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D'Oria M, Jubouri M, Piffaretti G, Franchin M, Lepidi S, Bashir M. Current expert-based opinions on endovascular treatment of blunt thoracic aortic injury: A state-of-the-art narrative review on indications, techniques, results, and challenges. Vascular 2024:17085381241254629. [PMID: 38741044 DOI: 10.1177/17085381241254629] [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: 05/16/2024]
Abstract
INTRODUCTION Blunt thoracic aortic injury (BTAI) represents one of the most devastating scenarios of vascular trauma which warrants prompt recognition with expedited management. Clinical manifestations of BTAI may not be straightforward to detect and may be misdiagnosed. Therefore, diagnosis of BTAI requires a high index of suspicion based on the mechanism of injury along with urgent transfer to centers with appropriate expertise and facilities. METHODS We provide an expert-based narrative review on endovascular treatment of BTAI highlighting indications, techniques, results, and challenges. RESULTS Multiple imaging modalities can be used including computed tomography angiography, transesophageal echocardiography, magnetic resonance imaging, and intravascular ultrasound. Whilst conservative pharmacological management can be a safe option in low-grade BTAI, thoracic endovascular aortic repair has become the gold-standard strategy in most cases, replacing open surgical repair. Nevertheless, it is important to account for patient demographics particularly age, severity of injury, choice of endograft including its type and size, and endovascular technique including landing zone and left subclavian artery revascularization. CONCLUSIONS Overall, TEVAR in BTAI has been shown to be an efficacious strategy with favorable early outcomes. In contrast, less is known on the long-term clinical outcomes of TEVAR in BTAI. Hence, despite the optimal early technical and clinical success rates, concerns remain about the need for long-term surveillance. The exact timing of follow-up and the integration of different modalities that can also investigate potential downstream cardiovascular effects remain hot topics for future research. Finally, industry should focus on developing more compliant endografts to improve the stiffness mismatch between the endograft and the aorta to optimize results.
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Affiliation(s)
- Mario D'Oria
- Division of Vascular and Endovascular Surgery, Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Matti Jubouri
- University of York, Hull York Medical School, York, UK
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Marco Franchin
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Mohamad Bashir
- Vascular & Endovascular Surgery, Health & Education Improvement Wales (HEIW), Velindre University NHS Trust, Cardiff, UK
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Minici R, Serra R, Ierardi AM, Petullà M, Bracale UM, Carrafiello G, Laganà D. Thoracic endovascular repair for blunt traumatic thoracic aortic injury: Long-term results. Vascular 2024; 32:5-18. [PMID: 36121832 DOI: 10.1177/17085381221127740] [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] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study aims to evaluate the endoprosthesis complications in patients undergoing TEVAR for blunt traumatic thoracic aortic injury, through long-term clinical and diagnostic follow-up. METHODS During the study interval (November 2000-October 2020), a total of 38 patients (63% male; average age 37.5 years) with thoracic aortic injury underwent thoracic endovascular aortic repair. Patients underwent routine follow-up with clinical examination and radiological evaluation (CT-angiography or MRI-angiography plus chest radiograph), scheduled at 1 month, at 6 months (only in the cases of thoracic aortic dissection), at 1 year after the procedure and every 1 year thereafter. RESULTS Technical success was achieved in 38 procedures (100%). The TEVAR-related mortality rate was 0%. No immediate major complications related to the endovascular procedure were observed. The median duration of diagnostic follow-up was 80 months. A total of four procedure-related complications (10.5%) were identified at the follow-up. Three (7.9%) distal infoldings and collapses of the thoracic endoprosthesis and one (2.6%) type Ia endoleak were observed. No thrombosis of the prosthesis, nor signs of aortic pseudocoarctation were identified. No further complications related to endograft (endoleaks, infections, rupture, partial or complete thrombosis) occurred. No changes in the native aorta, stenosis, or increases in the endograft's diameters were observed. A total of 20 patients (52.6%) underwent MRI-angiography examinations, while a total of 34 patients (89.5%) underwent chest radiographs at the follow-up. In all cases, CT-angiography examinations were performed at the follow-up. CONCLUSIONS Procedure-related complications were observed within one year of TEVAR, limiting concerns related to the durability of the prosthesis. No morphological changes in the aorta were observed despite long-term follow-up. The consequences of lifelong surveillance in terms of radiation exposure deserve special consideration, especially in younger patients treated for TAI.
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Affiliation(s)
- Roberto Minici
- Radiology Division, Department of Experimental and Clinical Medicine, University Hospital Mater Domini, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Raffaele Serra
- Vascular Surgery Division, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Anna Maria Ierardi
- Radiology Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Maria Petullà
- Radiology Division, Department of Experimental and Clinical Medicine, University Hospital Mater Domini, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Umberto M Bracale
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Gianpaolo Carrafiello
- Radiology Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
| | - Domenico Laganà
- Radiology Division, Department of Experimental and Clinical Medicine, University Hospital Mater Domini, Magna Graecia University of Catanzaro, Catanzaro, Italy
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Late Stent Thrombosis in a Patient with Endovascular Aortic Repair for Blunt Thoracic Aortic Injury. Case Rep Vasc Med 2022; 2022:5583120. [PMID: 35198259 PMCID: PMC8860563 DOI: 10.1155/2022/5583120] [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: 01/21/2021] [Revised: 01/03/2022] [Accepted: 01/06/2022] [Indexed: 11/18/2022] Open
Abstract
Blunt thoracic aortic injury (BTAI) is associated with high mortality and morbidity. Thoracic endovascular aortic repair has become the recommended treatment modality given improved short-term results compared to open repair. We present a case of a 19-year-old male who presented with acute paralysis and multiorgan dysfunction from acute TEVAR thrombosis. Systemic thrombolysis, catheter-directed thrombolysis followed by aspiration thrombectomy, and angioplasty were initially successful in restoring perfusion. However, he developed progressive multiorgan failure related to prompt reocclusion within 48 hours. This case is the first to describe thrombolysis and angioplasty as a management strategy for acute TEVAR thrombosis. We also review the literature surrounding this uncommon complication.
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Kuo MC, Meena RA, Ramos CR, Benarroch-Gampel J, Leshnower BG, Duwayri Y, Jordan WD, Rajani RR. Female gender is associated with increased late luminal narrowing within the stent graft after thoracic endovascular aortic repair. J Vasc Surg 2021; 75:67-73. [PMID: 34450242 DOI: 10.1016/j.jvs.2021.07.226] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 07/21/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Luminal narrowing, suspected secondary to thrombus, occurs within stent grafts at an unclear incidence after thoracic endovascular aortic repair (TEVAR). The significance of this phenomenon has not been determined, nor have the risk factors for development of intragraft luminal narrowing. Small graft diameter is hypothesized to be a risk factor for the development of ingraft stenosis. METHODS A retrospective analysis was performed of a multicenter healthcare system including all patients who underwent TEVAR between July 2011 and July 2019 with at least 1 year of subsequently available surveillance contrast-enhanced computed tomography imaging. Standard demographic, preoperative, intraoperative, and postoperative variables were collected. Measurements were obtained via direct off-line images from computed tomography scans. Patent intragraft diameters were compared with baseline and interval change values were normalized to time to follow-up. The primary outcome measure was annual rate of intragraft luminal narrowing. RESULTS There were 208 patients who met the inclusion criteria (94 women, 114 men) with a median follow-up of 822 days. The mean annual rate of percent intragraft diameter reduction was 10.5 ± 7.7% for women and 7.6 ± 5.6% for men (P = .0026). Multivariate analysis demonstrated female gender (P = .0283), preoperative diagnosis of hypertension (P = .0449), and need for coverage of the left subclavian artery (P = .0328) were all significant predictors of intragraft luminal narrowing. Small aortic diameters were not found to be associated independently with ingraft luminal narrowing nor was the concomitant use of antiplatelet or anticoagulation medications. Significant amounts of ingraft luminal narrowing, defined as a greater than 20% intragraft diameter decrease, were associated with an increased need for any reintervention, including for malperfusion, endoleak, and symptomatic aneurysm (P = .0249). Kaplan-Meier estimates demonstrated a significant gender-associated difference in high rates of intragraft luminal narrowing (P = .00189). CONCLUSIONS In this analysis, female gender is shown to be a significant nonmodifiable risk factor for intragraft luminal narrowing after TEVAR. The development of this phenomenon is not benign; as such, these findings were associated with an increased need for reintervention. This finding may be attributable to differences in aortic compliance or gender-associated differences in coagulation pathways and merits further investigation. Surveillance after thoracic stent grafting must account for patient-specific variations in complication risk.
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Affiliation(s)
| | - R Anthony Meena
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Christopher R Ramos
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Jaime Benarroch-Gampel
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Yazan Duwayri
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - William D Jordan
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Ravi R Rajani
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
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Benz RM, Makaloski V, Brönnimann M, Mertineit N, von Tengg-Kobligk H. [Diagnostics and treatment of traumatic aortic injuries]. Unfallchirurg 2021; 124:601-609. [PMID: 34254152 PMCID: PMC8370906 DOI: 10.1007/s00113-021-01044-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2021] [Indexed: 11/30/2022]
Abstract
Hintergrund Traumatische Aortenverletzungen (TAV) sind seltene Folgen von stumpfen Traumata, die eine hohe Mortalität und Morbidität aufweisen. Die schnelle und akkurate Diagnostik sowie die Wahl der korrekten Therapie sind für das Patientenüberleben elementar. Fragestellung Bestimmung des aktuellen Standards der Abklärung von TAV im akuten Trauma-Setting und Evaluation der aktuellen Leitlinien zur Therapie. Material und Methode Eine Literaturrecherche wurde durchgeführt, mit der Suche nach Publikationen, die die Abklärung und Diagnostik der TAV beschreiben. Außerdem wurden Leitlinien für die Behandlung und Nachsorge von TAV zusammengefasst. Ergebnisse In der Literatur wird trotz geringer Spezifität eine konventionelle Thoraxröntgenaufnahme als Initialdiagnostik genannt. Es sollte primär, als Modalität der Wahl, zur Diagnostik und zur Therapiestratifizierung eine Computertomographie (CT) aufgrund der hohen Sensitivität und Spezifität nachfolgen. In allen Leitlinien ist die thorakale endovaskuläre Aortenrekonstruktion („thoracic endovascular aortic repair“, TEVAR) die Therapie der Wahl bei höhergradigen TAV (Grade II–IV) und hat die offene Chirurgie in dem meisten Fällen abgelöst. Schlussfolgerung Nach einer kurzfristig erfolgten CT-Diagnostik und Einteilung wird die TEVAR der offenen Chirurgie bei therapiebedürftigen TAV vorgezogen.
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Affiliation(s)
- R M Benz
- Diagnostische, Interventionelle und Pädiatrische Radiologie, Inselspital, Universität Bern, Freiburgstr. 18, 3010, Bern, Schweiz.
| | - V Makaloski
- Universitätsklinik für Herz- und Gefäßchirurgie, Inselspital, Universität Bern, Freiburgstr. 18, 3010, Bern, Schweiz
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Choi JH, Kim SP, Lee HC, Park TS, Park JH, Kim BW, Ahn J, Park JS, Lee HW, Oh JH, Choi JH, Cha KS, Hong TJ. Clinical outcomes of endovascular treatment for ruptured thoracic aortic disease. Korean J Intern Med 2021; 36:S72-S79. [PMID: 32264656 PMCID: PMC8009169 DOI: 10.3904/kjim.2019.080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 07/15/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND/AIMS Untreated rupture of the thoracic aorta is associated with a high mortality rate. We aimed to review the clinical results of endovascular treatment for ruptured thoracic aortic disease. METHODS We retrospectively reviewed data on 37 patients (mean age, 67.0 ± 15.18 years) treated for ruptured thoracic aortic disease from January 2005 to May 2016. The median follow-up duration was 308 days (interquartile range, 61 to 1,036.5). The primary end-point of the study was the composite of death, secondary intervention, endoleak, and major stroke/paraplegia after endovascular treatment. RESULTS The etiologies of ruptured thoracic aortic disease were aortic dissection (n = 11, 29.7%), intramural hematoma (n = 7, 18.9%), thoracic aortic aneurysm (n = 14, 37.8%), and traumatic aortic transection (n = 5, 13.5%). Three patients died within 24 hours of thoracic endovascular aortic repair, and one showed type I endoleak. The technical success rate was 89.2% (33/37). The in-hospital mortality rate was 13.5% (5/37); no deaths occurred during follow-up. The composite outcome rate during follow-up was 37.8% (14/37), comprising death (n = 5, 13.5%), secondary intervention (n = 5, 13.5%), endoleak (n = 5, 13.5%), and major stroke/paraplegia (n = 3, 8.1%). Left subclavian artery revascularization and proximal landing zone were not associated with the composite outcome. Low mean arterial pressure (MAP; ≤ 60 mmHg, [hazard ratio, 13.018; 95% confidence interval, 2.435 to 69.583, p = 0.003]) was the most significant predictor and high transfusion requirement in the first 24 hours was associated with event-free survival (log rank p = 0.018). CONCLUSION Endovascular treatment achieves high technical success rates and acceptable clinical outcome. High transfusion volume and low MAP were associated with poor clinical outcomes.
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Affiliation(s)
- Jong Hyun Choi
- Division of Cardiology, Department of Internal Medicine, Busan Veterans Hospital, Busan, Korea
| | - Sang-Pil Kim
- Department of Thoracic Surgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Han Cheol Lee
- Division of Cardiology, Department of Internal Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
- Correspondence to Han Cheol Lee, M.D. Division of Cardiology, Department of Internal Medicine, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan 49241, Korea Tel.: +82-51-240-7217 Fax: +82-51-240-7795 E-mail:
| | - Tae Sik Park
- Division of Cardiology, Department of Internal Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jong Ha Park
- Division of Cardiology, Department of Internal Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Bo Won Kim
- Division of Cardiology, Department of Internal Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jinhee Ahn
- Division of Cardiology, Department of Internal Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jin Sup Park
- Division of Cardiology, Department of Internal Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Hye Won Lee
- Division of Cardiology, Department of Internal Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jun-Hyok Oh
- Division of Cardiology, Department of Internal Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jung Hyun Choi
- Division of Cardiology, Department of Internal Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Kwang Soo Cha
- Division of Cardiology, Department of Internal Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Taek Jong Hong
- Division of Cardiology, Department of Internal Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
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Sarquis LM, Michaelis W, Santos AL, Pinto CS, Yokoyama RA, Seguro EF, Martins ALDC, do Vale VB. Endovascular treatment of traumatic dissection of the thoracic aorta - series of 16 cases. J Vasc Bras 2020; 19:e20200074. [PMID: 34211523 PMCID: PMC8218017 DOI: 10.1590/1677-5449.200074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Aortic injuries caused by blunt chest traumas have high pre-hospital and emergency mortality. The endovascular approach is one option for treatment of these injuries, but many outcomes related to this approach remain unknown. Objectives The aim of this study is to describe a specialist trauma center’s experience with endovascular treatment of cases like these. Methods This is a descriptive study based on review of the electronic medical records of patients who had suffered from blunt thoracic aorta trauma and were seen at a hospital specializing in trauma cases in the city of Curitiba (Paraná, Brazil). Results Sixteen patients were included in the study. All patients were traffic accident victims and 75% of the accidents were the result of vehicle collisions. Aortic lesions ranged from grade I to IV and the majority had grade II lesions (50%). All patients underwent endovascular treatment with endografts, an average of 71 hours after the trauma. Two patients died, both from causes unrelated to their aortic injuries. During follow-up, only two patients presented complications (endoleak and progression of the dissection). Conclusions The endovascular method is a viable alternative for treatment of blunt trauma thoracic aortic injuries. Randomized and controlled studies are needed to provide evidence to support indication of this method to treat this type of injury.
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Affiliation(s)
| | - Wilson Michaelis
- Hospital Universitário Evangélico Mackenzie - HUEM, Serviço de Cirurgia Vascular, Curitiba, PR, Brasil
| | - Antonio Lacerda Santos
- Hospital Universitário Evangélico Mackenzie - HUEM, Serviço de Cirurgia Vascular, Curitiba, PR, Brasil
| | | | - Rogerio Akira Yokoyama
- Hospital Universitário Evangélico Mackenzie - HUEM, Serviço de Cirurgia Vascular, Curitiba, PR, Brasil
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Kohler C, Wyss TR, Mertineit N, Makaloski V, Schmidli J. Emergent open conversion for stent-graft deployment failure in a ruptured thoracic aneurysm. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2020; 7:180-182. [PMID: 33748558 PMCID: PMC7966836 DOI: 10.1016/j.jvscit.2020.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/30/2020] [Indexed: 11/30/2022]
Abstract
Thoracic endovascular aortic repair (TEVAR) is the standard of care for ruptured thoracic aortic aneurysms. A 92-year-old man had presented in stable condition but with acute severe back pain. Computed tomography revealed a ruptured thoracic aortic aneurysm. TEVAR (Valiant; Medtronic Vascular, Santa Rosa, Calif) into zone 2 with intentional coverage of the left subclavian artery was planned. After release of the stent-graft body, proximal release of the bare springs was impossible. Troubleshooting techniques were applied; but tip capture could not be released. Emergent conversion to open repair was performed. Intraoperative device deployment failure in TEVAR is rare. The findings from the present report have demonstrated the advantages of having in-house cardiac surgery backup available.
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Affiliation(s)
- Corinne Kohler
- Department of Cardiovascular Surgery, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas R Wyss
- Department of Cardiovascular Surgery, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nando Mertineit
- Division of Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Vladimir Makaloski
- Department of Cardiovascular Surgery, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Juerg Schmidli
- Department of Cardiovascular Surgery, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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D'Alessio I, Domanin M, Bissacco D, Rimoldi P, Palmieri B, Piffaretti G, Trimarchi S. Thoracic endovascular aortic repair for traumatic aortic injuries: insight from literature and practical recommendations. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:681-696. [PMID: 32964899 DOI: 10.23736/s0021-9509.20.11580-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Thoracic endovascular aortic repair (TEVAR) for treatment of blunt traumatic aortic injuries (BTAIs) is nowadays the gold standard technique in adult patients, replacing gradually the use of open repair (OR). Although randomized controlled trials will never be performed comparing TEVAR to OR for BTAIs management, trauma and vascular societies guidelines today primarily recommend the former for BTAI patients with a suitable anatomy. The aim of this review was to describe past and recent data published in literature regarding pros and cons of TEVAR treatment in BTAI, and to analyze some debated issues and future perspectives. EVIDENCE ACQUISITION Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and Scale for the Assessment of Narrative Review Articles (SANRA) were used to obtain and describe selected articles on TEVAR in BTAI. EVIDENCE SYNTHESIS Young (<50 years) men were the most operated population. The use of TEVAR increased over the years, with a progressive reduction in mortality and overall postoperative complication rates when compared with OR. Lack of information remains about the percentage of urgent cases. CONCLUSIONS TEVAR is considered nowadays the treatment of choice in BTAI patients. In case of aortic rupture (grade IV) the treatment is mandatory, while intimal tear (grade I) and intramural hematoma (grade II) can be safely managed with no operative management (NOM). Debate is still ongoing on grade III (pseudoaneurysms). Unfortunately, several aspects remain not yet clarified, including disease classification, type and grade to treat, timing (urgent versus elective), priority of vascular injuries in polytrauma patients, and TEVAR use in pediatrics and young patients.
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Affiliation(s)
- Ilenia D'Alessio
- Unit of Vascular Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Domanin
- Unit of Vascular Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy - .,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Daniele Bissacco
- Unit of Vascular Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Pierantonio Rimoldi
- Department of Cardio-Thoraco-Vascular Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Bruno Palmieri
- Department of Cardio-Thoraco-Vascular Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Gabriele Piffaretti
- Unit of Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Santi Trimarchi
- Unit of Vascular Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Patel HJ, Azizzadeh A, Matsumoto AH, Velazquez OC, Rovin JD, Lombardi JV, Khoynezhad A, Dai Y, White RA. Five-Year Outcomes From the United States Pivotal Trial of Valiant Captivia Stent Graft for Blunt Aortic Injury. Ann Thorac Surg 2020; 110:815-820. [DOI: 10.1016/j.athoracsur.2019.12.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 11/24/2019] [Accepted: 12/10/2019] [Indexed: 11/25/2022]
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The need for more information. J Vasc Surg 2020; 71:1823-1824. [PMID: 32446505 DOI: 10.1016/j.jvs.2019.05.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 05/31/2019] [Indexed: 11/21/2022]
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Bavaria JE, Brinkman WT, Hughes GC, Shah AS, Charlton-Ouw KM, Azizzadeh A, White RA. Five-year outcomes of endovascular repair of complicated acute type B aortic dissections. J Thorac Cardiovasc Surg 2020; 163:539-548.e2. [DOI: 10.1016/j.jtcvs.2020.03.162] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 03/05/2020] [Accepted: 03/16/2020] [Indexed: 11/28/2022]
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Mouawad NJ, Paulisin J, Hofmeister S, Thomas MB. Blunt thoracic aortic injury - concepts and management. J Cardiothorac Surg 2020; 15:62. [PMID: 32307000 PMCID: PMC7169033 DOI: 10.1186/s13019-020-01101-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 04/06/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Blunt thoracic aortic injury, a life-threatening concern, remains the second most common cause of mortality among all non-penetrating traumatic injuries, second only to intracranial hemorrhage. Kinetic forces from the rapid deceleration are the impetus for the injury mechanism and are graded accordingly. Given the prevalence of trauma as a public health problem, contemporary management considerations are important. MAIN BODY Blunt thoracic aortic injury may be fatal if not diagnosed and treated expeditiously. Endovascular options allow safe and effective management of these dangerous injuries. This paper describes the overview of blunt thoracic aortic trauma, the epidemiology, presentation, diagnosis, and treatment options with a focus on endovascular management. CONCLUSION Blunt thoracic aortic injury requires a high index of suspicion based on mechanism of injury in the trauma population. Endovascular options have become the mainstay of blunt thoracic aortic injury treatment whenever feasible with satisfactory results and long-term outcomes.
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Affiliation(s)
- Nicolas J Mouawad
- McLaren Bay Heart & Vascular, McLaren Bay Region, 1900 Columbus Avenue, 4th Floor, South Tower, Bay City, MI, 48708, USA.
| | - Joseph Paulisin
- McLaren Bay Heart & Vascular, McLaren Bay Region, 1900 Columbus Avenue, 4th Floor, South Tower, Bay City, MI, 48708, USA
| | - Stephen Hofmeister
- McLaren Bay Heart & Vascular, McLaren Bay Region, 1900 Columbus Avenue, 4th Floor, South Tower, Bay City, MI, 48708, USA
| | - Matthew B Thomas
- McLaren Bay Heart & Vascular, McLaren Bay Region, 1900 Columbus Avenue, 4th Floor, South Tower, Bay City, MI, 48708, USA
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Martinelli O, Malaj A, Faccenna F, Ruberto F, Alunno A, Totaro M, Irace L. Open Conversion for Recurrent Endograft Occlusion after Endovascular Treatment of Blunt Traumatic Aortic Injury: A Peculiar Case Report. Ann Vasc Surg 2020; 67:568.e1-568.e8. [PMID: 32234576 DOI: 10.1016/j.avsg.2020.03.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 03/14/2020] [Accepted: 03/15/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND We report a rare case of delayed, symptomatic thoracic endograft thrombosis after the initial thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury which was successfully retreated with a redo TEVAR, followed by open conversion due to recurrent partial occlusion of the distal edge of the endografts. METHODS Two years ago, a 22-year-old man had undergone an emergency TEVAR for blunt thoracic aortic injury. A Zenith Cook 22 × 100 mm (Cook Incorporated, Bloomington, IN) endograft was used. Six months later, he underwent an emergency endovascular relining of the endograft using the same type of device. The multiorgan perfusion was completely restored except for the spinal cord injury. After 8 months, a recurrent partial occlusion of the distal edge of the second graft was documented. The thoracic aorta was replaced with a 22-mm silver-coated graft (Maquet Spain, SLU). RESULTS Histology examination showed a neointimal formation and thickening and fibrosis of the inner 1/3 of the media with loss of smooth muscle cells and increase of the elastic fibers. CONCLUSIONS The need for secondary interventions or open conversion because of potential complications after TEVAR for traumatic aortic injury is an additional consideration when weighing the risks and benefits of endovascular repair and subsequent surveillance strategies.
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Affiliation(s)
| | - Alban Malaj
- American Hospital, Laprake, Tirana, Albania.
| | - Federico Faccenna
- Department of Vascular Surgery, "Sapienza" University of Rome, Rome, Italy
| | - Franco Ruberto
- Department of Anaesthesiology, Critical Care Medicine and Pain Therapy, "Sapienza" University of Rome, Rome, Italy
| | - Alessia Alunno
- Department of Vascular Surgery, "Sapienza" University of Rome, Rome, Italy
| | - Marco Totaro
- Department of the Heart and Great Vessels, "Sapienza" University of Rome, Rome, Italy
| | - Luigi Irace
- Department of Vascular Surgery, "Sapienza" University of Rome, Rome, Italy
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15
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Leon M, Chavez LO, Chavez A, Surani S. Blunt Aortic / Inferior Vena Cava Injury: Are We Consistently Providing the Same Level of Care? Cureus 2020; 12:e6832. [PMID: 32181075 PMCID: PMC7051116 DOI: 10.7759/cureus.6832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Major vascular traumatic injuries have a higher pre-hospital and in-hospital mortality rate. The different mechanisms of injury and anatomy of the aorta and inferior vena cava (IVC) make the management a constant challenge to surgeons and clinicians. Blunt traumatic aortic injury (BTAI) can occur at the thoracic or abdominal level, each of which possesses different considerations. Blunt traumatic inferior vena cava injury (BTIVCI) also has important diagnostic challenges since the lesion may not be as evident in the IVC as compared to the aorta, possibly due to lower caval pressures or the ability to self-tamponade from adjacent structures. Endovascular management has significantly increased in the past years, and despite an improvement in mortality, the approach to aortic and IVC injuries is not well standardized. Diagnostic imaging helps to classify the extent of the lesions and guide towards the best therapeutic options for each case. Conservative management, in some cases, has shown to reduce mortality, and close follow-up has proven good outcomes. Future research will provide more evidence to determine the best approach to BTAI and BTIVCI for better long-term outcomes. This article aims to provide an updated review of the current literature regarding diagnosis, classification, and management of BTAI and BTIVCI.
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Affiliation(s)
- Monica Leon
- General Surgery, ABC Medical Center, Mexico City, MEX
| | - Luis O Chavez
- Internal Medicine, Texas Tech University Health Sciences Center, El Paso, USA
| | - Alda Chavez
- Faculty of Medicine and Psychology, Autonomous University of Baja California, Tijuana, MEX
| | - Salim Surani
- Internal Medicine, Texas A&M Health Science Center, Bryan, USA
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Mansukhani NA, Haleem MS, Eskandari MK. Thoracic Endovascular Aortic Repair Adverse Events Reported In The Food And Drug Administration Manufacturer And User Facility Device Experience Database. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2019; 12:461-467. [PMID: 31814779 PMCID: PMC6861529 DOI: 10.2147/mder.s206269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 06/13/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose The purpose of this study is to identify adverse events (device- and patient-related) associated with thoracic aortic stent graft systems and their timing post-procedure. Materials and methods The Food and Drug Administration’s Manufacturer and User Facility Device Experience (FDA-MAUDE) voluntary database was searched for Thoracic Aortic Endovascular Repair (TEVAR) devices reported over the course of 1 year (January 1, 2014 to December 31, 2014). The data abstracted included the indication for treatment, device used, and adverse events. Results During 2014, there were 334 original submissions to the FDA-MAUDE database describing 371 adverse events regarding TEVAR devices that met inclusion criteria for this study. All submissions were from manufacturers, and none were from physicians. The most common pathologies treated were thoracic aortic aneurysm (67.6%) and type B aortic dissection (25.1%). The most frequently reported intraoperative, early postoperative (<30 days), and late postoperative (>30 days) events overall were technical device failure, neurologic complications (stroke, paraplegia), and endoleak, respectively. Of note, there were descriptions of retained deployment materials, late graft infections, and aorto-visceral fistula formation up to 3 years postoperatively. Conclusion The MAUDE database is a valuable repository for complications and device failures that are not otherwise in the published literature and submitted by manufacturers relating to this relatively new technology.
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Affiliation(s)
- Neel A Mansukhani
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Meraaj S Haleem
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Mark K Eskandari
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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18
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Kim HM, Cho YK, Kim JH, Seo TS, Song MG, Jeon YS, Cho SB, Im NY. Clinical Outcomes of the Seal® Thoracic Stent Graft for Traumatic Aortic Injury in a Korean Multicenter Retrospective Study. Ann Vasc Surg 2019; 61:400-409. [PMID: 31394246 DOI: 10.1016/j.avsg.2019.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 05/24/2019] [Accepted: 06/03/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Thoracic endovascular aneurysm repair (TEVAR) has been used as a primary treatment for blunt traumatic aortic injury (TAI). However, the outcomes of midterm surveillance of Seal® stent-graft durability for TAI have not been extensively studied. Thus, we aimed to report the midterm outcomes of TEVAR using the Seal® stent graft for blunt TAI. METHODS Patients with blunt TAI treated with TEVAR using the Seal® thoracic stent graft between 2007 and 2013 in Korea were included. Midterm outcomes included technical/clinical success, in-hospital death, aorta/procedure/device-related adverse events, secondary procedures, and 30-day and all-cause mortality. RESULTS A total of 99 patients (54% men; mean age, 48 years) were included. Grade III or higher injuries were present in 95% of patients, including 15 free ruptures of the thoracic aorta, and 64% of injuries were located in zone III. The median procedure and hospitalization duration were 90 min and 11 days, respectively. The technical success rate was 98%. The number of in-hospital mortalities (n = 8) and stroke (n = 2) were observed at 30 days. Late stroke and paraplegia (>30 days) were not observed during the mean 49 ± 26 months of follow-up (median, 48 months; range, 0-117 months). There were no aorta-related mortalities or conversions to open repair. Secondary procedures were performed in 8 patients, all of which were carotid-subclavian bypasses for delayed left subclavian occlusion. The all-cause mortality rate was 5% at 30 days and 8% at 1 year. The survival rate was 95% at 30 days, 92% at 1 year, 92% at 3 years, and 89% at 5 years. One type Ia endoleak occurred at 18 months after the procedure. CONCLUSIONS TEVAR with the Seal® stent graft for TAI showed favorable midterm outcomes. The incidence of major adverse events after the procedure was low.
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Affiliation(s)
- Han Myun Kim
- Department of Radiology, Kangnam Seong-Sim Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Young Kwon Cho
- Department of Radiology, Kangdong Seong-Sim Hospital, Hallym University College of Medicine, Seoul, Korea.
| | - Jeong Ho Kim
- Department of Radiology, Gachon University Gil Hospital, Gachon University College of Medicine, Incheon, Korea
| | - Tae-Seok Seo
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Myung Gyu Song
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Yong Sun Jeon
- Department of Radiology, Inha University Hospital, Inha University College of Medicine, Incheon, Korea
| | - Sung Bum Cho
- Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Nam Yeul Im
- Department of Radiology, Chonnam National University Hospital, Chonnam National University College of Medicine, Gwangju-si, Korea
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19
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Agostinelli A, Carino D, Borrello B, Marcato C, Volpi A, Gherli T, Nicolini F. Blunt traumatic injury to the thoracic aorta treated with thoracic endovascular aortic repair: a single-centre 20-year experience. Interact Cardiovasc Thorac Surg 2019; 28:17-22. [PMID: 30007311 DOI: 10.1093/icvts/ivy211] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 06/03/2018] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Blunt thoracic aortic injury can be treated with thoracic endovascular aortic repair (TEVAR) with excellent short and mid-term outcomes. However, few data are available about the long-term results. Our goal was to report our single-centre, 20-year experience using TEVAR to treat blunt thoracic aortic injury. METHODS We retrospectively reviewed our institutional database to identify all patients treated with TEVAR for traumatic lesions of the aortic isthmus. We identified 35 patients since 1998. Patients' charts were analysed for preoperative characteristics, intraoperative variables and short-term outcomes. Information about the long-term follow-up was collected by analysing cross-sectional images and via phone calls. Follow-up was 100% complete. Rates of survival and of freedom from aortic redo were estimated using Kaplan-Meier methods. RESULTS Twenty-nine patients were men (82%). The median age was 42 years (range 22-79 years) and the mean injury severity score was 38 (±13). The endovascular procedure was successfully carried out in all patients. The left subclavian artery was intentionally overstented in 11 patients (31%). Two patients died perioperatively (5.7%). The estimated survival was 92% and 87% at 5 and 10 years, respectively, with no aorta-related deaths. The estimated freedom from aortic redo was 96% and 91% at 5 and 10 years, respectively. CONCLUSIONS Our data corroborate the excellent results of the endovascular treatment of blunt thoracic aortic injury when follow-up is extended to 20 years. New-generation devices, which are more comfortable and have smaller diameters, may further improve the results of TEVAR in treating traumatic aortic injury. Surveillance with cross-sectional imaging remains mandatory.
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Affiliation(s)
| | - Davide Carino
- Department of Cardiac Surgery, Parma University Hospital, Parma, Italy.,Aortic Institute at Yale-New Haven, Yale University School of Medicine, New Haven, CT, USA
| | - Bruno Borrello
- Department of Cardiac Surgery, Parma University Hospital, Parma, Italy
| | - Carla Marcato
- Department of Radiology, Parma University Hospital, Parma, Italy
| | - Annalisa Volpi
- 1st Anesthesia and Intensive Care Department, Parma University Hospital, Parma, Italy
| | - Tiziano Gherli
- Department of Cardiac Surgery, Parma University Hospital, Parma, Italy
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20
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Glaser JD, Kalapatapu VR. Endovascular Therapy of Vascular Trauma—Current Options and Review of the Literature. Vasc Endovascular Surg 2019; 53:477-487. [DOI: 10.1177/1538574419844073] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Objective: To review the current use of endovascular techniques in trauma. Summary Background Data: Multiple studies have demonstrated that, despite current guidelines, endovascular therapies are used in instances of arterial trauma. Methods: The existing literature concerning arterial trauma was reviewed. Studies reviewed included case reports, single-center case series, large database studies, official industry publications and instructions for use, and society guidelines. Results: Endovascular therapies are used in arterial trauma in all systems. The use of thoracic endografts in blunt thoracic aortic trauma is accepted and endorsed by society guidelines. The use of endovascular therapies in other anatomic locations is largely limited to single-center studies. Advantages potentially include less morbidity due to smaller incisions as well as shorter operating room times. Many report using endovascular therapies even with hard signs of injury. Long-term results are limited by a lack of long-term follow-up but, in general, suggest that these techniques produce acceptable outcomes. The adoption of these techniques may be limited by resource and surgeon availability. Conclusions: The use of endovascular therapies in trauma has gained acceptance despite not yet having a place in official guidelines.
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Affiliation(s)
- Julia D. Glaser
- Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Venkat R. Kalapatapu
- Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, PA, USA
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21
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Ho XN, Wee IJ, Syn N, Harrison M, Wilson L, Choong AM. The endovascular repair of blunt traumatic thoracic aortic injury in Asia: A systematic review and meta-analysis. Vascular 2019; 27:213-223. [PMID: 30739602 DOI: 10.1177/1708538119828887] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Blunt traumatic thoracic aortic injury, the second leading cause of death from trauma, poses unique challenges in its management. However, there has not yet been a corresponding consolidated series of outcomes reported in Asia, which this systematic review aims to address. METHOD This review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Searches were performed on MEDLINE, EMBASE, Google Scholar, and Cochrane Database for studies performed in Asia reporting the endovascular management of blunt traumatic thoracic aortic injury. Risk of bias was assessed using the Newcastle-Ottawa scale. Meta-analyses of pooled proportions were performed using the metaprop command in STATA. This review has been prospectively registered in PROSPERO (CRD42018083773). RESULTS Sixteen retrospective cohort studies were included, reporting a total of 238 patients. The pooled Injury Severity Score was 32.5 (95%CI 27.8-37.1). The pooled mean time to operation from diagnosis was 39.2 hours (95%CI 24.6-53.8 hours), and operation time was 100 min (95%CI 63.5-136.5 min). The pooled rate of procedural conversion from endovascular repair to open surgery was 0.17% (95%CI 0-3.7%), and the proportion of left subclavian artery coverage was 55% (95%CI 37-72%). The pooled prevalence of intra-operative all-cause and aortic-related mortality was 0.72% (95%CI 0-4.9%) and 0.27% (95%CI 0-3.8%), respectively. The pooled prevalence of 30-day all-cause and aortic-related mortality was 2.2% (95%CI 0.16-5.6%) and 2.1% (95%CI 0-3.7%), respectively. In terms of 30-day complication, the pooled prevalence rates of type 1 endoleak, endograft complications, vascular access injury, strokes, and aortic re-rupture were 1.2%, 0.34%, 0.14%, 0.02%, and 0.01%, respectively. There were no cases of types II and III endoleak, and renal failure. CONCLUSION Short- to mid-term results for thoracic endovascular aortic repair for blunt traumatic thoracic aortic injury in Asia are encouraging. However, there is a distinct disparity in reporting across Asia. We propose a prospective database for outcome reporting post thoracic endovascular aortic repair in this patient population, and ongoing follow up to assess long-term efficacy of this treatment strategy.
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Affiliation(s)
- Xin Nee Ho
- 1 SingVaSC, Singapore Vascular Collaborative, Singapore.,2 Division of Vascular Surgery, National University Heart Centre, Singapore
| | - Ian Jy Wee
- 1 SingVaSC, Singapore Vascular Collaborative, Singapore.,3 Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nicholas Syn
- 1 SingVaSC, Singapore Vascular Collaborative, Singapore
| | - Michael Harrison
- 1 SingVaSC, Singapore Vascular Collaborative, Singapore.,4 Department of General Surgery, Sir Charles Gairdner Hospital, Perth, Australia
| | - Lauren Wilson
- 1 SingVaSC, Singapore Vascular Collaborative, Singapore.,5 School of Medicine, Griffith University, Gold Coast, Australia
| | - Andrew Mtl Choong
- 1 SingVaSC, Singapore Vascular Collaborative, Singapore.,2 Division of Vascular Surgery, National University Heart Centre, Singapore.,6 Cardiovascular Research Institute, National University Heart Centre Singapore, Singapore.,7 Department of Surgery, National University of Singapore, Singapore
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22
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Zierler RE, Jordan WD, Lal BK, Mussa F, Leers S, Fulton J, Pevec W, Hill A, Murad MH. The Society for Vascular Surgery practice guidelines on follow-up after vascular surgery arterial procedures. J Vasc Surg 2018; 68:256-284. [PMID: 29937033 DOI: 10.1016/j.jvs.2018.04.018] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 04/11/2018] [Indexed: 12/20/2022]
Abstract
Although follow-up after open surgical and endovascular procedures is generally regarded as an important part of the care provided by vascular surgeons, there are no detailed or comprehensive guidelines that specify the optimal approaches with regard to testing methods, indications for reintervention, and follow-up intervals. To provide guidance to the vascular surgeon, the Clinical Practice Council of the Society for Vascular Surgery appointed an expert panel and a methodologist to review the current clinical evidence and to develop recommendations for follow-up after vascular surgery procedures. For those procedures for which high-quality evidence was not available, recommendations were based on observational studies, committee consensus, and indirect evidence. Recognizing that there are numerous published reports on the role of duplex ultrasound for surveillance of infrainguinal vein bypass grafts, the Society commissioned a systematic review and meta-analysis on this topic. The panel classified the strength of each recommendation and the corresponding quality of evidence on the basis of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system: recommendations were graded either strong or weak, and the quality of evidence was graded high, moderate, or low. The resulting recommendations represent a wide variety of open surgical and endovascular procedures involving the extracranial carotid artery, thoracic and abdominal aorta, mesenteric and renal arteries, and lower extremity arterial revascularization. The panel also identified many areas in which there was a lack of high-quality evidence to support their recommendations. This suggests that there are opportunities for further clinical research on testing methods, threshold criteria, and the role of surveillance as well as on the modes of failure and indications for reintervention after vascular surgery procedures.
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Affiliation(s)
| | | | - Brajesh K Lal
- Department of Surgery, University of Maryland, Baltimore, Md
| | - Firas Mussa
- Department of Surgery Palmetto Health/University of South Carolina School of Medicine, Columbia, SC
| | - Steven Leers
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Joseph Fulton
- Department of Surgery, Westchester Medical Center, Poughkeepsie, NY
| | - William Pevec
- Division of Vascular Surgery, University of California, Davis, Sacramento, Calif
| | - Andrew Hill
- Division of Vascular & Endovascular Surgery, The Ottawa Hospital & University of Ottawa, Ottawa, Ontario, Canada
| | - M Hassan Murad
- Division of Preventive Medicine, Mayo Clinic, Rochester, Minn
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23
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Grigorian A, Spencer D, Donayre C, Nahmias J, Schubl S, Gabriel V, Barrios C. National Trends of Thoracic Endovascular Aortic Repair Versus Open Repair in Blunt Thoracic Aortic Injury. Ann Vasc Surg 2018; 52:72-78. [PMID: 29886219 DOI: 10.1016/j.avsg.2018.03.045] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 03/23/2018] [Accepted: 03/29/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Blunt thoracic aortic injury (BTAI) occurs in <1% of all trauma admissions. Considering the advent of multiple thoracic endovascular aortic repair (TEVAR) devices over the past decade, improved outcomes of TEVAR supported in the literature, rapid diagnosis, and improved preoperative planning of BTAI using computed tomography imaging, we hypothesized that the national incidence of TEVAR in BTAI has increased while open repair has decreased. In addition, we hypothesized that the mortality risk in BTAI patients undergoing TEVAR would be lower than open repair. METHODS This was a retrospective analysis of the National Trauma Data Bank from 2007 to 2015. The primary end points of interest included the incidence of TEVAR and open repair, as well as mortality in BTAI patients undergoing intervention. Covariates were included in a multivariable analysis to determine risk for mortality in BTAI patients undergoing open repair versus TEVAR. RESULTS We identified 3,628 BTAI patients undergoing intervention. Of these, 3,226 underwent TEVAR (87.9%), and 445 (12.1%) underwent open repair. Compared with open repair, TEVAR had a shorter mean length of stay (LOS) (19.8 vs. 21.3 days, P < 0.05) and lower rates of acute kidney injury (AKI) (5.6% vs. 9.0%, P < 0.05) and mortality (8.8% vs. 12.8%, P < 0.05). Open repair had greater risk for mortality than TEVAR (odds ratio = 1.63, confidence intervals = 1.19-2.23, P < 0.05). CONCLUSIONS The rate of open repair decreased from 7.4% in 2007 to 1.9% in 2015, whereas TEVAR increased from 12.1 to 25.7% during the same time period. We confirmed previous findings that endovascular repair is associated with decreased mortality, LOS, and major complications, including AKI. Future investigations should focus on identifying the ideal patient candidate for TEVAR and elucidate precise indications for TEVAR in BTAI.
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Affiliation(s)
- Areg Grigorian
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA.
| | - Dean Spencer
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA
| | - Carlos Donayre
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA
| | - Jeffry Nahmias
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA
| | - Sebastian Schubl
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA
| | - Viktor Gabriel
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA
| | - Cristobal Barrios
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA
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25
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Limited influence of blunt aortic injuries on the outcome of polytraumatized patients: a matched pair analysis. Arch Orthop Trauma Surg 2018; 138:211-218. [PMID: 29143168 DOI: 10.1007/s00402-017-2842-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Traumatic lesions of great vessels such as the aorta are life-threatening injuries. There is limited evidence about the influence of traumatic aortic injuries in multiple trauma patients in particular with regard to posttraumatic complications. The aim of this study was to evaluate the influence of blunt thoracic aortic injuries in multiple trauma patients compared to a multiple trauma cohort without this specific injury. In addition, the safety of Thoracic Endovascular Aortic Repair (TEVAR) in multiple trauma patients was analyzed. MATERIALS AND METHODS A retrospective study was performed. We included all multiple trauma patients (ISS ≥ 16, age > 14 years) between 2005 and 2014 with (group BTAI) and without (group nBTAI) blunt traumatic aortic injuries who were treated at our level-1 trauma center. Demographic as well as clinical parameters were analyzed including injury pattern, mechanism of injury, posttraumatic complications such as ARDS, multiple organ dysfunction syndrome (MODS) and others. A matched pair analysis was performed by propensity score matching. RESULTS In total, 721 patients were enrolled (group BTAI: n = 45; nBTAI: n = 676). In the initial study population, surgical intervention was done in n = 32 (71.1%) patients (TEVAR: n = 25; 78.1%), there was an increased AISChest and overall injury severity in group BTAI with associated significantly more posttraumatic complications in group BTAI. The matched pair analysis consisted of 42 patients per group. Beside an increased ventilation time, no significant differences were evident after the matching process. There was a trend to increased risk for SIRS using binary logistic regression analysis. CONCLUSIONS Multiple trauma patients with blunt thoracic aortic injuries who are treated at a level-1 trauma center show a comparable outcome matched to their counterparts without aortic injuries. Our study confirms that using TEVAR in polytraumatized patients is a safe procedure. In all patients treated with TEVAR, there were no procedure-related complications, especially no neurological deficit.
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Ghazy T, Mikulasch S, Reeps C, Hoffmann RT, Wijatkowska K, Diab AH, Kappert U, Matschke K, Weiss N, Mahlmann A. Experts' Results in Blunt Thoracic Aortic Injury are Reproducible in Lower Volume Tertiary Institutions. Early and Mid-term Results of an Observational Study. Eur J Vasc Endovasc Surg 2017; 54:604-612. [PMID: 28958467 DOI: 10.1016/j.ejvs.2017.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Accepted: 08/09/2017] [Indexed: 01/16/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate the early and mid-term clinical results, the device performance, and the mid-term re-intervention rates of patients suffering blunt thoracic aortic injury (BTAI) managed by a multidisciplinary team in a low-volume BTAI centre. METHODS This was a retrospective observational study in a tertiary hospital setting. From December 2005 to March 2016, all patients over 18 years old admitted with BTAI were included in the study. No exclusion criteria were applied. The study data were collected and analysed retrospectively. Follow-up of survivors included computed tomography imaging 3 and 9 months post-procedure, then annually. RESULTS Twenty-eight patients were included in the study. Their mean age was 42 ± 16 years and 89% were male. A contained aortic rupture was diagnosed in 20 patients, a Stanford type B dissection in six, and intramural haematoma in two patients. Multidisciplinary evaluations were performed and an intervention was indicated in 25 patients (89%), four of whom died before the intervention. Nineteen patients underwent thoracic endovascular aortic repair of the descending thoracic aorta and two patients underwent a frozen elephant trunk procedure. The procedures were performed 0.7 ± 1.2 days after injury. All procedures were successful. There were no device related complications. The post-operative 30 day mortality was 5%, with one patient dying on the day of operation from other vascular injuries. The 30 day mortality of all patients was 18%. The median mid-term follow-up period was 786 days. All 30 day survivors survived the follow-up period. The mid-term imaging showed stable results in 19 patients. Two patients required frozen elephant trunk procedures after 240 and 681 days and both procedures were successful. CONCLUSIONS In a low volume centre, a multidisciplinary team using a standardised protocol with the endovascular first approach demonstrated excellent outcomes, similar to those of large centres. If the aortic trauma is adequately managed, the patient's outcome is closely related to the additional trauma.
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Affiliation(s)
- Tamer Ghazy
- Department of Cardiac Surgery of the Dresden Heart Centre University Hospital, Dresden University of Technology, Dresden, Germany.
| | - Sandra Mikulasch
- University Centre for Vascular Medicine and Division of Angiology, Department of Internal Medicine III, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Christian Reeps
- University Centre for Vascular Medicine and Department of Vascular Surgery, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Ralf-Thorsten Hoffmann
- University Centre for Vascular Medicine and Institute for Diagnostic Radiology, University Hospital Carl Gustav Carus Dresden, Dresden University of Technology, Dresden, Germany
| | - Kasia Wijatkowska
- Department of Cardiac Surgery of the Dresden Heart Centre University Hospital, Dresden University of Technology, Dresden, Germany
| | - Abdel-Hannan Diab
- Department of Cardiac Surgery of the Dresden Heart Centre University Hospital, Dresden University of Technology, Dresden, Germany
| | - Utz Kappert
- Department of Cardiac Surgery of the Dresden Heart Centre University Hospital, Dresden University of Technology, Dresden, Germany
| | - Klaus Matschke
- Department of Cardiac Surgery of the Dresden Heart Centre University Hospital, Dresden University of Technology, Dresden, Germany
| | - Norbert Weiss
- University Centre for Vascular Medicine and Division of Angiology, Department of Internal Medicine III, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Adrian Mahlmann
- University Centre for Vascular Medicine and Division of Angiology, Department of Internal Medicine III, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
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Lim CY. Endovascular Repair in Acute Complicated Type B Aortic Dissection: 3-Year Results from the Valiant US Investigational Device Exemption Study. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2017; 50:137-143. [PMID: 28593148 PMCID: PMC5460959 DOI: 10.5090/kjtcs.2017.50.3.137] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 05/05/2017] [Accepted: 05/11/2017] [Indexed: 01/09/2023]
Abstract
Acute complicated type B aortic dissection (TBAD) is a potentially catastrophic, life-threatening condition. If left untreated, there is a high risk of aortic rupture, irreversible organ or limb damage, or death. Several risk factors have been associated with acute complicated TBAD, including age and refractory hypertension. In the acute phase, even uncomplicated patients are more prone to develop complications if hypertension and pain are left medically untreated. Innovations in stent graft technologies have incrementally improved outcomes since their first use for this condition in 1999, though improvement is needed in mitigating periprocedural complications, adverse events, and mortality. In the past decade, endovascular repair has become the preferred treatment because of its superior outcomes to open repair and medical therapy. The Valiant Captivia Thoracic Stent Graft System is a third-generation endovascular stent graft with advancements in minimally invasive delivery, conformability to the anatomy, and the minimization of adverse sequelae. Herein, this stent graft is briefly reviewed and its 3-year outcomes are presented. Freedom from all-cause and dissection-related mortality was 79.1% and 90.0%, respectively. The Valiant Captivia Stent Graft represents a safe, effective intervention for acute complicated TBAD. Continued surveillance is needed to verify its longer-term durability.
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Affiliation(s)
- Chang Young Lim
- Department of Thoracic and Cardiovascular Surgery, Andong General Hospital
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Gandhi SS, Blas JV, Lee S, Eidt JF, Carsten CG. Nonoperative management of grade III blunt thoracic aortic injuries. J Vasc Surg 2016; 64:1580-1586. [DOI: 10.1016/j.jvs.2016.05.070] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 05/24/2016] [Indexed: 10/21/2022]
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Harris DG, Rabin J, Starnes BW, Khoynezhad A, Conway RG, Taylor BS, Toursavadkohi S, Crawford RS. Evolution of lesion-specific management of blunt thoracic aortic injury. J Vasc Surg 2016; 64:500-505. [DOI: 10.1016/j.jvs.2015.12.066] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 12/19/2015] [Indexed: 10/21/2022]
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Abstract
Surgery of the aortic arch is arguably one of the most complex areas of cardiac surgery. Despite that, studies and guidelines have not sufficiently addressed the aortic arch specifically. In general, indications for aortic arch intervention parallel those of the ascending aorta. Herein we review indications for aortic arch intervention in various aortic pathologies based on the scant evidence available combined with surgical expertise and expert opinion.
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Gombert A, Barbati ME, Grommes J, Jalaie H, Schleimer K, Jacobs MJ, Kalder J. Blunt Thoracic Aortic Injury in Case of a 15-Year-Old Boy: Difficulties and Possibilities of the Endovascular Approach. Ann Vasc Surg 2016; 33:228.e15-9. [PMID: 26965820 DOI: 10.1016/j.avsg.2015.10.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Revised: 10/14/2015] [Accepted: 10/24/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Blunt thoracic aortic injuries (BTAIs) are rare but life threatening. Most BTAI are caused by high-energy trauma. Among children with blunt trauma, the incidence of BTAI is below 1 percent. The present case deals with covered thoracic aortic rupture of a 15-year-old boy. Emphasizing the value and the difficulties of endovascular surgery in children is the motivation for this case report. CASE REPORT We are presenting the case of a 15-year-old boy, who suffered multiple traumata after accident. Beneath multiple fractures and a liver laceration, a thoracic aortic rupture with pseudoaneurysm of the aortic wall was diagnosed. Owing to the comorbidities, an endovascular therapy in combination with a transposition of the left subclavian artery to the common carotid artery was performed. The chronological line-up of the events and the endovascular treatment as well as the in-hospital follow-up are described. DISCUSSION Injury-induced BTAI in pubescent children rarely occurs. Only few cases can be found in literature, none of which were associated with the presented pattern of injury. CONCLUSIONS The optimal treatment for childhood BTAI is a case-by-case decision. We critically discuss the value of endovascular therapy in the present case.
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Affiliation(s)
- Alexander Gombert
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany.
| | - Mohammad Esmaeil Barbati
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany
| | - Jochen Grommes
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany; Institute for Cardiovascular Prevention, Ludwig-Maximilians University Munich, München, Germany
| | - Houman Jalaie
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany
| | - Karina Schleimer
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany
| | - Michael J Jacobs
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany; European Vascular Center Aachen-Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Johannes Kalder
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany
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Aboyans V, De Carlo M, Kownator S, Mazzolai L, Meneveau N, Ricco JB, Vlachopoulos C, Brodmann M. The year in cardiology 2015: peripheral circulation. Eur Heart J 2016; 37:676-85. [PMID: 26726049 DOI: 10.1093/eurheartj/ehv709] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 12/03/2015] [Indexed: 11/12/2022] Open
Affiliation(s)
- Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, 2, Martin Luther King Avenue, 87042 Limoges, France Inserm 1094, Tropical Neuroepidemiology, University of Limoges, Limoges, France
| | - Marco De Carlo
- Cardiac Catheterization Laboratory, Cardiothoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | | | - Lucia Mazzolai
- Department of Angiology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Nicolas Meneveau
- Department of Cardiology, EA3920, University Hospital Jean Minjoz, Besançon, France
| | - Jean-Baptiste Ricco
- Department of Vascular Surgery, University Hospital of Poitiers, Poitiers, France
| | - Charalambos Vlachopoulos
- Peripheral Vessels and Hypertension Units, 1st Department Cardiology, Athens Medical School, Athens, Greece
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Khoynezhad A. Between a rock and a hard place? Not when dealing with traumatic aortic injuries! J Thorac Cardiovasc Surg 2015; 150:1663. [DOI: 10.1016/j.jtcvs.2015.08.102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 08/27/2015] [Indexed: 10/23/2022]
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Myers PO, Hachulla-Lemaire AL, Murith N. Traumatic thoracic aortic rupture: Caught between a thoracic vertebral osteophyte and a hard place. J Thorac Cardiovasc Surg 2015; 150:1661-2. [PMID: 26341283 DOI: 10.1016/j.jtcvs.2015.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 08/08/2015] [Indexed: 11/18/2022]
Affiliation(s)
- Patrick O Myers
- Division of Cardiovascular Surgery, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
| | | | - Nicolas Murith
- Division of Cardiovascular Surgery, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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"RESCUE me": Sweet music for patients with aortic transection. J Thorac Cardiovasc Surg 2014; 149:161-2. [PMID: 25451489 DOI: 10.1016/j.jtcvs.2014.09.089] [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: 09/23/2014] [Accepted: 09/25/2014] [Indexed: 11/20/2022]
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