1
|
Alanezi T, Altoijry A, AlSheikh S, Al-Mubarak H, Alhamzah M, Alomran F, Abdulrahim O, Aljabri B, Greco E, Hussain MA, Al-Omran M. Predicting the need for subclavian artery revascularization in thoracic endovascular aortic repair: A systematic review and meta-analysis. J Vasc Surg 2024:S0741-5214(24)00985-6. [PMID: 38621636 DOI: 10.1016/j.jvs.2024.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/21/2024] [Accepted: 04/09/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVE This systematic review and meta-analysis aims to investigate the effectiveness of left subclavian artery revascularization compared with non-revascularization in thoracic endovascular aortic repair, and to summarize the current evidence on its indications. METHODS A computerized search was conducted across multiple databases, including MEDLINE, SCOPUS, Cochrane Library, and Web of Science, for studies published up to November 2023. Study selection, data abstraction, and quality assessment (using the Newcastle-Ottawa Scale) were independently conducted by two reviewers, with a third author resolving discrepancies. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models and publication bias was assessed using funnel plots. RESULTS In the 76 included studies, left subclavian artery revascularization was associated with reduced risks of stroke (OR, 0.67; 95% CI, 0.45-0.98; n = 15,331), spinal cord ischemia (OR, 0.75; 95% CI, 0.56-0.99; n = 11,995), and arm ischemia (OR, 0.09; 95% CI, 0.01-0.59; n = 8438). No significant reduction in paraplegia (OR, 0.56; 95% CI, 0.21-1.47; n = 1802) or mortality (OR, 0.77; 95% CI, 0.53-1.12; n = 11,831) was observed. Moreover, the risk of endoleak was comparable in both groups (OR, 1.25; 95% CI, 0.55-2.84; P = .60; n = 793), whereas the risk of reintervention was significantly higher in the revascularization group (OR, 1.98; 95% CI, 1.03-3.83; P = .04; n = 272). Both groups had similar risks of major (OR, 0.45; 95% CI, 0.19-1.09; P = .08; n = 1113), minor (OR, 0.21; 95% CI, 0.01-3.45; P = .27; n = 183), renal (OR, 0.61; 95% CI, 0.12-3.06; P = .55; n = 310), and pulmonary (OR, 0.59; 95% CI, 0.16-2.15; P = .42; n = 8083) complications. The most frequent indications for left subclavian artery revascularization were primary prevention of spinal cord ischemia, augmentation of the landing zone, and primary stroke prevention. CONCLUSIONS Left subclavian artery revascularization in thoracic endovascular aortic repair was associated with reduced neurological complications but was not found to impact mortality. The study highlights important indications for revascularization as well as significant predictors of complications, providing a basis for clinical decision-making and future research.
Collapse
Affiliation(s)
- Tariq Alanezi
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulmajeed Altoijry
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Sultan AlSheikh
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Husain Al-Mubarak
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Musaad Alhamzah
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Faris Alomran
- Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Omer Abdulrahim
- Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Badr Aljabri
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Elisa Greco
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Mohamad A Hussain
- Harvard Medical School, Boston, MA; Division of Vascular and Endovascular Surgery and the Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston
| | - Mohammed Al-Omran
- Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
| |
Collapse
|
2
|
Lin F, He Z, Gao J, Huang X, Wang H, Han L, Zhu X, Zhan Y, Wang W. Comparison of surgical and endovascular left subclavian artery revascularization during thoracic aortic endovascular repair: a systematic review and meta-analysis. Front Cardiovasc Med 2023; 10:1274629. [PMID: 38028461 PMCID: PMC10658894 DOI: 10.3389/fcvm.2023.1274629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/20/2023] [Indexed: 12/01/2023] Open
Abstract
Objective The purpose of this systematic review and meta-analysis was to incorporate data from the latest clinical studies and compare the safety and efficacy of surgical left subclavian artery (LSA) revascularization and endovascular LSA revascularization during thoracic endovascular aortic repair (TEVAR). Methods This study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered with the PROSPERO database on 16 April 2023 (CRD42023414579). The Embase, MEDLINE (PubMed), and the Cochrane Library databases were searched from January 2000 to May 2023. Results A total of 14 retrospective cohort studies with a total of 1,695 patients, were included for review. The peri-operative stroke rates of the surgical and endovascular LSA revascularization groups were 3.8% and 2.6%, respectively (P = 0.97). The peri-operative technical success rates for the surgical and endovascular LSA revascularization groups were 95.6% and 93.0%, respectively (P = 0.24). The peri-operative spinal cord ischemia rates were 1.6% (n = 18) and 1.9% (n = 7) in the surgical and endovascular LSA revascularization groups, respectively (P = 0.90). The peri-operative type Ⅰ endoleak rates for the surgical and endovascular LSA revascularization groups were 6.6% and 23.2%, respectively (P = 0.25). The subgroup analysis showed that the incidence of peri-operative type I endoleak in the parallel stent group was significantly higher than that in the surgical LSA revascularization group (P < 0.0001). The peri-operative left upper limb ischemia rates for the surgical and endovascular LSA revascularization groups were 1.2% and 0.6%, respectively (P = 0.96). The peri-operative mortality rates of the surgical and endovascular LSA revascularization groups were 2.0% and 2.0%, respectively (P = 0.88). Conclusion There was no significant difference in the terms of short-term outcomes when comparing the two revascularization techniques. The quality of evidence assessed by GRADE scale was low to very-low. Surgical and endovascular LSA revascularization during TEVAR were both safe and effective. Compared with surgical LSA revascularization techniques, parallel stent revascularization of LSA significantly increased the rate of type I endoleak.
Collapse
Affiliation(s)
- Feng Lin
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of General Surgery, Anhui Public Health Clinical Center, Hefei, China
| | - Zhipeng He
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Junpeng Gao
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xiaoci Huang
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Haoran Wang
- Department of Vascular Surgery, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Long Han
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of General Surgery, Anhui Public Health Clinical Center, Hefei, China
| | - Xingyang Zhu
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of General Surgery, Anhui Public Health Clinical Center, Hefei, China
| | - Yanqing Zhan
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of General Surgery, Anhui Public Health Clinical Center, Hefei, China
| | - Wenbin Wang
- Department of General Surgery, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of Vascular Surgery, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| |
Collapse
|
3
|
Zhang Y, Xie X, Yuan Y, Hu C, Wang E, Zhao Y, Lin P, Li Z, Mo F, Fu W, Wang L. Comparison of techniques for left subclavian artery preservation during thoracic endovascular aortic repair: A systematic review and single-arm meta-analysis of both endovascular and surgical revascularization. Front Cardiovasc Med 2022; 9:991937. [PMID: 36186963 PMCID: PMC9520576 DOI: 10.3389/fcvm.2022.991937] [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: 07/12/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundCurrently, the optimal technique to revascularize the left subclavian artery (LSA) during thoracic endovascular aortic repair (TEVAR) remains controversial. Our study seeks to characterize early and late clinical results and to assess the advantages and disadvantages of endovascular vs. surgical strategies for the preservation of LSA.MethodsPubMed, Embase and Cochrane Library searches were conducted under the PRISMA (Preferred Reporting Items for Systematic review and Meta-Analyses) standards. Only literature published after January 1994 was included. Studies reporting on endovascular revascularization (ER), surgical revascularization (SR) for LSA preservation were included. 30-day mortality and morbidity rates, restenosis rates, and rates of early and late reintervention are measured as outcomes.ResultsA total of 28 studies involving 2,759 patients were reviewed. All articles were retrospective in design. Single-arm analysis found no significant statistical differences in ER vs. SR in terms of 30-day mortality and perioperative complication rates. The mean follow-up time for the ER cohort was 12.9 months and for the SR cohort was 26.6 months, respectively. Subgroup analysis revealed a higher risk of perioperative stroke (4.2%) and endoleaks (14.2%) with the chimney technique compared to the fenestrated and single-branched stent approaches. Analysis of the double-arm studies did not yield statistically significant results.ConclusionBoth ER and SR are safe and feasible in the preservation of LSA while achieving an adequate proximal landing zone. Among ER strategies, the chimney technique may presents a greater risk of neurological complications and endoleaks, while the single-branched stent grafts demonstrate the lowest complication rate, and the fenestration method for revascularization lies in an intermediate position. Given that the data quality of the included studies were relatively not satisfactory, more randomized controlled trials (RCTs) are needed to provide convincing evidence for optimal approaches to LSA revascularization in the future.
Collapse
Affiliation(s)
- Yuchong Zhang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Xiamen, China
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Vascular Surgery Institute of Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Fudan Zhangjiang Institute, Shanghai, China
| | - Xinsheng Xie
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Xiamen, China
| | - Ye Yuan
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Xiamen, China
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Vascular Surgery Institute of Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Fudan Zhangjiang Institute, Shanghai, China
| | - Chengkai Hu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Xiamen, China
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Vascular Surgery Institute of Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Fudan Zhangjiang Institute, Shanghai, China
| | - Enci Wang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Xiamen, China
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Vascular Surgery Institute of Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Fudan Zhangjiang Institute, Shanghai, China
| | - Yufei Zhao
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Xiamen, China
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Vascular Surgery Institute of Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Fudan Zhangjiang Institute, Shanghai, China
| | - Peng Lin
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Xiamen, China
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Vascular Surgery Institute of Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Fudan Zhangjiang Institute, Shanghai, China
| | - Zheyun Li
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Xiamen, China
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Vascular Surgery Institute of Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Fudan Zhangjiang Institute, Shanghai, China
| | - Fandi Mo
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Xiamen, China
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Vascular Surgery Institute of Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Fudan Zhangjiang Institute, Shanghai, China
| | - Weiguo Fu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Xiamen, China
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Vascular Surgery Institute of Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Fudan Zhangjiang Institute, Shanghai, China
- *Correspondence: Weiguo Fu,
| | - Lixin Wang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Xiamen, China
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Vascular Surgery Institute of Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Fudan Zhangjiang Institute, Shanghai, China
- Lixin Wang,
| |
Collapse
|
4
|
Grigorian A, Lewis M, Wlodarczyk JR, Chien CY, Park T, Demetriades D. Left subclavian artery coverage during endovascular repair of thoracic aorta injury in trauma and non-trauma patients. Eur J Trauma Emerg Surg 2022; 48:4425-4429. [PMID: 35713681 DOI: 10.1007/s00068-022-02027-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/28/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE In thoracic endovascular aortic repair (TEVAR), the left subclavian artery (LSA) is often occluded. Although most patients tolerate this, some develop ischemic symptoms to the brain or left upper extremity (LUE). A revascularization procedure may be associated with significant complications. The purpose of this review was to assess the incidence of LSA occlusion, resulting ischemic symptoms, and complications related to revascularization operations in trauma patients compared to non-trauma patients. METHODS Studies from 2010 to 2020 were fully reviewed if they discussed incidence of LSA coverage, LUE ischemia, carotid-subclavian bypass, or complications associated with carotid-subclavian bypass. RESULTS Seventeen articles were included in this analysis. A total of 167 patients were identified as trauma cases. Incidence of LSA occlusion in trauma was 91/167 (54%) compared to 281/1446 (19%) in the population exclusive of trauma (p < 0.001). Following LSA occlusion, the rate of LUE claudication/ischemia was 21/56 (38%) for trauma, compared to 12/193 (6%) in non-trauma cases (p < 0.001). The overall complication rate after carotid-subclavian rescue bypass was 29.2% (33/112), with phrenic nerve palsy (24%), recurrent laryngeal nerve palsy (5%), and pseudoaneurysm (1.7%) being the most common. CONCLUSION LSA coverage following TEVAR is common and associated with significant complications, often requiring operative management. The incidence of ischemic complications after occlusion of the LSA is significantly higher in the trauma population. Revascularization procedures to correct the occlusion have a high rate of complications.
Collapse
Affiliation(s)
- Areg Grigorian
- Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA.
| | - Meghan Lewis
- Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA
| | - Jordan R Wlodarczyk
- Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA
| | - Chih Ying Chien
- Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA
| | - Timothy Park
- Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA
| | - Demetrios Demetriades
- Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA
| |
Collapse
|
5
|
Batubara EAD, Nugraha RA, Amshar M, Taofan, Indriani S, Adiarto S. Ischemic Complications Following Thoracic Endovascular Aortic Repair with and without Revascularization of Left Subclavian Artery: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2022; 86:417-427. [DOI: 10.1016/j.avsg.2022.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 11/01/2022]
|
6
|
Karaolanis GI, Antonopoulos CN, Charbonneau P, Georgakarakos E, Moris D, Scali S, Kotelis D, Donas K. A systematic review and meta-analysis of stroke rates in patients undergoing Thoracic Endovascular Aortic Repair for descending thoracic aortic aneurysm and type B dissection. J Vasc Surg 2022; 76:292-301.e3. [DOI: 10.1016/j.jvs.2022.02.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 02/15/2022] [Indexed: 01/28/2023]
|
7
|
Pei Y, Zhu H, Xiao Y, Zhou J, Jing Z. The Mini-Cross Prefenestration for Endovascular Repair of Aortic Arch Pathologies. Front Cardiovasc Med 2022; 8:745871. [PMID: 35087876 PMCID: PMC8787069 DOI: 10.3389/fcvm.2021.745871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 12/13/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To examine the feasibility, integrity, efficacy, and safety of endovascular repair of the aortic arch pathologies with the mini-cross prefenestration (MCPF) on stent grafts. Methods: First, to prove the feasibility of the MCPF, an in-vitro prefenestration experiment was conducted. Second, to examine the integrity of the MCPF stent grafts, a fatigue test was conducted. Then, the membranes and metal structures of stent grafts were examined by light microscopy and scanning electron microscopy (SEM). Third, a clinical experiment was conducted to investigate the efficacy and safety of this novel technique (ClinicalTrials.gov Identifier: NCT04544579). Results: All the 12 branch stents were successfully implanted and flared in vitro. After the fatigue test stimulating a 5-year cardiac cycle, no obvious disintegration or fracture was found in light microscopy or SEM. From December 2017 to February 2020, 26 patients with left subclavian arteries and/or left common carotid arteries involved received the novel technique. The endovascular repair with the MCPF was successfully performed on all the 26 (100%) patients. Eighteen (69.2%) patients underwent the reconstruction of the left subclavian artery (LSCA) only. The fenestrations of both the LSCA and left common carotid artery (LCCA) were conducted in 8 (30.8%) patients. Median operative time was 120 [interquartile range (IQR), 95–137.5] min and median revascularization time of the LSCA and LCCA was 30.5 (IQR, 22.8–42.0) s and 20.0 (IQR, 18.0–32.0) s separately. During the median follow-up duration of 38.9 (range, 18.8–44.2) months, one case needed an open surgery because of retrograde type A aortic dissection 3 months after implantation and no other complications or mortality occurred. The maximum aortic diameters were significantly decreased in patients with thoracic aortic dissection and thoracic aortic aneurysm (p < 0.05). Conclusion: The existing evidence demonstrated the safety, rapid branch artery revascularization, and positive aortic remodeling of the novel technique. Long-term observation is warranted to prove the durability.
Collapse
|
8
|
Upchurch GR, Escobar GA, Azizzadeh A, Beck AW, Conrad MF, Matsumura JS, Murad MH, Perry RJ, Singh MJ, Veeraswamy RK, Wang GJ. Society for Vascular Surgery clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms. J Vasc Surg 2021; 73:55S-83S. [DOI: 10.1016/j.jvs.2020.05.076] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 12/17/2022]
|
9
|
Open stented elephant trunk for complicated Stanford type B aortic dissection: a single-center experience. J Cardiothorac Surg 2020; 15:282. [PMID: 32993726 PMCID: PMC7526183 DOI: 10.1186/s13019-020-01341-6] [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: 05/29/2020] [Accepted: 09/22/2020] [Indexed: 11/24/2022] Open
Abstract
Background Open stented elephant trunk (SET) or SET with left subclavian artery (LSCA) to left common carotid artery (LCCA) bypass is proven to a potentially alternative treatment for complicated Stanford type B aortic dissection (TBAD). In the current study, we reported our experience with ten consecutive TBAD patients who underwent open SET. Methods Patients with complicated TBAD underwent open SET from May 2016 to November 2018 in our institution were included. Patients’ clinical data were obtained from the electronic medical record system, and long-term clinical outcomes were collected by telephone interviews or outpatient interviews. Results A total of ten patients with nine males and one female were included, and the average age was 47.3 (31–65) years. Increased D-dimer and fibrinogen degradation products were observed in all patients at admission, and two patients had renal insufficiency. The average postoperative mechanical ventilation time, length of stay in intensive care unit, and postoperative hospital length of stay were 46.9 (6.7–151.2) hours, 7.7 (4–17) days, and 15.7 (10–26) days. No postoperative death occurred. Acute kidney injury and other complications were observed, and they were recovered well when discharge. In long-term follow-up, computed tomography angiography indicated that aortas were completely well remodeled, and blood supply of the brachiocephalic trunks was normal without anastomotic complications. All patients lived well. Conclusion SET or SET with subclavian artery correction shows satisfactory clinical outcomes, and it could be considered as an alternative treatment. Well-designed, large-scale studies with long-term follow-up are still needed.
Collapse
|
10
|
Munshi B, Ritter JC, Doyle BJ, Norman PE. Management of acute type B aortic dissection. ANZ J Surg 2020; 90:2425-2433. [PMID: 32893461 DOI: 10.1111/ans.16270] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 08/01/2020] [Accepted: 08/05/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND The best management of acute uncomplicated type B aortic dissection is currently a controversial area. Recent advances in endovascular intervention have begun to establish pre-emptive thoracic endovascular aortic repair as a potential strategy. A review about the management for type B aortic dissection has been conducted. METHODS A narrative review consisting of 157 original articles, meta-analyses and guidelines was conducted. The findings were synthesized and summarized using 70 articles. RESULTS There are clear guidelines directing surgical management of acute complicated type B aortic dissection. However, the best management of acute uncomplicated disease is more ambiguous, which is especially concerning in a condition which is associated with significant morbidity and mortality. Medical management alone is generally favoured. Endovascular intervention is now being considered by some surgeons, but it can be technically difficult, while exposing the patient to potential surgical risks. CONCLUSIONS Clinical and anatomical risk factors have been identified to help vascular surgeons make decisions about treatment in acute uncomplicated type B aortic dissection. New endovascular strategies are being developed to reduce surgical risk and address technical challenges. Registry data should be used to support future best management.
Collapse
Affiliation(s)
- Bijit Munshi
- Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre, Perth, Western Australia, Australia.,Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Medical School, The University of Western Australia, Perth, Western Australia, Australia.,Department of Vascular Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Jens C Ritter
- Department of Vascular Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Barry J Doyle
- Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre, Perth, Western Australia, Australia.,School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Paul E Norman
- Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre, Perth, Western Australia, Australia.,Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Medical School, The University of Western Australia, Perth, Western Australia, Australia.,Department of Vascular Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
| |
Collapse
|
11
|
Conway AM, Qato K, Nhan Nguyen Tran N, Giangola G, Carroccio A. Management of the Left Subclavian Artery in TEVAR for Chronic Type B Aortic Dissection. Vasc Endovascular Surg 2020; 54:586-591. [DOI: 10.1177/1538574420942353] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: Left subclavian artery (LSA) revascularization in thoracic endovascular aortic repair (TEVAR) remains controversial. Left subclavian artery coverage without revascularization can cause stroke and death. TEVAR has gained popularity for the treatment of chronic type B aortic dissection (cTBD). Using the Vascular Quality Initiative (VQI) database, we reviewed outcomes of LSA revascularization in TEVAR for cTBD. Methods: The VQI registry identified 5683 patients treated with TEVAR from July 2010 to July 2016, including 208 repairs for cTBD. We analyzed outcomes per the Society for Vascular Surgery reporting standards. Results: Of the 208 patients, 150 (72.1%) were male with a median age of 65.0 years (interquartile range [IQR], 55.0-72.0). Median aneurysm diameter was 5.7 cm (IQR, 5.0-6.5 cm). Data on the patency of the LSA was available in 131 (63.0%) patients. Twenty-five (19.1%) had occlusion of the LSA without revascularization, while 106 (80.9%) maintained patency or had revascularization. Successful device delivery occurred in all 131 (100%) patients. Maintaining LSA patency did not affect the rate of cerebrovascular accident ( P = .16), spinal cord ischemia ( P = 1.00), or death ( P = 1.00). This was also nonsignificant when analyzing the subgroup of 98 elective cases. There was no difference in the rates of endoleak. Any intervention for the LSA (revascularization or occlusion) led to a longer procedure time (203.6 minutes vs 163.7 minutes, P = .04). Conclusions: Maintaining LSA patency during TEVAR for cTBD offers no advantage in perioperative morbidity or endoleak. Occlusion of LSA may be performed safely in this cohort and revascularization reserved for those who have anatomy that compromises perfusion to critical organs.
Collapse
Affiliation(s)
- Allan M. Conway
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Khalil Qato
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - N. Nhan Nguyen Tran
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Gary Giangola
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Alfio Carroccio
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| |
Collapse
|
12
|
Chen X, Wang J, Premaratne S, Zhao J, Zhang WW. Meta-analysis of the outcomes of revascularization after intentional coverage of the left subclavian artery for thoracic endovascular aortic repair. J Vasc Surg 2019; 70:1330-1340. [PMID: 31176636 DOI: 10.1016/j.jvs.2019.03.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 03/07/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Coverage of the left subclavian artery (LSA) is often required to achieve complete proximal sealing during thoracic endovascular aortic repair. However, whether LSA revascularization should be performed remains controversial. METHODS MEDLINE, Embase, and Cochrane databases were systematically searched to identify all the relevant studies. A random-effects model was applied to pool the effect measures. Dichotomous data were presented using an odds ratio (OR). RESULTS There were 32 studies included for qualitative analysis and 31 studies for quantitative analysis. We found that patients who underwent LSA revascularization had a significantly decreased risk of spinal cord ischemia (OR, 0.62; 95% confidence interval [CI], 0.41-0.92; P = .02; I2 = 0%), cerebrovascular accident (OR, 0.63; 95% CI, 0.42-0.95; P = .03; I2 = 22%), and left upper extremity ischemia (OR, 0.18; 95% CI, 0.09-0.36; P < .00001; I2 = 0%). However, no significant differences were found in the risk of paraplegia (OR, 0.91; 95% CI, 0.55-1.51; P = .71; I2 = 0%) and 30-day mortality (OR, 0.89; 95% CI, 0.59-1.36; P = .60; I2 = 21%) between the groups of patients with and without LSA revascularization. CONCLUSIONS Revascularization of the LSA is associated with decreased risks of cerebrovascular accident, spinal cord ischemia, and left upper limb ischemia in thoracic endovascular aortic repair with LSA coverage at the cost of higher local complications, such as possible vocal cord paresis.
Collapse
Affiliation(s)
- Xiyang Chen
- Department of Vascular Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Jiarong Wang
- Department of Vascular Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Shyamal Premaratne
- Hunter Holmes McGuire Veterans Administration Medical Center, Richmond, Va
| | - Jichun Zhao
- Department of Vascular Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Wayne W Zhang
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Washington and Puget Sound VA Health Care System, Seattle, Wash.
| |
Collapse
|
13
|
Piffaretti G, Pratesi G, Gelpi G, Galli M, Criado FJ, Antonello M, Fontana F, Piacentino F, Macchi E, Tozzi M, Castelli P, Barbante M, Ippoliti A, Romagnoni C, Antona C, Paggi A, Xodo A, Grego F. Comparison of Two Different Techniques for Isolated Left Subclavian Artery Revascularization During Thoracic Endovascular Aortic Repair in Zone 2. J Endovasc Ther 2018; 25:740-749. [DOI: 10.1177/1526602818802581] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Purpose: To analyze the results of isolated left subclavian artery (LSA) revascularization during thoracic endovascular aortic repair (TEVAR) using carotid-subclavian bypass (CSbp) or chimney grafts (CGs). Methods: A retrospective multicenter, observational study identified 73 patients (mean age 68±13 years, range 22–87; 56 men) with acute or chronic thoracic aortic lesions who underwent TEVAR with isolated LSA revascularization using either CSbp (n=42) or CGs (n=31) from January 2010 and February 2017. Primary endpoints were TEVAR-related mortality, postoperative stroke, freedom from type Ia endoleak, and LSA patency. Results: Primary technical success was achieved in all cases. Early TEVAR-related mortality was 4.2% (CSbp 2% vs CG 6%, p=0.571). Two (3%) patients had major ischemic strokes (one in each group). Mean follow-up was 24±21 months (range 1–72; median 15). Estimated freedom from TEVAR-related mortality was 93%±3% (95% CI 84.3% to 97.0%) at 12 and 36 months, with no significant difference between CSbp and CG (p=0.258). Aortic reintervention did not differ between the groups (CSbp 5% vs CG 6%, p=0.356); nor did freedom from type Ia endoleak (CSbp 98% vs CG 87%, p=0.134). Gutter-related endoleaks occurred in 4 (13%) CG patients, but none of the patients experienced sac enlargement or the need for reintervention and none died. Primary patency of the LSA was 100% for the entire group during the observation period. Conclusion: In our experience, LSA revascularization proved most satisfactory and equally effective with both the CSbp and CG techniques, without discernible differences at midterm follow-up.
Collapse
Affiliation(s)
- Gabriele Piffaretti
- Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, Circolo University Hospital, Varese, Italy
| | - Giovanni Pratesi
- Vascular Surgery, Department of Surgery, Policlinico Tor Vergata, Rome, Italy
| | - Guido Gelpi
- Cardiac Surgery, Department of Cardiovascular Surgery, Sacco Hospital, Milan, Italy
| | - Mario Galli
- Interventional Cardiology, Department of Medicine, Sant’Anna Hospital, Como, Italy
| | - Frank J. Criado
- Division of Vascular Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Michele Antonello
- Vascular Surgery, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua School of Medicine, Padua University Hospital, Padua, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Huang Q, Chen XM, Yang H, Lin QN, Qin X. Effect of Left Subclavian Artery Revascularisation in Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg 2018; 56:644-651. [PMID: 30122331 DOI: 10.1016/j.ejvs.2018.07.018] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 07/11/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE/BACKGROUND Thoracic endovascular aortic repair (TEVAR) is an emerging therapy for thoracic aortic pathologies. However, the role of left subclavian artery (LSA) revascularisation in patients with LSA coverage in TEVAR has not been established. A systematic review and meta-analysis was done to investigate the effect of LSA revascularisation in TEVAR when the LSA was covered. METHODS PubMed, Embase, and the Cochrane Library were searched to find relevant randomised controlled trials (RCTs) and cohort studies. The Cochrane Risk of Bias Tool and Newcastle-Ottawa Scale was used to evaluate the methodological quality of RCTs and cohort studies respectively. Relative risks (RRs) with 95% confidence intervals (CIs) were calculated to express differences for dichotomous outcomes. Random effects models were used to combine outcomes for studies with I2 > 50%; otherwise, fixed effects models were used. Subgroup analyses and sensitivity analyses were performed to further validate the results. RESULTS Sixteen cohort studies with a total of 2591 patients were included in this systematic review and meta-analysis. The average score of the included studies was 7.56. Of the included patients, the peri-operative stroke rate was 6.8% (n = 176/2591). The peri-operative stroke rates of the with and without LSA revascularisation groups were 5.4% and 7.8%, respectively. Compared with no LSA revascularisation, patients with LSA revascularisation had a significantly lower peri-operative stroke rate (RR 0.61; 95% CI 0.45-0.82; I2 = 20%) and peri-operative spinal cord ischaemia (SCI) rate (RR 0.59; 95% CI 0.39-0.90; I2 = 0). No significant difference was found between the with and without LSA revascularisation groups with respect to peri-operative mortality (RR 0.86; 95% CI 0.60-1.21; I2 = 35%) and peri-operative paraplegia (RR 0.81; 95% CI 0.45-1.44; I2 = 17%). CONCLUSION The results of this review reveal that LSA revascularisation was associated with significantly lower peri-operative stroke and SCI rates. LSA revascularisation should be recommended for patients with LSA coverage in TEVAR. High quality RCTs are needed to further validate the conclusion.
Collapse
Affiliation(s)
- Qun Huang
- Department of Vascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Xiao M Chen
- Department of Vascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Han Yang
- Department of Vascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Qiu N Lin
- Department of Vascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Xiao Qin
- Department of Vascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China.
| |
Collapse
|
15
|
van Bakel TM, Romarowski RM, Morganti S, van Herwaarden JA, Moll FL, de Beaufort HW, Marrocco-Trischitta MM, Secchi F, Conti M, Auricchio F, Trimarchi S. Blood Flow after Endovascular Repair in the Aortic Arch: A Computational Analysis. AORTA (STAMFORD, CONN.) 2018; 6:81-87. [PMID: 30795032 PMCID: PMC6386644 DOI: 10.1055/s-0039-1683771] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 11/05/2018] [Indexed: 01/26/2023]
Abstract
BACKGROUND The benefits of thoracic endovascular aortic repair (TEVAR) have encouraged stent graft deployment more proximally in the aortic arch. This study quantifies the hemodynamic impact of TEVAR in proximal landing zone 2 on the thoracic aorta and the proximal supra-aortic branches. METHODS Patients treated with TEVAR in proximal landing zone 2 having available preoperative and 30-day postoperative computer tomography angiography and phase-contrast magnetic resonance imaging data were retrospectively selected. Blood flow was studied using patient-specific computational fluid dynamics simulations. RESULTS Four patients were included. Following TEVAR in proximal landing zone 2, the mean flow in the left common carotid artery (LCCA) increased almost threefold, from 0.21 (0.12-0.41) L/min to 0.61 (0.24-1.08) L/min (+294%). The surface area of the LCCA had not yet increased commensurately and therefore maximum flow velocity in the LCCA increased from 44.9 (27.0-89.3) cm/s to 72.6 (40.8-135.0) cm/s (+62%). One of the patients presented with Type Ib endoleak at 1-year follow-up. The displacement force in this patient measured 32.1 N and was directed dorsocranial, perpendicular to the distal sealing zone. There was a linear correlation between the surface area of the stent graft and the resulting displacement force (p = 0.04). CONCLUSION TEVAR in proximal landing zone 2 alters blood flow in the supra-aortic branches, resulting in increased flow with high flow velocities in the LCCA. High displacement forces were calculated and related to stent graft migration and Type I endoleak during 1-year follow-up.
Collapse
Affiliation(s)
- Theodorus M. van Bakel
- Thoracic Aortic Research Center, IRCCS—Policlinico San Donato, University of Milan, Milan, Italy
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rodrigo M. Romarowski
- Thoracic Aortic Research Center, IRCCS—Policlinico San Donato, University of Milan, Milan, Italy
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | - Simone Morganti
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | | | - Frans L. Moll
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hector W. de Beaufort
- Thoracic Aortic Research Center, IRCCS—Policlinico San Donato, University of Milan, Milan, Italy
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Francesco Secchi
- Department of Radiology, IRCCS—Policlinico San Donato, San Donato Milanese, Italy
| | - Michele Conti
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | - Ferdinando Auricchio
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | - Santi Trimarchi
- Thoracic Aortic Research Center, IRCCS—Policlinico San Donato, University of Milan, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| |
Collapse
|
16
|
van der Weijde E, Saouti N, Vos JA, Tromp SC, Heijmen RH. Surgical left subclavian artery revascularization for thoracic aortic stent grafting: a single-centre experience in 101 patients†. Interact Cardiovasc Thorac Surg 2018; 27:284-289. [DOI: 10.1093/icvts/ivy059] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 02/04/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Emma van der Weijde
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Nabil Saouti
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Jan Albert Vos
- Department of Interventional Radiology, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Selma C Tromp
- Department of Clinical Neurophysiology, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Robin H Heijmen
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, Netherlands
- Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, Netherlands
| |
Collapse
|
17
|
van der Weijde E, Bakker OJ, Kamman AV, van Herwaarden JA, Trimarchi S, Vos JA, Heijmen RH. A Feasibility Study of Off-the-Shelf Scalloped Stent-Grafts in Acute Type B Aortic Dissection. J Endovasc Ther 2017; 24:819-824. [DOI: 10.1177/1526602817726329] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Emma van der Weijde
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Olaf J. Bakker
- Department of Vascular & Endovascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Arnoud V. Kamman
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, San Donato Milanese, Milan, Italy
| | - Joost A. van Herwaarden
- Department of Vascular & Endovascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Santi Trimarchi
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, San Donato Milanese, Milan, Italy
| | - Jan Albert Vos
- Department of Interventional Radiology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Robin H. Heijmen
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| |
Collapse
|
18
|
Fadda GF, Marino M, Kasemi H, Di Angelo CL, Dionisi CP, Cammalleri V, Setacci C. Aortic aneurysm endovascular treatment with the parallel graft technique from the aortic arch to the iliac axis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2017; 60:589-598. [PMID: 28548474 DOI: 10.23736/s0021-9509.17.09899-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The chimney technique has been developed for the treatment of complex aortic aneurysms. We analyzed the midterm to long-term outcomes of this approach from a single-center experience. METHODS From October 2008 to July 2016, 58 patients underwent endovascular aortic aneurysm repair using the chimney technique. Indications for treatment were thoracic aortic aneurysm (TAA) (N.=11), thoracoabdominal aortic aneurysm (TAAA) (N.=2), pararenal aortic aneurysm (PAAA) (N.=15), aortoiliac/isolated hypogastric artery aneurysm (N.=25), type I endoleak after previous TEVAR/EVAR (N.=4), proximal pseudoaneurysm after AAA open repair (N.=1). Elective (82.8%) and emergent (17.2%) procedures were included. RESULTS The immediate technical success was 100%. Single, double and triple chimneys were performed in 46, 10, and two patients, respectively. Overall, 61 target vessels (three left common carotid arteries, eight left subclavian arteries, three celiac trunks, three superior mesenteric arteries, 19 renal arteries and 25 hypogastric arteries) were involved. Postoperative mortality was 0. No neurologic complications were registered. Primary patency rate of the chimney stent/stent graft was 98.3%. Low-flow type I endoleak was observed in four patients (6.9%). Postoperative chimney graft re-intervention rate was 1.7%. The median follow-up was 32±20 months (range 3-96 months). Overall estimated survival at 12, 50, and 80 months was 100%, 89% and 44%, respectively. Estimated freedom from endoleak at 1, 12, 24, and 36 months was 96.5%, 95%, 95%, and 93%, respectively. One hypogastric artery stent-graft occluded at the 3rd month of follow-up. No reintervention was performed. CONCLUSIONS Our experience with the chimney technique for aortic aneurysms from the aortic arch to the iliac axis shows promising and durable mid- and long-term results. Endograft oversizing, associated with the chimney graft diameter and length choice remain fundamental to reduce the risk of the most frequent procedure complications: type I endoleak and CG occlusion. The wider use of this technique should be justified in patients considered at high risk for open repair and/or not suitable for the custom-made branched/fenestrated endografts.
Collapse
Affiliation(s)
- Gian Franco Fadda
- Unit of Vascular and Endovascular Surgery, Department of Surgery, San Francesco Hospital, Nuoro, Italy
| | - Mario Marino
- Unit of Vascular and Endovascular Surgery, Department of Surgery, San Francesco Hospital, Nuoro, Italy
| | - Holta Kasemi
- Unit of Vascular and Endovascular Surgery, Department of Surgery, San Francesco Hospital, Nuoro, Italy -
| | - Costantino L Di Angelo
- Unit of Vascular and Endovascular Surgery, Department of Surgery, San Francesco Hospital, Nuoro, Italy
| | - Carlo P Dionisi
- Unit of Vascular Surgery, Department of Surgery, Cardinal Panico Hospital, Tricase, Lecce, Italy
| | - Valeria Cammalleri
- Unit of Cardiology, Department of Cardiovascular Disease, Tor Vergata University, Rome, Italy
| | - Carlo Setacci
- Unit of Vascular and Endovascular Surgery, Department of Medicine, Surgery and Neurological Sciences, University of Siena, Siena, Italy
| |
Collapse
|
19
|
Left subclavian artery revascularization in zone 2 thoracic endovascular aortic repair is associated with lower stroke risk across all aortic diseases. J Vasc Surg 2017; 65:1270-1279. [DOI: 10.1016/j.jvs.2016.10.111] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 10/25/2016] [Indexed: 10/20/2022]
|
20
|
Belczak SQ, Silva ES, Klajner R, Puech-Leão P, De Luccia N. Type II Endoleaks, Left-Arm Complications, and Need of Revascularization after Left Subclavian Artery Coverage for Thoracic Aortic Aneurysms Endovascular Repair: A Systematic Review. Ann Vasc Surg 2017; 41:294-299. [PMID: 28242407 DOI: 10.1016/j.avsg.2016.08.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 08/03/2016] [Accepted: 08/16/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The status of the left arm, the need of revascularization, and the occurrence of type II endoleakes from de left subclavian artery (LSA) after intention LSA coverage for thoracic aortic aneurysm endovascular repair need to be better understood. This systematic review was developed for contributing with such issue. METHODS Systematic literature review of studies published from January 2000 through December 2015 identified 7 studies comprising 201 patients submitted to elective endovascular repair for thoracic aortic aneurysms requiring intentional LSA coverage. Outcomes of interest included left-arm complications (ischemia, symptoms of claudication, and subclavian steal syndrome [SSS]) requiring postoperative revascularization of LSA, as well as endoleaks from the subclavian artery requiring postoperative embolization of LSA. RESULTS Left-arm complication rate was 4.5% (9 patients), requiring postoperative revascularization of LSA in 1 case (0.5%) of SSS. Type II endoleaks from the subclavian artery requiring postoperative embolization of LSA were reported in 2 cases (1.0%). CONCLUSIONS Low-quality evidence suggests very low rates of arm complications with need of LSA revascularization and of type II endoleaks requiring embolization in elective endovascular treatment of thoracic aortic aneurysms with intentional coverage of LSA without prophylactic revascularization of LSA.
Collapse
Affiliation(s)
- Sergio Quilici Belczak
- Department of Vascular Surgery, School of Medicine, São Paulo University, São Paulo, SP, Brazil.
| | - Erasmo Simão Silva
- Department of Vascular Surgery, School of Medicine, São Paulo University, São Paulo, SP, Brazil
| | - Rafael Klajner
- Department of Vascular Surgery, São Camilo University, São Paulo, SP, Brazil
| | - Pedro Puech-Leão
- Department of Vascular Surgery, School of Medicine, São Paulo University, São Paulo, SP, Brazil
| | - Nelson De Luccia
- Department of Vascular Surgery, School of Medicine, São Paulo University, São Paulo, SP, Brazil
| |
Collapse
|
21
|
van der Weijde E, Bakker OJ, Tielliu IFJ, Zeebregts CJ, Heijmen RH. Results From a Nationwide Registry on Scalloped Thoracic Stent-Grafts for Short Landing Zones. J Endovasc Ther 2016; 24:97-106. [DOI: 10.1177/1526602816674942] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To report the perioperative results and short-term follow-up of patients treated with scalloped thoracic stent-grafts. Methods: A multicenter registry in the Netherlands captured data on 30 patients (mean age 68 years; 17 men) with thoracic aortic pathology and a short (<20 mm) proximal or distal landing zone who received a custom-made scalloped stent-graft between January 2013 and February 2016. Patients were treated for saccular (n=13) aneurysms, fusiform (n=9) aneurysms, pseudoaneurysms (n=4), or chronic type B dissections (n=4). The scallop was used to preserve flow in the left subclavian artery (LSA) (n=17), left common carotid artery (n=5), innominate artery (n=1), and celiac trunk (n=7). In 7 (23%) patients, the scallop also included the adjacent artery. Results: Technical success was achieved in 28 (93%) patients. In 1 patient, a minor type Ia endoleak was observed intraoperatively, which was no longer visible on computed tomography angiography at 3 months. In another patient, the LSA was unintentionally obstructed due to migration of the stent-graft on deployment. Concomitant carotid-carotid or carotid-subclavian bypass was performed in 4 patients. There was no retrograde type A dissection or conversion to open surgery. In-hospital mortality was 3%, and the perioperative ischemic stroke rate was 3%. At a mean follow-up of 9.7 months (range <1 to 31), 29 of 30 target vessels were patent. Conclusion: The scalloped stent-graft appears to be a safe and relatively simple alternative for the treatment of thoracic aortic lesions with short landing zones. Larger patient series and long-term follow-up are required to confirm these early results.
Collapse
Affiliation(s)
- Emma van der Weijde
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Olaf J. Bakker
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
- Department of Vascular & Endovascular Surgery, University Medical Centre Utrecht, the Netherlands
| | - Ignace F. J. Tielliu
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, the Netherlands
| | - Clark J. Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, the Netherlands
| | - Robin H. Heijmen
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| |
Collapse
|
22
|
Hajibandeh S, Hajibandeh S, Antoniou SA, Torella F, Antoniou GA. Meta-analysis of Left Subclavian Artery Coverage With and Without Revascularization in Thoracic Endovascular Aortic Repair. J Endovasc Ther 2016; 23:634-41. [DOI: 10.1177/1526602816651417] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To examine the role of left subclavian artery (LSA) revascularization in thoracic endovascular aortic repair (TEVAR) with LSA coverage. Methods: A systematic search was conducted to identify all studies providing comparative outcomes with or without LSA revascularization for LSA occlusion during TEVAR. The search included MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of Controlled Trials, the World Health Organization International Clinical Trials Registry, ClinicalTrials.gov , ISRCTN Register, and bibliographic reference lists. The primary outcome parameters were perioperative stroke, spinal cord ischemia (SCI), and mortality. Combined overall effect sizes were calculated using fixed effect or random effects models; results are reported as the odds ratio (OR) and 95% confidence interval (CI). Results: Five observational studies reporting a total of 1161 patients were identified; 444 patients underwent LSA revascularization and the remaining 717 patients did not. LSA revascularization was associated with a similar risk of stroke (OR 0.70, 95% CI 0.43 to 1.14, p=0.15), SCI (OR 0.56, 95% CI 0.28 to 1.10, p=0.09), and mortality (OR 0.87, 95% CI 0.55 to 1.39, p=0.56) compared with no LSA revascularization. Conclusion: LSA revascularization was not found to significantly reduce neurologic complications or mortality in patients undergoing TEVAR with coverage of the LSA origin. Randomized clinical trials are required to elucidate the role of routine or selective LSA revascularization in these cases.
Collapse
Affiliation(s)
- Shahin Hajibandeh
- Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
| | - Shahab Hajibandeh
- Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
| | - Stavros A. Antoniou
- Department of General Surgery, University Hospital of Heraklion, University of Crete, Heraklion, Greece
| | - Francesco Torella
- Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
| | - George A. Antoniou
- Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Manchester, UK
| |
Collapse
|
23
|
Hajibandeh S, Hajibandeh S, Antoniou SA, Torella F, Antoniou GA. Revascularisation of the left subclavian artery for thoracic endovascular aortic repair. Cochrane Database Syst Rev 2016; 4:CD011738. [PMID: 27119426 PMCID: PMC8266261 DOI: 10.1002/14651858.cd011738.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Controversy exists as to whether revascularisation of the left subclavian artery (LSA) confers improved outcomes in patients undergoing thoracic endovascular aortic repair (TEVAR). Even though preemptive revascularisation of the LSA has theoretical advantages, including a reduced risk of ischaemic damage to vital organs, such as the brain and the spinal cord, it is not without risks. Current practice guidelines recommend routine revascularisation of the LSA in patients undergoing elective TEVAR where achievement of a proximal seal necessitates coverage of the LSA, and in patients who have an anatomy that compromises perfusion to critical organs. However, this recommendation was based on very low-quality evidence. OBJECTIVES To assess the comparative efficacy of routine LSA revascularisation versus either selective or no revascularisation in patients with descending thoracic aortic disease undergoing TEVAR with coverage of the LSA origin. SEARCH METHODS The Cochrane Vascular Trials Search Co-ordinator (TSC) searched the Specialised Register (June 2015). In addition, the TSC searched the Cochrane Register of Studies (CENTRAL (2015, Issue 5)).Trials databases were also searched (June 2015). SELECTION CRITERIA We had planned to consider all randomised controlled trials (RCTs) that compared routine revascularisation of the LSA with selective or no revascularisation, in patients undergoing TEVAR. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the title and abstract of articles identified through literature searches. An independent third review author was consulted in the event of disagreement. We had planned for two review authors to independently extract data and assess the risk of bias of identified trials using the criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS We did not identify any RCTs relevant to our review topic. Therefore, no quantitative analysis was conducted. AUTHORS' CONCLUSIONS High quality RCT evidence for or against routine or selective revascularisation of the LSA in TEVAR is not currently available. It is not possible to draw conclusions with regard to the optimal management of LSA coverage in TEVAR, and whether routine revascularisation, which was defined as the intervention of interest in our review, confers beneficial effects, as indicated by reduced mortality, cerebrovascular events, and spinal cord ischaemia. This review highlights the need for continued research to provide RCT evidence and define the role of LSA revascularisation in the context of TEVAR with coverage of the LSA.
Collapse
Affiliation(s)
- Shahin Hajibandeh
- Royal Liverpool University HospitalLiverpool Vascular and Endovascular ServicePrescot StreetLiverpoolUKL78XP
| | - Shahab Hajibandeh
- Royal Liverpool University HospitalLiverpool Vascular and Endovascular ServicePrescot StreetLiverpoolUKL78XP
| | - Stavros A Antoniou
- University Hospital of Heraklion, University of CreteDepartment of SurgerySouniou 11HeraklionGreece19001
| | - Francesco Torella
- Royal Liverpool University HospitalLiverpool Vascular and Endovascular ServicePrescot StreetLiverpoolUKL78XP
| | - George A Antoniou
- The Royal Oldham Hospital, Pennine Acute Hospitals NHS TrustDepartment of Vascular and Endovascular SurgeryManchesterUK
| | | |
Collapse
|
24
|
Van Der Weijde E, Bakker OJ, Heijmen RH. A custom-made scalloped stentgraft to preserve left subclavian artery flow in descending thoracic aortic disease with a short neck. Expert Rev Med Devices 2016; 13:487-96. [PMID: 27018248 DOI: 10.1586/17434440.2016.1171710] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
In thoracic stentgrafting, a short proximal landing zone may necessitate intentional occlusion of the left subclavian artery, which may lead to brain, spinal cord, and left arm malperfusion. A scalloped stentgraft is designed for adequate proximal sealing and preserving the left subclavian artery flow. We performed a systematic review, describe the required pre-operative planning and details of the perioperative technique used and report our own experience. In literature, only 29 patients were reported so far using a proximal scalloped stentgraft. Results show a high technical success rate and low complication rate. These results are comparable to the results from our own institution. From these first small series the scalloped thoracic endovascular aortic repair appears to be a safe and relatively simple solution for thoracic aortic disease involving the left subclavian artery.
Collapse
Affiliation(s)
- Emma Van Der Weijde
- a Department of Cardiothoracic Surgery , St. Antonius Hospital , Nieuwegein , The Netherlands
| | - Olaf J Bakker
- a Department of Cardiothoracic Surgery , St. Antonius Hospital , Nieuwegein , The Netherlands.,b Department of Vascular & Endovascular Surgery , University Medical Center Utrecht , Utrecht , The Netherlands
| | - Robin H Heijmen
- a Department of Cardiothoracic Surgery , St. Antonius Hospital , Nieuwegein , The Netherlands
| |
Collapse
|