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Walter T, Berger T, Kondov S, Gottardi R, Benk J, Discher P, Rylski B, Czerny M, Kreibich M. Thoracic aortic emergencies involving the aortic arch: An integrated cardiovascular surgical treatment approach. Semin Vasc Surg 2023; 36:150-156. [PMID: 37330229 DOI: 10.1053/j.semvascsurg.2023.04.016] [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: 02/11/2023] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 06/19/2023]
Abstract
Thoracic aortic emergencies involving the aortic arch are potentially fatal conditions that require the entire surgical repertoire of conventional surgery, such as complete aortic arch replacement using the frozen-elephant-trunk technique, through hybrid procedures, to full surgical endovascular options with conventional or delivered/fenestrated stent-grafts. An interdisciplinary aortic team should choose the optimal treatment of the pathologies of the aortic arch, considering the morphology of the entire aorta, from the root to beyond the bifurcation, as well as the clinical comorbidities. The treatment goal is a complication-free postoperative result and lasting freedom from aortic reinterventions. Irrespective of the selected therapy method, patients should then be connected to a specialized aortic outpatient clinic. The aim of this review was to provide an overview of pathophysiology and current treatment options in emergencies of the thoracic aorta, also involving the aortic arch. We wanted to summarize the preoperative considerations, intraoperative settings, and strategies, as well the postoperative follow-up.
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Affiliation(s)
- Tim Walter
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwig's University of Freiburg, Faculty of Medicine, Freiburg, Germany.
| | - Tim Berger
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwig's University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwig's University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Roman Gottardi
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwig's University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Julia Benk
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwig's University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Phillip Discher
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwig's University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwig's University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwig's University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwig's University of Freiburg, Faculty of Medicine, Freiburg, Germany
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Benk J, Siepe M, Berger T, Beyersdorf F, Kondov S, Rylski B, Czerny M, Kreibich M. Early and mid-term outcomes of thoracic endovascular aortic repair to treat aortic rupture in patients with aneurysms, dissections and trauma. Interact Cardiovasc Thorac Surg 2022; 35:ivac042. [PMID: 35167665 PMCID: PMC9714596 DOI: 10.1093/icvts/ivac042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/27/2022] [Accepted: 01/31/2022] [Indexed: 09/10/2023] Open
Abstract
OBJECTIVES The aim of this study was to analyse outcomes of thoracic endovascular aortic repair to treat aortic rupture. METHODS Patient and outcome characteristics of all emergent endovascular treatments for thoracic aortic rupture between January 2009 and December 2019 were analysed. RESULTS Thoracic aortic rupture occurred in patients with aortic aneurysms (n = 42, 49%), aortic dissection (n = 13, 16%) or after trauma (n = 30, 35%). Preoperative cerebrospinal fluid drainage was placed in 9 patients (11%) and 18 patients (21%) underwent perioperative supra-aortic transposition. The proximal landing zones were: zone 1 (n = 1, 1%), zone 2 (n = 23, 27%), zone 3 (n = 52, 61%) and zone 4 (n = 9, 11%). Temporary spinal cord injury occurred in 1 patient (1%), permanent spinal cord injury in 7 patients (8%). Two patients (2%) experienced a postoperative stroke. Seventeen patients (20%) expired in-hospital. Aortic dissection (odds ratio: 16.246, p = 0.001), aneurysm (odds ratio: 9.090, P = 0.003) and preoperative shock (odds ratio: 4.646, P < 0.001) were predictive for mortality. Eighteen patients (21%) required a stent-graft-related aortic reintervention for symptomatic supra-aortic malperfusion (n = 3, 4%), endoleaks (n = 6, 7%), a second aortic rupture (n = 4, 5%), retrograde type A aortic dissection (n = 2, 2%), aortic-oesophageal fistulation (n = 2, 2%) and stent-graft kinking (n = 1, 1%). CONCLUSIONS Thoracic endovascular aortic repair in patients with aortic rupture has become a valuable treatment modality to stabilize patients. However, a significant risk of postoperative morbidity and mortality remains, particularly in patients with aortic dissections, aneurysms or shock. Patients require thorough follow-up ideally in an aortic clinic with a staff having the entire spectrum of cardiovascular and thoracic surgical expertise.
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Affiliation(s)
- Julia Benk
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Tim Berger
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
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Aru RG, Tyagi SC, Minion DJ, Orr NT, Bounds MC. Carotid-Carotid Transposition for Zone 1 Thoracic Endovascular Aortic Repair. Ann Vasc Surg 2021; 76:325-329. [PMID: 33951527 DOI: 10.1016/j.avsg.2021.04.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/05/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Carotid-carotid bypass is the standard technique for cervical aortic arch debranching to maintain left common carotid artery perfusion with zone I thoracic endovascular aortic repair (TEVAR), while left-to-right carotid-carotid transposition (CCT) has been described as an autologous alternative. We report on our center's experience with CCT in the setting of zone I TEVAR. This is the only published series of this technique. METHODS All patients who underwent CCT, defined by CPT code 35509, between 2017 and 2020 were identified at our tertiary care center. Patient demographics, indications for CCT, complications specific to CCT, operative details, post-operative course, and outcomes were retrospectively reviewed. RESULTS A total of 13 patients underwent CCT prior to zone 1 TEVAR. The indications for intervention were thoracic or thoracoabdominal aortic aneurysms and dissections secondary to hypertension (n = 10), Marfan syndrome (n = 2), and Turner syndrome with aneurysmal degeneration of previous coarctation repair (n = 1). There was a high incidence of preexisting hypertension (92%), malnutrition (69%), and smoking (61%) in this cohort. Operative intervention was performed on both an elective (n = 7, 54%) and an urgent (n = 6, 46%) basis. Complications directly related to CCT included transient unilateral recurrent laryngeal nerve deficit (n = 1, 7.7%). There were no cerebrovascular events, surgical site infections, or procedure-related mortalities. All transpositions with follow-up imaging were patent without stenosis or thrombosis (average 7.2 months, n = 10). There were no late complications related to CCT. CONCLUSIONS CCT is a safe and autologous alternative to carotid-carotid bypass for left common carotid artery revascularization with zone I TEVAR.
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Affiliation(s)
- Roberto G Aru
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY.
| | - Sam C Tyagi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY
| | - David J Minion
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY
| | - Nathan T Orr
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY
| | - Michael C Bounds
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY
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Di Tommaso L, Giordano R, Di Tommaso E, Di Palo G, Iannelli G. Treatment with transfemoral bare-metal stent of residual aortic arch dissection after surgical repair of acute type an aortic dissection. J Thorac Dis 2019; 10:6097-6106. [PMID: 30622781 DOI: 10.21037/jtd.2018.10.51] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Here we evaluate the usefulness of transfemoral uncovered stent implantation to avoid secondary conventional surgery for residual type A aortic dissection (TAAD) of the aortic arch after ascending aorta replacement. Methods From June 2009 to April 2015, 11 patients were treated with transfemoral implantation of uncovered stents in the aortic arch after surgical replacement of ascending aorta performed on average 4.7±2.3 years earlier. An enlarged dissected aortic arch or a dangerous median growth of more than 5 mm/yr or impending rupture presenting as chest pain were indications for treatment. The dissected aortic tracts diameter must not exceed 45 mm. Five patients (45.5%) were treated with Djumbodies Dissection System, 6 patients (54.5%) with Jotec E-XL aortic stent. Results There were no perioperative deaths or permanent neurologic complications. Primary procedural success was obtained in all patients and the residual TAAD in aortic arch was obliterated, with disappearance of the false lumen. Median intensive care unit (ICU) stay was 24 hours; post-operative hospital stay was 5.2±1.4 days. One death, not aortic related, occurred during follow-up period (mean 5.2±1.9 years). Descending thoracic aorta diameter significantly increased in 3 patients (27.3%): one patient (9.0%) needed a secondary conventional surgery, the other 2 (18.2%) of a distal extension with PETTICOAT approach. Conclusions Endovascular approach with uncovered metal bare stent is surely an evolving strategy to perform a purely endovascular treatment, indicated only for treatment of an aortic arch with a diameter of less than 40 or 45 mm, to avoid progressive thoracic aortic dilatation and/or rupture.
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Affiliation(s)
- Luigi Di Tommaso
- Adult and Pediatric Cardiac Surgery, Department of Advanced Biomedical Sciences, University of Naples Federico II, Napoli, Italy
| | - Raffaele Giordano
- Adult and Pediatric Cardiac Surgery, Department of Advanced Biomedical Sciences, University of Naples Federico II, Napoli, Italy
| | - Ettorino Di Tommaso
- Adult and Pediatric Cardiac Surgery, Department of Advanced Biomedical Sciences, University of Naples Federico II, Napoli, Italy
| | - Giusi Di Palo
- Adult and Pediatric Cardiac Surgery, Department of Advanced Biomedical Sciences, University of Naples Federico II, Napoli, Italy
| | - Gabriele Iannelli
- Adult and Pediatric Cardiac Surgery, Department of Advanced Biomedical Sciences, University of Naples Federico II, Napoli, Italy
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Desai ND, Wang G, Hoedt A, Szeto W, Bavaria JE. Double transposition and single branched TEVAR for total arch replacement in chronic dissection. Ann Cardiothorac Surg 2018; 7:434-436. [PMID: 30155424 DOI: 10.21037/acs.2018.05.02] [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)
- Nimesh D Desai
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Grace Wang
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ashley Hoedt
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Wilson Szeto
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Arokiaraj MC, De Beule M, De Santis G. A novel sax-stent method in treatment of ascending aorta and aortic arch aneurysms evaluated by finite element simulations. JOURNAL DE MÉDECINE VASCULAIRE 2017; 42:39-45. [PMID: 28705446 DOI: 10.1016/j.jdmv.2017.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 11/25/2016] [Indexed: 10/19/2022]
Abstract
OBJECTIVES A novel stent method to simplify treatment of proximal ascending aorta and aortic arch aneurysms was developed and investigated by finite element analysis. Therapy of ascending aortic and aortic arch aneurysms is difficult and challenging and is associated with various complications. METHODS A 55mm wide×120mm long stent was designed without the stent graft and the stent was deployed by an endovascular method in a virtual patient-specific aneurysm model. The stress-strain analysis and deployment characteristics were performed in a finite element analysis using the Abaqus software. RESULTS The stent, when embedded in the aortic wall, significantly reduced aortic wall stresses, while preserving the side coronary ostia and side branches in the aortic arch. When tissue growth was modeled computationally over the stent struts the wall stresses in aorta was reduced. This effect became more pronounced when increasing the thickness of the tissue growth. There were no abnormal stresses in the aorta, coronary ostium and at the origin of aortic branches. The stent reduced aneurysm expansion cause by hypertensive condition from 2mm without stenting to 1.3mm after stenting and embedding. CONCLUSION In summary, we uncovered a simple treatment method using a bare nitinol stent without stent graft in the treatment of the proximal aorta and aortic arch aneurysms, which could eventually replace the complex treatment methods for this disease.
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Affiliation(s)
- M C Arokiaraj
- Cardiology, Pondicherry institute of medical sciences, 605014 Pondicherry, India.
| | - M De Beule
- FEops nv, Technologiepark 3, IBiTech-bioMMeda, University of Ghent (UGent), 9000 Gent, Belgium
| | - G De Santis
- FEops nv, Technologiepark 3, IBiTech-bioMMeda, University of Ghent (UGent), 9000 Gent, Belgium
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Czerny M, Rylski B, Kari F, Kreibich M, Morlock J, Scheumann J, Kondov S, Südkamp M, Siepe M, Beyersdorf F. Transposition der Kopf- und Halsgefäße. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2016. [DOI: 10.1007/s00398-016-0081-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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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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Preventza O, Garcia A, Cooley DA, Haywood-Watson RJ, Simpson K, Bakaeen FG, Cornwell LD, Omer S, de la Cruz KI, Price MD, Rosengart TK, LeMaire SA, Coselli JS. Total aortic arch replacement: A comparative study of zone 0 hybrid arch exclusion versus traditional open repair. J Thorac Cardiovasc Surg 2015; 150:1591-8; discussion 1598-600. [DOI: 10.1016/j.jtcvs.2015.08.117] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 08/11/2015] [Accepted: 08/22/2015] [Indexed: 10/23/2022]
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Abstract
BACKGROUND The treatment of patients with aneurysms of the ascending aorta and aortic arch often represents a challenge due to their complexity. The clinical picture is characterized by further progression of the disease and severe complications, such as acute aortic dissection or even aortic rupture are not uncommon. OBJECTIVES This article gives a review of definitions, etiology and indications for operative treatment of patients with aneurysms of the ascending aorta and aortic arch. RESULTS AND DISCUSSION An aortic aneurysm of the ascending aorta is defined as a dilatation of all wall layers of the aorta of more than 50 % in comparison to the normal diameter. This is dependent on age, sex, body surface area and the underlying diseases. In most cases the cause is the presence of atherosclerosis. Connective tissue diseases, bicuspid or monocuspid aortic valves and aortitis represent additional risk factors. Surgical treatment of the ascending aorta, aortic root and aortic arch is carried out in patients without connective tissue diseases and a diameter of ≥ 55 mm and for patients with Marfan syndrome and bicuspid aortic valves with a diameter of ≥ 50 mm. Earlier indications for surgery are present with an aortic diameter of ≥ 45 mm in patients with the following risk factors: familial disposition for aortic dissection (often unrecognized as sudden cardiac death), annual growth rate of the aortic diameter of > 2 mm, comorbid severe aortic valve or mitral valve insufficiency and female patients with a desire to have children. The standard surgical procedures include aortic root replacement, aortic valve reconstruction with aortic root or ascending aorta replacement and partial or total aortic arch replacement depending on the extent of the aneurysm. The so-called hybrid procedures for aortic arch surgery include frozen elephant trunk (ET) techniques and debranching procedures. Good perioperative and postoperative results can be achieved by early diagnostics and an assessment of the indications depending on the individual etiology. Individual and valve-preserving treatment strategies have a favorable influence on the operative outcome.
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Affiliation(s)
- S Leontyev
- Klinik für Herzchirurgie, Herzzentrum, Universität Leipzig, Strümpellstr. 39, 04289, Leipzig, Deutschland,
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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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Mosquera VX, Marini M, Velasco C, Estévez-Cid F, Herrera-Noreña JM, Cao I, Gulías D, Cuenca JJ. Análisis morfológico del arco aórtico en pacientes sometidos a cirugía híbrida y correlación con resultados a medio plazo. CIRUGIA CARDIOVASCULAR 2014. [DOI: 10.1016/j.circv.2013.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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13
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Zipfel B, Hetzer R. „Aortenbogen-Debranching“ mit Implantation von Stent-Prothesen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2013. [DOI: 10.1007/s00398-013-1021-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Czerny M, Schmidli J, Carrel T, Grimm M. Hybrid aortic arch repair. Ann Cardiothorac Surg 2013; 2:372-7. [PMID: 23977610 DOI: 10.3978/j.issn.2225-319x.2013.03.05] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 03/15/2013] [Indexed: 11/14/2022]
Abstract
The successes of thoracic endovascular aortic repair (TEVAR) have spurned new approaches to addressing thoracic aortic pathologies. These hybrid techniques offer an alternative in patients with multi-segmental thoracic aortic pathologies which would have otherwise required a two-step arch replacement and open descending arch repair. The following article offers a clinical insight to the available hybrid approaches, such as rerouting of supra-aortic vessels. Unique complications to endovascular repairs, and technical risks and issues, are also presented along with management options and strategies to minimize such concerns.
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Affiliation(s)
- Martin Czerny
- Department of Cardiovascular Surgery, Inselspital, University Hospital Berne, Switzerland
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