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Takazawa A, Asakura T, Kinoshita O, Nakajima H, Yoshitake A. Mid- and long-term results of open repair for chronic type B aortic dissection in endovascular era. Heart Vessels 2024; 39:818-825. [PMID: 38536509 PMCID: PMC11344721 DOI: 10.1007/s00380-024-02399-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/13/2024] [Indexed: 08/25/2024]
Abstract
Medical management is the standard treatment of chronic type B aortic dissection (CTBAD). However, the roles of open surgical repair (OSR) and thoracic endovascular repair (TEVAR) in patients with CTBAD remain controversial. Thus, this study aimed to assess and compare the mid- and long-term clinical outcomes of OSR via left thoracotomy with that of TEVAR for CTBAD. The data of 85 consecutive patients who underwent surgery for CTBAD from April 2007 to May 2021 were retrospectively reviewed. The patients were divided into two groups: Group G, which included patients who underwent OSR, and Group E, which included patients who underwent TEVAR. Groups G and E comprised 33 and 52 patients, respectively. Preoperative and postoperative computed tomography (CT) studies were retrospectively analyzed for the maximum diameter. The mean duration of the follow-up period was 5.8 years. Operative mortality did not occur. There was no difference in complications, such as stroke (G: 2 vs. E: 0, p = 0.30), paraplegia (G: 1 vs. E: 1, p = 0.66), and respiratory failure (G: 2, vs. E: 0, p = 0.30). The difference in preoperative factors was observed, including the intervals between onset and operation (G; 4.9 years vs. E; 1.9 years, p < 0.01), maximum diameter in preoperative CT (G; 59.0 mm vs. E; 50.5 mm, p < 0.001), and maximum false lumen diameter (G; 35.5 mm vs. E; 29.0 mm, p < 0.01). There was no significant difference in the mid- and long-term survival rates (p = 0.49), aorta-related deaths (p = 0.33), and thoracic re-intervention rates (p = 0.34). Postoperative adverse events occurred in Group E: four cases of retrospective type A aortic dissection, two cases of aorto-bronchial fistula, and one case of aorto-esophagus fistula. Aorta-related death and re-intervention rates crossed over in both groups after seven years postoperatively. Although endovascular repair of CTBAD is less invasive, the rate of freedom from re-intervention was unsatisfactory. Some fatal complications were observed in the endovascular group, and the mid- and long-term outcomes were reversed compared with those in the OSR group. Although OSR is an invasive procedure, it could be performed safely without perioperative complications. OSR has more feasible mid- and long-term outcomes.
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Affiliation(s)
- Akitoshi Takazawa
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka City, Saitama, Japan.
| | - Toshihisa Asakura
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka City, Saitama, Japan
| | - Osamu Kinoshita
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka City, Saitama, Japan
| | - Hiroyuki Nakajima
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka City, Saitama, Japan
| | - Akihiro Yoshitake
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka City, Saitama, Japan
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Lozano R, DiLosa K, Schneck M, Maximus S, Callcut R, Shatz D, Mell M. Comparison of treatment and outcomes in blunt thoracic aortic injury based on different vascular surgery guidelines. J Vasc Surg 2023; 78:48-52. [PMID: 37088445 DOI: 10.1016/j.jvs.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 02/23/2023] [Accepted: 03/05/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE Society for Vascular Surgery (SVS) recommendations for managing intimal (grade 1) blunt thoracic aortic injuries (BTAIs) include observation and medical management. University of Washington (UW) revised criteria suggest that intimal injuries with ≥1 cm flap should be upgraded to a moderate injury and treatment be considered. We sought to evaluate and compare SVS and UW criteria for BTAI and determine how discordance in grading affected treatment and outcome. METHODS We reviewed all patients admitted with BTAI from January 1, 2011, to March 31, 2022. Data included injury grading, demographics, and concomitant traumatic injuries. Images were reviewed to categorize the injury with both grading systems. Treatment and outcomes were analyzed for concordant and discordant groups. RESULTS Our cohort comprised 208 patients after excluding four who died upon arrival. The mean age was 45 ± 19 years, 69% were men, and the median injury severity score was 34 (interquartile range, 26-45). Strong agreement was observed between the grading systems (kappa = 0.88). All patients with concordant grade 1 injuries (n = 54) were observed. SVS grade 1/2 BTAIs were reclassified in 12 of 71 patients (16.9%). Two (28.6%) SVS grade 2 injuries were graded lower with the UW criteria; neither patient required immediate or delayed repair. Ten (15.6%) SVS grade 1 BTAIs were graded higher with UW criteria. Of these, six underwent repair (one for preoperative embolization), and four were observed without sequalae. Overall mortality was 7.7% with no difference for concordant or discordant grades (7.7% vs 8.3%; P = .99). No aneurysm-related mortalities were observed. Follow-up imaging was available for 94 survivors (49.0%) at a median of 193 days (interquartile range, 42-522 days). Two patients unrepaired at the index hospitalization (SVS grade 3/UW grade 2) underwent successful delayed repair. No patient observed for a minimal injury had BTAI progression or required treatment. CONCLUSIONS The UW grading system may upgrade or downgrade SVS grade 1 or 2 BTAI for as many as one in six injuries. Upgraded injuries should prompt consideration of repair if there is evidence of flap progression or thromboembolic complications. Downgraded injuries suggest that treatment may not be necessary; clinical expertise is key to determine optimal management in these patients.
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Affiliation(s)
- Rafael Lozano
- Department of Surgery, University of California, Davis Health, Sacramento, CA.
| | - Kathryn DiLosa
- Department of Surgery, University of California, Davis Health, Sacramento, CA
| | - Matthew Schneck
- Department of Surgery, University of California, Davis Health, Sacramento, CA
| | - Steven Maximus
- Department of Surgery, University of California, Davis Health, Sacramento, CA
| | - Rachael Callcut
- Department of Surgery, University of California, Davis Health, Sacramento, CA
| | - David Shatz
- Department of Surgery, University of California, Davis Health, Sacramento, CA
| | - Matthew Mell
- Department of Surgery, University of California, Davis Health, Sacramento, CA
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Volevski LA, Vasiloi I, Abudureheman N, Talipov I, König A, Dielmann K, Glück AC, Andrási TB. Impact of the underlying aortic pathology on postimplantation syndrome after endovascular thoracic aortic repair. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:93-99. [PMID: 36239926 DOI: 10.23736/s0021-9509.22.12384-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) is the treatment option of choice for almost all pathologies of the descending thoracic aorta. The aim of the present study was to determine the impact of aortic pathology on the occurrence of postimplantation syndrome (PIS) after TEVAR. METHODS Seventy-four patients undergoing TEVAR for aortic dissection (TAD, 25), aortic aneurysm (TAA, 26), and aortic rupture or perforated ulcer (TAR/PAU, 23) were included in this retrospective study. The clinical outcome measures were persistent inflammation at hospital discharge and in-hospital mortality. RESULTS PIS was assessed in 22.97% of all patients, predominantly in the TAD group (P=0.03). CRP increased after TEVAR (156.6±94.5, P<0.001; 108.1±57.7, P<0.01 and 117.8±70.4, P<0.05) vs. baseline (58.1±77.5, 31.94±52.1 and 31.9±52.1 mg/L, in TAD, TAA and TAR/PAU, respectively) and this increase was more accentuated in TAD group (P<0.05). Stent-length was similar in all groups (P=0.226) but correlated with postoperative CRP only in TAD (R=0.576, P=0.013). Fresh parietal thrombus correlated with CRP (R=0.4507, P=0.0005) and is (OR=1.0883, P=0.0001), together with the pathology of aortic dissection (OR=6.2268, P=0.0288), a predictor of PIS after TEVAR. Whereas mortality (5.4%) did not correlate with PIS (P=0.38) either with aortic pathology (P=0.225), hospital stay after TEVAR was significantly prolonged by PIS (P=0.03). CONCLUSIONS Aortic dissection is associated with more inflammation after TEVAR than aortic aneurysm, rupture or perforated ulcer, with the amount of fresh parietal thrombus playing the most significant role in the occurrence of PIS. Importantly, PIS prolongs hospital stay but not mortality after TEVAR.
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Affiliation(s)
| | - Ion Vasiloi
- Department of Cardiac Surgery, Philipps University, Marburg, Germany
| | | | - Ildar Talipov
- Department of Cardiac Surgery, Philipps University, Marburg, Germany
| | - Alexander König
- Department of Radiology, Philipps University, Marburg, Germany
| | - Kai Dielmann
- Department of Anesthesiology and Intensive Care, Philipps University, Marburg, Germany
| | - Alannah C Glück
- Department of Cardiac Surgery, Philipps University, Marburg, Germany
| | - Terézia B Andrási
- Department of Cardiac Surgery, Philipps University, Marburg, Germany -
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Kamman AV, van Bakel PAJ, Yang B, Williams DM, Kim KM, Khaja MS, Moll FL, van Herwaarden JA, Trimarchi S, Eagle KA, Eliason JL, Patel HJ. Stroke Following Thoracic Endovascular Aortic Repair: Determinants, Short and Long Term Impact. Semin Thorac Cardiovasc Surg 2023; 35:19-30. [PMID: 35091051 DOI: 10.1053/j.semtcvs.2021.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 08/18/2021] [Indexed: 11/11/2022]
Abstract
We performed a contemporary assessment of clinical and radiographic factors of stroke after thoracic endovascular aortic repair (TEVAR). Patients undergoing TEVAR from 2006 to 2017 were identified. We assessed clinical and radiographic data, including preoperative head and neck computed tomography, Doppler ultrasonography, and intraoperative angiography. Our primary outcome was stroke after TEVAR. Four hundred seventy-nine patients underwent TEVAR, mean age 68.1 ± 19.5 years, 52.6% male. Indications for TEVAR included aneurysms (n = 238, 49.7%) or dissections (n = 152, 31.7%). Ishimaru landing zones were Zone 2 (n = 225, 47.0%), Zone 3 (n = 151, 31.5%), or Zone 4 (n = 103, 21.5%). Stroke occurred in 3.8% (n = 18) of patients, with 1.9% (8) major events (modified Rankin Scale >3). Pathophysiology was predominantly embolic (n = 14), and occurred in posterior (n = 6), anterior (n = 6), or combined circulation (n = 4), and in the left hemisphere (n = 10) or bilateral (n = 6). Univariate analysis suggested use of lumbar drain (33.3% versus 57.2%, P = 0.04), inability to revascularize the left subclavian artery (16.7% vs 5.2%, P = 0.04) and number of implanted components (2.5 ± 1.2 vs 2.0 ± 0.97, P = 0.03) were associated with stroke. Multivariable analysis identified number of implanted components (OR 1.7, 95%CI 1.17-2.67 P = 0.00) and inability to revascularize the left subclavian artery as independent predictors of stroke. Stroke was associated with a higher perioperative mortality (27.8% vs 3.9%, P < 0.01). Stroke after TEVAR is primarily embolic in nature and related to both anatomic and procedural factors. This may have important implications for device development in the era of endovascular arch repair.
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Affiliation(s)
- Arnoud V Kamman
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands; Thoracic Aortic Research Center, Policlinico San Donato IRCCS, San Donato Milanese, Italy; Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Pieter A J van Bakel
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Bo Yang
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - David M Williams
- Department of Radiology, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Karen M Kim
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Minhaj S Khaja
- Department of Radiology, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Frans L Moll
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Joost A van Herwaarden
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Santi Trimarchi
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, San Donato Milanese, Italy
| | - Kim A Eagle
- Department of Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Jonathan L Eliason
- Department of Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Himanshu J Patel
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan.
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Singh S, Pupovac SS, Assi R, Vallabhajosyula P. Comprehensive review of hybrid aortic arch repair with focus on zone 0 TEVAR and our institutional experience. Front Cardiovasc Med 2022; 9:991824. [PMID: 36187018 PMCID: PMC9520124 DOI: 10.3389/fcvm.2022.991824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/25/2022] [Indexed: 11/24/2022] Open
Abstract
Even with increasing operator experience and a better understanding of the disease and the operation, intervention for aortic arch pathologies continues to struggle with relatively higher mortality, reintervention, and neurologic complications. The hybrid aortic arch repair was introduced to simplify the procedure and improve the outcome. With recent industry-driven advances, hybrid repairs are not only offered to poor surgical candidates but have become mainstream. This review discusses the evolution of hybrid repair, terminology pertinent to this technique, and results. In addition, we aim to provide a pervasive review of hybrid aortic arch repairs with reference to relevant literature for a detailed understanding. We have also discussed our institutional experience with hybrid repairs.
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López Espada C, Linares Palomino JP, Domínguez González JM, Iborra Ortega E, Lozano Vilardell P, Solanich Valldaura T, Volo Pérez G, Blanco Cañibano E, Álvarez Salgado A, Fernández Fernández JC, Hernando Rydings M, Miralles Hernández M. A multicenter study of emergency endovascular repair of the thoracic aorta: Indications and outcomes. Med Intensiva 2021; 45:280-288. [PMID: 34059218 DOI: 10.1016/j.medine.2021.04.008] [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: 09/11/2019] [Accepted: 10/28/2019] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Endovascular techniques have become an essential tool for the treatment of descending thoracic aortic disease (thoracic endovascular aneurysm repair [TEVAR]). The aim is to analyze the indications and outcomes of emergency TEVAR at national level in relation to elective surgery. STUDY DESIGN AND SCOPE A retrospective multicenter registry of patients with descending thoracic aortic disease treated on an emergency basis using endovascular techniques between 2012-2016, in 11 clinical units. PATIENTS, INCLUSION CRITERIA 1) Ruptured descending thoracic aortic aneurysms (RTAA); 2) Blunt traumatic thoracic aortic injury (TAI); and 3) Complicated acute type B aortic dissections (TBADc). PRIMARY VARIABLES Patient mortality, survival and reoperation rate. SECONDARY VARIABLES Demographic data, cardiovascular risk factors, specific data by indication, technical resources and postoperative complications. RESULTS A total of 135 urgent TEVARs were included (111 men, mean age 60.4 ± 16.3 years): 43 ruptured thoracic aortic aneurysms (31.9%), 54 type B dissections (40%) and 32 traumatic aortic injuries (23.7%), and other etiologies 4.4%. The overall mortality rate at 30 days was 18.5%, and proved higher in the RTAA group (27.9%). The mean actuarial survival rate was 67 ± 6% at 5 years. The postoperative stroke rate was 5.2%, and the paraplegia rate was 5.9%. Aortic reoperations proved necessary in 12 patients (9%). CONCLUSIONS Emergency descending thoracic aortic diseases can be treated by endovascular techniques with optimal results and low morbidity and mortality - though the figures are slightly higher than in elective cases. This registry provides, for the first time, real information on the daily clinical practice of emergency TEVAR in Spain.
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Affiliation(s)
- C López Espada
- Servicio de Cirugía Vascular, Hospital Universitario Virgen de las Nieves, Granada, Spain.
| | - J P Linares Palomino
- Servicio de Cirugía Vascular, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | | | - E Iborra Ortega
- Servicio de Cirugía Vascular, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - P Lozano Vilardell
- Servicio de Cirugía Vascular, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | | | - G Volo Pérez
- Servicio de Cirugía Vascular, Hospital Universitario Dr. Negrín, Gran Canaria, Spain
| | - E Blanco Cañibano
- Servicio de Cirugía Vascular, Hospital Universitario de Guadalajara, Guadalajara, Spain
| | - A Álvarez Salgado
- Servicio de Cirugía Vascular, Hospital Universitario de Cabueñes, Spain
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Zhou M, Shi Z, Li X, Cai L, Ding Y, Si Y, Deng H, Fu W. Prediction of Distal Aortic Enlargement after Proximal Repair of Aortic Dissection Using Machine Learning. Ann Vasc Surg 2021; 75:332-340. [PMID: 33823266 DOI: 10.1016/j.avsg.2021.02.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/28/2020] [Accepted: 02/08/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES This study aimed to construct a risk prediction model for distal aortic enlargement in patients with type B aortic dissection (TBAD) treated with proximal thoracic endovascular aortic repair (TEVAR). METHODS From June 2010 to June 2016, patients with TBAD who underwent proximal TEVAR were retrospectively analyzed. A total of 38 clinical and imaging variables were collected. Univariable logistic regression was conducted to explore potential risk factors associated with distal aortic enlargement. Elastic net regression was employed to select significantly influential variables. Then, machine learning algorithms (logistic regression (LR), artificial neutral network (ANN), random forest and support vector machine) were applied to build risk prediction models. The area under the receiver operating characteristic curve (AUC), sensitivity and specificity were used to evaluate the performance of these models. RESULTS A total of 503 patients were enrolled in this study. During the follow-up, 105 (20.9%) patients were identified as having distal aortic enlargement, and 69 (13.7%) patients were found to have distal aortic aneurysm formation. Five patients were identified with aortic rupture. True lumen collapse and multi-false lumens were two potential risk factors for distal aortic enlargement after proximal repair of TBAD. The LR model performed the best in predicting distal aortic enlargement, with the highest sensitivity (96.7%) and an AUC of 0.773. The best model for predicting distal aneurysm formation was the ANN model, which yielded the highest AUC (0.876) and a specificity of 79.1%. CONCLUSIONS Machine learning approaches can produce accurate predictions of distal aortic enlargement after proximal repair of TBAD, which potentially benefits subsequent management.
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Affiliation(s)
- Min Zhou
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhenyu Shi
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xu Li
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Liang Cai
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yong Ding
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi Si
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hongwen Deng
- Department of Global Biostatistics and Data Science, Center for Bioinformatics and Genomics, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Los Angeles
| | - Weiguo Fu
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.
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Chen SW, Lee KB, Napolitano MA, Murillo-Berlioz AE, Sattah AP, Sarin S, Trachiotis G. Complications and Management of the Thoracic Endovascular Aortic Repair. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2020; 8:49-58. [PMID: 33152785 PMCID: PMC7644296 DOI: 10.1055/s-0040-1714089] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Endovascular treatment in thoracic aortic diseases has increased in use exponentially since Dake and colleagues first described the use of a home-made transluminal endovascular graft on 13 patients with descending thoracic aortic aneurysm at Stanford University in the early 1990s. Thoracic endovascular aneurysm repair (TEVAR) was initially developed for therapy in patients deemed unfit for open surgery. Innovations in endograft engineering design and popularization of endovascular techniques have transformed TEVAR to the predominant treatment choice in elective thoracic aortic repair. The number of TEVARs performed in the United States increased by 600% from 1998 to 2007, while the total number of thoracic aortic repairs increased by 60%. As larger multicenter trials and meta-analysis studies in the 2000s demonstrate the significant decrease in perioperative morbidity and mortality of TEVAR over open repair, TEVAR became incorporated into standard guidelines. The 2010 American consensus guidelines recommend TEVAR to be “strongly considered” when feasible for patients with degenerative or traumatic aneurysms of the descending thoracic aorta exceeding 5.5 cm, saccular aneurysms, or postoperative pseudoaneurysms. Nowadays, TEVAR is the predominant treatment for degenerative and traumatic descending thoracic aortic aneurysm repair. Although TEVAR has been shown to have decreased early morbidity and mortality compared with open surgical repair, endovascular manipulation of a diseased aorta with endovascular devices continues to have significant risks. Despite continued advancement in endovascular technique and devices since the first prospective trial examined the complications associated with TEVAR, common complications, two decades later, still include stroke, spinal cord ischemia, device failure, unintentional great vessel coverage, access site complications, and renal injury. In this article, we review common TEVAR complications with some corresponding radiographic imaging and their management.
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Affiliation(s)
- Sheena W Chen
- George Washington University Hospital, Washington, District of Columbia
| | - Kyongjune B Lee
- George Washington University Hospital, Washington, District of Columbia
| | | | | | | | - Shawn Sarin
- George Washington University Hospital, Washington, District of Columbia
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9
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López Espada C, Linares Palomino JP, Domínguez González JM, Iborra Ortega E, Lozano Vilardell P, Solanich Valldaura T, Volo Pérez G, Blanco Cañibano E, Álvarez Salgado A, Fernández Fernández JC, Hernando Rydings M, Miralles Hernández M. Endovascular Treatment of Descending Thoracic Aortic Pathology: Results of the Regis-TEVAR Study. Ann Vasc Surg 2020; 67:306-315. [PMID: 32173472 DOI: 10.1016/j.avsg.2020.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 01/12/2020] [Accepted: 02/06/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Endovascular techniques have become an essential tool for treatment of thoracic aortic pathology. The objective of this study was to analyze indications and results of thoracic endovascular aortic repair (TEVAR) in vascular surgery units, through a retrospective and multicentric national registry called Regis-TEVAR. METHODS From 2012 to 2016, a total of 287 patients from 11 vascular surgery units, treated urgently and electively, were recruited consecutively. The primary variables analyzed are mortality, survival, and reintervention rate. The following indications for TEVAR were also analyzed: aortic dissections, thoracic aneurysms, traumatisms, and intramural hematomas or penetrating ulcers, as well as results and postoperative complications in accordance with each indication. RESULTS Of the 287 TEVAR performed (239 men, mean age 64.1 ± 14.1 years), 155 were because of aortic aneurysm (54%), 90 because of type B aortic dissection (31.4%), 36 because of traumatic aortic rupture (12.5%), and 6 because of penetrating ulcers or intramural hematomas (2.1%). Overall mortality at 30 days was 11.5% (18.5% in urgent and 5.3% in elective), being higher in dissections (13.3%). The median actuarial survival was 73% at 4 years. The stroke rate was 3.1%, and the rate of spinal cord ischemia was 4.9%. Aortic reoperations were necessary in 23 patients (8.1%). CONCLUSIONS This registry provides complete and reliable information on real clinical practice of TEVAR in Spain, with results similar to international series of open surgery. In accordance with these data, TEVAR can be performed with acceptable morbidity and mortality and with low rates of postoperative complications.
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Affiliation(s)
| | | | | | | | | | | | - Guido Volo Pérez
- Vascular Surgery Unit, University Hospital Dr.Negrín de Gran Canaria, Spain
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10
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Lou X, Duwayri YM, Jordan WD, Chen EP, Veeraswamy RK, Leshnower BG. The Safety and Efficacy of Extended TEVAR in Acute Type B Aortic Dissection. Ann Thorac Surg 2020; 110:799-806. [PMID: 32006479 DOI: 10.1016/j.athoracsur.2019.12.036] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 11/25/2019] [Accepted: 12/16/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) with endograft coverage from the left subclavian artery to the celiac artery has been hypothesized to increase spinal cord ischemia. This study analyzes the impact of extended coverage on adverse outcomes and aortic remodeling in patients with complicated acute type B aortic dissection (aTBAD). METHODS From January 2012 to October 2018, 91 patients underwent TEVAR for aTBAD. Median follow-up was 3.1 (interquartile range, 1.2-4.9) years and was complete in 94% of patients. The extent of aortic endograft coverage was categorized as standard (n = 39) or extended (n = 52). Contrast-enhanced imaging scans were analyzed to determine length of coverage, maximum aortic diameters, and false lumen (FL) status. RESULTS The mean age was 52.6 ± 13.9 years, and 66% were men. The most common indications for intervention were malperfusion (42%) and refractory pain (34%). Thirteen (14%) patients required a lumbar drain (preoperative: n = 3; postoperative: n = 10). Mean duration between scans was 2.0 ± 1.9 years. Length of aortic coverage was significantly longer in the extended group (241.7 ± 29.2 mm vs 180.8 ± 22.3 mm in the standard group; P < .001). In-hospital and overall mortality were 6% and 11%, respectively. There were no cases of paraplegia, and the incidence of spinal cord ischemia was 3%. After TEVAR, there was a higher incidence of FL obliteration or thrombosis at the distal descending thoracic aorta in the extended group (53% vs 16% in the standard group; P = .004). CONCLUSIONS Extended TEVAR carries a low risk of spinal cord ischemia and improves FL remodeling of the descending thoracic aorta in patients with aTBAD. This strategy may decrease the need for reinterventions on the thoracic aorta in the chronic phase of TBAD.
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Affiliation(s)
- Xiaoying Lou
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Yazan M Duwayri
- Division of Vascular and Endovascular Therapy, Emory University School of Medicine, Atlanta, Georgia
| | - William D Jordan
- Division of Vascular and Endovascular Therapy, Emory University School of Medicine, Atlanta, Georgia
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Ravi K Veeraswamy
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
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Coster BD, Houthoofd S, Laenen A, Fourneau I, Maleux G. Overall survival and factors predicting long-term outcome after thoracic aortic endovascular repair. Scand J Surg 2020; 110:386-394. [PMID: 32126933 DOI: 10.1177/1457496920910004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSES To assess overall survival and to determine factors predicting outcome after thoracic endovascular aortic repair. MATERIALS AND METHODS A Retrospective analysis was performed on a cohort of 212 consecutive patients (165 men and 47 women; mean age 64 years) who underwent thoracic endovascular aortic repair in a tertiary referral center for aortic disease. Main indications were true thoracic aortic aneurysm (n = 58; 27.6%), traumatic aortic rupture (n = 33; 15.7%), anastomotic pseudoaneurysms (n = 23; 10.9%), chronic type B aortic dissection (n = 22; 10.5%), and symptomatic, acute type B dissection (n = 21; 10.0%). In 79 patients (37.3%), a hybrid procedure, including supra-aortic rerouting, was performed. Kaplan-Meier estimates were used for overall survival and Cox regression models were used for univariable analysis of the association between risk factors and survival. RESULTS Proximal landing zones were predominantly zone 3 (n = 66; 31.3%), zone 2 (n = 63; 29.9%), and zone 1 (n = 38; 18%). In-hospital mortality was n = 18 (8.5%). Overall survival was 79.6%, 65.9%, and 51.1% at 2, 5, and 10 years, respectively; better overall survival was shown for traumatic aortic rupture, anastomotic pseudoaneurysms, and chronic posttraumatic pseudoaneurysms (p < 0.05). Clinical risk factors influencing overall survival include prior coronary bypass surgery, atrial flutter, arterial hypertension, renal failure, chronic obstructive pulmonary disease, and associated abdominal aortic aneurysm (p < 0.05). CONCLUSIONS Thoracic endovascular aortic repair is an effective treatment option for various thoracic aortic diseases with highest survival rates for traumatic aortic rupture and anastomotic pseudoaneurysms. Several clinical parameters are identified as risk factors for overall survival.
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Affiliation(s)
- Bruno De Coster
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Sabrina Houthoofd
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Annouschka Laenen
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, KU Leuven and Universiteit Hasselt, Leuven, Belgium
| | - Inge Fourneau
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Geert Maleux
- Department of Radiology, University Hospitals Leuven, Herestraat 49, Leuven, B-3000, Belgium
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12
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López Espada C, Linares Palomino JP, Domínguez González JM, Iborra Ortega E, Lozano Vilardell P, Solanich Valldaura T, Volo Pérez G, Blanco Cañibano E, Álvarez Salgado A, Fernández Fernández JC, Hernando Rydings M, Miralles Hernández M. A multicenter study of emergency endovascular repair of the thoracic aorta: indications and outcomes. Med Intensiva 2019; 45:280-288. [PMID: 31836259 DOI: 10.1016/j.medin.2019.10.008] [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: 09/11/2019] [Revised: 10/22/2019] [Accepted: 10/28/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Endovascular techniques have become an essential tool for the treatment of descending thoracic aortic disease (thoracic endovascular aneurysm repair [TEVAR]). The aim is to analyze the indications and outcomes of emergency TEVAR at national level in relation to elective surgery. STUDY DESIGN AND SCOPE A retrospective multicenter registry of patients with descending thoracic aortic disease treated on an emergency basis using endovascular techniques between 2012-2016, in 11 clinical units. PATIENTS, INCLUSION CRITERIA 1) Ruptured descending thoracic aortic aneurysms; 2) Blunt traumatic thoracic aortic injury; and 3) Complicated acute type B aortic dissections (TBADc). PRIMARY VARIABLES Patient mortality, survival and reoperation rate. SECONDARY VARIABLES Demographic data, cardiovascular risk factors, specific data by indication, technical resources and postoperative complications. RESULTS A total of 135 urgent TEVARs were included (111 men, mean age 60.4 ± 16.3 years): 43 ruptured thoracic aortic aneurysms (31.9%), 54 type B dissections (40%) and 32 traumatic aortic injuries (23.7%), and other etiologies 4.4%. The overall mortality rate at 30 days was 18.5%, and proved higher in the ruptured descending thoracic aortic aneurysms group (27.9%). The mean actuarial survival rate was 67± 6% at 5 years. The postoperative stroke rate was 5.2%, and the paraplegia rate was 5.9%. Aortic reoperations proved necessary in 12 patients (9%). CONCLUSIONS Emergency descending thoracic aortic diseases can be treated by endovascular techniques with optimal results and low morbidity and mortality - though the figures are slightly higher than in elective cases. This registry provides, for the first time, real information on the daily clinical practice of emergency TEVAR in Spain.
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Affiliation(s)
- C López Espada
- Servicio de Cirugía Vascular, Hospital Universitario Virgen de las Nieves, Granada, España.
| | - J P Linares Palomino
- Servicio de Cirugía Vascular, Hospital Universitario Virgen de las Nieves, Granada, España
| | | | - E Iborra Ortega
- Servicio de Cirugía Vascular, Hospital Universitari de Bellvitge, Barcelona, España
| | - P Lozano Vilardell
- Servicio de Cirugía Vascular, Hospital Universitari Son Espases, Palma de Mallorca, España
| | | | - G Volo Pérez
- Servicio de Cirugía Vascular, Hospital Universitario Dr. Negrín, Gran Canaria, España
| | - E Blanco Cañibano
- Servicio de Cirugía Vascular, Hospital Universitario de Guadalajara, Guadalajara, España
| | - A Álvarez Salgado
- Servicio de Cirugía Vascular, Hospital Universitario de Cabueñes, España
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Quantification of aortic shagginess as a predictive factor of perioperative stroke and long-term prognosis after endovascular treatment of aortic arch disease. J Vasc Surg 2019; 69:15-23. [DOI: 10.1016/j.jvs.2018.03.425] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 03/15/2018] [Indexed: 11/21/2022]
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14
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Tan GJS, Khoo PLZ, Chan KMJ. A review of endovascular treatment of thoracic aorta disease. Ann R Coll Surg Engl 2018; 100:1-6. [PMID: 30286634 PMCID: PMC6204499 DOI: 10.1308/rcsann.2018.0143] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2018] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION The development of thoracic endovascular aortic repair has altered the approach and reduced the risk of treating the majority of descending thoracic aortic conditions. Primarily developed for the exclusion of thoracic aortic aneurysms, it is now used in place of open repair surgery for most descending thoracic aortic diseases, and has also been used to treat aortic arch diseases in selected cases. METHODS A literature search was conducted of Medline and Embase databases from January 2007 to February 2017, using the key words 'aortic disease', 'thoracic aorta' and 'endovascular repair'; 205 articles were identified, of which 25 studies were selected for review based on their relevance. FINDINGS The key findings of the indications, techniques, outcomes, complications and comparisons with open surgical repair were extracted from the published studies and are summarised in this review. Thoracic endovascular aortic repair is the preferred choice of intervention for patients with descending thoracic aortic disease. With time, it has improved to be safer and has the potential to expand aortic treatment choices in future.
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Affiliation(s)
- GJS Tan
- Faculty of Medical Sciences, Newcastle University Medical School, Newcastle Upon Tyne, UK
| | - PLZ Khoo
- Faculty of Medical Sciences, Newcastle University Medical School, Newcastle Upon Tyne, UK
| | - KMJ Chan
- National Heart and Lung Institute, Imperial College London, London, UK
- Cardiac Vascular Sentral Kuala Lumpur (CVSKL) Hospital, Kuala Lumpur, Malaysia
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15
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Piffaretti G, Pratesi G, Gelpi G, Galli M, Criado FJ, Antonello M, Fontana F, Piacentino F, Macchi E, Tozzi M, Castelli P, Barbante M, Ippoliti A, Romagnoni C, Antona C, Paggi A, Xodo A, Grego F. Comparison of Two Different Techniques for Isolated Left Subclavian Artery Revascularization During Thoracic Endovascular Aortic Repair in Zone 2. J Endovasc Ther 2018; 25:740-749. [DOI: 10.1177/1526602818802581] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Purpose: To analyze the results of isolated left subclavian artery (LSA) revascularization during thoracic endovascular aortic repair (TEVAR) using carotid-subclavian bypass (CSbp) or chimney grafts (CGs). Methods: A retrospective multicenter, observational study identified 73 patients (mean age 68±13 years, range 22–87; 56 men) with acute or chronic thoracic aortic lesions who underwent TEVAR with isolated LSA revascularization using either CSbp (n=42) or CGs (n=31) from January 2010 and February 2017. Primary endpoints were TEVAR-related mortality, postoperative stroke, freedom from type Ia endoleak, and LSA patency. Results: Primary technical success was achieved in all cases. Early TEVAR-related mortality was 4.2% (CSbp 2% vs CG 6%, p=0.571). Two (3%) patients had major ischemic strokes (one in each group). Mean follow-up was 24±21 months (range 1–72; median 15). Estimated freedom from TEVAR-related mortality was 93%±3% (95% CI 84.3% to 97.0%) at 12 and 36 months, with no significant difference between CSbp and CG (p=0.258). Aortic reintervention did not differ between the groups (CSbp 5% vs CG 6%, p=0.356); nor did freedom from type Ia endoleak (CSbp 98% vs CG 87%, p=0.134). Gutter-related endoleaks occurred in 4 (13%) CG patients, but none of the patients experienced sac enlargement or the need for reintervention and none died. Primary patency of the LSA was 100% for the entire group during the observation period. Conclusion: In our experience, LSA revascularization proved most satisfactory and equally effective with both the CSbp and CG techniques, without discernible differences at midterm follow-up.
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Affiliation(s)
- Gabriele Piffaretti
- Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, Circolo University Hospital, Varese, Italy
| | - Giovanni Pratesi
- Vascular Surgery, Department of Surgery, Policlinico Tor Vergata, Rome, Italy
| | - Guido Gelpi
- Cardiac Surgery, Department of Cardiovascular Surgery, Sacco Hospital, Milan, Italy
| | - Mario Galli
- Interventional Cardiology, Department of Medicine, Sant’Anna Hospital, Como, Italy
| | - Frank J. Criado
- Division of Vascular Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Michele Antonello
- Vascular Surgery, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua School of Medicine, Padua University Hospital, Padua, Italy
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16
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Results of the VALOR II trial of the Medtronic Valiant Thoracic Stent Graft. J Vasc Surg 2017; 66:335-342. [DOI: 10.1016/j.jvs.2016.12.136] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 12/05/2016] [Indexed: 11/17/2022]
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17
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van der Zee CP, Vainas T, van Brussel FA, Tielliu IF, Zeebregts CJ, van der Laan MJ. Endovascular treatment of traumatic thoracic aortic lesions: a systematic review and meta-analysis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2017; 60:100-110. [PMID: 28471152 DOI: 10.23736/s0021-9509.17.09942-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION To provide an overview of the experience of endovascular treatment for traumatic thoracic aortic lesions (TTAL). Thoracic aortic injury secondary to high-energy chest trauma constitutes an emergency situation with potentially devastating outcome. In the present time, the majority of patients are treated with thoracic endovascular aortic repair. The aim of this study was to provide a systematic overview of endovascular aortic repair in patients with TTAL with special attention to perioperative mortality, paraplegia, stroke, influence of left subclavian artery (LSA) coverage herein, and long-term stent-related complications. EVIDENCE ACQUISITION PubMed and Embase were searched for studies describing endovascular treatment of TTAL in the period between January 1st, 2000 and January 30th, 2016. The methodological quality of articles was assessed using the MINORS score and PRISMA guidelines. Data on early mortality, perioperative complications, and long-term stent-related complications were extracted. EVIDENCE SYNTHESIS A total of 2005 reports were screened, and 74 publications were finally included in the analysis describing treatment of 1882 patients. Early mortality rate, paraplegia rate, and stroke rate were 7.5%, 0.4%, and 1.5%, respectively. LSA coverage did not increase the risk of stroke. The severity of injuries had a positive association on early mortality. Late stent related mortality and morbidity were uncommon. CONCLUSIONS TTAL can be treated endovascularly with low mortality and (neurological) morbidity. LSA coverage does not increase the risk of neurological complications but is associated with a moderate risk of left arm ischemia. Long-term stent-related complications are rare, but the available data is limited.
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Affiliation(s)
- Cornelis P van der Zee
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands -
| | - Tryfon Vainas
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Ignace F Tielliu
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten J van der Laan
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Ziza V, Canaud L, Molinari N, Branchereau P, Marty-Ané C, Alric P. Thoracic endovascular aortic repair: A single center's 15-year experience. J Thorac Cardiovasc Surg 2016; 151:1595-1603.e7. [DOI: 10.1016/j.jtcvs.2015.12.030] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 11/22/2015] [Accepted: 12/12/2015] [Indexed: 11/26/2022]
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Krajcer Z, Echeverria A. The "open branch" technique: A new way to prevent paraplegia after total endovascular repair of thoracoabdominal aneurysm. Catheter Cardiovasc Interv 2016; 87:781-2. [PMID: 26994983 DOI: 10.1002/ccd.26471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 01/29/2016] [Indexed: 11/11/2022]
Abstract
Spinal cord ischemia (SCI) has been one of the most concerning complications after surgical and endovascular thoracoabdominal aortic aneurysm repair "Open Branch" is an innovative technique to reduce the incidence of SCI Further studies in a larger number of patients with varying pathologies are needed to confirm the advantages of this technique.
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Affiliation(s)
| | - Angela Echeverria
- Department of Vascular Surgery, Baylor College of Medicine, Houston, Texas
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20
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Open versus Endovascular Repair of Arch and Descending Thoracic Aneurysms: A Retrospective Comparison. Ann Vasc Surg 2016; 31:30-8. [DOI: 10.1016/j.avsg.2015.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 08/02/2015] [Accepted: 08/04/2015] [Indexed: 11/21/2022]
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21
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Waterford SD, Chou D, Bombien R, Uzun I, Shah A, Khoynezhad A. Left Subclavian Arterial Coverage and Stroke During Thoracic Aortic Endografting: A Systematic Review. Ann Thorac Surg 2016; 101:381-9. [DOI: 10.1016/j.athoracsur.2015.05.138] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 04/22/2015] [Accepted: 05/14/2015] [Indexed: 11/26/2022]
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22
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Bavaria JE, Brinkman WT, Hughes GC, Khoynezhad A, Szeto WY, Azizzadeh A, Lee WA, White RA. Outcomes of Thoracic Endovascular Aortic Repair in Acute Type B Aortic Dissection: Results From the Valiant United States Investigational Device Exemption Study∗. Ann Thorac Surg 2015. [DOI: 10.1016/j.athoracsur.2015.03.108] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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23
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Panthee N, Ono M. Spinal cord injury following thoracic and thoracoabdominal aortic repairs. Asian Cardiovasc Thorac Ann 2015; 23:235-246. [DOI: 10.1177/0218492314548901] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Objective To discuss the currently available approaches to prevent spinal cord injury during thoracic and thoracoabdominal aortic repairs. Methods We carried out a PubMed search up to 2013 using the Medical Subject Headings: “aortic aneurysm/surgery” and “spinal cord ischemia”; “aortic aneurysm, thoracic/surgery” and “spinal cord ischemia”; “aneurysm/surgery” and “spinal cord ischemia/cerebrospinal fluid”; “aortic aneurysm/surgery” and “paraplegia”. All 190 original articles satisfying our inclusion criteria were analyzed for incidence, predictors, and other pertinent variables related to spinal cord injury, and we compared the results in recent publications with those in earlier reports. Results The mean age of the 38,491 patients was 65.3 ± 4.9 years. The overall incidence of paraplegia and/or paraparesis was 7.1% ± 6.1% (range 0%–32%). The incidence of spinal cord injury before 2000, from 2001 to 2007, and 2008–2013 was 9.0% ± 6.7%, 7.0% ± 6.1%, and 5.9% ± 5.2%, respectively ( p = 0.019). Various predictors of spinal cord injury were identified, extent of disease being the most common. Modification of surgical techniques, use of adjuncts, and better understanding of spinal cord perfusion physiology were attributed to the decrease in postoperative spinal cord injury in recent years. Conclusions Spinal cord injury after thoracic and thoracoabdominal aortic repair poses a real challenge to cardiovascular surgeons. However, with evolving surgical strategies, identification of predictors, and use of various adjuncts over the years, the incidence of spinal cord injury after thoracic/thoracoabdominal aortic repair has declined. Embracing a multimodality approach offers a good insight into combating this grave complication.
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Affiliation(s)
- Nirmal Panthee
- Department of Cardiac Surgery, University of Tokyo, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, University of Tokyo, Tokyo, Japan
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Matsuyama M, Nakamura K, Nagahama H, Nina K, Endou J, Kojima K, Nishimura M, Ishii H, Yokota A. Long-term results of endovascular repair for distal arch and descending thoracic aortic aneurysms treated by custom-made endografts: usefulness of fenestrated endografts. Ann Vasc Dis 2015; 7:383-92. [PMID: 25593623 DOI: 10.3400/avd.oa.14-00057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 08/14/2014] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE We evaluated early and long-term results of atherosclerotic aneurysm repair with custom-made endografts. MATERIALS AND METHODS Eighty-one consecutive patients underwent thoracic endovascular aortic repair with custom-made endografts. Fenestrated grafts were used in 37 patients (45.7%) to maintain blood flow of the neck and a landing zone for as long as possible for distal arch or proximal descending aneurysms. The rates of perioperative mortality, stroke, paraplegia, and primary endoleaks were assessed to evaluate in-hospital safety. The rates of endoleak development, survival, and freedom from aortic-related death were assessed to evaluate long-term efficiency. RESULTS Twenty-four patients (29.6%) underwent urgent operations, and 38 (46.9%) underwent distal arch or proximal descending aortic aneurysm repair. There was one case (1.2%) of in-hospital mortality and no cases of stroke. Permanent spinal injury occurred in one patient (1.2%). Early and late endoleaks occurred in one and 16 patients, respectively. The actuarial survival rates were 88.9%, 64.9%, and 51.7% at 1, 5, and 10 years, respectively. The actuarial rates of freedom from endoleaks were 90.1%, 81.3%, and 68.6% at 1, 5, and 10 years, respectively. CONCLUSION Early results of custom-made endografts were excellent, and fenestrated endografts were safe for distal arch and proximal descending aortic aneurysms.
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Affiliation(s)
- Masakazu Matsuyama
- Department of Cardiovascular, Thoracic and General Surgery, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Kunihide Nakamura
- Department of Cardiovascular, Thoracic and General Surgery, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Hiroyuki Nagahama
- Department of Cardiovascular, Thoracic and General Surgery, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Katsuhiko Nina
- Department of Cardiovascular Surgery, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Miyazaki, Japan
| | - Jouji Endou
- Department of Cardiovascular, Thoracic and General Surgery, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Kazushi Kojima
- Department of Cardiovascular Surgery, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Miyazaki, Japan
| | - Masanori Nishimura
- Department of Cardiovascular, Thoracic and General Surgery, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Hirohito Ishii
- Department of Cardiovascular, Thoracic and General Surgery, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Atsuko Yokota
- Department of Cardiovascular Surgery, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Miyazaki, Japan
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Abstract
The incidence and operations of thoracic and thoracoabdominal aortic aneurysms have significantly increased. The indications for repair are considered to be a diameter of 6 cm or more and 5.5 cm for patient groups with increased risk of rupture. Complex open surgical repair is associated with significant mortality and complication rates. Total or hybrid endovascular repair seems to reduce early postoperative complications and mortality. The endovascular approach has evolved to be a good and predominant alternative to open repair of these aneurysms for older and high-risk patients as well as for aneurysms with optimal morphological suitability. Notwithstanding, at present a complete paradigm shift from open to endovascular repair for all patients, especially those with complex aneurysms, cannot yet be established.
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Affiliation(s)
- J Zanow
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland,
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Tanaka K, Yoshitaka H, Chikazawa G, Sakaguchi T, Totsugawa T, Tamura K. Investigation of the surgical complications during thoracic endovascular aortic repair: experiences with 148 consecutive cases treated at a single institution in Japan. Surg Today 2014; 45:22-8. [DOI: 10.1007/s00595-014-0840-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 12/10/2013] [Indexed: 10/25/2022]
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Botsios S, Frömke J, Walterbusch G, Schuermann K, Subramanian S, Reinstadler J, Dohmen G. Secondary Interventions After Endovascular Thoracic Aortic Repair. J Card Surg 2013; 29:66-73. [DOI: 10.1111/jocs.12252] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Spiridon Botsios
- Department of Thoracic- and Cardiovascular Surgery; St. Johannes Hospital Dortmund; Dortmund Germany
- Faculty of Health; University Witten/Herdecke; Witten Germany
| | - Johannes Frömke
- Department of Thoracic- and Cardiovascular Surgery; St. Johannes Hospital Dortmund; Dortmund Germany
| | - Gerhard Walterbusch
- Department of Thoracic- and Cardiovascular Surgery; St. Johannes Hospital Dortmund; Dortmund Germany
| | - Karl Schuermann
- Department of Radiology; St. Johannes Hospital Dortmund; Dortmund Germany
| | | | - Jan Reinstadler
- Department of Thoracic- and Cardiovascular Surgery; St. Johannes Hospital Dortmund; Dortmund Germany
| | - Guido Dohmen
- Department of Thoracic- and Cardiovascular Surgery; St. Johannes Hospital Dortmund; Dortmund Germany
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Ramponi F, Stephen MS, Wilson MK, Vallely MP. Think differently: trans-apical platform for TEVAR. Ann Cardiothorac Surg 2013; 1:412-6. [PMID: 23977530 DOI: 10.3978/j.issn.2225-319x.2012.08.15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 08/24/2012] [Indexed: 11/14/2022]
Affiliation(s)
- Fabio Ramponi
- Department of Cardiothoracic, Royal Prince Alfred Hospital, The University of Sydney, Sydney, Australia ; The Baird Research Institute for Applied Heart and Lung Surgical Research, Royal Prince Alfred Hospital, The University of Sydney, Sydney, Australia
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29
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Affiliation(s)
- Joseph E. Bavaria
- From the Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA (J.E.B., W.Y.S.)
| | - Wilson Y. Szeto
- From the Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA (J.E.B., W.Y.S.)
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Nozdrzykowski M, Etz CD, Luehr M, Garbade J, Misfeld M, Borger MA, Mohr FW. Optimal treatment for patients with chronic Stanford type B aortic dissection: endovascularly, surgically or both? Eur J Cardiothorac Surg 2013; 44:e165-74; discussion e174. [PMID: 23761415 DOI: 10.1093/ejcts/ezt291] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Patients with chronic Stanford type B aortic dissections (TBAD) are traditionally treated medically, but some of the affected thoracic and thoracoabdominal aortic segments progress to large aneurysms with a significant risk of rupture. The purpose of this study is to retrospectively evaluate, with an 'all-comers' approach, the survival and the outcome of patients following thoracic endovascular aortic repair (TEVAR) or conventional open surgery for chronic TBAD as a first-line therapy or a secondary option after failed medical treatment. METHODS Between January 2000 and May 2010, 80 consecutive patients (59 males, median age 63, inter-quartile range (IQR) 55-69) suffering from chronic TBAD were treated at our institution. Thirty-three were treated medically (Group A, median age: 65, IQR: 58.5-71.5), 32 received TEVAR (Group B, median age: 62, IQR: 54-67.5) and 15 patients underwent conventional open surgery (Group C, median age: 61, IQR: 54-66). The median follow-up was 42 months (range: 0.1-124.7) and 100% complete. RESULTS There were no significant differences with regard to age, gender and associated comorbidities between the treatment groups. The overall hospital mortality for chronic TBAD was 6.3% (n = 5); in-hospital mortalities for Groups A, B and C were 3.0, 6.2 and 13.4%, respectively. The incidence of major complications, such as paraplegia, malperfusion, renal failure and cardiac arrhythmia, did not significantly differ between the three groups. Postoperative stroke occurred more often after conventional open surgery (Group C: 13.3%; P = 0.07). Reintervention for TBAD pathology was required in Groups A, B and C in 12.1, 28.1 and 0%, respectively (P = 0.03). Secondary open surgery post-TEVAR was required in 7 cases (21.8%) with no postoperative paraplegia. CONCLUSIONS Open surgery for extensive thoracic and thoracoabdominal repair in chronic TBAD may be performed with acceptable early and mid-term outcomes. TEVAR for aortic complications in patients with chronic dissection may be successfully performed as a first-stage procedure in order to stabilize the patient and serve as a 'bridge' to secondary open surgery. However, close surveillance is mandatory for the timely detection of aneurysm enlargement, malperfusion or impending rupture after TEVAR.
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Affiliation(s)
- Michal Nozdrzykowski
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
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31
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Secondary interventions after elective thoracic endovascular aortic repair for degenerative aneurysms. J Vasc Surg 2013; 57:1269-74. [DOI: 10.1016/j.jvs.2012.10.124] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Revised: 10/23/2012] [Accepted: 10/29/2012] [Indexed: 11/21/2022]
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32
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Szeto WY, Desai ND, Moeller P, Moser GW, Woo EY, Fairman RM, Pochettino A, Bavaria JE. Reintervention for endograft failures after thoracic endovascular aortic repair. J Thorac Cardiovasc Surg 2013; 145:S165-70. [PMID: 23410774 DOI: 10.1016/j.jtcvs.2012.11.046] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Revised: 10/11/2012] [Accepted: 11/20/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Thoracic endovascular aortic repair has emerged as an effective therapy for a variety of thoracic aortic pathologic entities. However, endograft failure remains a concern, and its treatment is often challenging. We examined our experience with endograft failure and its treatment by endovascular and open repair. METHODS From January 2000 to January 2012, 680 patients underwent thoracic endovascular aortic repair at the University of Pennsylvania, and their charts were reviewed for the late outcomes and follow-up data. RESULTS Of the 680 patients, 73 underwent 80 reinterventions (11.7%) during follow-up. The indications for index thoracic endovascular aortic repair were thoracic aortic aneurysms in 381, type A dissection with frozen elephant trunk in 52, type B dissection in 111, hybrid arch repair in 46, traumatic transection in 37, infection in 10, penetrating atherosclerotic ulcer in 25, and others in 18. The median interval from index thoracic endovascular aortic repair to reintervention was 210 days. Endograft failures included endoleak in 45, proximal aortic events in 11, distal aortic events in 15, endograft infection in 3, and others in 6. Endovascular reintervention (n = 80) was performed in 60 patients. In 20 patients, open aortic reconstructive procedures were performed. The overall 30-day mortality was 8.7% (7/80). During follow-up, 10 late deaths occurred. The overall survival in all patients was 81%, 60%, and 52% at 1, 5, and 7 years, respectively. The late survival for patients after reintervention for endograft failure was similar that for the patients who did not require reintervention (P = .31). CONCLUSIONS Reintervention for endograft failure can be performed with acceptable early outcomes. The mid-term survival for patients requiring reintervention for endograft failure was similar to that of the patients without endograft failure. Thus, reintervention for endograft failure should be aggressively considered when indicated.
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Affiliation(s)
- Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania Medical Center, Philadelphia, Pa 19104, USA.
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33
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Transposition of the supra-aortic vessels before stent grafting the aortic arch and descending aorta. J Thorac Cardiovasc Surg 2013; 145:S91-7. [DOI: 10.1016/j.jtcvs.2012.11.056] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Revised: 08/06/2012] [Accepted: 11/28/2012] [Indexed: 11/18/2022]
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34
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Hemoptysis as a first symptom of endoleak after thoracic endovascular aortic repair, which caused aortic rupture and required complex management. Wideochir Inne Tech Maloinwazyjne 2013; 8:178-81. [PMID: 23837105 PMCID: PMC3699777 DOI: 10.5114/wiitm.2011.33453] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 02/03/2013] [Accepted: 02/03/2013] [Indexed: 11/17/2022] Open
Abstract
Thoracic endovascular aortic repair (TEVAR) has become the most common procedure in the treatment of thoracic aorta aneurysms. However, potential long-term complications of this technique could be life-threatening. Hemoptysis is a common symptom of lung tumor, especially cancer. On the other hand, hemoptysis can also be caused by bronchitis, tuberculosis, mycosis, and trauma. In this case report, we present a patient with hemoptysis and lung tumor suggesting lung cancer, which was a unique symptom of type IA endoleak after TEVAR and led to rupture of the thoracic aneurysm. It was decided to perform next an endovascular procedure due to the severe state of the patient. Next the thoracotomy was performed because drainage of the left pleural cavity was unsuccessful. In the last stage bronchoscopy was needed to remove the thrombus, which occluded the left main bronchi. Successful management has led to the patient's full recovery. Despite justified popularity of endovascular procedures in the treatment of thoracic aorta aneurysms, we should remember about potential long-term complications. Hemoptysis could be a unique symptom of the endoleak after TEVAR and treatment of such complications could be complex and demanding.
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35
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The results of stent graft versus medication therapy for chronic type B dissection. J Vasc Surg 2013; 57:406-14. [DOI: 10.1016/j.jvs.2012.08.064] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 08/22/2012] [Accepted: 08/22/2012] [Indexed: 11/18/2022]
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Late diagnosis of silent thoracic aortic rupture presented as a right pleural effusion. Case Rep Med 2013; 2012:906250. [PMID: 23319958 PMCID: PMC3539670 DOI: 10.1155/2012/906250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2012] [Revised: 12/01/2012] [Accepted: 12/15/2012] [Indexed: 11/23/2022] Open
Abstract
Patients with ruptured thoracic aortic aneurysm rarely present in a stable clinical condition. A man was referred to our hospital with the diagnosis of ruptured saccular aneurysm of the descending thoracic aorta. He successfully underwent both endovascular graft repair and open thoracotomy.
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37
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Di Luozzo G, Geisbüsch S, Lin HM, Bischoff MS, Schray D, Pawale A, Griepp RB. Open Repair of Descending and Thoracoabdominal Aortic Aneurysms and Dissections in Patients Aged Younger Than 60 Years: Superior to Endovascular Repair? Ann Thorac Surg 2013; 95:12-9; discussion 19. [DOI: 10.1016/j.athoracsur.2012.05.071] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 05/09/2012] [Accepted: 05/11/2012] [Indexed: 11/29/2022]
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38
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Cho JW, Kwon OC, Lee S, Jang JS. Traumatic Aortic Injury: Single-center Comparison of Open versus Endovascular Repair. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2013; 45:390-5. [PMID: 23275921 PMCID: PMC3530723 DOI: 10.5090/kjtcs.2012.45.6.390] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Revised: 08/01/2012] [Accepted: 08/16/2012] [Indexed: 11/16/2022]
Abstract
Background Conventional open repair is a suboptimal therapy for blunt traumatic aortic injury (BTAI) due to the high postoperative mortality and morbidity rates. Recent advances in the thoracic endovascular repair technique may improve outcomes so that it becomes an attractive therapeutic option. Materials and Methods From August 2003 to March 2012, 21 patients (mean age, 45.81 years) with BTAI were admitted to our institution. Of these, 18 cases (open repair in 11 patients and endovascular repair in 7 patients) were retrospectively reviewed and the early perioperative results of the two groups were compared. Results Although not statistically significant, there was a trend toward the reduction of mortality in the endovascular repair group (18.2% vs. 0%). There were no cases of paraplegia or endoleak. Statistically significant reductions in heparin dosage, blood loss, and transfusion amounts during the operations and in procedure duration were observed. Conclusion Compared with open repair, endovascular repair can be performed with favorable mortality and morbidity rates. However, relatively younger patients who have acute aortic arch angulation and a small aortic diameter may be a therapeutic challenge. Improvements in graft design, delivery sheaths, and graft durability are the cornerstone of successful endovascular repair.
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Affiliation(s)
- Jun Woo Cho
- Department of Cardiovascular and Thoracic Surgery, Catholic University of Daegu School of Medicine, Korea
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39
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Bessho R, Fujii M, Ishii Y, Ochi M, Shimizu K. Open stent grafting with a trifurcated graft for an infected aortic arch aneurysm concomitant with severe calcified aorta. Ann Thorac Cardiovasc Surg 2012; 19:239-42. [PMID: 23232261 DOI: 10.5761/atcs.cr.12.01932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
An infected aortic arch aneurysm is a rare but life-threatening condition. Moreover, surgical treatment for patients with severe calcified aorta is challenging and needs a well-planned strategy. We report a patient with an infected aortic arch aneurysm concomitant with severe calcification of the aorta in whom good results were obtained with open stent grafting in combination with a trifurcated graft.
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Affiliation(s)
- Ryuzo Bessho
- Department of Cardiothoracic Surgery, Nippon Medical School, Chiba Hokusoh Hospital, Inzai, Chiba, Japan.
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40
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Ullery BW, McGarvey M, Cheung AT, Fairman RM, Jackson BM, Woo EY, Desai ND, Wang GJ. Vascular distribution of stroke and its relationship to perioperative mortality and neurologic outcome after thoracic endovascular aortic repair. J Vasc Surg 2012; 56:1510-7. [DOI: 10.1016/j.jvs.2012.05.086] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 05/18/2012] [Accepted: 05/23/2012] [Indexed: 10/28/2022]
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41
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Systematic review of clinical outcomes in hybrid procedures for aortic arch dissections and other arch diseases. J Thorac Cardiovasc Surg 2012; 144:1286-300, 1300.e1-2. [DOI: 10.1016/j.jtcvs.2012.06.013] [Citation(s) in RCA: 141] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 05/20/2012] [Accepted: 06/08/2012] [Indexed: 11/21/2022]
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Andersen ND, Williams JB, Hanna JM, Shah AA, McCann RL, Hughes GC. Results with an algorithmic approach to hybrid repair of the aortic arch. J Vasc Surg 2012. [PMID: 23186868 DOI: 10.1016/j.jvs.2012.09.039] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Hybrid repair of the transverse aortic arch may allow for aortic arch repair with reduced morbidity in patients who are suboptimal candidates for conventional open surgery. We present our results with an algorithmic approach to hybrid arch repair, based on the extent of aortic disease and patient comorbidities. METHODS Between August 2005 and January 2012, 87 patients underwent hybrid arch repair by three principal procedures: zone 1 endograft coverage with extra-anatomic left carotid revascularization (zone 1; n = 19), zone 0 endograft coverage with aortic arch debranching (zone 0; n = 48), or total arch replacement with staged stented elephant trunk completion (stented elephant trunk; n = 20). RESULTS The mean patient age was 64 years, and the mean expected in-hospital mortality rate was 16.3% as calculated by the EuroSCORE II. Of operations, 22% (n = 19) were nonelective. Sternotomy, cardiopulmonary bypass, and deep hypothermic circulatory arrest were required in 78% (n = 68), 45% (n = 39), and 31% (n = 27) of patients to allow for total arch replacement, arch debranching, or other concomitant cardiac procedures, including ascending with or without hemiarch replacement in 17% (n = 8) of patients undergoing zone 0 repair. All stented elephant trunk procedures (n = 20) and 19% (n = 9) of zone 0 procedures were staged, with 41% (n = 12) of patients undergoing staged repair during a single hospitalization. The 30-day/in-hospital rates of stroke and permanent paraplegia or paraparesis were 4.6% (n = 4) and 1.2% (n = 1). Of 27 patients with native ascending aorta zone 0 proximal landing zone, three (11.1%) experienced retrograde type A dissection after endograft placement. The overall in-hospital mortality rate was 5.7% (n = 5); however, 30-day/in-hospital mortality increased to 14.9% (n = 13) owing to eight 30-day out-of-hospital deaths. Native ascending aorta zone 0 endograft placement was found to be the only univariate predictor of 30-day in-hospital mortality (odds ratio, 4.63; 95% confidence interval, 1.35-15.89; P = .02). Over a mean follow-up period of 28.5 ± 22.2 months, 13% (n = 11) of patients required reintervention for type 1A (n = 4), type 2 (n = 6), or type 3 (n = 1) endoleak. Kaplan-Meier estimates of survival at 1 year, 3 years, and 5 years were 73%, 60%, and 51%. CONCLUSIONS Hybrid aortic arch repair can be tailored to patient anatomy and comorbid status to allow complete repair of aortic pathology, frequently in a single stage, with acceptable outcomes. However, endograft placement in the native ascending aorta is associated with high rates of retrograde type A dissection and 30-day/in-hospital mortality and should be approached with caution.
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Affiliation(s)
- Nicholas D Andersen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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43
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Shah AA, Barfield ME, Andersen ND, Williams JB, Shah JA, Hanna JM, McCann RL, Hughes GC. Results of thoracic endovascular aortic repair 6 years after United States Food and Drug Administration approval. Ann Thorac Surg 2012; 94:1394-9. [PMID: 22785216 PMCID: PMC4089907 DOI: 10.1016/j.athoracsur.2012.05.072] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 05/13/2012] [Accepted: 05/16/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Since United States Food and Drug Administration approval in 2005, the short-term safety and efficacy of thoracic endovascular aortic repair (TEVAR) have been established. However, longer-term follow-up data remain lacking. The objective of this study is to report 6-year outcomes of TEVAR in clinical practice. METHODS A prospective cohort review was performed of all patients undergoing TEVAR at a single referral institution between March 2005 and May 2011. Rates of reintervention were noted. Overall and aortic-specific survival were determined using Kaplan-Meier methods. Log-rank tests were used to compare survival between groups. RESULTS During the study interval, 332 TEVAR procedures were performed in 297 patients. Reintervention was required after 12% of procedures at a mean of 8 ± 14 months after initial TEVAR and was higher in the initial tercile of patients (15.0% vs 9.9%). The 6-year freedom from reintervention was 84%. Type I endoleak was the most common cause of reintervention (5%). Six-year overall survival was 54%, and aorta-specific survival was 92%. Long-term survival was significantly lower than that of an age- and sex-matched United States population (p < 0.001). Survival was similar between patients requiring a reintervention vs those not (p = 0.26). Survival was different based on indication for TEVAR (p = 0.007), and patients with degenerative aneurysms had the lowest survival (47% at 6 years). Cardiopulmonary pathologies were the most common cause of death (27 of 93 total deaths). CONCLUSIONS Long-term aortic-related survival after TEVAR is high, and the need for reintervention is infrequent. However, overall long-term survival is low, particularly for patients with degenerative aneurysms, and additional work is needed to identify patients unlikely to derive a survival benefit from TEVAR.
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Affiliation(s)
- Asad A Shah
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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44
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Andacheh ID, Donayre C, Othman F, Walot I, Kopchok G, White R. Patient outcomes and thoracic aortic volume and morphologic changes following thoracic endovascular aortic repair in patients with complicated chronic type B aortic dissection. J Vasc Surg 2012; 56:644-50; discussion 650. [DOI: 10.1016/j.jvs.2012.02.050] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 02/22/2012] [Accepted: 02/22/2012] [Indexed: 11/28/2022]
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45
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Johnson PT, Black JH, Zimmerman SL, Fishman EK. Thoracic Endovascular Aortic Repair: Literature Review With Emphasis on the Role of Multidetector Computed Tomography. Semin Ultrasound CT MR 2012; 33:247-64. [DOI: 10.1053/j.sult.2012.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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46
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Uthoff H, Garcia-Covarrubias L, Samuels S, Benenati JF, Moreno NL, Katzen BT. Transapical Endovascular Aortic Repair to Treat Complex Aortic Pathologies. Ann Thorac Surg 2012; 93:1735-7. [DOI: 10.1016/j.athoracsur.2011.12.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Revised: 11/30/2011] [Accepted: 12/02/2011] [Indexed: 11/26/2022]
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Abstract
Thromboendarterectomy remains a high-risk procedure. The use of circulatory arrest as a technique to allow pulmonary artery visualization is associated with cerebral and organ damage secondary to the ischaemic insult. Application of techniques learned from thoracic aortic stenting and minimal invasive valvular surgery may mean that circulatory arrest becomes an uncommon accompaniment to thromboendarterectomy.
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Affiliation(s)
- Michael Poullis
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.
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49
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Zoli S, Trabattoni P, Dainese L, Annoni A, Saccu C, Fumagalli M, Spirito R, Biglioli P. Cumulative radiation exposure during thoracic endovascular aneurysm repair and subsequent follow-up. Eur J Cardiothorac Surg 2012; 42:254-59; discussion 259-60. [DOI: 10.1093/ejcts/ezr301] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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50
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Murashita T, Ogino H, Matsuda H, Sasaki H, Tanaka H, Iba Y, Domae K, Fujiwara T. Clinical Outcome of Emergency Surgery for Complicated Acute Type B Aortic Dissection. Circ J 2012; 76:650-4. [DOI: 10.1253/circj.cj-11-0982] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Takashi Murashita
- Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital
| | - Hitoshi Ogino
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Hiroaki Sasaki
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Hiroshi Tanaka
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Yutaka Iba
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Keitaro Domae
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Tatsuki Fujiwara
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
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