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Mylonas SN, Aras T, Dorweiler B. A Systematic Review and an Updated Meta-Analysis of Fenestrated/Branched Endovascular Aortic Repair of Chronic Post-Dissection Thoracoabdominal Aortic Aneurysms. J Clin Med 2024; 13:410. [PMID: 38256542 PMCID: PMC10816959 DOI: 10.3390/jcm13020410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/07/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
The objective of this study is to present the current outcomes of fenestrated/branched endovascular repair (F/BEVAR) for post-dissection thoracoabdominal aortic aneurysms (PDTAAAs). A systematic review of the literature according to PRISMA guidelines up to October 2023 was conducted (protocol CRD42023473403). Studies were included if ≥10 patients were reported and at least one of the major outcomes was stated. A total of 10 studies with 585 patients overall were included. The pooled estimate for technical success was 94.3% (95% CI 91.4% to 96.2%). Permanent paraplegia developed with a pooled rate of 2.5% (95% CI 1.5% to 4.3%), whereas a cerebrovascular event developed with a pooled rate of 1.6% (95% CI 0.8% to 3.0%). An acute renal function impairment requiring new-onset dialysis occurred with a pooled rate of 2.0% (95% CI 1.0% to 3.8%). Postoperative respiratory failure was observed with a pooled estimate of 5.5% (95% CI 3.8% to 8.1%). The pooled estimate for 12-month overall survival was 90% (95% CI 85% to 93.5%), and the pooled estimates for 24-month and 36-month survival were 87.8% (95% CI 80.9% to 92.5%) and 85.5% (95% CI 76.5% to 91.5%), respectively. Freedom from reintervention was estimated at 83.9% (95% CI 75.9% to 89.6%) for 12 months, 82.8% (95% CI 68.7% to 91.4%) for 24 months and 76.1% (95% CI 60.6% to 86.8%) for 36 months. According to the present findings, F/BEVAR can be performed in PD-TAAAs with high rates of technical success and good mid-term results.
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Affiliation(s)
- Spyridon N. Mylonas
- Department of Vascular and Endovascular Surgery, Faculty of Medicine and University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany; (T.A.); (B.D.)
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O'Donnell TFX, Patel PB, Marcaccio CL, Dansey KD, Swerdlow NJ, Rastogi V, Patel VI, Beck AW, Zettervall SL, Schermerhorn ML. Outcomes of Complex Endovascular Treatment of Post-Dissection Aneurysms. Eur J Vasc Endovasc Surg 2023; 66:58-66. [PMID: 37087065 PMCID: PMC10524097 DOI: 10.1016/j.ejvs.2023.04.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/17/2023] [Accepted: 04/13/2023] [Indexed: 04/24/2023]
Abstract
OBJECTIVE Reports of endovascular treatment of chronic post-dissection aneurysms are limited to high volumes centres, posing questions about generalisability. METHODS All endovascular repairs of intact pararenal and thoraco-abdominal aneurysms in the Vascular Quality Initiative from 2014 to 2021 were studied, and peri-operative and long term outcomes were compared between repairs of degenerative and post-dissection aneurysms. Peri-operative outcomes were compared using mixed effects logistic regression, and long term outcomes using Medicare linkage. RESULTS There were 123 patients who completed treatment for post-dissection aneurysms and 3 635 for degenerative aneurysms, with 36% of post-dissection repairs and 6.7% of degenerative repairs performed in a staged fashion (p < .001). The majority (84%) of post-dissection aneurysms were extensive thoraco-abdominal aneurysms (TAAAs: Crawford Type 1, 2, 3, 5), compared with 22% of degenerative aneurysms (p < .001). Physician modified endografts were the primary repair type for post-dissection (73%), while commercially available fenestrated grafts were the dominant repair for degenerative (48%). The first stage of staged procedures was associated with a 2.8% peri-operative mortality rate, 5.1% spinal cord ischaemia, and 8.9% thoraco-abdominal life altering events (the composite of peri-operative death, stroke, permanent spinal cord ischaemia, and dialysis). Th final stage procedure and fluoroscopy times were similar, but technical success was lower in post-dissection repairs (75% vs. 83%, p = .018), both due to issues with the main endograft or bridging vessels (11% vs. 6.6%, p = .055), and types 1and 3 endoleak at completion (17% vs. 10%, p = .035). In addition, high volume surgeons had two fold higher odds of technical success than their low volume counterparts. Adjusted peri-operative outcomes were similar between pathology types, including when comparisons were restricted to extensive TAAAs. Crude and adjusted three year survival were similar, but three year re-interventions were significantly higher following post-dissection repairs (p < .001). CONCLUSION Complex endovascular repair of chronic post-dissection aneurysms is feasible but is associated with high rates of re-interventions and non-trivial rates of lack of technical success. More data are needed to evaluate the long term durability of these procedures, and the utility of centralising these complex procedures.
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Affiliation(s)
- Thomas F X O'Donnell
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA; Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian/Columbia University Irving Medical Centre/Columbia University Vagelos College of Physicians & Surgeons, New York, NY, USA
| | - Priya B Patel
- Division of General Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Christina L Marcaccio
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Kirsten D Dansey
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Nicholas J Swerdlow
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Vinamr Rastogi
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Virendra I Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian/Columbia University Irving Medical Centre/Columbia University Vagelos College of Physicians & Surgeons, New York, NY, USA
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, University of Washington, Seattle, WA, USA
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
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Kawajiri H, Saran N, Dearani JA, Schaff HV, Daly RC, Viehman JK, King KS, Pochettino A. Whole Body Retrograde Perfusion Combined With Central Aortic Perfusion Strategy in the Repair of Distal Arch Pathology Through a Lateral Thoracotomy. Mayo Clin Proc 2023; 98:432-442. [PMID: 36868750 DOI: 10.1016/j.mayocp.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/29/2022] [Accepted: 08/10/2022] [Indexed: 03/05/2023]
Abstract
OBJECTIVE To compare the results of the hypothermic circulatory arrest (HCA) + retrograde whole-body perfusion (RBP) technique with those of deep hypothermic circulatory arrest (DHCA-only) approach. METHODS Limited data are available on cerebral protection techniques when distal arch repairs are performed through a lateral thoracotomy. In 2012, the RBP technique was introduced as adjunct to HCA during open distal arch repair via thoracotomy. We reviewed the results of the HCA + RBP technique compared with those of the DHCA-only approach. From February 2000 to November 2019, 189 patients (median age, 59 [IQR, 46 to 71] years; 30.7% female) underwent open distal arch repair via lateral thoracotomy to treat aortic aneurysms. The DHCA technique was used in 117 patients (62%, median age 53 [IQR, 41 to 60] years), whereas HCA + RBP was used in 72 patients (38%, median age 65 [IQR, 51 to 74] years). In HCA + RBP patients, cardiopulmonary bypass was interrupted when systemic cooling achieved isoelectric electroencephalogram; once the distal arch had been opened, RBP was then initiated via the venous cannula (flow of 700 to 1000 mL/min, central venous pressure <15 to 20 mm Hg). RESULTS The stroke rate was significantly lower in the HCA + RBP group (3%, n=2) compared with the DHCA-only (12%, n=14) (P=.031), despite longer circulatory arrest times in HCA + RBP compared with the DHCA-only (31 [IQR, 25 to 40] minutes vs 22 [IQR, 17 to 30] minutes, respectively; P<.001). Operative mortality for patients undergoing HCA + RBP was 6.7% (n=4), whereas for those undergoing DHCA-only it was 10.4% (n=12) (P=.410). The 1-, 3-, and 5-year age-adjusted survival rates for the DHCA group are 86%, 81%, and 75%, respectively. The 1-, 3-, and 5-year age-adjusted survival rates for the HCA + RBP group are 88%, 88%, and 76%, respectively. CONCLUSION The addition of RBP to HCA in the treatment of distal open arch repair via a lateral thoracotomy is safe and provides excellent neurological protection.
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Affiliation(s)
- Hidetake Kawajiri
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Nishant Saran
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA.
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jason K Viehman
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Katherine S King
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
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Spinelli F, Montelione N, Benedetto F, Spinelli D, Tomaselli E, Stilo F. Type B aortic dissection residual after proximal aortic repair: an innovative open surgical approach in patients not eligible for endovascular treatment. INT ANGIOL 2022; 41:110-117. [PMID: 35112823 DOI: 10.23736/s0392-9590.22.04611-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Residual type B aortic dissection (R-TBAD) is a challenging kind of disease affecting an increasing number of patients. Management of R-TBAD has not been specifically addressed in current literature and many of those patients are not eligible for endovascular treatment. Aim of the study was to evaluate the efficacy and feasibility of a specifically conceived procedure the "saguaro branched graft technique" to treat R-TBAD distal to a proximal stent-graft. METHODS Data of patients treated between 2015 and 2019 were prospectively collected and retrospectively analysed. Indication for surgery was R-TBAD with chronic malperfusion, aortic enlargement >55mm or rapid growth, and symptomatic aortic enlargement. A dacron graft with four branches has been tailored on the back table by implanting two bifurcated grafts to a tube or bifurcated graft. After left thoracoabdominal incision the proximal endograft has been used as a solid starting point for the distal branched graft. Sequential revascularization of the visceral vessels was performed step by step by suturing each artery outside the aneurysm before opening the distal aorta, while a continued retrograde aortic and visceral perfusion was maintained by a left pump atrio-femoral bypass. After that all visceral branches had been regularly perfused from above, the thoraco-abdominal aorta was open and repaired. Outcome measures were 30-day mortality and 30-day major complications as were long-term all-cause mortality, aorta-related mortality, reintervention and patency rates of the branches. RESULTS Thirteen patients with R-TBAD were treated during the study period. Indication for surgery was chronic malperfusion in one patient (7.7%), aortic enlargement >55mm or rapid growth in 9 patients (69.2%), persistent pain with aortic enlargement ≥50mm in 3 patients (23.1%). All patients were considered not eligible for endovascular repair. At 30-days no deaths or re-interventions occurred and major complications including acute cardiovascular events and renal function impairment were not reported; one patient (7.7%) developed postoperative paraplegia. At a mean follow-up period of 19.6±10.2 (range, 8-48) months, reintervention and mortality rates were null. Visceral malperfusion and late-onset renal failure were not reported, and all visceral branches were still patent. CONCLUSIONS Despite the potential high risk of open surgery, the "saguaro branched graft technique" appears to be a safe surgical solution for R-TBAD.
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Affiliation(s)
- Francesco Spinelli
- Division of Vascular Surgery, University of Campus Bio-Medico, Rome, Italy
| | - Nunzio Montelione
- Division of Vascular Surgery, University of Campus Bio-Medico, Rome, Italy -
| | - Filippo Benedetto
- Unit of Vascular Surgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G. Martino, University of Messina, Messina, Italy
| | - Domenico Spinelli
- Unit of Vascular Surgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G. Martino, University of Messina, Messina, Italy
| | - Eleonora Tomaselli
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, University of Campus Bio-Medico, Rome, Italy
| | - Francesco Stilo
- Division of Vascular Surgery, University of Campus Bio-Medico, Rome, Italy
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 61:1328-1335. [DOI: 10.1093/ejcts/ezac052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 01/11/2022] [Accepted: 02/02/2022] [Indexed: 11/13/2022] Open
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Orozco-Sevilla V, Coselli JS. Surgical strategies in the management of chronic dissection of the thoracoabdominal aorta. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 62:302-315. [PMID: 33565747 DOI: 10.23736/s0021-9509.21.11806-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Most operations for dissection of the thoracoabdominal aorta take place in the chronic phase of the disease, because the acutely dissected distal aorta is almost always initially treated non-surgically with aggressive pharmacological anti-impulse therapy. Identifying patients who are no longer responding to medical treatment is the first step in preventing further disease progression and rupture. Symptomatic aneurysms should be promptly repaired. Asymptomatic patients are followed until significant aortic dilation occurs and reaches a threshold of intervention: current guidelines endorse repair once a diameter of 5.5 cm is reached. In patients with heritable thoracic aortic disease (such as Marfan Syndrome), the threshold of intervention is often lowered. Aortic replacement typically centers on the dilatated segment. For all extents of repair, we use passive mild hypothermia, sequential aortic cross-clamping, aggressive reimplantation of intercostal and lumbar arteries, and cold renal perfusion whenever possible. For Crawford extents I and II thoracoabdominal aneurysm repair, we routinely use cerebrospinal fluid drainage, left heart bypass, and selective visceral perfusion. A four-branched graft approach to thoracoabdominal aortic aneurysm repair is frequently used in patients with chronic aortic dissection; this approach facilitates visceral artery perfusion during repair, expedites the distal anastomosis, and prevents subsequent visceral patch aneurysms. Lifelong imaging surveillance is necessary, because the distal aorta often continues to expand; residual aortic dissection commonly remains after repair and may necessitate further repair.
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Affiliation(s)
- Vicente Orozco-Sevilla
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA - .,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA.,Department of Cardiovascular Surgery, CHI St. Luke's Health - Baylor St. Luke's Medical Center, Houston, TX, USA
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Tanaka A, Sandhu HK, Afifi RO, Miller CC, Ray A, Hassan M, Safi HJ, Estrera AL. Outcomes of open repairs of chronic distal aortic dissection anatomically amenable to endovascular repairs. J Thorac Cardiovasc Surg 2021; 161:36-43.e6. [PMID: 31699416 DOI: 10.1016/j.jtcvs.2019.09.083] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 09/12/2019] [Accepted: 09/15/2019] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To review short-term outcomes and long-term survival and durability after open surgical repairs for chronic distal aortic dissections in patients whose anatomy was amenable to thoracic endovascular aortic repair (TEVAR). METHODS Between February 1991 and August 2017, we repaired chronic distal dissections in 697 patients. Of those patients, we enrolled 427 with anatomy amenable to TEVAR, which included 314 descending thoracic aortic aneurysms (DTAAs) and 105 extent I thoracoabdominal aortic aneurysms (TAAAs). One hundred eighty-five patients (44%) had a history of type A dissection, and 33 (7.9%) had a previous DTAA/TAAA repair. Variables were assessed with logistic regression for 30-day mortality and Cox regression for long-term mortality. Time-to-event analysis was performed using Kaplan-Meier methods. RESULTS Thirty-day mortality was 8.4% (n = 36). In all, 22 patients (5.2%) developed motor deficit (paraplegia/paraparesis), and 17 (4.0%) experienced stroke. Multivariable analysis identified low estimated glomerular filtration rate (eGFR; <60 mL/min/1.73 m2), previous DTAA/TAAA repair, and chronic obstructive pulmonary disease (COPD) as associated with 30-day mortality. Patients without all 3 risk factors had a 30-day mortality rate of 2.6%. During a median follow-up of 6.5 years, 160 patients died. The survival rate was 81% at 1 year and 61% at 10 years. Cox regression analysis identified preoperative aortic rupture, eGFR <60 mL/min/1.73 m2, previous DTAA/TAAA repair, COPD, and age >60 years as predictive of long-term mortality. Forty-five patients required subsequent aortic procedures, including 8 reinterventions to the treated segment. Freedom from any aortic procedures was 85% at 10 years, and aortic procedure-free survival was 45% at 10 years. Hereditary aortic disease was the sole predictor for any aortic interventions (hazard ratio, 3.2; P = .004). CONCLUSIONS Open surgical repair provided satisfactory low neurologic complication rates and durable repairs in chronic distal aortic dissection. Patients without low eGFR, redo, and COPD are the low-risk surgical candidates and may benefit from open surgical repair at centers with similar experience to ours. Patients with hereditary aortic disease warrant close surveillance.
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Affiliation(s)
- Akiko Tanaka
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Harleen K Sandhu
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Rana O Afifi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Charles C Miller
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Amberly Ray
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Madiha Hassan
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Hazim J Safi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex.
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Çekmecelioglu D, Orozco-Sevilla V, Coselli JS. Open vs. endovascular thoracoabdominal aortic aneurysm repair: tale of the tape. Asian Cardiovasc Thorac Ann 2020; 29:643-653. [PMID: 32772547 DOI: 10.1177/0218492320949073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Open surgical repair persists as the gold-standard operation for thoracoabdominal aortic aneurysm; however, endovascular repair has become commonplace. Technical considerations in thoracoabdominal aortic aneurysm treatment are particularly complex, insofar as it involves critical branching arteries feeding the visceral organs. Newer, low-profile devices make total endovascular thoracoabdominal aortic aneurysm repair more feasible and, thus, appealing. For younger and low-risk patients, the choice between open and endovascular therapy remains controversial. Despite the advantages of a minimally invasive procedure, data suggest that endovascular aortic repair incurs a greater risk of spinal cord deficit, and the durability of endovascular aortic repair remains unclear. It is difficult to compare outcomes between endovascular and open thoracoabdominal aortic aneurysm repair, primarily because of the current investigational status of endovascular devices, the variety of approaches to endovascular repair, differing patient populations, lack of prospective randomized studies, and minimal medium- and long-tern follow-up data on endovascular repair. When deciding between open and endovascular approaches, one should consider which is more suitable for each patient. Older patients generally benefit from a less invasive approach. Open repair should be considered for young patients and those with heritable thoracic aortic disease. Infection and fistulae are best treated by open repair, although endovascular intervention as a lifesaving bridge to definitive repair has evolved to become a critical component of initial treatment. It is crucial to have technical expertise in both open and endovascular procedures to provide the best aortic repair for the patient. This may require dedicated aortic programs at tertiary institutions.
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Affiliation(s)
- Davut Çekmecelioglu
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA.,Division of Cardiothoracic Surgery, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Department of Cardiovascular Surgery, CHI St. Luke's Health, Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Vicente Orozco-Sevilla
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA.,Division of Cardiothoracic Surgery, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Department of Cardiovascular Surgery, CHI St. Luke's Health, Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Joseph S Coselli
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA.,Division of Cardiothoracic Surgery, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Department of Cardiovascular Surgery, CHI St. Luke's Health, Baylor St. Luke's Medical Center, Houston, Texas, USA.,Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas, USA
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Alfonsi J, Murana G, Smeenk HG, Kelder H, Schepens M, Sonker U, Morshuis WJ, Heijmen RH. Open surgical repair of post-dissection thoraco-abdominal aortic aneurysms: early and late outcomes of a single-centre study involving over 200 patients. Eur J Cardiothorac Surg 2019; 54:382-388. [PMID: 29462490 DOI: 10.1093/ejcts/ezy050] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 01/13/2018] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES Chronic, post-dissection thoraco-abdominal aortic aneurysms (TAAAs) are increasingly being treated by (hybrid) endovascular means. Although it is less invasive, thoracic endovascular aortic repair is technically complex with the risk of incomplete aneurysm exclusion, necessitating frequent reinterventions with potentially reduced long-term outcomes. The aim of this study was to evaluate contemporary early and late outcomes after open surgical repair of post-dissection TAAA. METHODS At our centre, 633 patients underwent open repair for TAAA over a 20-year period (1994-2015), including 217 (34%) patients for post-dissection TAAA, who were included in this analysis. Circulatory support was obtained by either left heart bypass (173 patients, 79.7%), deep hypothermic circulatory arrest (41 patients, 18.9%) or simple aortic cross-clamping in 3 patients. We analysed all relevant perioperative and intraoperative variables with respect to adverse outcomes. Additionally, long-term survival and the need for aortic reinterventions were studied. RESULTS The mean age was 60.2 ± 11.9 years (men 68.2%). We identified 66 Type I (30.4%), 113 Type II (52.1%), 25 Type III (11.5%), 10 Type IV (4.6%) and 3 Type V (1.4%) TAAAs. Early mortality and spinal cord deficit were 5.9% and 5.5%, respectively. Follow-up was 100% complete (mean 6.0 ± 5.8 years), with long-term survival of 71.4% at 10 years, and freedom from death and reoperation was 68.2% at 10 years. CONCLUSIONS Although it is more invasive than current endovascular approaches for post-dissection TAAA, open surgical repair can be performed safely with acceptable rates of morbidity and mortality when it is done in a specialized aortic centre. Long-term survival and freedom from aortic reintervention are excellent and should also be taken into account when evaluating less invasive alternatives.
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Affiliation(s)
- Jacopo Alfonsi
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Giacomo Murana
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Henri G Smeenk
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Hans Kelder
- Department of Cardiology Research and Statistical Analysis, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Marc Schepens
- Department of Cardiothoracic Surgery, AZ St. Jan, Bruges, Belgium
| | - Uday Sonker
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Wim J Morshuis
- Department of Cardiac Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Robin H Heijmen
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, Netherlands.,Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, Netherlands
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Assi R, Bavaria JE, Desai ND. Techniques and outcomes of secondary open repair for chronic dissection after acute repair of type A aortic dissection. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 59:759-766. [PMID: 29943963 DOI: 10.23736/s0021-9509.18.10646-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Despite successful repair of acute type A aortic dissection (TAAD), the distal false lumen may remain patent resulting in progressive degeneration of the remaining distal aorta. This can lead to aneurysmal dilatation and risk of rupture. Open distal reoperation to replace the residually dissected thoraco-abdominal aorta may be accomplished with acceptable morbidity and mortality in experienced hands. This can be facilitated when the index operation for acute TAAD is tailored to exclude all primary tears and set the arch and descending aorta for a subsequent open, endovascular or hybrid procedure.
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Affiliation(s)
- Roland Assi
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA -
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Oderich GS. Evidence of use of multilayer flow modulator stents in treatment of thoracoabdominal aortic aneurysms and dissections. J Vasc Surg 2018; 65:935-937. [PMID: 28342519 DOI: 10.1016/j.jvs.2016.12.092] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 12/22/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Gustavo S Oderich
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
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13
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Coselli JS, Amarasekara HS, Green SY, Price MD, Preventza O, de la Cruz KI, Zhang Q, LeMaire SA. Open Repair of Thoracoabdominal Aortic Aneurysm in Patients 50 Years Old and Younger. Ann Thorac Surg 2017; 103:1849-1857. [DOI: 10.1016/j.athoracsur.2016.09.058] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 09/06/2016] [Accepted: 09/12/2016] [Indexed: 11/27/2022]
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de la Cruz KI, Green SY, Preventza OA, Coselli JS. Aortic Arch Replacement in Patients With Chronic Dissection: Special Considerations. Semin Cardiothorac Vasc Anesth 2016; 20:314-321. [PMID: 27418026 DOI: 10.1177/1089253216659144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The progressive expansion of residual, chronic DeBakey type I dissection often necessitates repair of the aortic arch and the distal aorta (ie, descending thoracic and thoracoabdominal aorta). The vast majority of patients with chronic aortic dissection facing aortic arch surgery are survivors of emergent proximal aortic repair for acute dissection, and thus, these patients now face a reoperative procedure necessitating a redo median sternotomy. One approach for repairing the chronic type I aortic dissection incorporates total transverse aortic arch replacement with and without an elephant trunk extension; an elephant trunk extension is a useful strategy, because the proximal descending thoracic aorta is commonly ectatic or aneurysmal at the time of aortic arch repair-using an elephant trunk approach facilitates subsequent repair in the distal aorta. Patients with chronic DeBakey type I dissection should participate in an imaging surveillance protocol.
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Affiliation(s)
- Kim I de la Cruz
- Baylor College of Medicine, Houston, TX, USA .,Texas Heart Institute, Houston, TX, USA.,Baylor St. Luke's Medical Center, CHI St. Luke's Health System, Houston, TX, USA
| | | | - Ourania A Preventza
- Baylor College of Medicine, Houston, TX, USA.,Texas Heart Institute, Houston, TX, USA.,Baylor St. Luke's Medical Center, CHI St. Luke's Health System, Houston, TX, USA
| | - Joseph S Coselli
- Baylor College of Medicine, Houston, TX, USA.,Texas Heart Institute, Houston, TX, USA.,Baylor St. Luke's Medical Center, CHI St. Luke's Health System, Houston, TX, USA
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Preventza O, Coselli JS. Type A aortic dissection in self-selected patients: What seems to fit a few does not fit all. J Thorac Cardiovasc Surg 2016; 151:1593-4. [DOI: 10.1016/j.jtcvs.2016.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 02/10/2016] [Indexed: 11/17/2022]
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Coselli JS, LeMaire SA, Preventza O, de la Cruz KI, Cooley DA, Price MD, Stolz AP, Green SY, Arredondo CN, Rosengart TK. Outcomes of 3309 thoracoabdominal aortic aneurysm repairs. J Thorac Cardiovasc Surg 2016; 151:1323-37. [DOI: 10.1016/j.jtcvs.2015.12.050] [Citation(s) in RCA: 359] [Impact Index Per Article: 44.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 12/01/2015] [Accepted: 12/14/2015] [Indexed: 11/24/2022]
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Leshnower BG, Thourani VH. Thoracic endovascular aortic repair for chronic distal aortic dissection: the jury is still out. J Thorac Cardiovasc Surg 2015; 149:S168-9. [PMID: 25726077 DOI: 10.1016/j.jtcvs.2014.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 12/03/2014] [Indexed: 11/26/2022]
Affiliation(s)
- Bradley G Leshnower
- Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Vinod H Thourani
- Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, Ga.
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