1
|
Buczkowski P, Puslecki M, Ligowski M, Dabrowski M, Stefaniak S, Fryska Z, Kulesza J, Juszkat R, Jemielity M, Perek B. Emergency Endovascular Interventions on Descending Thoracic Aorta: A Single-Center Experience. Emerg Med Int 2023; 2023:6600035. [PMID: 36636029 PMCID: PMC9831698 DOI: 10.1155/2023/6600035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/15/2022] [Accepted: 12/22/2022] [Indexed: 01/05/2023] Open
Abstract
Background Implementation of emergency endovascular aortic repair provides an attractive opportunity in the treatment of complicated acute aortic syndromes involving descending aorta. Aim The aim of this study was to analyze the effectiveness of thoracic endovascular aortic repair (TEVAR) for the treatment of acute surgical emergencies involving the descending thoracic aorta. Methods A retrospective review of the medical records of all patients undergoing TEVAR in a single center since 2007 was undertaken. Patients with the aortic disease treated on emergency inclusion criteria were complicated spontaneous acute aortic syndrome (csAAS), traumatic aortic acute injuries (TAIs), and other indications requiring emergent intervention. Technical and clinical success with patient mortality, survival, and reoperation rate was evaluated according to Society for Vascular Surgery reporting standards for thoracic endovascular aortic repair (TEVAR). Results The emergency interventions were necessary in 74 cases (51.0%), including patients with the complicated spontaneous acute aortic syndrome (csAAS) (64.8%; n = 48) and traumatic aortic acute injuries (TAIs) (31.1%). In addition, in one case aortic iatrogenic dissection (AID) and in 2 other fistulas after the previous stent graft, implantations were diagnosed. All procedures were done through surgically exposed femoral arteries while 2 hybrid procedures required additional approaches. The primary technical success rate was 95.9%, in 3 cases endoleak was reported. The primary clinical success occurred in 94.5%. All patients survived the endovascular interventions, whereas during in-hospital stay one of them died due to multiorgan failure (early mortality 1.3%). During the follow-up period, lasting 6 through 164 months (median 67), 11 patients died. Annual, five- and ten-year probability of survival was 86.4 ± 0.04%, 80.0 ± 0.05%, and 76.6 ± 0.06%, respectively. However, the rate of 5-year survivors was significantly higher after TAI (95.2%) than scAAS (63.4%) (p=0.008). Early after the procedure, one individual developed transient paraparesis (1.3%). No other serious stent-graft-related adverse events were noted within the postdischarge follow-up period. Conclusions Descending aortic pathologies requiring emergent interventions can be treated by endovascular techniques with optimal results and low morbidity and mortality in an experienced and dedicated team.
Collapse
Affiliation(s)
- Piotr Buczkowski
- Department of Cardiac Surgery and Transplantology, Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Dluga Street 1/2, Poznan 61–848, Poland
| | - Mateusz Puslecki
- Department of Cardiac Surgery and Transplantology, Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Dluga Street 1/2, Poznan 61–848, Poland
- Department of Medical Rescue, Emergency Medicine, Poznan University of Medical Sciences, Collegium Adama Wrzoska, Rokietnicka Street 7, Poznan 60-806, Poland
- Polish Society of Medical Simulation, Slupca, Poland
| | - Marcin Ligowski
- Department of Cardiac Surgery and Transplantology, Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Dluga Street 1/2, Poznan 61–848, Poland
| | - Marek Dabrowski
- Polish Society of Medical Simulation, Slupca, Poland
- Department of Medical Education, Poznan University of Medical Sciences, Collegium Adama Wrzoska, Rokietnicka Street 7, Poznan 60-806, Poland
| | - Sebastian Stefaniak
- Department of Cardiac Surgery and Transplantology, Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Dluga Street 1/2, Poznan 61–848, Poland
| | - Zuzanna Fryska
- Faculty of Medicine, Poznan University of Medical Sciences, Poland
| | - Jerzy Kulesza
- Department of Radiology, Poznan University of Medical Sciences, Dluga Street 1/2, Poznan 61–848, Poland
| | - Robert Juszkat
- Department of Radiology, Poznan University of Medical Sciences, Dluga Street 1/2, Poznan 61–848, Poland
| | - Marek Jemielity
- Department of Cardiac Surgery and Transplantology, Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Dluga Street 1/2, Poznan 61–848, Poland
| | - Bartlomiej Perek
- Department of Cardiac Surgery and Transplantology, Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Dluga Street 1/2, Poznan 61–848, Poland
| |
Collapse
|
2
|
Cooper MA, Shahid Z, Upchurch GR. Endovascular Repair of Descending Thoracic Aortic Aneurysms. Adv Surg 2022; 56:129-150. [PMID: 36096564 DOI: 10.1016/j.yasu.2022.02.005] [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: 11/20/2022]
Abstract
Descending thoracic aortic aneurysms (DTAAs) are an important cause of morbidity and mortality in the elderly. Once diagnosed, they should be surveilled and then repaired at a diameter of 5.5 to 6 cm, depending on the individual patient's physiologic and anatomic risk of repair. Thoracic endovascular aortic repair (TEVAR) is the preferred approach for repair and there are multiple procedural adjuncts that can expand indications for and use of TEVAR. Spinal cord injuries are an important and highly morbid complication after TEVAR and it is imperative to mitigate this risk.
Collapse
Affiliation(s)
- Michol A Cooper
- University of Florida College of Medicine, Division of Vascular Surgery and Endovascular Therapy, 1600 SW Archer Road, Room NG-45, Gainesville, FL 32610-0128 USA.
| | - Zain Shahid
- University of Florida College of Medicine, Division of Vascular Surgery and Endovascular Therapy, 1600 SW Archer Road, Room NG-45, Gainesville, FL 32610-0128 USA
| | - Gilbert R Upchurch
- University of Florida College of Medicine, Department of Surgery, 1600 SW Archer Road, Room 6174, Gainesville, FL 32610-0286 USA
| |
Collapse
|
3
|
Abstract
Thoracoabdominal aortic aneurysms, although rare, continue to be associated with high morbidity and mortality in the modern era of vascular surgery, and knowledge of this disease is essential for those in clinical practice. Given the clinically silent nature of the disease, it is difficult to determine disease incidence, with most epidemiologic recommendations not made based on evidence regarding those diagnosed with the disease, but extrapolated from data on surgical outcomes. It appears that although men are more likely to develop thoracoabdominal aortic aneurysms, the distribution is not as skewed as in abdominal aortic aneurysms. Current evidence suggests that Black and Hispanic patients continue to have disproportionately poor disease outcomes, mostly attributed to later presentation and undergoing interventions at lower-volume centers. Although select patients meet criteria for disease screening based on personal or family history of aneurysmal disease, general population screening has not been recommended by any professional organization to date. Vascular surgeons need to continue to be at the forefront of thoracoabdominal aortic aneurysm management, especially as care becomes centered around comprehensive "aortic care centers" and as more endovascular therapies become available.
Collapse
Affiliation(s)
- Jordan B Stoecker
- Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Maloney 4th Floor, Philadelphia, PA 19104.
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, 3400 Spruce Street, Maloney 4th Floor, Philadelphia, PA 19104.
| |
Collapse
|
4
|
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]
|
5
|
Open Repair of Descending Thoracic and Thoracoabdominal Aortic Aneurysms: A Meta-Analysis. Ann Thorac Surg 2020; 110:1941-1949. [DOI: 10.1016/j.athoracsur.2020.04.069] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/06/2020] [Accepted: 04/10/2020] [Indexed: 01/11/2023]
|
6
|
Tracheostomy After Thoracoabdominal Aortic Aneurysm Repair: Risk Factors and Outcomes. Ann Thorac Surg 2019; 108:778-784. [DOI: 10.1016/j.athoracsur.2019.02.063] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 01/23/2019] [Accepted: 02/25/2019] [Indexed: 11/22/2022]
|
7
|
Chen T, Jiang N, Zhao F, Xu D, Gao J, Chen Q. Endovascular graft exclusion for treating Stanford type B acute aortic dissection in aged population. Medicine (Baltimore) 2019; 98:e16046. [PMID: 31261509 PMCID: PMC6616322 DOI: 10.1097/md.0000000000016046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
The aim of this study was to investigate the efficiency of endovascular graft exclusion for treating Stanford type B acute aortic dissection (AAD) in aged population.Forty-six consecutive patients aged ≥65 years with Stanford type B AAD underwent endovascular therapy in Tianjin Chest Hospital between 2010and 2015 were included in this study. All patients received echocardiography, contrast-enhanced CT, hepatic and renal functions tests, and the blood and urine routine examinations. After the procedure, annual review of the whole aortic computed tomography (CT) was performed for all patients before discharge, as well as 3 months, 6 months and12 months after surgery. All patients were followed up until December, 2015. The outcomes of the whole aortic CT and survival rate were analyzed.Five patients (10.87%) died. Among the 5 cases, 2 showed perioperative death induced by cerebral infarction, 1 died because of newly developed AD 8 months after surgery, and 2 died because of acute myocardial infarction (n = 1) and renal/cardiac failure (n = 1). The other 41 patients (89.13%) were symptom-free with satisfactory conditions.Endovascular stent-graft placement was effective for treating the senior patients with Stanford type B AAD.
Collapse
|
8
|
Hammo S, Larzon T, Hultgren R, Wanhainen A, Mani K, Resch T, Falkenberg M, Forssell C, Sonesson B, Pirouzram A, Roos H, Hellgren T, Khan S, Höijer J, Wahlgren CM. Outcome After Endovascular Repair of Ruptured Descending Thoracic Aortic Aneurysm: A National Multicentre Study. Eur J Vasc Endovasc Surg 2019; 57:788-794. [PMID: 30910493 DOI: 10.1016/j.ejvs.2018.10.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 10/25/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The purpose of this multicentre study was to analyse the outcome of thoracic endovascular aortic repair (TEVAR) in patients with ruptured descending thoracic aortic aneurysm (rDTAA). METHODS This is a nationwide retrospective study including all patients who underwent TEVAR for rDTAA at six major vascular university centres in Sweden between January 2000 and December 2015. Outcome measures were analysed using Kaplan-Meier estimator and multivariable Cox regression. RESULTS There were 140 patients (age [mean ± SD] 74.1 ± 8.8 years; 56% men; aneurysm size 64.8 ± 19 mm), with rDTAA. In 53 patients (37.9%), the left subclavian artery was covered, and in 25 patients (17.9%) arch vessel revascularisation was performed. In total, 61/136 patients (45%) had a major complication within 30 days post TEVAR. Stroke (n = 20; 14.7%) was the most common complication, followed by paraplegia (n = 13; 9.6%) and major bleeding (n = 13; 9.6%). TEVAR related complications during follow up included endoleaks 22.1% (30/136; 14 type 1a, six type 1b, 10 not defined). In total, re-interventions (n = 31) were required in 27/137 (19.7%) patients. The median follow up time was 17.0 months (range 0-132 months). The Kaplan-Meier estimated survival was 80.0% at one month, 71.7% at three months, 65.3% at one year, 45.9% at three years, and 31.9% at five years. Age (HR 1.03; 95% CI 1.00-1.07; p = .046), history of stroke (HR 2.35; 95% CI 1.19-4.63; p = .014), previous aortic surgery (HR 2.11; 95% CI 1.15-3.87; p = .016) as well as post-operative major bleeding (HR 4.40; 95% CI 2.20-8.81; p = .001), stroke (HR 2.63; 95% CI 1.37-5.03; p = .004), and renal failure (HR 8.25; 95% CI 2.69-25.35; p = .001) were all associated with mortality. CONCLUSIONS This nationwide multicentre study of patients with rDTAA undergoing TEVAR showed acceptable short- but poor long-term survival. Adequate proximal and distal aortic sealing zones are important for technical success. High risk patients and post-operative complications need to be further addressed in an effort to improve outcome.
Collapse
Affiliation(s)
- Sari Hammo
- Department of Vascular Surgery, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Larzon
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Vascular Surgery, Örebro University Hospital, Örebro, Sweden
| | - Rebecka Hultgren
- Department of Vascular Surgery, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Timothy Resch
- Vascular Centre, Skåne University Hospital, Malmö, Sweden
| | - Mårten Falkenberg
- Unit of Vascular Surgery, Department of Hybrid and Interventional Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Claes Forssell
- Department of Thoracic and Vascular Surgery, Linköping University, Linköping, Sweden; Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Björn Sonesson
- Vascular Centre, Skåne University Hospital, Malmö, Sweden
| | - Artai Pirouzram
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Vascular Surgery, Örebro University Hospital, Örebro, Sweden
| | - Håkan Roos
- Unit of Vascular Surgery, Department of Hybrid and Interventional Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Tina Hellgren
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Shazhad Khan
- Vascular Centre, Skåne University Hospital, Malmö, Sweden
| | - Jonas Höijer
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Carl-Magnus Wahlgren
- Department of Vascular Surgery, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.
| |
Collapse
|
9
|
Alternative Debranching in Patients with Thoracoabdominal Aortic Aneurysm after Open and Endovascular Aortic Aneurysm Repair. Ann Vasc Surg 2019; 57:272.e1-272.e4. [PMID: 30684616 DOI: 10.1016/j.avsg.2018.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 10/01/2018] [Accepted: 10/08/2018] [Indexed: 11/21/2022]
Abstract
Management of recurrent thoracoabdominal aneurysmal disease of the aorta is challenging. We report three patients with previous endovascular or open aortic repair requiring redo repair by treatment by stent-graft implantation of the thoracoabdominal aorta and visceral debranching using an antegrade inflow from the ascending aorta. All three interventions were successful, with two patients alive 5 and 2 years, respectively, after this operation, while the third patient died 2 days after the procedure due to cardiac failure. No paraplegia was observed. As complications from complex open and endovascular procedures are increasing, vascular surgeons should get familiar with alternative management options.
Collapse
|
10
|
Agrawal V, Anand V, Kumar R, Patra V, Swain P, Biswas B, Jha M, Tripathy G. Six years' experience of thoracic endovascular aortic repair in patients with thoracic aortic diseases: A single-center study. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2019. [DOI: 10.4103/ijves.ijves_29_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
11
|
Lau C, Leonard JR, Iannacone E, Gaudino M, Girardi LN. Surgery for Acute Presentation of Thoracoabdominal Aortic Disease. Semin Thorac Cardiovasc Surg 2018; 31:11-16. [PMID: 30071280 DOI: 10.1053/j.semtcvs.2018.07.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 07/24/2018] [Indexed: 01/16/2023]
Abstract
Thoracoabdominal aortic aneurysms are most commonly asymptomatic until there is either an impending aortic catastrophe or one that has already occurred. While open surgery remains the gold-standard method for repair, modern technology has led to the development of less invasive endovascular devices and techniques. We provide an expert review of open and endovascular therapies for 3 highly lethal thoracoabdominal aortic emergencies in order to highlight expectations for both short- and long-term outcomes in an era of evolving technology and improvements in patient evaluation and postoperative care. Open repair of ruptured thoracoabdominal aortic aneurysms is associated with a dramatic increase in all postoperative complications, even in specialized aortic surgery centers. Mycotic thoracic aortic aneurysms are highly lethal if surgical treatment is not initiated quickly as they have a propensity toward rapid growth and fatal rupture. Thoracic endovascular aortic repair is well-suited for the treatment of acute complicated type B aortic dissection with outcomes superior to open repair in some centers. Acute aortic events associated with thoracoabdominal aneurysms represent technically challenging situations that require rapid diagnosis and treatment to avoid a fatal outcome. Endovascular techniques have evolved as a viable alternative therapy for acute complicated type B aortic dissection or as a bridge to more definitive repair in the setting of infection or rupture.
Collapse
Affiliation(s)
- Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Jeremy R Leonard
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Erin Iannacone
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York.
| |
Collapse
|
12
|
Effectiveness of surgical interventions for thoracic aortic aneurysms: A systematic review and meta-analysis. J Vasc Surg 2017; 66:1258-1268.e8. [DOI: 10.1016/j.jvs.2017.05.082] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 05/12/2017] [Indexed: 11/24/2022]
|
13
|
Ultee KHJ, Zettervall SL, Soden PA, Buck DB, Deery SE, Shean KE, Verhagen HJM, Schermerhorn ML. The impact of endovascular repair on management and outcome of ruptured thoracic aortic aneurysms. J Vasc Surg 2017; 66:343-352.e1. [PMID: 28366304 DOI: 10.1016/j.jvs.2017.01.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 01/09/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) has become an alternative to open repair for the treatment of ruptured thoracic aortic aneurysms (rTAAs). The aim of this study was to assess national trends in the use of TEVAR for the treatment of rTAA and to determine its impact on perioperative outcomes. METHODS Patients admitted with an rTAA between 1993 and 2012 were identified from the National Inpatient Sample. Patients were grouped in accordance with their treatment: TEVAR, open repair, or nonoperative treatment. The primary outcomes were treatment trends over time and in-hospital death. Secondary outcomes included perioperative complications and length of stay. Trend analyses were performed using the Cochran-Armitage test for trend, and adjusted mortality risks were established using multivariable logistic regression analysis. RESULTS A total of 12,399 patients were included, with 1622 (13%) undergoing TEVAR, 2808 (23%) undergoing open repair, and 7969 (64%) not undergoing surgical treatment. TEVAR has been increasingly used from 2% of total admissions in 2003-2004 to 43% in 2011-2012 (P < .001). Concurrently, there was a decline in the proportion of patients undergoing open repair (29% to 12%; P < .001) and nonoperative treatment (69% to 45%; P < .001). The proportion of patients undergoing surgical repair has increased for all age groups since 1993-1994 (P < .001 for all) but was most pronounced among those aged 80 years with a 7.5-fold increase. After TEVAR was introduced, procedural mortality decreased from 36% in 2003-2004 to 27% in 2011-2012 (P < .001); mortality among those undergoing nonoperative treatment remained stable between 63% and 60% (P = .167). Overall mortality after rTAA admission decreased from 55% to 42% (P < .001). Since 2005, mortality for open repair was 33% and 22% for TEVAR (P < .001). In adjusted analysis, open repair was associated with a twofold higher mortality than TEVAR (odds ratio, 2.0; 95% confidence interval, 1.7-2.5). CONCLUSIONS TEVAR has replaced open repair as primary surgical treatment for rTAA. The introduction of endovascular treatment appears to have broadened the eligibility of patients for surgical treatment, particularly among the elderly. Mortality after rTAA admission has declined since the introduction of TEVAR, which is the result of improved operative mortality as well as the increased proportion of patients undergoing surgical repair.
Collapse
Affiliation(s)
- Klaas H J Ultee
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Peter A Soden
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Dominique B Buck
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Sarah E Deery
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Katie E Shean
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass.
| |
Collapse
|
14
|
Ahmed Z, McHugh SM, Elmallah A, Colgan MP, O'Callaghan A, O'Neill SM, Madhavan P, Martin Z. Emergency endovascular management of acute thoracic aortic pathology A safe and feasible option. Surgeon 2016; 15:325-328. [PMID: 28034631 DOI: 10.1016/j.surge.2016.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 10/16/2016] [Indexed: 11/19/2022]
Abstract
Endovascular repair has revolutionised the emergency treatment of thoracic aortic disease. We report our 10 year experience using this treatment in emergency cases. A prospectively maintained vascular database was analysed. Patients' medical records and CT images stored on the hospital PACS system were also reviewed. Statistical analysis was done using IBM SPSS V21. There were a total of 59 thoracic aortic stenting procedures of which 33 (60% males with a mean age of 58 yrs) were performed for emergency thoracic pathologies: traumatic transection (n = 10), ruptured aneurysm (n = 6), non-traumatic dissection (n = 8) and penetrating aortic ulcer (n = 9). All patients had self-expanding endografts implanted. Two patients required debranching procedures before the endovascular treatment. Thirty-day mortality was 12.1% (4/33). 70% of patients received a single device. There were 7 procedure related complications, 6 requiring re-intervention: thoracotomy and drainage in 2 patients, proximal graft extension in 2, open drainage of groin haematoma in 1 and open repair of a common femoral artery pseudo-aneurysm in one patient. In total 23 patients were transferred from 11 centres nationwide. There were no mortalities or other complications related to patient transfer from peripheral centres. Although acute thoracic aortic pathology is life threatening, appropriate blood pressure management and treatment of associated injuries can result in favourable outcomes. Endovascular repair is a safe and effective treatment option which enables patients to be treated with reduced morbidity and mortality. Transfer of patients with acute pathology to a tertiary centre can safely be performed.
Collapse
Affiliation(s)
- Z Ahmed
- St James's Vascular Institute, St James's Hospital, Dublin, Ireland.
| | - S M McHugh
- St James's Vascular Institute, St James's Hospital, Dublin, Ireland
| | - A Elmallah
- St James's Vascular Institute, St James's Hospital, Dublin, Ireland
| | - M P Colgan
- St James's Vascular Institute, St James's Hospital, Dublin, Ireland
| | - A O'Callaghan
- St James's Vascular Institute, St James's Hospital, Dublin, Ireland
| | - S M O'Neill
- St James's Vascular Institute, St James's Hospital, Dublin, Ireland
| | - P Madhavan
- St James's Vascular Institute, St James's Hospital, Dublin, Ireland
| | - Z Martin
- St James's Vascular Institute, St James's Hospital, Dublin, Ireland
| |
Collapse
|
15
|
Uğuz E, Canyiğit M, Hıdıroğlu M, Şener E. Treatment of acute thoracic aortic syndromes using endovascular techniques. Diagn Interv Radiol 2016; 22:365-70. [PMID: 27113420 DOI: 10.5152/dir.2015.15270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE Acute thoracic aortic syndrome (ATAS) is a novel term to define emergency aortic conditions with common clinical features and challenges. Traditional management of ATAS includes surgical replacement of the aorta and is correlated with high perioperative mortality and morbidity. We aimed to evaluate our experience and outcomes in patients presenting with ATAS, managed by endovascular techniques. METHODS This cohort consisted of 31 consecutive patients (24 males; mean age, 57.5±13.81 years; range, 19-84 years) with acute thoracic aortic pathologies who underwent endovascular repair between January 2011 and January 2015. The study was designed as a retrospective analysis of prospectively maintained data. RESULTS Complicated acute type-B aortic dissection was the most common pathology (35.5%). All aortic stent-grafts (n=37) and dissection stents (n=9) were implanted with 100% procedural success. The overall in-hospital mortality was 9.7%. The mean follow-up duration of patients who were alive at 30 days was 25.9±11.49 months (3-53 months). So far, there have been no late deaths after 30 days. CONCLUSION In the high-risk setting of ATAS, endovascular procedures come forward as novel therapeutic strategies with promising results. Endovascular repair of ATAS can be considered as a first-line treatment alternative under emergency conditions with encouraging results, particularly when conventional surgical repair cannot be implemented due to prohibitive comorbidities.
Collapse
Affiliation(s)
- Emrah Uğuz
- Department of Cardiovascular Surgery, Ankara Atatürk Training and Research Hospital, Ankara, Turkey.
| | | | | | | |
Collapse
|
16
|
Choi JS, Oh SJ, Sung YW, Moon HJ, Lee JS. Early Experiences with the Endovascular Repair of Ruptured Descending Thoracic Aortic Aneurysm. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 49:73-9. [PMID: 27064672 PMCID: PMC4825906 DOI: 10.5090/kjtcs.2016.49.2.73] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/12/2016] [Accepted: 02/12/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The aim of this study was to report our early experiences with the endovascular repair of ruptured descending thoracic aortic aneurysms (rDTAAs), which are a rare and life-threatening condition. METHODS Among 42 patients who underwent thoracic endovascular aortic repair (TEVAR) between October 2010 and September 2015, five patients (11.9%) suffered an rDTAA. RESULTS The mean age was 72.4±5.1 years, and all patients were male. Hemoptysis and hemothorax were present in three (60%) and two (40%) patients, respectively. Hypovolemic shock was noted in three patients who underwent emergency operations. A hybrid operation was performed in three patients. The mean operative time was 269.8±72.3 minutes. The mean total length of aortic coverage was 186.0±49.2 mm. No 30-day mortality occurred. Stroke, delirium, and atrial fibrillation were observed in one patient each. Paraplegia did not occur. Endoleak was found in two patients (40%), one of whom underwent an early and successful reintervention. During the mean follow-up period of 16.8±14.8 months, two patients died; one cause of death was a persistent type 1 endoleak and the other cause was unknown. CONCLUSION TEVAR for rDTAA was associated with favorable early mortality and morbidity outcomes. However, early reintervention should be considered if persistent endoleak occurs.
Collapse
Affiliation(s)
- Jae-Sung Choi
- Department of Thoracic and Cardiovascular Surgery, SMG-SNU Boramae Medical Center
| | - Se Jin Oh
- Department of Thoracic and Cardiovascular Surgery, SMG-SNU Boramae Medical Center
| | - Yong Won Sung
- Department of Thoracic and Cardiovascular Surgery, SMG-SNU Boramae Medical Center
| | - Hyun Jong Moon
- Department of Thoracic and Cardiovascular Surgery, SMG-SNU Boramae Medical Center
| | - Jung Sang Lee
- Department of Thoracic and Cardiovascular Surgery, SMG-SNU Boramae Medical Center
| |
Collapse
|
17
|
Gaudino M, Lau C, Munjal M, Girardi LN. Open repair of ruptured descending thoracic and thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg 2015; 150:814-21. [DOI: 10.1016/j.jtcvs.2015.06.077] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 06/12/2015] [Accepted: 06/19/2015] [Indexed: 10/23/2022]
|
18
|
Minami T, Imoto K, Uchida K, Karube N, Yasuda S, Choh T, Suzuki S, Masuda M. Thoracic Endovascular Aortic Repair for Ruptured Descending Thoracic Aortic Aneurysm. J Card Surg 2014; 30:163-9. [DOI: 10.1111/jocs.12499] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Tomoyuki Minami
- Cardiovascular Center; Yokohama City University Medical Center; Yokohama Kanagawa Japan
- Cardiovascular Surgery; Yokohama Municipal Citizen's Hospital; Yokohama Kanagawa Japan
| | - Kiyotaka Imoto
- Cardiovascular Center; Yokohama City University Medical Center; Yokohama Kanagawa Japan
| | - Keiji Uchida
- Cardiovascular Center; Yokohama City University Medical Center; Yokohama Kanagawa Japan
| | - Norihisa Karube
- Cardiovascular Center; Yokohama City University Medical Center; Yokohama Kanagawa Japan
| | - Shota Yasuda
- Cardiovascular Center; Yokohama City University Medical Center; Yokohama Kanagawa Japan
| | - Tomoki Choh
- Cardiovascular Center; Yokohama City University Medical Center; Yokohama Kanagawa Japan
| | - Shinichi Suzuki
- Department of Surgery; Yokohama City University Hospital; Yokohama Kanagawa Japan
| | - Munetaka Masuda
- Department of Surgery; Yokohama City University Hospital; Yokohama Kanagawa Japan
| |
Collapse
|
19
|
Applicability and Mid-Term Results of Endovascular Treatment for Descending Thoracic Acute Aortic Syndromes. Ann Vasc Surg 2013; 27:1029-35. [DOI: 10.1016/j.avsg.2012.10.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Revised: 09/27/2012] [Accepted: 10/04/2012] [Indexed: 11/24/2022]
|
20
|
Riga CV, Jenkins MP. Best surgical option for thoracoabdominal aneurysm repair - the hybrid approach. Ann Cardiothorac Surg 2013; 1:339-44. [PMID: 23977518 DOI: 10.3978/j.issn.2225-319x.2012.08.11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 08/21/2012] [Indexed: 11/14/2022]
|
21
|
|
22
|
Janczak D, Garcarek J, Bogdanik R, Szydelko T, Chabowski M, Wojtanowski M. Eight-year follow-up of a high-risk patient treated for Crawford Type II thoracoabdominal aortic aneurysm (TAAA) with a multistage hybrid open-endovascular repair. Ann Thorac Cardiovasc Surg 2012; 19:166-9. [PMID: 22971708 DOI: 10.5761/atcs.cr.12.01924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The case of a patient with type II TAAA (thoracoabdominal aortic aneurysm), who underwent multistage hybrid procedure, is presented. This high-risk patient was excluded as ineligible for conventional open repair. At first, the bypass between both common carotid arteries was inserted. Then, the transperitoneal viscerorenal revascularization was performed to ensure blood perfusion. At the end, the stent graft from the aorta arch to its bifurcation was deployed with endovascular techniques. This stent graft covered left common carotid artery, left subclavian artery, visceral trunk, superior mesenteric artery and both renal arteries. The patient had been observed for eight years with relatively low complication rate. The hybrid open-endovascular repair (HOER) shows promising results in patients at prohibitive risk for classic reconstruction.
Collapse
Affiliation(s)
- Dariusz Janczak
- Department of Clinical Proceedings, Faculty of Health Science, Medical University Wroclaw, 5 Weigla Street, Wroclaw, Poland
| | | | | | | | | | | |
Collapse
|
23
|
Rusults of classical crawford and hybrid operations in thoracic-abdominal aorta aneurysms treatment--comparative assessment. POLISH JOURNAL OF SURGERY 2012; 84:126-35. [PMID: 22659355 DOI: 10.2478/v10035-012-0021-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
UNLABELLED Thoracic-abdominal aortic aneurysms (TAAA) are still serious medical problem. Classical procedure requires two cavities approach and implantation of vascular prosthetic in the place of aneurysm--Crawford's procedure. Significant progress was made during last years by using endovascular procedures (stentgrafts). Alternative is hybrid procedure--prosthetic appliance of visceral and kidney arteries and then stentgraft implantation in whole thoracic-abdominal aorta. THE AIM OF THE STUDY was comparative analysis of classical and hybrid procedures in thoracic-abdominal aneurysms treatment. MATERIAL AND METHODS Between 1989-2011 in Department of Vascular, General and Transplantological Surgery Medical University in Wrocław and Surgical Department of 4th Military Clinical Hospital in Wrocław 53 patients were operated due to thoracic-abdominal aortic aneurysms. Classical Crawford's procedure was performed in 41 patients (group I) and hybrid procedure was performed in 12 patients (group II). Additionally 7 patients required aortic arc branches reconstruction due to achieve optimal conditions to stentgraft amplantation. Procedures were performed at one or two stages. RESULTS Mortality in patients treated classically (group I) depended on type of aneurysm in Crawford's classification. In type I-II mortality rate was 54% ((7 deaths/12 patients), in type III do V 17% (5 deaths/ 29 patients). In the group after hybrid procedure (group II) mortality rate was 28% (2 deaths/ 7 patients) in type I-II and 20% (1 death/5 patients) in type III to V. Observed serious perioperative complications. CONCLUSIONS 1. Endovascular procedures development enabled introducing of new methods in thoracic-abdominal aortic aneurysms treatment (hybrid procedures) and allowed to get better results. 2. Clear advantage of hybrid procedures above classical Crawford's procedure is observed in type I and II of TAAA. 3. Mortality and morbidity rates recommend hybrid procedure in type I and II of TAAA. 4. Surgical results of classical and hybrid procedures in type III-V TAAA treatment are comparative, with indication on classical approach.
Collapse
|
24
|
Delayed open conversions after endovascular abdominal aortic aneurysm repair. J Vasc Surg 2012; 55:1562-9.e1. [DOI: 10.1016/j.jvs.2011.12.007] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2011] [Revised: 11/29/2011] [Accepted: 12/09/2011] [Indexed: 11/18/2022]
|
25
|
Saqib N, Park SC, Park T, Rhee RY, Chaer RA, Makaroun MS, Cho JS. Endovascular repair of ruptured abdominal aortic aneurysm does not confer survival benefits over open repair. J Vasc Surg 2012; 56:614-9. [PMID: 22572008 DOI: 10.1016/j.jvs.2012.01.081] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Revised: 12/29/2011] [Accepted: 01/03/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Endovascular repair of ruptured abdominal aortic aneurysm (rAAA) is being increasingly performed despite lack of good evidence for its superiority. Other reported studies suffer from patient selection and publication bias with limited follow-up. This study is a single-center propensity score comparing early and midterm outcomes between open surgical repair (OSR) and endovascular repair of rAAA (REVAR). METHODS A retrospective review from January 2001 to November 2010 identified 312 patients who underwent rAAA repairs. Thirty-one patients with antecedent AAA repair and three with incomplete records were excluded, leaving 37 REVARs and 241 OSRs. Propensity score-based matching for sex, age, preoperative hemodynamic status, surgeon's annual AAA volume, and preoperative cardiopulmonary resuscitation was performed in a 1:3 ratio to compare outcomes. Thirty-seven REVARs were matched with 111 OSRs. Late survival was estimated by Kaplan-Meier methods. RESULTS Operative time and blood replacement were higher with OSR. Overall complication rates were similar (54% REVAR vs 66% OSR; P = .23), except for higher incidences of tracheostomies (21% vs 3%; P = .015), myocardial infarction (38% vs 18%; P = .036), and acute tubular necrosis (47% vs 21%; P = .009) with OSR. Operative mortality rates were similar (22% REVAR vs 32% OSR), with an odds ratio of 0.63 for REVAR (95% confidence interval = [0.24, 1.48]; P = .40). No differences in the incidences for secondary interventions for aneurysm- or graft-related complications were noted (22% REVAR vs 22% OSR; P = .99). Kaplan-Meier estimates of 1-, 2-, and 3-year survival rates were also similar (50%, 50%, 42% REVAR vs 54%, 52%, 47% OSR; P = .66). CONCLUSIONS REVAR for rAAA does not seem to conclusively confer either acute or late survival advantages. Routine use of REVAR should be deferred until prospective, randomized trial data become available.
Collapse
Affiliation(s)
- Naveed Saqib
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa 15213, USA
| | | | | | | | | | | | | |
Collapse
|
26
|
Piazza M, Ricotta JJ. Open Surgical Repair of Thoracoabdominal Aortic Aneurysms. Ann Vasc Surg 2012; 26:600-5. [DOI: 10.1016/j.avsg.2011.11.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Accepted: 11/07/2011] [Indexed: 11/27/2022]
|
27
|
Carmona AF, Redondo AD, Pareja JCF, Maldonado LP. Endovascular treatment of descending thoracic aortic rupture. J Cardiovasc Med (Hagerstown) 2012; 13:266-8. [DOI: 10.2459/jcm.0b013e3283515b61] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
28
|
Clough RE, Mani K, Lyons OT, Bell RE, Zayed HA, Waltham M, Carrell TW, Taylor PR. Endovascular treatment of acute aortic syndrome. J Vasc Surg 2011; 54:1580-7. [DOI: 10.1016/j.jvs.2011.07.034] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Revised: 06/16/2011] [Accepted: 07/01/2011] [Indexed: 11/25/2022]
|
29
|
Mitchell ME, Rushton FW, Boland AB, Byrd TC, Baldwin ZK. Emergency procedures on the descending thoracic aorta in the endovascular era. J Vasc Surg 2011; 54:1298-302; discussion 1302. [PMID: 21784605 DOI: 10.1016/j.jvs.2011.05.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Revised: 04/29/2011] [Accepted: 05/02/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR), initially developed for the treatment of degenerative aneurysms of the descending thoracic aorta, has been applied to the entire spectrum of descending thoracic aortic pathology in both the elective and emergent settings. This single center study evaluates the effectiveness of TEVAR for the treatment of acute surgical emergencies involving the descending thoracic aorta, including traumatic aortic disruption (TAD), ruptured descending thoracic aneurysm (RDTA), and acute complicated Type B dissection (cTBD). METHODS A retrospective review of the medical records of all patients undergoing emergent TEVAR at the University of Mississippi Medical Center between August 2007 and November 2010 was undertaken. Patients were studied for 30-day survival, complications, type of device used for the repair, and technical aspects of the procedure. RESULTS A total of 44 patients (59% male) with an average age of 49 years (range, 16-87 years) underwent emergent TEVAR during the study period. The technical success rate was 100%, with no patient requiring emergent open surgery for conditions involving the descending thoracic aorta at our institution during the study period. The majority (73%) of the repairs were accomplished using commercially available thoracic stent grafts. Abdominal endograft proximal extension cuffs were used in 12 (38%) of the 32 patients undergoing repair of TAD. Twenty-one patients (48%) required coverage of the left subclavian artery, two (10%) of whom subsequently required subclavian artery revascularization. Procedure-related complications included two strokes, one spinal cord ischemia, one unintentional coverage of the left carotid artery, one episode of acute renal failure, and three access site injuries. One patient undergoing repair of TAD had collapse of the stent graft in the early postoperative period. He was successfully treated by placement of an additional stent graft. Seven patients (16%) died within 30 days of surgery. Three of the deaths occurred in patients who had successfully undergone repair of a TAD and died of associated injuries. CONCLUSIONS Emergent TEVAR has become the treatment of choice for acute surgical emergencies involving the descending thoracic aorta. Short-term morbidity and mortality compare favorably with historic results for emergent open surgical procedures on the descending thoracic aorta. Survival is highest in patients undergoing repair of TAD. Using current endograft technology, nearly all emergent conditions of the descending thoracic aorta can be successfully treated with TEVAR.
Collapse
Affiliation(s)
- Marc E Mitchell
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of Mississippi Medical Center, Jackson, MS 39216, USA.
| | | | | | | | | |
Collapse
|
30
|
Jonker FH, Verhagen HJ, Lin PH, Heijmen RH, Trimarchi S, Lee WA, Moll FL, Atamneh H, Rampoldi V, Muhs BE. Open surgery versus endovascular repair of ruptured thoracic aortic aneurysms. J Vasc Surg 2011; 53:1210-6. [DOI: 10.1016/j.jvs.2010.10.135] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Revised: 10/27/2010] [Accepted: 10/31/2010] [Indexed: 11/30/2022]
|
31
|
|
32
|
Knowles M, Murphy EH, Dimaio JM, Modrall JG, Timaran CH, Jessen ME, Arko FR. The effects of operative indication and urgency of intervention on patient outcomes after thoracic aortic endografting. J Vasc Surg 2011; 53:926-34. [PMID: 21236618 DOI: 10.1016/j.jvs.2010.10.052] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Revised: 10/01/2010] [Accepted: 10/01/2010] [Indexed: 11/17/2022]
Abstract
BACKGROUND Endovascular repair for complex thoracic aortic pathology has emerged over the past decade as an alternative to open surgical repair. Reports suggest lower morbidity and mortality rates associated with endovascular interventions. The purpose of this report was to analyze a large single institution experience in endovascular thoracic aortic repair based on clinical presentation as well as within and outside specific instructions for use. METHODS Records of all patients undergoing thoracic aortic endografting at our institution were retrospectively reviewed for demographics, interventional indications and acuity, operative details, and clinical outcomes. Study outcomes were analyzed by clinical presentation (urgent/emergent vs elective) and aneurysm morphology that was within and outside specific instructions for use as recommended by the manufacturer. RESULTS Between March 2006 and October 2009, 96 patients underwent thoracic endografting for aneurysm (n = 43), transection (n = 7), penetrating ulcer (n = 11), dissection (n = 19; acute = 9, chronic = 10), pseudoaneurysm (n = 11), or miscellaneous indications (n = 5). Endografting was performed with various endografts (Gore TAG: 59; Medtrontic Talent: 26; Zenith-TX2: 7; Combination: 4.Involvement of the arch (n = 42, 43.75%) was treated with subclavian artery coverage without revascularization in 13 (13.5%), debranching in 20 (20.8%), and fenestration/stenting in 9 (9.38%). Involvement of the visceral vessels (n = 24, 25%) was treated with debranching in 15 (15.6%) or fenestration/stenting in 9 (9.4%). Patients had a mean follow-up of 11.5 ± 10.96 (range: 0-38) months. Overall mortality was 6.25% (n = 6). Mean intensive care unit stay was 6.26 ± 8.55 (range: 1-63, median: 4) days, and hospital stay was 9.97 ± 10.31 (range: 1-65, median: 65) days. Major complications were infrequent and included: spinal cord ischemia (n = 6, 6.25%), stroke (n = 6, 6.25%), myocardial infarction (n = 3, 3.15%), renal failure (n = 6, 6.25%), and wound complications (n = 9, 9.38%). Reoperation was required in 13 (13.54%), with early intervention in 2 (2.1%). The vast majority of patients were discharged directly to home (n = 66, 68.8%). There were no significant differences between death (1/49 [2%] vs 5/47 [10.6%], P = .07), stroke (3/49 [6%] vs 3/47 [6%], P = 1.0), or spinal cord ischemia (3/49 [6%] vs 3/47 [6%], P = 1.0) when comparing urgent/emergent presentation to elective cases, respectively. However, there were significant differences in death (6/58 [10.5%] vs 0/38 [0%], P = .04) and spinal cord ischemia (6/58 [10.5%] vs 0/38 [0%], P = .04) but not stroke (5/58 [8.8%] vs 1/38 [2.5%], P = .24] when procedures were performed outside the specific instructions for use. CONCLUSIONS Results of this single-institution report suggest that endovascular thoracic aortic repair is a safe and effective treatment option for a variety of thoracic pathology including both elective and emergent cases. However, off-label usage of the devices is associated with a significantly higher risk of mortality and spinal cord ischemia, but the risk still appears acceptable given the majority of cases were emergent.
Collapse
Affiliation(s)
- Martyn Knowles
- Division of Vascular and Endovascular Surgery, University of Texas Southwestern Medical School, Dallas, TX 75390-9157, USA
| | | | | | | | | | | | | |
Collapse
|
33
|
Endovascular Repair of Ruptured Thoracic Aortic Aneurysms: Predictors of Procedure-Related Stroke. Ann Vasc Surg 2011; 25:3-8. [DOI: 10.1016/j.avsg.2010.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Revised: 04/02/2010] [Accepted: 05/16/2010] [Indexed: 11/20/2022]
|
34
|
Endovascular Treatment of Ruptured Thoracic Aortic Aneurysm in Patients Older than 75 Years. Eur J Vasc Endovasc Surg 2011; 41:48-53. [DOI: 10.1016/j.ejvs.2010.09.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Accepted: 09/20/2010] [Indexed: 11/19/2022]
|
35
|
Tefera G. Traumatic thoracic aortic injury and ruptures. J Vasc Surg 2010; 52:41S-4S. [PMID: 20800420 DOI: 10.1016/j.jvs.2010.06.142] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Revised: 06/21/2010] [Accepted: 06/21/2010] [Indexed: 10/19/2022]
Affiliation(s)
- Girma Tefera
- Department of Surgery, Division of Vascular Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA.
| |
Collapse
|
36
|
Jonker FH, Verhagen HJ, Lin PH, Heijmen RH, Trimarchi S, Lee WA, Moll FL, Athamneh H, Muhs BE. Outcomes of Endovascular Repair of Ruptured Descending Thoracic Aortic Aneurysms. Circulation 2010; 121:2718-23. [PMID: 20547930 DOI: 10.1161/circulationaha.109.908871] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Thoracic endovascular aortic repair offers a less invasive approach for the treatment of ruptured descending thoracic aortic aneurysms (rDTAA). Due to the low incidence of this life-threatening condition, little is known about the outcomes of endovascular repair of rDTAA and the factors that affect these outcomes.
Methods and Results—
We retrospectively investigated the outcomes of 87 patients who underwent thoracic endovascular aortic repair for rDTAA at 7 referral centers between 2002 and 2009. The mean age was 69.8±12 years and 69.0% of the patients were men. Hypovolemic shock was present in 21.8% of patients, and 40.2% were hemodynamically unstable. The 30-day mortality rate was 18.4%, and hypovolemic shock (odds ratio 4.75; 95% confidence interval, 1.37 to 16.5;
P
=0.014) and hemothorax at admission (odds ratio 6.65; 95% confidence interval, 1.64 to 27.1;
P
=0.008) were associated with increased 30-day mortality after adjusting for age. Stroke and paraplegia occurred each in 8.0%, and endoleak was diagnosed in 18.4% of patients within the first 30 days after thoracic endovascular aortic repair. Four additional patients died as a result of procedure-related complications during a median follow-up of 13 months; the estimated aneurysm-related mortality at 4 years was 25.4%.
Conclusion—
Endovascular repair of rDTAA is associated with encouraging results. The endovascular approach was associated with considerable rates of neurological complications and procedure-related complications such as endoleak.
Collapse
Affiliation(s)
- Frederik H.W. Jonker
- From the Section of Vascular Surgery, Cardiothoracic Surgery and Interventional Radiology, Yale University School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven, Conn (F.H.W.J., B.E.M.); Erasmus University Medical Center (H.J.M.V.), Rotterdam; St. Antonius Hospital (R.H.H.), Nieuwegein; University Medical Center Utrecht (F.L.M.), Utrecht, the Netherlands; Baylor College of Medicine (P.H.L., H.A.), Houston, Tex; Policlinico San Donato IRCCS, Cardiovascular Center “E. Malan,”
| | - Hence J.M. Verhagen
- From the Section of Vascular Surgery, Cardiothoracic Surgery and Interventional Radiology, Yale University School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven, Conn (F.H.W.J., B.E.M.); Erasmus University Medical Center (H.J.M.V.), Rotterdam; St. Antonius Hospital (R.H.H.), Nieuwegein; University Medical Center Utrecht (F.L.M.), Utrecht, the Netherlands; Baylor College of Medicine (P.H.L., H.A.), Houston, Tex; Policlinico San Donato IRCCS, Cardiovascular Center “E. Malan,”
| | - Peter H. Lin
- From the Section of Vascular Surgery, Cardiothoracic Surgery and Interventional Radiology, Yale University School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven, Conn (F.H.W.J., B.E.M.); Erasmus University Medical Center (H.J.M.V.), Rotterdam; St. Antonius Hospital (R.H.H.), Nieuwegein; University Medical Center Utrecht (F.L.M.), Utrecht, the Netherlands; Baylor College of Medicine (P.H.L., H.A.), Houston, Tex; Policlinico San Donato IRCCS, Cardiovascular Center “E. Malan,”
| | - Robin H. Heijmen
- From the Section of Vascular Surgery, Cardiothoracic Surgery and Interventional Radiology, Yale University School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven, Conn (F.H.W.J., B.E.M.); Erasmus University Medical Center (H.J.M.V.), Rotterdam; St. Antonius Hospital (R.H.H.), Nieuwegein; University Medical Center Utrecht (F.L.M.), Utrecht, the Netherlands; Baylor College of Medicine (P.H.L., H.A.), Houston, Tex; Policlinico San Donato IRCCS, Cardiovascular Center “E. Malan,”
| | - Santi Trimarchi
- From the Section of Vascular Surgery, Cardiothoracic Surgery and Interventional Radiology, Yale University School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven, Conn (F.H.W.J., B.E.M.); Erasmus University Medical Center (H.J.M.V.), Rotterdam; St. Antonius Hospital (R.H.H.), Nieuwegein; University Medical Center Utrecht (F.L.M.), Utrecht, the Netherlands; Baylor College of Medicine (P.H.L., H.A.), Houston, Tex; Policlinico San Donato IRCCS, Cardiovascular Center “E. Malan,”
| | - W. Anthony Lee
- From the Section of Vascular Surgery, Cardiothoracic Surgery and Interventional Radiology, Yale University School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven, Conn (F.H.W.J., B.E.M.); Erasmus University Medical Center (H.J.M.V.), Rotterdam; St. Antonius Hospital (R.H.H.), Nieuwegein; University Medical Center Utrecht (F.L.M.), Utrecht, the Netherlands; Baylor College of Medicine (P.H.L., H.A.), Houston, Tex; Policlinico San Donato IRCCS, Cardiovascular Center “E. Malan,”
| | - Frans L. Moll
- From the Section of Vascular Surgery, Cardiothoracic Surgery and Interventional Radiology, Yale University School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven, Conn (F.H.W.J., B.E.M.); Erasmus University Medical Center (H.J.M.V.), Rotterdam; St. Antonius Hospital (R.H.H.), Nieuwegein; University Medical Center Utrecht (F.L.M.), Utrecht, the Netherlands; Baylor College of Medicine (P.H.L., H.A.), Houston, Tex; Policlinico San Donato IRCCS, Cardiovascular Center “E. Malan,”
| | - Husam Athamneh
- From the Section of Vascular Surgery, Cardiothoracic Surgery and Interventional Radiology, Yale University School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven, Conn (F.H.W.J., B.E.M.); Erasmus University Medical Center (H.J.M.V.), Rotterdam; St. Antonius Hospital (R.H.H.), Nieuwegein; University Medical Center Utrecht (F.L.M.), Utrecht, the Netherlands; Baylor College of Medicine (P.H.L., H.A.), Houston, Tex; Policlinico San Donato IRCCS, Cardiovascular Center “E. Malan,”
| | - Bart E. Muhs
- From the Section of Vascular Surgery, Cardiothoracic Surgery and Interventional Radiology, Yale University School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven, Conn (F.H.W.J., B.E.M.); Erasmus University Medical Center (H.J.M.V.), Rotterdam; St. Antonius Hospital (R.H.H.), Nieuwegein; University Medical Center Utrecht (F.L.M.), Utrecht, the Netherlands; Baylor College of Medicine (P.H.L., H.A.), Houston, Tex; Policlinico San Donato IRCCS, Cardiovascular Center “E. Malan,”
| |
Collapse
|
37
|
Jonker FHW, Verhagen HJM, Mojibian H, Davis KA, Moll FL, Muhs BE. Aortic endograft sizing in trauma patients with hemodynamic instability. J Vasc Surg 2010; 52:39-44. [PMID: 20494542 DOI: 10.1016/j.jvs.2010.02.256] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Revised: 02/01/2010] [Accepted: 02/19/2010] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To investigate changes in aortic diameter in hemodynamically unstable trauma patients and the implications for sizing of thoracic endovascular aortic repair (TEVAR) in patients with traumatic thoracic aortic injury (TTAI). METHODS We retrospectively evaluated all trauma patients that were admitted with hemodynamic instability (mean arterial pressure <95 mm Hg and a pulse >or=100 beats/min) and underwent computed tomography (CT) of the thorax and abdomen both at admission and at another moment (control CT scan), at the Yale New Haven Hospital between 2002 and 2009. The CT examinations were reviewed in a blinded fashion and the aortic diameter was measured at six different levels by a cardiovascular radiologist. Differences in aortic diameter between the initial CTs obtained in the trauma bay and the control CTs were compared using the paired Student t test. RESULTS Forty-three patients were identified, including 32 males. Mean age was 37 +/- 16 years, mean injury severity score was 26 +/- 15, the mean pulse and blood pressure were 122 beats/min and 103/63 mm Hg, respectively. Overall, the mean aortic diameter was significantly larger at the control CT examinations compared with the initial CT examinations while hemodynamically unstable, at all evaluated levels. Among patients with a pulse >or=130/min, the mean increase in aortic diameter was most consistent at the level of the mid descending thoracic aorta (DTA, +12.6%, P = .003) and at the level of the infrarenal aorta (+12.6%, P = .004). CONCLUSIONS The aortic diameter decreases dramatically in trauma patients with hemodynamic instability. This decrease in aortic diameter could theoretically lead to inaccurate aortic measurements and undersizing of the endograft in hemodynamically unstable TTAI patients requiring TEVAR. Further research is needed to better predict the actual aortic diameters in individual hemodynamically unstable patients requiring endovascular aortic repair.
Collapse
Affiliation(s)
- Frederik H W Jonker
- Sections of Vascular Surgery, Interventional Radiology, and Trauma, Surgical Critical Care and Surgical Emergencies, Yale University School of Medicine, New Haven, CT 06510, USA
| | | | | | | | | | | |
Collapse
|
38
|
Kabbani LS, Criado E, Upchurch GR, Patel HJ, Eliason JL, Rectenwald J, Berguer R. Hybrid Repair of Aortic Aneurysms Involving the Visceral and Renal Vessels. Ann Vasc Surg 2010; 24:219-24. [DOI: 10.1016/j.avsg.2009.08.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2009] [Revised: 07/21/2009] [Accepted: 08/18/2009] [Indexed: 11/17/2022]
|
39
|
Abstract
Adequate seal at the proximal and distal extent of stent grafts in the aorta is paramount to the success of thoracic endovascular aortic repair (TEVAR). Thoracoabdominal aneurysms pose a formidable challenge given their extension into the arch branches proximally and the visceral segment distally. Extension of the landing zone of even 3 to 5 mm can possibly increase the durability of the stent graft and may decrease the chances of future migration or collapse. Although coverage of the subclavian artery to extend the proximal landing zone has been met with initial success, the outcome of coverage of the celiac axis in order to extend the distal landing zone has not been as well studied. Because of the abundance of rich collateral vessels in the foregut, it has been perceived as a potentially safe practice. However, careful angiographic anatomic delineation and patient selection is vital to determine whether concomitant revascularization procedures are warranted.
Collapse
Affiliation(s)
- Atul S Rao
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15232, USA
| | | |
Collapse
|
40
|
Bakaeen FG, Chu D, Huh J, LeMaire SA, Soltero ER, Petersen NJ, Sansgiry S, Lin P, Kougias P, Shenaq S, Coselli JS. Contemporary outcomes of open thoracic aortic surgery in a veteran population: do risk models exaggerate mortality? Am J Surg 2009; 198:889-94. [DOI: 10.1016/j.amjsurg.2009.04.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Revised: 04/05/2009] [Accepted: 04/08/2009] [Indexed: 11/27/2022]
|
41
|
Cambria RP, Crawford RS, Cho JS, Bavaria J, Farber M, Lee WA, Ramaiah V, Kwolek CJ. A multicenter clinical trial of endovascular stent graft repair of acute catastrophes of the descending thoracic aorta. J Vasc Surg 2009; 50:1255-64.e1-4. [PMID: 19958982 DOI: 10.1016/j.jvs.2009.07.104] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Revised: 07/03/2009] [Accepted: 07/25/2009] [Indexed: 11/19/2022]
Affiliation(s)
- Richard P Cambria
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Mass, USA.
| | | | | | | | | | | | | | | |
Collapse
|
42
|
Patel HJ, Williams DM, Upchurch GR, Dasika NL, Deeb GM. A comparative analysis of open and endovascular repair for the ruptured descending thoracic aorta. J Vasc Surg 2009; 50:1265-70. [PMID: 19782517 DOI: 10.1016/j.jvs.2009.07.091] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Revised: 07/14/2009] [Accepted: 07/20/2009] [Indexed: 11/26/2022]
Abstract
BACKGROUND Successful repair of the ruptured (non-traumatic) descending thoracic aorta (rTA) remains a formidable clinical challenge. Although effective for rTA, traditional open repair (DTAR) has significant associated morbidity. With expanding indications for thoracic endovascular aortic repair (TEVAR), we describe our experience with TEVAR and DTAR in this high-risk setting to elucidate their evolving roles. METHODS Since the inception of our thoracic aortic endovascular program in 1993, 69 patients underwent DTAR (34) or TEVAR (35) for rTA. Patients underwent TEVAR if they were considered nonoperative candidates because of extensive comorbidities (n = 31; 88.6%) or had extremely favorable anatomy for endovascular repair (eg, mid-descending saccular aneurysm, n = 4). Aortic pathology causing rupture was fusiform aneurysm (18), saccular aneurysm/ulcer (22), and dissection (29). Associated aortobronchial fistulae (12) and aortoesophageal (1) fistulae were also present in 18.8%. Arch repair was needed in 46; total descending repair was needed in 33. Follow-up was 100% complete (mean 37.4 months). RESULTS Mean age was 65.9 years (DTAR 60.3 year vs TEVAR 71.3 years, P = .005). In-hospital or 30-day mortality was seen in 13 patients (TEVAR n = 4; 11.4% vs DTAR n = 9; 26.5%, P = .13). Median length of stay was shorter after TEVAR (8 days vs DTAR 15 days, P = .02). Mean Kaplan-Meier survival was similar between groups (TEVAR 67.4 months vs DTAR 65.0 months, P = .7). By multivariate analysis, independent predictors of a composite outcome of early mortality, stroke, permanent spinal cord ischemia, or need for dialysis or tracheostomy included the presentation with hemodynamic instability (P < .001) and treatment with conventional open repair (P = .02). CONCLUSION An endovascular approach for the ruptured (non-traumatic) descending thoracic aorta reduces early morbidity, mortality, and duration of hospitalization, while providing equivalent late outcomes even in an older group largely considered high risk for open repair. These data support a paradigm shift, with TEVAR emerging as the preferred therapy for all patients presenting with descending aortic rupture.
Collapse
Affiliation(s)
- Himanshu J Patel
- Department of Surgery, University of Michigan Cardiovascular Center, Ann Arbor, Mich, USA.
| | | | | | | | | |
Collapse
|
43
|
von Meyenfeldt E, Schnater J, Reekers J, Balm R. An Emergency Visceral Hybrid Procedure for Ruptured Thoraco-Abdominal Aortic Aneurysms. Eur J Vasc Endovasc Surg 2009; 38:162-8. [DOI: 10.1016/j.ejvs.2009.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2008] [Accepted: 03/07/2009] [Indexed: 11/25/2022]
|
44
|
Eagleton MJ, Greenberg RK. Late Complications after Endovascular Thoracoabdominal Aneurysm Repair. Semin Vasc Surg 2009; 22:87-92. [DOI: 10.1053/j.semvascsurg.2009.04.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
45
|
Walsh SR, Tang TY, Sadat U, Naik J, Gaunt ME, Boyle JR, Hayes PD, Varty K. Endovascular stenting versus open surgery for thoracic aortic disease: Systematic review and meta-analysis of perioperative results. J Vasc Surg 2008; 47:1094-1098. [DOI: 10.1016/j.jvs.2007.09.062] [Citation(s) in RCA: 176] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2007] [Revised: 09/26/2007] [Accepted: 09/26/2007] [Indexed: 11/30/2022]
|
46
|
Abstract
Background—
Morbidity and mortality after conventional repair of thoracoabdominal aneurysms remain high. Alternative techniques have been proposed and are the subject of this report.
Methods and Results—
Endovascular grafts that have a means of incorporating the visceral vessels into the aortic repair were divided into devices with fenestrations and those with formal branches. Hybrid procedures whereby an extra-anatomic bypass procedure is used to provide inflow to the renal and mesenteric arteries followed by aortic relining with stent grafts were reviewed and tabulated. A description of the techniques and review of the current results are provided. Only 4 series with >10 cases of hybrid procedures have been published. The experience with such a procedure suggests feasibility, but most reports describe a persistently high risk of mortality (up to 25%). Larger series of fenestrated stent grafts to treat juxtarenal aneurysms have been published, and intermediate-term results confirm the safety and efficacy of the procedure. A larger multicenter trial is under way. Other pure endovascular methods have been used to treat thoracoabdominal aneurysms with both reinforced fenestrations and directional branches. Without counting small series (<10 cases), 2 series exist with ≈100 cases that noted perioperative mortality rates between 3% and 6%, without evidence of late ruptures.
Conclusions—
Endovascular repair of thoracoabdominal aneurysms is feasible and is associated with relatively low perioperative mortality. Several methods of visceral vessel incorporation have been described. Because of persistently high mortality, hybrid procedures will likely be relegated to nonsurgical and nonendovascular patients with sizable aneurysms. Endografts with branches continue to evolve and will be assessed in the context of clinical trials.
Collapse
Affiliation(s)
- Roy K. Greenberg
- From the Departments of Vascular Surgery (R.K.G.), Cardiothoracic Surgery (R.K.G., B.L.), and Biomedical Engineering (R.K.G.), The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Bruce Lytle
- From the Departments of Vascular Surgery (R.K.G.), Cardiothoracic Surgery (R.K.G., B.L.), and Biomedical Engineering (R.K.G.), The Cleveland Clinic Foundation, Cleveland, Ohio
| |
Collapse
|