in type B acute aortic dissection (TBAAD) patients. Recent advances in TEVAR appear to improve in-hospital mortality. METHODS We examined 1,129 consecutive patients with TBAAD enrolled in IRAD (International Registry of Acute Aortic Dissection) between 1995 and 2012 who received medical (n = 853, 75.6%) or TEVAR (n = 276, 24.4%) therapy. RESULTS Clinical history was similar between groups. TEVAR patients were more likely to present with a pulse deficit (28.3% vs. 13.4%, p < 0.001) and lower extremity ischemia (16.8% vs. 3.6%, p < 0.001), and to characterize their pain as the "worst pain ever" (27.5% vs. 15.7%, p < 0.001). TEVAR patients were also most likely to present with complicated acute aortic dissection, defined as shock, periaortic hematoma, signs of malperfusion, stroke, spinal cord ischemia, mesenteric ischemia, and/or renal failure (61.7% vs. 37.2%). In-hospital mortality was similar in patients managed with endovascular repair (10.9% vs. 8.7%, p = 0.273) compared with medically managed patients. One-year mortality was also similar in both groups (8.1% endovascular vs. 9.8% medical, p = 0.604). Among adverse events during follow-up, aortic growth/new aneurysm was most common, occurring in 73.3% of patients with medical therapy and in 62.7% of patients after TEVAR, based on 5-year Kaplan-Meier estimates. Kaplan-Meier survival estimates showed that patients undergoing TEVAR had a lower death rate (15.5% vs. 29.0%, p = 0.018) at 5 years. CONCLUSIONS Results from IRAD show that TEVAR is associated with lower mortality over a 5-year period than medical therapy for TBAAD. Further randomized trials with long-term follow-up are needed.
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Shimura S, Yamaguchi M, Cho Y, Aki A, Furuya H, Ueda T. External carotid-to-subclavian artery bypass in stent grafting of thoracic aorta. Asian Cardiovasc Thorac Ann 2014; 21:546-50. [PMID: 24570556 DOI: 10.1177/0218492312462224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND A bypass between the left common carotid artery and the left subclavian artery has been made in some patients undergoing thoracic endovascular aortic repair that covers the orifice of the left subclavian artery. However, complications associated with temporary occlusion of the left common carotid artery are reportedly not uncommon. METHODS Between January 2009 and September 2011, left external carotid-to-left subclavian artery bypass was made using a polytetrafluoroethylene graft in 15 patients undergoing a thoracic endovascular aortic repair that covered the orifice of the left subclavian artery. Adverse effects associated with the procedure were assessed, and patency of the bypass graft was determined by contrast-enhanced computed tomography before discharge and at least once during follow-up. RESULTS All patients were discharged without any brain complications. All 15 bypass grafts were patent prior to discharge and during the follow-up period. One patient suffered temporary left recurrent laryngeal nerve palsy postoperatively. No other sequelae were associated with left external carotid-to-left subclavian artery bypass. CONCLUSION Left external carotid-to-left subclavian artery bypass is a promising procedure in patients undergoing thoracic endovascular aortic repair that covers the orifice of the left subclavian artery.
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Affiliation(s)
- Shinichiro Shimura
- Department of Cardiovascular Surgery, School of Medicine, Tokai University, Kanagawa, Japan
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Matsumoto AH, Angle JF, Secic M, Carlson GA, Fisher L, Fairman RM. Secondary procedures following thoracic aortic stent grafting in the first 3 years of the VALOR test and VALOR II trials. J Vasc Interv Radiol 2014; 25:685-692.e5. [PMID: 24529546 DOI: 10.1016/j.jvir.2013.12.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 12/05/2013] [Accepted: 12/13/2013] [Indexed: 10/25/2022] Open
Abstract
PURPOSE To compare the durability of thoracic endovascular aortic repair (TEVAR) in two similar clinical trials that used early- and later-generation stent grafts. MATERIALS AND METHODS Secondary procedures from the prospective, nonrandomized, multicenter, clinical trial databases of the test arm of the VALOR and VALOR II trials were analyzed at 3 years. Descriptive and statistical analyses were employed to compare the rate of and potential predictors for secondary procedures. RESULTS A total of 127 and 96 patients were available for a minimum of 3 years of follow-up in the test arm of VALOR and VALOR II, respectively. By the first year after the index procedure, VALOR II patients were significantly less likely to have undergone a secondary procedure versus patients in the test arm of VALOR (odds ratio [OR], 0.08; 95% confidence interval [CI], 0.01-0.63; P = .02), with most procedures performed for type I endoleak. Multivariate predictors at 3 years for the need for a secondary procedure in the VALOR test arm were maximum aneurysm diameter (P = .002) and aneurysm length (P = .01), both of which remained significant at the end of the study period. The estimated freedoms from secondary procedures in the VALOR test arm and VALOR II at 3 years were 85.1% (95% CI, 78.5%-89.8%) and 94.9% (95% CI, 88.8%-97.7%), respectively (P < .001). CONCLUSIONS The rate of secondary procedures after TEVAR differed between the two cohorts, being substantially lower in the VALOR II trial at 1 year of follow-up. This finding suggests significant benefit from advances in some combination of operator experience, imaging systems, treatment planning, and device design.
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Affiliation(s)
- Alan H Matsumoto
- Department of Radiology and Medical Imaging, University of Virginia Health System, 1215 Lee St., Box 800170, Room 1839, Charlottesville, VA 22908.
| | - John F Angle
- Department of Radiology and Medical Imaging, University of Virginia Health System, 1215 Lee St., Box 800170, Room 1839, Charlottesville, VA 22908
| | | | - Grace A Carlson
- Office of Medical Affairs, Medtronic Vascular, Santa Rosa, California
| | - Lois Fisher
- Office of Medical Affairs, Medtronic Vascular, Santa Rosa, California
| | - Ronald M Fairman
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Kiguchi M, Chaer RA. Endovascular repair of thoracic aortic pathology. Expert Rev Med Devices 2014; 8:515-25. [DOI: 10.1586/erd.11.17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Zahn R, Erbel R, Nienaber CA, Neumann FJ, Nef H, Eggebrecht H, Senges J. Endovascular aortic repair of thoracic aortic disease: early and 1-year results from a German multicenter registry. J Endovasc Ther 2014; 20:265-72. [PMID: 23731294 DOI: 10.1583/12-4107r.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To report a "real-world" multicenter experience in the use of thoracic endovascular aortic repair (TEVAR) for diseases of the descending thoracic aorta. METHODS A prospective, multicenter, German TEVAR Registry was established in October 2008 and enrolled 191 patients (134 men; mean age 64.5±13.2 years) from 7 hospitals up to March 2011. Stent-graft implantation was performed for Stanford type B aortic dissection (104, 55.3%), true thoracic aortic aneurysm (91, 48.7%), intramural hematoma (20, 10.7%), penetrating aortic ulcer (16, 8.6%), and traumatic aortic rupture (6, 3.2%). RESULTS Per patient, a mean of 1.2±0.7 stent-grafts were implanted. Technical success was 92.1% (164/178); 15 (8.5%) endoleaks (types I-III) were reported. Intervention duration was a mean 107±122 minutes. During the hospital stay, stroke occurred in 3.9% of patients (7/180) and paraplegia in 1.7% (3/180). Reintervention was performed in 3.3% (6/180). The mortality was 5.5% (10/181) in-hospital and 5.6% at 30 days. The mean follow-up was 24.5±27.7 months. The Kaplan-Meier estimates of 1-year reintervention and death rates were 7.2% and 11.4%, respectively. CONCLUSION In this real-world TEVAR registry for acute or chronic descending aortic diseases, technical success was high and the short-term complication rate was acceptable. However, the high reintervention rate observed in the present study mandates thorough clinical and imaging follow-up after an initially successful procedure.
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Affiliation(s)
- Ralf Zahn
- Abteilung für Kardiologie, Herzzentrum Ludwigshafen, Germany.
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