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Baghbani-Oskouei A, Savadi S, Mesnard T, Sulzer T, Mirza AK, Baig S, Timaran CH, Oderich GS. Transcatheter electrosurgical septotomy technique for chronic postdissection aortic aneurysms. J Vasc Surg Cases Innov Tech 2024; 10:101402. [PMID: 38304296 PMCID: PMC10830870 DOI: 10.1016/j.jvscit.2023.101402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
Aortic dissection often results in chronic aneurysmal degeneration due to progressive false lumen expansion. Thoracic endovascular aortic repair and other techniques of vessel incorporation such as fenestrated-branched or parallel grafts have been increasingly used to treat chronic postdissection aneurysms. True lumen compression or a vessel origin from the false lumen can present considerable technical challenges. In these cases, the limited true lumen space can result in inadequate stent graft expansion or restrict the ability to reposition the device or manipulate catheters. Reentrance techniques can be used selectively to assist with target vessel catheterization. Transcatheter electrosurgical septotomy is a novel technique that has evolved from the cardiology experience with transseptal or transcatheter aortic valve procedures. This technique has been applied in select patients with chronic dissection to create a proximal or distal landing zone, disrupt the septum in patients with an excessively compressed true lumen, or connect the true and false lumen in patients with vessels that have separate origins. In the present report, we summarize the indications and technical pitfalls of transcatheter electrosurgical septotomy in patients treated by endovascular repair for chronic postdissection aortic aneurysms.
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Affiliation(s)
- Aidin Baghbani-Oskouei
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Safa Savadi
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Thomas Mesnard
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Titia Sulzer
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Aleem K. Mirza
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Shadman Baig
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Carlos H. Timaran
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Gustavo S. Oderich
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de Las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Sá MP, Jacquemyn X, Van den Eynde J, Chu D, Serna-Gallegos D, Singh MJ, Chaer RA, Sultan I. Midterm Outcomes of Endovascular vs. Medical Therapy for Uncomplicated Type B Aortic Dissection: Meta-Analysis of Reconstructed Time to Event Data. Eur J Vasc Endovasc Surg 2023; 66:609-619. [PMID: 37422209 DOI: 10.1016/j.ejvs.2023.07.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/16/2023] [Accepted: 07/03/2023] [Indexed: 07/10/2023]
Abstract
OBJECTIVE To evaluate outcomes of thoracic endovascular aortic repair (TEVAR) vs. medical therapy in uncomplicated type B aortic dissections (TBAD). DATA SOURCES PubMed/MEDLINE, EMBASE, SciELO, LILACS, CENTRAL/CCTR, Google Scholar, and reference lists of relevant articles. REVIEW METHODS This was a pooled meta-analysis of time to event data extracted from studies published by December 2022 for the following outcomes: all cause mortality, aortic related mortality, and late aortic interventions. Certainty of evidence was evaluated through the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool. RESULTS Ten studies met the eligibility criteria (eight observational; two randomised trials), comprising 17 906 patients (2 332 patients in the TEVAR groups and 15 574 patients in the medical therapy group). Compared with patients who received medical therapy, patients who underwent TEVAR had a statistically significantly lower risk of all cause death (HR 0.79, 95% CI 0.72 - 0.87, p < .001; GRADE certainty: low) and lower risk of aortic related death (HR 0.43, 95% CI 0.30 - 0.62, p < .001; GRADE certainty: low) without statistically significant difference in the risk of late aortic interventions (HR 1.05, 95% CI 0.88 - 1.26, p = .56; GRADE certainty: low). In the subgroup analyses, TEVAR was associated with lower risk of all cause death when randomised controlled trials only were pooled (HR 0.44, 95% CI 0.23 - 0.83, p = .012; GRADE certainty: moderate), younger patients only (HR 0.56, 95% CI 0.47 - 0.67, p < .001; GRADE certainty: low), Western populations only (HR 0.85, 95% CI 0.77 - 0.93, p = .001; GRADE certainty: low) and non-Western populations only (HR 0.47, 95% CI 0.35 - 0.62, p < .001; GRADE certainty: low). For all cause mortality and aortic related mortality, restricted mean survival time was overall 396 days and 398 days longer with TEVAR (p < .001), respectively, which means that TEVAR was associated with lifetime gain. CONCLUSION TEVAR may be associated with better midterm survival and lower risk of aortic related death in the follow up of patients treated for uncomplicated TBAD compared with medical therapy; however, randomised controlled trials with larger sample sizes and longer follow up are still warranted.
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Affiliation(s)
- Michel Pompeu Sá
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA.
| | - Xander Jacquemyn
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | | | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
| | - Derek Serna-Gallegos
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
| | - Michael J Singh
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA; Division of Vascular Surgery, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
| | - Rabih A Chaer
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA; Division of Vascular Surgery, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA. https://twitter.com/IbrahimSultanMD
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Natour AK, Shepard A, Onofrey K, Peshkepija A, Nypaver T, Weaver M, Lee A, Kabbani L. Left subclavian artery revascularization is associated with less neurologic injury after endovascular repair of acute type B aortic dissection. J Vasc Surg 2023; 78:1170-1179.e2. [PMID: 37524152 DOI: 10.1016/j.jvs.2023.07.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/16/2023] [Accepted: 07/22/2023] [Indexed: 08/02/2023]
Abstract
OBJECTIVE The aim of this study was to analyze patients with acute type B aortic dissection (aTBAD) requiring thoracic endovascular aortic repair (TEVAR) with left subclavian artery (LSA) coverage to determine whether LSA revascularization decreased the risk of neurologic complications. METHODS The national Vascular Quality Initiative TEVAR module was queried for all procedures performed between 2014 and 2021. Patients presenting with aortic aneurysms or aortic ruptures were excluded from the analysis. Patients were divided into two groups according to whether their LSA was revascularized (prior to or during TEVAR) or not. Univariate followed by multivariate analysis was used to account for possible confounders and evaluate the association of LSA revascularization with the primary outcome of neurologic injury (stroke or spinal cord ischemia). RESULTS Among patients who had TEVAR for aTBAD, 501 patients had the LSA covered. The LSA was revascularized prior to or concomitant with TEVAR in 28% of these patients (n = 139). Average age was 57 years, and 73% (n = 366) were male. Neurologic injury developed in 88 patients (18%). On univariate analysis, patients who had their LSA revascularized were significantly less likely to develop neurologic injury (10% vs 20%; P < .01). This association persisted after accounting for potential confounders (odds ratio, 0.4; P = .02). No significant difference was seen when comparing 30-day or 1-year mortality between patients who had LSA revascularization and those who did not. Follow-up averaged 1.9 years (range, 0-8.1 years). Long-term survival did not differ between the two groups on Kaplan-Meier analysis. CONCLUSIONS In this study of patients with aTBAD who underwent LSA coverage during TEVAR, the addition of a LSA revascularization procedure was associated with a significantly lower incidence of neurological injury including spinal cord ischemia and/or stroke.
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Affiliation(s)
| | | | - Kevin Onofrey
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
| | - Andi Peshkepija
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
| | - Timothy Nypaver
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
| | - Mitchell Weaver
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
| | - Alice Lee
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
| | - Loay Kabbani
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
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Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
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Oberhuber A, Raddatz A, Betge S, Ploenes C, Ito W, Janosi RA, Ott C, Langheim E, Czerny M, Puls R, Maßmann A, Zeyer K, Schelzig H. Interdisciplinary German clinical practice guidelines on the management of type B aortic dissection. GEFASSCHIRURGIE 2023; 28:1-28. [PMCID: PMC10123596 DOI: 10.1007/s00772-023-00995-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 08/13/2023]
Affiliation(s)
- A. Oberhuber
- German Society of Vascular Surgery and Vascular Medicine (DGG); Department of Vascular and Endovascular Surgery, University Hospital of Münster, Münster, Germany
| | - A. Raddatz
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI); Department of Anaesthesiology, Critical Care and Pain Medicine, Saarland University Hospital, Homburg, Germany
| | - S. Betge
- German Society of Angiology and Vascular Medicine (DGG); Department of Internal Medicine and Angiology, Helios Hospital Salzgitter, Salzgitter, Germany
| | - C. Ploenes
- German Society of Geriatrics (DGG); Department of Angiology, Schön Klinik Düsseldorf, Düsseldorf, Germany
| | - W. Ito
- German Society of Internal Medicine (GSIM) (DGIM); cardiovascular center Oberallgäu Kempten, Hospital Kempten, Kempten, Germany
| | - R. A. Janosi
- German Cardiac Society (DGK); Department of Cardiology and Angiology, University Hospital Essen, Essen, Germany
| | - C. Ott
- German Society of Nephrology (DGfN); Department of Nephrology and Hypertension, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
- Department of Nephrology and Hypertension, Paracelsus Medical University, Nürnberg, Germany
| | - E. Langheim
- German Society of prevention and rehabilitation of cardiovascular diseaese (DGPR), Reha Center Seehof, Teltow, Germany
| | - M. Czerny
- German Society of Thoracic and Cardiovascular Surgery (DGTHG), Department University Heart Center Freiburg – Bad Krozingen, Freiburg, Germany
- Albert Ludwigs University Freiburg, Freiburg, Germany
| | - R. Puls
- German Radiologic Society (DRG); Institute of Diagnostic an Interventional Radiology and Neuroradiology, Helios Klinikum Erfurt, Erfurt, Germany
| | - A. Maßmann
- German Society of Interventional Radiology (DeGIR); Department of Diagnostic an Interventional Radiology, Saarland University Hospital, Homburg, Germany
| | - K. Zeyer
- Marfanhilfe e. V., Weiden, Germany
| | - H. Schelzig
- German Society of Surgery (DGCH); Department of Vascular and Endovascular Surgery, University Hospital of Düsseldorf, Düsseldorf, Germany
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2022; 146:e334-e482. [PMID: 36322642 PMCID: PMC9876736 DOI: 10.1161/cir.0000000000001106] [Citation(s) in RCA: 348] [Impact Index Per Article: 174.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce E Bray
- AHA/ACC Joint Committee on Clinical Data Standards liaison
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- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
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8
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Isselbacher EM, Preventza O, Hamilton Black Iii J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Jones WS, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Times SS, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 80:e223-e393. [PMID: 36334952 PMCID: PMC9860464 DOI: 10.1016/j.jacc.2022.08.004] [Citation(s) in RCA: 114] [Impact Index Per Article: 57.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Yang J, Shi Y, Jiang J. Thoracic endovascular aortic repair or best medical therapy for uncomplicated type B aortic dissection? A meta-analysis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:288-298. [PMID: 25658975 DOI: 10.23736/s0021-9509.16.08594-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
INTRODUCTION The aim of this meta-analysis was to investigate all studies comparing thoracic endovascular aortic repair (TEVAR) and best medical therapy (BMT) for the treatment of uncomplicated type B aortic dissection (TBAD). EVIDENCE ACQUISITION PubMed/Medline and Web of Knowledge were searched until September 2014 for relevant studies published in English. Pooled odds ratio (OR) and its corresponding 95% CI were analyzed with Cochrane Review Manager (RevMan v.5.3). EVIDENCE SYNTHESIS Our analysis showed that compared with BMT, TEVAR did not significantly affect 30-day (hospital) mortality. A significantly lower 1-year and 2- or 3-year survival rates was observed with TEVAR vs. BMT. Interestingly, a trend just short of statistical significance towards higher 4- or 5-year survival was found with TEVAR treatment (P=0.08). No significant differences were found in false lumen (FL) thrombosis formation with TEVAR vs. BMT treatment. However, a trend toward less incomplete or no FL thrombosis was noted with TEVAR. No significantly impact on the risk of later re-intervention was found with TEVAR vs. BMT. CONCLUSIONS TEVAR did not provide obvious early survival advantage for uncomplicated TBAD over BMT, especially in the patients using TEVAR alone. It may remain a treatment option in uncomplicated TBAD patients with high risks for later complications. More randomized, prospective, long-term studies are needed to further clarify whether TEVAR could be a better first-line treatment strategy vs. BMT for uncomplicated TBAD.
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Affiliation(s)
- Jue Yang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yun Shi
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Junhao Jiang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China -
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10
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Roselli EE, Atkins MD, Brinkman W, Coselli J, Desai N, Estrera A, Johnston DR, Patel H, Preventza O, Vargo PR, Fleischman F, Taylor BS, Reardon MJ. ARISE: First-In-Human Evaluation of a Novel Stent Graft to Treat Ascending Aortic Dissection. J Endovasc Ther 2022:15266028221095018. [PMID: 35587698 DOI: 10.1177/15266028221095018] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Operative mortality for type A aortic dissection is still 10-20% at centers of excellence. Additionally, 10-20% are not considered as viable candidates for open surgical repair and not offered life-saving emergency surgery. ARISE is a multicenter investigation evaluating the novel GORE® Ascending Stent Graft (ASG; Flagstaff, AZ). OBJECTIVE The purpose of this study is to assess early feasibility of using these investigational devices to treat ascending aortic dissection. METHODS This a prospective, multicenter, non-randomized, single-arm study that enrolls patients at high surgical risk with appropriate anatomical requirements based on computed tomography imaging at 7 of 9 US sites. Devices are delivered transfemorally under fluoroscopic guidance. Primary endpoint is all-cause mortality at 30 days. Secondary endpoints include major adverse cardiovascular and cerebrovascular events (MACCE) at 30 days, 6 months, and 12 months. RESULTS Nineteen patients were enrolled with a mean age of 75.7 years (range 47-91) and 11 (57.9%) were female. Ten (52.6%) had DeBakey type I disease, and the rest were type II. Sixteen (84.2%) of the patients were acute. Patients were treated with safe access, (7/19 (36.8%) percutaneous, 10/19 (52.6%) transfemoral, 2/19 (10.5%) iliac conduit), delivery, and deployment completed in all cases. Median procedure time was 154 mins (range 52-392) and median contrast used was 111 mL (range 75-200). MACCE at 30 days occurred in 5 patients including mortality 3/19 (15.8%), disabling stroke in 1/19 (5.3%), and myocardial infarction in 1/19 (5.3%). CONCLUSION Results from the ARISE early feasibility study of a specific ascending stent graft device to treat ascending aortic dissection are promising.
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Affiliation(s)
- Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Aortic Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | | | - Nimesh Desai
- University of Pennsylvania, Philadelphia, PA, USA
| | | | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Aortic Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Himanshu Patel
- University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA
| | | | - Patrick R Vargo
- Department of Thoracic and Cardiovascular Surgery, Aortic Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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11
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Wang J, Jin T, Chen B, Pan Y, Shao C. Systematic review and meta-analysis of current evidences in endograft therapy versus medical treatment for uncomplicated type B aortic dissection. J Vasc Surg 2022; 76:1099-1108.e3. [PMID: 35390485 DOI: 10.1016/j.jvs.2022.03.876] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 03/26/2022] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Best medical therapy (BMT) should be recommended for treating uncomplicated Stanford type B aortic dissection (uSTBAD), whereas thoracic aortic endovascular repair (TEVAR) has been controversial for uSTBAD. METHODS In this paper, a meta-analysis was conducted on all available randomized controlled trials and observational studies that evaluated the relative benefits and harms of TEVAR and BMT for the management of patients suffering from uSTBAD. Primary endpoints consisted of early adverse events, long-term adverse events and aortic remodeling. In addition, Risk difference (RD) or Odds ratios (OR) with 95% confidence intervals (CI) were estimated. The random effects model or the fixed-effects model was used in accordance with the 50% heterogeneity threshold. RESULTS Seven observational studies and two RCT studies from 11 articles that contained 15066 patients suffering from uSTBAD (1518 TEVARs) met the inclusion criteria. For early outcomes, no significant differences were found between the TEVAR group and the BMT group in aortic rupture, retrograde dissection, paraplegia/paraparesis, reintervention, aorta-related death and all caused death. In the long run, the TEVAR group was found to have a significantly lower incidence of adverse events, which included aortic rupture (OR:0.26, CI:0.16∼0.42, P<0.05; heterogeneity: P=0.90, I2=0%), reintervention (OR:0.45, CI:0.26∼0.75, P<0.05; heterogeneity: P=0.17, I2=41%), aorta-related death (OR:0.27, CI:0.18∼0.42, P<0.05; heterogeneity: P=0.61, I2=0%) and all caused death (OR:0.52, CI:0.42∼0.66, P<0.05; heterogeneity: P=0.05, I2=53%) as compared with the BMT group. Moreover, in compared with BMT, TEVAR was found to significantly contribute to the complete thrombosis of thoracic false lumen (OR:55.34, CI:34.32∼89.21, P<0.05; heterogeneity: P=0.97, I2=0%) and aortic regression (true lumen expansion and false lumen shrinkage). CONCLUSIONS Although early endovascular repair of uSTBAD does not outperform BMT, its implementation is found to be necessary to facilitate the long-term prognosis. Accordingly, if early TEVAR is to be deferred, close follow-up is critical to allow for timely reintervention.
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Affiliation(s)
- Jian Wang
- The Second Affiliated Hospital of Zhejiang University's Medical College, Department of Vascular Surgery, Hangzhou 310051, Zhejiang, China.
| | - Tao Jin
- The West China Medical School of Sichuan University, Chengdu 610041, Sichuan, China
| | - Bing Chen
- The Second Affiliated Hospital of Zhejiang University's Medical College, Department of Vascular Surgery, Hangzhou 310051, Zhejiang, China.
| | - Yifeng Pan
- The Second Affiliated Hospital of Zhejiang University's Medical College, Department of Vascular Surgery, Hangzhou 310051, Zhejiang, China
| | - Changming Shao
- The Second Affiliated Hospital of Zhejiang University's Medical College, Department of Vascular Surgery, Hangzhou 310051, Zhejiang, China
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12
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Li Z, Wang X, He Y, Xiang Y, Wu Z, Zhang H, Li D. Long-Term Aortic Remodeling After Thoracic Endovascular Aortic Repair of Acute, Subacute, and Chronic Type B Dissections. Front Cardiovasc Med 2022; 9:819501. [PMID: 35433882 PMCID: PMC9005851 DOI: 10.3389/fcvm.2022.819501] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/25/2022] [Indexed: 12/04/2022] Open
Abstract
Objective This study aimed to investigate the characteristics and predictors of aortic remodeling over a long-term follow-up period after thoracic endovascular aortic repair (TEVAR) for acute, subacute, and chronic type B aortic dissections (TBADs). Methods Patients who underwent TEVAR for TBAD from July 2011 to December 2013 were included, and relevant data were retrospectively analyzed. Results After TEVAR, the true lumen (TL) dimension increased and the false lumen (FL) dimension decreased or did not change over a 5-year follow-up period in all three temporal groups. Shrinkage proportion of the thoracic aorta was the highest in the subacute group (acute, 28.1%; subacute, 39.1%; and chronic, 17.4%; p = 0.048), while abdominal expansion showed no significant differences among the groups (acute, 29.6%; subacute, 40.5%; and chronic, 44.4%; p = 0.502). The chronic group had a rate of complete FL regression, which is lower than the subacute or acute group at all anatomic sections, with significant differences only in the stented section (chronic, 21.7%; acute, 92.2%; and subacute, 80.4%; p < 0.05) and in the distal thoracic aortic section (chronic, 13.0%; acute, 31.1%; and subacute, 50.0%; p < 0.05). Logistic regression analysis demonstrated that chronic dissection, TL compression, endoleak, the number of branches from FL, and the number of residual tears affected optimal FL remodeling. Conclusion The present study provides data on aortic remodeling of TBAD after TEVAR during a long-term follow-up period. The features and risk factors of aortic remodeling in the acute, subacute, and chronic phases are different in different aortic segments. These findings may have implications in the timing of TEVAR.
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13
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DeAnda A, Lipsitz E. Commentary: The Evolving Management of Type B Aortic Dissection. J Thorac Cardiovasc Surg 2022; 163:1250-1251. [DOI: 10.1016/j.jtcvs.2022.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 01/23/2022] [Accepted: 01/25/2022] [Indexed: 10/19/2022]
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14
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Singh S, Nassiri N, Vallabhajosyula P. All type B aortic dissections should undergo thoracic endovascular aneurysm repair. JTCVS Tech 2021; 9:17-24. [PMID: 34647046 PMCID: PMC8501243 DOI: 10.1016/j.xjtc.2021.05.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 05/25/2021] [Indexed: 12/26/2022] Open
Affiliation(s)
- Saket Singh
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Conn
| | - Naiem Nassiri
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
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15
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Xiang D, Wu F, Chen L, Liang H, Xiong B, Liang B, Yang F, Zheng C. Timing of endovascular repair impacts long-term outcomes of uncomplicated acute type B aortic dissection. J Vasc Surg 2021; 75:851-860.e3. [PMID: 34592378 DOI: 10.1016/j.jvs.2021.09.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 09/01/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To compare the 5-year outcomes of acute versus subacute thoracic endovascular aortic repair (TEVAR) in patients with uncomplicated acute type B aortic dissection (ATBAD). METHODS Between March 2008 and September 2018, 238 consecutive patients with uncomplicated ATBAD underwent TEVAR in the acute or subacute phase and were analyzed retrospectively. The primary end points were all-cause death and aortic-related death. The secondary end point was a composite of the outcomes of death from any cause, rupture, new dissection, retrograde type A aortic dissection, endoleak, and late reintervention. Inverse probability treatment weighting was used to balance baseline characteristics. Weight-adjusted Kaplan-Meier estimate with landmark analysis and weighted Cox model were performed to assess time-to-event outcomes. RESULTS In the inverse probability treatment weighting-adjusted population, the 30-day mortality was 1.5% in the acute TEVAR group and 0% in the subacute TEVAR group (P = .24). The incidence of 30-day adverse events occurred in 16.8% and 6.9% patients in the acute TEVAR and subacute TEVAR groups, respectively (P = .13). At 5 years, there was no statistically significant difference in all-cause death (hazard ratio [HR], 1.50; 95% confidence interval [CI], 0.59-3.81; P = .39) and aortic-related death (HR, 1.11; 95% CI, 0.34-3.60; P = .86) between the two groups. The composite outcomes occurred in 30 patients (23.0%) in the acute TEVAR group and 18 patients (22.3%) in the subacute TEVAR group, respectively (HR, 0.67; 95% CI, 0.36-1.25; P = .20). However, a landmark analysis of the composite outcomes indicated that there was a significant interaction between treatment effect and time (Pinteraction = .01), with a significantly higher incidence of the composite outcomes in the acute TEVAR group compared with the subacute TEVAR group within 1 year (HR, 0.25; 95% CI, 0.08-0.79; P = .02), and a comparable rate between 1 and 5 years (HR, 1.25; 95% CI, 0.56-2.76; P = .59). CONCLUSIONS At the 5-year follow-up, no significant differences exist in the all-cause death and aortic-related death between acute and subacute TEVAR. However, acute TEVAR is associated with an increased rate of severe complications within 1 year, which suggests that performing TEVAR in the subacute phase of ATBAD may be the preferable option.
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Affiliation(s)
- Dongqiao Xiang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Feihong Wu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Lei Chen
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Huimin Liang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Bin Xiong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Bin Liang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Fan Yang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China.
| | - Chuansheng Zheng
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China.
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16
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Gao Z, Qin Z, Qian D, Pan W, Zhou G, An Z, Hou C, Wang L, Zhang L, Gu T, Jin J. Risk factors for incomplete thrombosis in false lumen in sub-acute type B aortic dissection post-TEVAR. Heart Vessels 2021; 37:505-512. [PMID: 34417627 DOI: 10.1007/s00380-021-01926-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 08/13/2021] [Indexed: 11/30/2022]
Abstract
There is scarce information about the risk factors for incomplete false lumen thrombosis (FLT) among type B aortic dissection (AD) patients, particularly in the sub-acute phase following thoracic endovascular aortic repair (TEVAR). We enrolled consecutive sub-acute type B AD patients at Xinqiao Hospital (Chongqing, China) from May 2010 to December 2019. Patients with severe heart failure, cancer, and myocardial infarction were excluded. The postoperative computed tomography angiography (CTA) data were extracted from the most recent follow-up aortic CTA. Multivariate logistic regressions were applied to identify the association between FLT and clinical or imaging factors. Fifty-five subjects were enrolled in our study. Twelve participants showed complete FLT, and 2 of these died during the follow-up, while 8 patients died in incomplete FLT group. In the multivariate analysis, maximum abdominal aorta diameter (OR 1.20, 95% CI 1.016-1.417 p = 0.032) and the number of branches arising from the false lumen (FL) (OR 15.062, 95% 1.681-134.982 p = 0.015) were significantly associated with incomplete FLT. The C-statistics was 0.873 (95% CI 0.773-0.972) for the model. The FL diameter (p < 0.001) was significantly shorter following TEVAR, while the true lumen diameter (p < 0.001) and maximum abdominal aorta diameter (p = 0.011) were larger after the aortic repair. There were 21.8% of sub-acute type B AD patients presented complete FLT post-TEVAR. Maximum abdominal aorta diameter and the number of branches arising from the FL were independent risk factors for incomplete FLT. The true lumen diameter, maximum abdominal aorta diameter, and FL diameter changed notably following TEVAR.
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Affiliation(s)
- Zhichun Gao
- Institute of Cardiovascular Diseases of PLA, PLA, Xinqiao Street, Chongqing, 400038, China.,Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Xinqiao Street, Shapingba District, Chongqing, 400038, China
| | - Zhexue Qin
- Institute of Cardiovascular Diseases of PLA, PLA, Xinqiao Street, Chongqing, 400038, China.,Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Xinqiao Street, Shapingba District, Chongqing, 400038, China
| | - Dehui Qian
- Institute of Cardiovascular Diseases of PLA, PLA, Xinqiao Street, Chongqing, 400038, China.,Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Xinqiao Street, Shapingba District, Chongqing, 400038, China
| | - Wenxu Pan
- Institute of Cardiovascular Diseases of PLA, PLA, Xinqiao Street, Chongqing, 400038, China.,Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Xinqiao Street, Shapingba District, Chongqing, 400038, China
| | - Guiquan Zhou
- Institute of Cardiovascular Diseases of PLA, PLA, Xinqiao Street, Chongqing, 400038, China.,Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Xinqiao Street, Shapingba District, Chongqing, 400038, China
| | - Zhixia An
- Institute of Cardiovascular Diseases of PLA, PLA, Xinqiao Street, Chongqing, 400038, China.,Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Xinqiao Street, Shapingba District, Chongqing, 400038, China
| | - Changchun Hou
- Institute of Cardiovascular Diseases of PLA, PLA, Xinqiao Street, Chongqing, 400038, China.,Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Xinqiao Street, Shapingba District, Chongqing, 400038, China
| | - Luyu Wang
- Institute of Cardiovascular Diseases of PLA, PLA, Xinqiao Street, Chongqing, 400038, China.,Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Xinqiao Street, Shapingba District, Chongqing, 400038, China
| | - Liying Zhang
- Institute of Cardiovascular Diseases of PLA, PLA, Xinqiao Street, Chongqing, 400038, China.,Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Xinqiao Street, Shapingba District, Chongqing, 400038, China
| | - Tao Gu
- Department of Radiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400038, China
| | - Jun Jin
- Institute of Cardiovascular Diseases of PLA, PLA, Xinqiao Street, Chongqing, 400038, China. .,Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Xinqiao Street, Shapingba District, Chongqing, 400038, China.
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17
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Howard C, Sheridan J, Picca L, Reza S, Smith T, Ponnapalli A, Calow R, Cross O, Iddawela S, George M, Livra Dias D, Srinivasan A, Munir W, Bashir M, Idhrees M. TEVAR for complicated and uncomplicated type B aortic dissection-Systematic review and meta-analysis. J Card Surg 2021; 36:3820-3830. [PMID: 34310731 DOI: 10.1111/jocs.15827] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 06/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Type B aortic dissection (TBAD), is defined as a dissection involving the aorta distal to left subclavian artery with the ascending aorta and the aortic arch not affected. TBAD is classified due to the time frame and presence of complications. Complicated TBAD (co-TBAD) patients have a greater mortality rate than uncomplicated TBAD (un-TBAD) and thoracic endovascular aortic repair (TEVAR) is considered the gold-standard intervention for these clinical challenges. METHODS We undertook a systematic review of the literature regarding TEVAR intervention in co-TBAD and un-TBAD. A comprehensive search was undertaken across four major databases and was evaluated and assessed until June 2020. RESULTS A total of 16,104 patients were included in the study (7772 patients co-TBAD and 8352 un-TBAD). A significantly higher proportion of comorbidities were seen in co-TBAD patients compared with un-TBAD. Acute dissection was more frequent in the co-TBAD group (73.55% vs. 66.91%), while chronic dissection was more common in un-TBAD patients (33.8% vs. 70.73%). Postprocedure stroke was higher in co-TBAD (5.85% vs. 3.92%; p < .01), while postprocedural renal failure was higher in un-TBAD patients (7.23 vs. 11.38%; p < .01). No difference was observed in in-hospital mortality however the 30 days mortality was higher in the co-TBAD group. One-year survival was higher in the uncomplicated group but this difference was not observed in the 5-year survival. CONCLUSION In our analysis we can appreciate that despite significantly higher comorbidities in the co-TBAD cohort, there was no difference in in-hospital mortality between the two groups and the 5-year survival did not have any difference.
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Affiliation(s)
- Callum Howard
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Jonathan Sheridan
- Academic Unit of Medical Education, The University of Sheffield, Sheffield, UK
| | - Leonardo Picca
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Sihab Reza
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Tristan Smith
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Anuradha Ponnapalli
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Rachel Calow
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Olivia Cross
- School of Medicine, Keele University, Staffordshire, UK
| | - Sashini Iddawela
- Department of Respiratory Medicine, University Hospitals Birmingham, Birmingham, UK
| | - Melvin George
- Clinical Pharmacology, SRM Medical College Hospital, Kancheepuram, Tamil Nadu, India
| | - Deidre Livra Dias
- Senior Medical Reviewer, Cognizant Technology Solutions, Pune, India
| | - Anand Srinivasan
- Department of Pharmacology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Wahaj Munir
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mohammad Bashir
- Vascular and Endovascular Surgery, NHS Wales Health Education and Improvement, Cardiff, UK
| | - Mohammed Idhrees
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Vadapalani, Chennai, India
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18
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Xiang D, Kan X, Liang H, Xiong B, Liang B, Wang L, Zheng C. Comparison of mid-term outcomes of endovascular repair and medical management in patients with acute uncomplicated type B aortic dissection. J Thorac Cardiovasc Surg 2021; 162:26-36.e1. [DOI: 10.1016/j.jtcvs.2019.11.127] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 11/18/2019] [Accepted: 11/28/2019] [Indexed: 01/16/2023]
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19
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Rokosh RS, Chen S, Cayne N, Siracuse JJ, Patel VI, Maldonado TS, Rockman CB, Barfield ME, Jacobowitz GR, Garg K. Adjunctive false lumen intervention for chronic aortic dissections is safe but offers unclear benefit. Ann Vasc Surg 2021; 76:10-19. [PMID: 33838234 DOI: 10.1016/j.avsg.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/27/2021] [Accepted: 03/07/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Adjunctive false lumen embolization (FLE) with thoracic endovascular aortic repair (TEVAR) in patients with chronic aortic dissection is thought to induce FL thrombosis and favorable aortic remodeling. However, these data are derived from small single-institution experiences and the potential benefit of FLE remains unproven. In this study, we examined perioperative and midterm outcomes of patients with aortic dissection undergoing concomitant TEVAR and FLE.* METHODS: Patients 18 or older who underwent TEVAR for chronic aortic dissection with known FLE status in the Society for Vascular Surgery Vascular Quality Initiative database between January 2010 and February 2020 were included. Ruptured patients and emergent procedures were excluded. Patient characteristics, operative details and outcomes were analyzed by group: TEVAR with or without FLE. Primary outcomes were in-hospital post-operative complications and all-cause mortality. Secondary outcomes included follow-up mean maximum aortic diameter change, rates of false lumen thrombosis, re-intervention rates, and mortality. RESULTS 884 patients were included: 46 had TEVAR/FLE and 838 had TEVAR alone. There was no significant difference between groups in terms of age, gender, comorbidities, prior aortic interventions, mean maximum pre-operative aortic diameter (5.1cm vs. 5.0cm, P=0.43), presentation symptomatology, or intervention indication. FLE was associated with significantly longer procedural times (178min vs. 146min, P=0.0002), increased contrast use (134mL vs. 113mL, P=0.02), and prolonged fluoroscopy time (34min vs. 21min, P<0.0001). However, FLE was not associated with a significant difference in post-operative complications (17.4% vs. 13.8%, P=0.51), length of stay (6.5 vs. 5.7 days, P=0.18), or in-hospital all-cause mortality (0% vs. 1.3%, P=1). In mid-term follow-up (median 15.5months, IQR 2.2-36.2 months), all-cause mortality trended lower, but was not significant (2.2% vs. 7.8%); and Kaplan-Meier analysis demonstrated no difference in overall survival between groups (P=0.23). By Cox regression analysis, post-operative complications had the strongest independent association with all-cause mortality (HR 2.65, 95% CI 1.56-4.5, P<0.001). In patients with available follow-up imaging and re-intervention status, mean aortic diameter change (n=337, -0.71cm vs. -0.69cm, P=0.64) and re-intervention rates (n=487, 10% vs. 11.4%, P=1) were similar. CONCLUSIONS Adjunctive FLE, despite increased procedural times, can be performed safely for patients with chronic dissection without significantly higher overall perioperative morbidity or mortality. TEVAR/FLE demonstrates trends for improved survival and increased rates of FL thrombosis in the treated thoracic segment; however, given the lack of evidence to suggest a significant reduction in re-intervention rates or induction of more favorable aortic remodeling compared to TEVAR alone, the overall utility of this technique in practice remains unclear. Further investigation is needed to determine the most appropriate role for FLE in managing chronic aortic dissections.
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Affiliation(s)
- Rae S Rokosh
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY; Division of Vascular & Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Stacey Chen
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY
| | - Neal Cayne
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Jeffrey J Siracuse
- Division of Vascular Surgery, Department of Surgery, Boston Medical Center, Boston, MA
| | - Virendra I Patel
- Division of Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Thomas S Maldonado
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Caron B Rockman
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Michael E Barfield
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Glenn R Jacobowitz
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Karan Garg
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY.
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Liu D, Luo H, Lin S, Zhao L, Qiao C. Comparison of the efficacy and safety of thoracic endovascular aortic repair with open surgical repair and optimal medical therapy for acute type B aortic dissection: A systematic review and meta-analysis. Int J Surg 2020; 83:53-61. [DOI: 10.1016/j.ijsu.2020.08.051] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/12/2020] [Accepted: 08/20/2020] [Indexed: 01/08/2023]
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21
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Lee SJ, Kang WC, Ko YG, Woo Y, Ahn CM, Won JY, Lee DY, Hong SJ, Kim JS, Kim BK, Choi D, Hong MK, Jang Y. Aortic Remodeling and Clinical Outcomes in Type B Aortic Dissection According to the Timing of Thoracic Endovascular Aortic Repair. Ann Vasc Surg 2020; 67:322-331. [DOI: 10.1016/j.avsg.2020.03.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 02/26/2020] [Accepted: 03/16/2020] [Indexed: 01/16/2023]
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22
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Commentary: The proximal descending aorta is a "cruel mistress" and should not be ignored. J Thorac Cardiovasc Surg 2020; 163:1762-1763. [PMID: 32950238 DOI: 10.1016/j.jtcvs.2020.06.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 06/16/2020] [Accepted: 06/16/2020] [Indexed: 11/23/2022]
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23
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Hossack M, Patel S, Gambardella I, Neequaye S, Antoniou GA, Torella F. Endovascular vs. Medical Management for Uncomplicated Acute and Sub-acute Type B Aortic Dissection: A Meta-analysis. Eur J Vasc Endovasc Surg 2020; 59:794-807. [DOI: 10.1016/j.ejvs.2019.08.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 07/07/2019] [Accepted: 08/02/2019] [Indexed: 12/29/2022]
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Atkins MD, Reardon MJ. Endovascular repair of type A dissection: the next frontier. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.23736/s1824-4777.20.01432-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Shah A, Gupta N, Gewertz BL, Azizzadeh A. TEVAR for high risk patients with uncomplicated type B aortic dissection: a paradigm shift. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.23736/s1824-4777.20.01450-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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26
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Commentary: Stents or surgery for chronic type-B dissection. J Thorac Cardiovasc Surg 2019; 161:44-45. [PMID: 31757450 DOI: 10.1016/j.jtcvs.2019.10.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 10/08/2019] [Accepted: 10/09/2019] [Indexed: 11/23/2022]
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27
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DeAnda A, Worsham J. Commentary: Extension of the Petticoat Junction into the abdominal aorta. J Thorac Cardiovasc Surg 2019; 158:1019-1020. [PMID: 31537254 DOI: 10.1016/j.jtcvs.2019.07.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 07/21/2019] [Accepted: 07/22/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Abe DeAnda
- Division of Cardiovascular and Thoracic Surgery, UTMB-Galveston, Galveston, Tex.
| | - Jennifer Worsham
- Division of Vascular and Endovascular Surgery, UTMB-Galveston, Galveston, Tex
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Ray HM, Besho JM, Au J, Charlton-Ouw KM, Estrera AL, Miller CC, Safi HJ, Azizzadeh A. The role of ascending aortic size in outcomes of patients with uncomplicated acute type B aortic dissection. J Vasc Surg 2019; 69:1011-1020. [DOI: 10.1016/j.jvs.2018.07.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 07/14/2018] [Indexed: 11/30/2022]
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Pellenc Q, Roussel A, De Blic R, Girault A, Cerceau P, Ben Abdallah I, Milleron O, Jondeau G, Castier Y. False lumen embolization in chronic aortic dissection promotes thoracic aortic remodeling at midterm follow-up. J Vasc Surg 2019; 70:710-717. [PMID: 30850289 DOI: 10.1016/j.jvs.2018.11.038] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 11/11/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Failure of thoracic endovascular aortic repair (TEVAR) in chronic aortic dissections can be partially explained by retrograde false lumen (FL) flow through distal re-entry tears. After implantation of a thoracic stent graft, FL thrombosis occurs in less than 50% of the cases. The objectives of this study were to describe the feasibility and outcomes of FL embolization in patients with chronic aortic dissections. METHODS Between June 2015 and January 2018, 27 patients (mean age, 61 ± 14 years) with chronic aortic dissection underwent FL embolization as an adjunct during or after TEVAR placement procedure. Indications for embolization were (1) symptomatic chronic aortic dissections with pain or rapid growth of aortic diameter (≥5 mm/y) requiring rapid exclusion of the aneurysm, (2) aneurysmal dilatation with persistent FL retrograde flow after TEVAR, and (3) large FL aneurysms (≥55 mm) that might lead to persistent retrograde flow. Twenty patients presented with type B chronic aortic dissections (74.1%) and seven presented a residual type A chronic aortic dissections (25.9%). Eight patients had a previous aortic arch replacement (29.6%). Six patients had previous repair with TEVAR (22.2%). The delay between the onset of dissection and the first endovascular repair was 47 months (range, 3-144). Spinal fluid drainage was used in 74.1% of cases (20/27 patients). Embolization devices included coils and vascular plugs. RESULTS The technical success rate was 100% (27/27). Complete spinal cord ischemia was observed in one patient (3.7%). There was one hospital death from pneumonia after zone 1 supra-aortic trunk debranching with TEVAR and embolization. After the index procedure, FL thrombosis was observed in 81.5% of patients (22/27) on late phase computed tomography angiography. Five patients required two or more embolization procedures, leading to a high rate of complete FL thrombosis (92.6%). One patient presented a type IB endoleak and one patient presented a type II endoleak. Radiologic follow-up was 20 ± 10 months. The maximum thoracic aortic diameter significantly decreased from 63 mm to 54 ± 10 mm (P < .001). CONCLUSIONS Embolization of the FL of chronic aortic dissections is technically feasible with a low morbidity rate. The FL thrombosis is observed in the majority of case and promotes favorable thoracic aortic remodeling. Longer follow-up is needed to confirm these good results on the thoracic aorta and this technique may, therefore, improve the results of TEVAR in chronic aortic dissections.
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Affiliation(s)
- Quentin Pellenc
- Vascular Surgery Department, Bichat Hospital, Assistance Publique-Hopitaux de Paris, Paris, France; Paris-Diderot University, Paris, France.
| | - Arnaud Roussel
- Vascular Surgery Department, Bichat Hospital, Assistance Publique-Hopitaux de Paris, Paris, France; Paris-Diderot University, Paris, France
| | - Romain De Blic
- Vascular Surgery Department, Bichat Hospital, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Antoine Girault
- Vascular Surgery Department, Bichat Hospital, Assistance Publique-Hopitaux de Paris, Paris, France; Paris-Diderot University, Paris, France
| | - Pierre Cerceau
- Vascular Surgery Department, Bichat Hospital, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Iannis Ben Abdallah
- Vascular Surgery Department, Bichat Hospital, Assistance Publique-Hopitaux de Paris, Paris, France; Paris-Diderot University, Paris, France
| | - Olivier Milleron
- Paris-Diderot University, Paris, France; Cardiology Department, Bichat Hospital, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Guillaume Jondeau
- Paris-Diderot University, Paris, France; Cardiology Department, Bichat Hospital, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Yves Castier
- Vascular Surgery Department, Bichat Hospital, Assistance Publique-Hopitaux de Paris, Paris, France; Paris-Diderot University, Paris, France
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Wang GJ, Cambria RP, Lombardi JV, Azizzadeh A, White RA, Abel DB, Cronenwett JL, Beck AW. Thirty-day outcomes from the Society for Vascular Surgery Vascular Quality Initiative thoracic endovascular aortic repair for type B dissection project. J Vasc Surg 2019; 69:680-691. [DOI: 10.1016/j.jvs.2018.06.203] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 06/01/2018] [Indexed: 11/26/2022]
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31
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Pang D, Hildebrand D, Bachoo P. Thoracic endovascular repair (TEVAR) versus open surgery for blunt traumatic thoracic aortic injury. Cochrane Database Syst Rev 2019; 2:CD006642. [PMID: 30723895 PMCID: PMC6363984 DOI: 10.1002/14651858.cd006642.pub3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Blunt traumatic thoracic aortic injury (BTAI) is a life-threatening surgical emergency associated with mortality up to 8000 per year, most commonly caused by rapid acceleration/deceleration injury sustained through motor vehicle accident and/or blunt thoracic trauma. BTAI has high pre-hospital mortality following the primary injury, with only 10% to 15% of patients surviving long enough to reach the hospital. Open surgical repair had remained the standard treatment option for BTAI since successfully introduced in 1959. However, with technological advances, thoracic endovascular repair (TEVAR) offers an alternative treatment option for BTAI. TEVAR is a less invasive surgical approach for management of these already critical patients; many reports have described favourable early outcomes.Thoracic endovascular repair may appear to be superior to open repair for treatment of BTAI. However, its long-term results and efficacy remain unknown. No randomised controlled trials (RCTs) have provided evidence to support the superiority of the endovascular approach versus open repair in the treatment of BTAI. This review aims to address this matter. This is an update of a review first published in 2015. OBJECTIVES To determine whether use of thoracic endovascular repair (TEVAR) for treatment of blunt traumatic thoracic aortic injury (BTAI) is associated with reduced mortality and morbidity when compared with conventional open surgery. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 20 August 2018. SELECTION CRITERIA We considered all published and unpublished randomised controlled trials (RCTs) comparing TEVAR and open surgery for BTAI. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed all RCTs identified by the Cochrane Vascular Information Specialist. MAIN RESULTS We found no RCTs that met the inclusion criteria for this review. AUTHORS' CONCLUSIONS We found no RCTs conducted to determine whether use of TEVAR for the treatment of BTAI is associated with reduced mortality and morbidity when compared to conventional open repair. Hence, we are unable to provide any evidence to guide the treatment option for this life-threatening condition. To perform a randomised controlled trial to clarify the optimal management of BTAI would be highly challenging due to the natural history of the condition. Despite the lack of RCT evidence, clinicians are moving forward with endovascular treatment of BTAI on the basis of meta-analyses of cohort studies and large clinical series.
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Affiliation(s)
| | | | - Paul Bachoo
- NHS GrampianDepartment of Vascular SurgeryForesterhill RoadAberdeenScotlandUKAB25 2ZN
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Iannuzzi JC, Stapleton SM, Bababekov YJ, Chang D, Lancaster RT, Conrad MF, Cambria RP, Patel VI. Favorable impact of thoracic endovascular aortic repair on survival of patients with acute uncomplicated type B aortic dissection. J Vasc Surg 2018; 68:1649-1655. [DOI: 10.1016/j.jvs.2018.04.034] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 04/07/2018] [Indexed: 11/28/2022]
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Tozzi P. Thoracic endovascular aortic repair to treat uncomplicated Stanford type B aortic dissection: The surgeon's dilemma to preventing future complications. Eur J Prev Cardiol 2018; 25:24-31. [PMID: 29708037 DOI: 10.1177/2047487318758100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Uncomplicated type B aortic dissections have traditionally been managed non-operatively with aggressive blood pressure control. However, the best medical treatment is associated with a considerable risk of disease progression to complicated dissection or aneurysmal degeneration of the affected aortic segment. Thoracic endovascular aortic repair could prevent long-term complications but, because the dissected aorta is vulnerable, it is a high-risk procedure performed in asymptomatic patient. Therefore, endovascular treatment is not a solution for all patients and it should be performed only in the subgroup prone to developing progression of the disease and future complications. A number of studies have suggested several prognostic factors of early or late adverse events such as the patency of the false lumen in the follow-up, an initial aortic diameter ≥4 cm with a patent false lumen, an initial false lumen diameter ≥22 mm in the proximal descending aorta, visceral involvement and recurrent or refractory pain or hypertension. Partial false lumen thrombosis and a proximal entry tear size >10 mm have also been suggested to be associated with an increased rate of aortic growth. We need randomised trials focused on these prognostic factors to reach level 1, class A recommendation for the optimal timing of intervention. Meanwhile, we have to discuss with the patient the pro and cons of this prophylactic, low-invasive but high-risk treatment to personalise medical care and provide the optimal risk-to-benefit ratio.
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Affiliation(s)
- Piergiorgio Tozzi
- Department of Cardiovascular Surgery, Centre Hospitalier Universitaire Vaudois, Switzerland
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34
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Analysis of Aortic Growth Rates in Uncomplicated Type B Dissection. Ann Vasc Surg 2018; 48:133-140. [DOI: 10.1016/j.avsg.2017.09.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 08/02/2017] [Accepted: 09/21/2017] [Indexed: 11/16/2022]
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35
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Gutiérrez Castillo D, Cenizo Revuelta N, San Norberto García E, Fuente Garrido R, Fidalgo Domingos L, Vaquero Puerta C. La reparación mediante TEVAR de disecciones agudas de aorta promueve su remodelación a largo plazo en los segmentos stentados comparados con segmentos no tratados de la aorta. ANGIOLOGIA 2018. [DOI: 10.1016/j.angio.2017.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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36
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Arnáiz-García ME, González-Santos JM, Arnáiz-García AM, Arnáiz J. Endovascular repair or best medical treatment: what is the optimal management of uncomplicated Type-B acute aortic dissection? J Thorac Dis 2017; 9:3458-3462. [PMID: 29268315 DOI: 10.21037/jtd.2017.08.145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | | | | | - Javier Arnáiz
- Radiology Department, Aspetar-Orthopaedic and Sports Medicine Hospital, Al Buwairda, Qatar
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Li FR, Wu X, Yuan J, Wang J, Mao C, Wu X. Comparison of thoracic endovascular aortic repair, open surgery and best medical treatment for type B aortic dissection: A meta-analysis. Int J Cardiol 2017; 250:240-246. [PMID: 29066151 DOI: 10.1016/j.ijcard.2017.10.050] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 08/24/2017] [Accepted: 10/13/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Treatments of type B aortic dissection (TBAD) include thoracic endovascular aortic repair (TEVAR), best medical treatment (BMT) and open surgery (OS). This meta-analysis was to compare these three strategies to evaluate which provides best outcomes. METHODS We searched clinical trials that compared treatment strategies for TBAD. The outcomes measures were 30-day/in-hospital mortality, long-term survival rate, paraplegia or paraparesis, renal failure, rupture, stroke, late re-intervention, late rupture and aneurismal dilatation/expansion. RESULTS Sixteen control trials covering 10,307 patients were evaluated. Meta-analysis showed that TEVAR provides preferable long-term survival rate (HR=0.71; 95% CI: 0.52-0.95), lower rate of late re-intervention (OR=0.33; 95% CI: 0.13-0.85), late rupture (OR=0.21; 95% CI: 0.10-0.43) and late aneurismal dilatation/expansion (OR=0.15; 95% CI: 0.04-0.63) compared with BMT. However, TEVAR seemed to be associated with higher stroke rate than BMT (OR=1.65; 95% CI: 1.21-2.23). 30-day/in-hospital mortality appeared to be lower in TEVAR (OR=0.49; 95% CI: 0.29-0.81) when compared with OS. In addition, OS induced higher 30-day/in-hospital mortality compared with BMT (OR=3.95, 95% CI: 1.56-10.02). CONCLUSIONS Our study shows that TEVAR may be favorable in long-term outcomes and effectively provide morphologic advantages compared to BMT. However, there is a need for prophylactic measures against stroke in TEVAR. OS seems to be inferior to TEVAR both in short-term and long-term outcomes. Further studies especially randomized clinical trials are needed to comprehensively compare the efficacy between TEVAR and BMT.
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Affiliation(s)
- Fu-Rong Li
- Department of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, China
| | - Xiaoxiang Wu
- Department of General Surgery, 157th Hospital, General Hospital of Guangzhou Military Command, Guangzhou,China
| | - Jinqiu Yuan
- The Chinese University of Hong Kong, Division of Epidemiology, The Jockey Club School of Public Health and Primary Care, Hong Kong, China
| | - Jiangyun Wang
- Department of Interventional Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, China
| | - Chen Mao
- Department of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, China.
| | - Xianbo Wu
- Department of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, China.
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Choo SJ. Treatment of uncomplicated acute type B aortic dissection in the endovascular era: is it time for a paradigm shift? J Thorac Dis 2017; 9:3450-3452. [PMID: 29268312 DOI: 10.21037/jtd.2017.09.05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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39
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Ray HM, Durham CA, Ocazionez D, Charlton-Ouw KM, Estrera AL, Miller CC, Safi HJ, Azizzadeh A. Predictors of intervention and mortality in patients with uncomplicated acute type B aortic dissection. J Vasc Surg 2016; 64:1560-1568. [DOI: 10.1016/j.jvs.2016.07.111] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 07/01/2016] [Indexed: 10/20/2022]
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40
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Fukunaga N, Koyama T. Evolution of diagnosis and clinical outcomes in acute aortic dissection: data from the International Registry of Acute Aortic Dissection. J Thorac Dis 2016; 8:E625-7. [PMID: 27500931 DOI: 10.21037/jtd.2016.05.31] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Naoto Fukunaga
- Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Tadaaki Koyama
- Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
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41
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Wang J, Li Y, Li Y, Ren Z, Chen P, Qian X, Wang S, Wang J. Endovascular Stent-Graft Placement in Patients with Stanford Type B Aortic Dissection in China: A Systematic Review. Ann Vasc Surg 2016; 36:298-309. [PMID: 27421201 DOI: 10.1016/j.avsg.2016.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 03/22/2016] [Accepted: 04/16/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Improvements in stent-graft devices and increasing clinical experience with the technique have improved outcomes and expanded clinical indications in patients with Stanford type B aortic dissection (AD) in China. However, the evolution of and modifications to stent grafts have not been reviewed. The aim of this study was to summarize all available published data on technical success, potential benefits, complications, stent evolution, and survival rates associated with endovascular stent-graft placements in patients with Stanford type B AD in China. METHODS We performed comprehensive searches of the Chinese-language medical literature in Chinese Biomedical Database, China National Knowledge Infrastructure, and Wanfang Data and of the English-language medical literature in PubMed, Web of Science, and the Cochrane Library. This systematic review was based on all retrospective studies assessing outcomes of Stanford type B AD treated with endovascular stent-graft placement in China. RESULTS A total of 153 retrospective studies that included 8,694 cases were analyzed in this study. Procedure success was reported in 99.7 ± 0.1% of patients. Overall complications were reported in 19.1 ± 0.6% of patients. Postoperative endoleaks occurred in 7.2 ± 0.3% of patients. Major complications were reported in 3.2 ± 0.2% of patients, with a neurological complication rate of 1.3 ± 0.1%. Periprocedural stroke occurred more frequently than did paraplegia (0.8 ± 0.1% vs. 0.1 ± 0.04%). Overall complications were significantly greater in patients treated with first-generation stents than in those treated with second-generation stents (25.1 ± 1.2% vs. 9.5 ± 0.9%, P < 0.001). The in-hospital mortality rate was 1.6 ± 0.1%. In addition, 1.8 ± 0.2% of patients died during a mean follow-up period of 29.4 ± 13.5 months. The Kaplan-Meier estimates of the overall survival rate were 99.0 ± 0.1% at 30 days, 98.5 ± 0.2% at 6 months, 98.4 ± 0.2% at 1 year, 98.1 ± 0.2% at 2 years, and 97.9 ± 0.2% at 5 years. CONCLUSIONS Endovascular stent-graft placement is feasible and has a high technique success rate as well as favorable neurological complication and survival rates when used to treat Stanford type B AD. The new generation of stent grafts appears to have favorable in-hospital and follow-up outcomes.
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Affiliation(s)
- Junwei Wang
- Department of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China; Department of Vascular Surgery, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yonghui Li
- Department of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yongxin Li
- Department of Vascular Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Zefang Ren
- The School of Public Health, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Peng Chen
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Xueke Qian
- Department of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Shenming Wang
- Department of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.
| | - Jinsong Wang
- Department of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.
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[Pre- and postoperative imaging of type B aortic dissection]. ACTA ACUST UNITED AC 2016; 41:260-71. [PMID: 27342640 DOI: 10.1016/j.jmv.2016.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 04/30/2016] [Indexed: 01/17/2023]
Abstract
Type B aortic dissections are serious diseases with a 60 to 80 % 5-year survival rate. Although typically managed with a medical treatment, surgery may be necessary in the acute/subacute or the chronic phase if significant complications are encountered. For these patients, CT angiography is the first-line imaging modality, used for indicating and preparing the surgical procedure as well as for follow-up. Physicians in charge of these patients should be familiar with the key reading points. Visceral malperfusion is the most common acute complication, while aneurysmal dilatation of the false lumen is the most common chronic complication, with surgical management generally indicated when the axial diameter of the aorta exceeds 55mm. Endovascular treatment tends to replace open surgery: it requires precise measurements and identification of the entry tear (contribution of 4D-MRA).
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43
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Qin YL, Wang F, Li TX, Ding W, Deng G, Xie B, Teng GJ. Endovascular Repair Compared With Medical Management of Patients With Uncomplicated Type B Acute Aortic Dissection. J Am Coll Cardiol 2016; 67:2835-42. [DOI: 10.1016/j.jacc.2016.03.578] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 03/29/2016] [Indexed: 01/21/2023]
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44
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San Norberto E, Vaquero C. La disección aórtica tipo B: tratamiento endovascular. ANGIOLOGIA 2016. [DOI: 10.1016/j.angio.2015.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Torsello GF, Austermann M, Van Aken HK, Torsello GB, Panuccio G. Initial clinical experience with the Zenith alpha stent-graft. J Endovasc Ther 2016; 22:153-9. [PMID: 25809352 DOI: 10.1177/1526602815573239] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To assess safety and short-term efficacy of endovascular repair of the thoracic aorta with the new Zenith Alpha stent-graft. METHODS Between August 2010 and May 2014, 33 patients (21 men; mean age 73.2±9.0 years) were treated Zenith Alpha stent-graft (group ZA). Outcomes of this group were compared with those of 34 patients (25 men; mean age 70.3±8.5 years) treated contemporaneously with the Zenith TX-2 for the same pathologies (group TX). The primary outcome measure was technical success. Data on iliac tortuosity, minimum access vessel diameter, and previous unsuccessful treatment with other endografts was also recorded. RESULTS Technical success was 93.9% in group ZA and 91.2% in group TX (p=0.67). There was no case of surgical death or conversion to open repair in either group. Two (6%) type I endoleaks occurred in group ZA and 3 (9%) in group TX (p=0.67). Three patients died within 30 days in group ZA vs. none in group TX (p=0.07). Mean minimum access vessel diameter was significantly smaller (5.07 vs. 6.65 mm, p=0.002) and iliac tortuosity indices significantly higher in group ZA (1.34 vs. 1.25, p=0.02). Access vessel complications occurred in 1 (3%) patient in group ZA and 4 (12%) patients in group TX (p=0.17). Significantly more patients in group ZA (6, 18%) were unsuccessfully treated previously with other endografts vs. none in group TX (p=0.01). CONCLUSION The new Zenith Alpha appears to be equally as safe and efficacious as the Zenith TX-2 while being used in patients with demanding access vessel morphology.
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Affiliation(s)
- Giovanni F Torsello
- Westphalian Center for Radiology, Münster, Germany St. Franziskus Hospital and University Clinic of Münster, Germany Department of Anesthesiology, Intensive Care and Pain Therapy, University Clinic of Münster, Germany
| | | | - Hugo K Van Aken
- Department of Anesthesiology, Intensive Care and Pain Therapy, University Clinic of Münster, Germany
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Havelka GE, Tomita TM, Malaisrie SC, Ho KJ, Eskandari MK. Two Cases of Aortic Intimal Intussusception During Endovascular Repair of an Acute Type B Dissection. J Endovasc Ther 2016; 23:521-8. [DOI: 10.1177/1526602816644917] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To raise awareness of a previously undescribed complication of thoracic endovascular aortic repair (TEVAR) for aortic dissection that can lead to acute aortic occlusion and to highlight that early recognition, excision of the intimal flap, and open aortic repair can be lifesaving. Case Report: Two patients underwent TEVAR for acute type B dissections complicated by abdominal malperfusion syndrome. During stent-graft deployment, the intimal flap circumferentially detached from its origin proximally with subsequent intussusception, leading to acute aortic occlusion. Both complications were recognized intraoperatively with immediate conversion to open aortic reconstruction and intimal flap excision. The first patient required an infrarenal aortobi-iliac bypass, while the second had an open aortic fenestration and bovine pericardial patch repair of the aortotomy. Their postoperative courses were uneventful. Follow-up imaging revealed excellent stent-graft approximation without endoleak and thrombosis of the false lumen. Conclusion: Aortic intimal flap detachment and intussusception is a rare but potentially fatal complication of TEVAR for acute complicated aortic dissection. Quick diagnosis and a low threshold for conversion to open repair are critical in achieving a successful outcome.
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Affiliation(s)
- George E. Havelka
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Tadaki M. Tomita
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - S. Chris Malaisrie
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Karen J. Ho
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mark K. Eskandari
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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García-Valentín A, Bernabeu E. Fisiopatología, clínica y diagnóstico de la disección tipo B complicada. Estrategias terapéuticas. CIRUGIA CARDIOVASCULAR 2016. [DOI: 10.1016/j.circv.2014.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Qing KX, Chan YC, Ting ACW, Cheng SWK. Persistent Intraluminal Pressure After Endovascular Stent Grafting for Type B Aortic Dissection. Eur J Vasc Endovasc Surg 2016; 51:656-63. [PMID: 26922108 DOI: 10.1016/j.ejvs.2016.01.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Accepted: 01/12/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Despite technically successful thoracic endovascular stent graft repair (TEVAR) in patients with Stanford Type B aortic dissection (TBAD), long-term follow up studies have shown that the false lumen may continue to dilate. The aim of this study was to analyze the possible mechanisms leading to such changes from a hemodynamic perspective. METHODS Twenty-eight ex vivo fresh porcine TBAD models (Mo A: 10; Model B: 12; Model C: 6) were established to simulate three clinical situations: Model A with patent false lumen (pre-TEVAR); Model B with distal re-entry only (post-TEVAR), and Model C with thrombus filling in the false lumen and a distal re-entry (chronic stage of post-TEVAR). Synchronous pressure waveforms were taken from both the true and the false lumen. True lumen and false lumen pressure differences were calculated for each model as four indices: systolic index (SI), diastolic index (DI), mean pressure index (MPI) and area under curve index (AUCI). These indices were compared between the three models. RESULTS False lumen pressure and corresponding pressure-accumulating effects were significantly higher in Model A than in Model C: SI (99.9% vs. 189.4%; p < .001); MPI and AUCI (99.5% vs. 128.2%; 99.5% vs. 128%; p < .001). The SI, MPI, and AUCI were significantly higher in Model B compared with Model C. The differences between the four indices were not significant between Model A and B. The false lumen area under curve (AUC) in Model C was merely lowered by 20% compared with its true lumen (67.5 mmHg vs. 85.2 mmHg). CONCLUSION The false lumen pressure remained unchanged in the non-thrombosed segment with patent blood flow after the primary entry tear sealed. Intraluminal pressure reduction in the thrombosed false lumen was significant. However, nearly 80% of the pressure remained in the thrombosed false lumen. If this high intra-thrombus pressure persists, it may contribute to delayed aneurysmal formation after endovascular treatment.
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Affiliation(s)
- K-X Qing
- Department of Vascular Surgery, The First Hospital Affiliated to Kunming Medical University, Kunming Medical University, Kunming, Yunnan, PR China
| | - Y-C Chan
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong Special Administrative Region
| | - A C W Ting
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong Special Administrative Region
| | - S W K Cheng
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong Special Administrative Region.
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Crawford TC, Beaulieu RJ, Ehlert BA, Ratchford EV, Black JH. Malperfusion syndromes in aortic dissections. Vasc Med 2016; 21:264-73. [PMID: 26858183 DOI: 10.1177/1358863x15625371] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aortic dissection remains a challenging clinical scenario, especially when complicated by peripheral malperfusion. Improvements in medical imaging have furthered understanding of the pathophysiology of malperfusion events in association with aortic dissection, including the elucidation of different mechanisms of branch vessel obstruction. Despite these advances, malperfusion syndrome remains a deadly entity with significant mortality. This review presents the latest knowledge regarding the pathogenesis of aortic dissection complicated by malperfusion syndrome, and discusses the diagnostic and therapeutic guidelines for management of this vicious entity.
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Affiliation(s)
- Todd C Crawford
- Johns Hopkins Hospital, Department of Surgery, Baltimore, MD, USA
| | | | - Bryan A Ehlert
- Johns Hopkins Hospital, Department of Surgery, Baltimore, MD, USA
| | | | - James H Black
- Johns Hopkins Hospital, Department of Surgery, Baltimore, MD, USA
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Cheng S. Novel endovascular procedures and new developments in aortic surgery. Br J Anaesth 2016; 117 Suppl 2:ii3-ii12. [DOI: 10.1093/bja/aew222] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2016] [Indexed: 12/17/2022] Open
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