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Gomez-Mayorga JL, Yadavalli SD, Allievi S, Wang SX, Rastogi V, Straus S, Mandigers TJ, Black JH, Zettervall SL, Schermerhorn ML. National registry insights on genetic aortopathies and thoracic endovascular aortic interventions. J Vasc Surg 2024:S0741-5214(24)01101-7. [PMID: 38729586 DOI: 10.1016/j.jvs.2024.05.002] [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: 02/23/2024] [Revised: 04/30/2024] [Accepted: 05/03/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVE Thoracic endovascular aortic repair (TEVAR) in patients with genetic aortopathies (GA) is controversial, given concerns of durability. We describe characteristics and outcomes after TEVAR in patients with GA. METHODS All patients undergoing TEVAR between 2010 and 2023 in the Vascular Quality Iniatitive were identified and categorized as having a GA or not. Demographics, baseline, and procedural characteristics were compared among groups. Multivariable logistic regression was used to evaluate the independent association of GA with postoperative outcomes. Kaplan-Meier methods and multivariable Cox regression analyses were used to evaluate 5-year survival and 2-year reinterventions. RESULTS Of 19,340 patients, 304 (1.6%) had GA (87% Marfan syndrome, 9% Loeys-Dietz syndrome, and 4% vascular Ehlers-Danlos syndrome). Compared with patients without GA, patients with GA were younger (50 years [interquartile range, 37-72 years] vs 70 years [interquartile range, 61-77 years]), more often presented with acute dissection (28% vs 18%), postdissection aneurysm (48% vs 17%), had a symptomatic presentation (50% vs 39%), and were less likely to have degenerative aneurysms (18% vs 47%) or penetrating aortic ulcer (and intramural hematoma) (3% vs 13%) (all P < .001). Patients with GA were more likely to have prior repair of the ascending aorta/arch (open, 56% vs 11% [P < .001]; endovascular, 5.6% vs 2.1% [P = .017]) or the descending thoracic aorta (open, 12% vs 2% [P = .007]; endovascular, 8.2% vs 3.6% [P = .011]). No significant differences were found in prior abdominal suprarenal repairs; however, patients with GA had more prior open infrarenal repairs (5.3% vs 3.2%), but fewer prior endovascular infrarenal repairs (3.3% vs 5.5%) (all P < .05). After adjusting for demographics, comorbidities, and disease characteristics, patients with GA had similar odds of perioperative mortality (4.6% vs 7.0%; adjusted odds ratio [aOR], 1.1; 95% confidence interval [CI], 0.57-1.9; P = .75), any in-hospital complication (26% vs 23%; aOR, 1.24; 95% CI, 0.92-1.6; P = .14), or in-hospital reintervention (13% vs 8.3%; aOR, 1.25; 95% CI, 0.84-1.80; P = .25) compared with patients without GA. However, patients with GA had a higher likelihood of postoperative vasopressors (33% vs 27%; aOR, 1.44; 95% CI, 1.1-1.9; P = .006) and transfusion (25% vs 23%; aOR, 1.39; 95% CI, 1.03-1.9; P = .006). The 2-year reintervention rates were higher in patients with GA (25% vs 13%; adjusted hazard ratio, 1.99; 95% CI, 1.4-2.9; P < .001), but 5-year survival was similar (81% vs 74%; adjusted hazard ratio, 1.02; 95% CI, 0.70-1.50; P = .1). CONCLUSIONS TEVAR for patients with GA seemed to be safe initially, with similar odds for in-hospital complications, in-hospital reinterventions, and perioperative mortality, as well as similar hazards for 5-year mortality compared with patients without GA. However, patients with GA had higher 2-year reintervention rates. Future studies should assess long-term durability after TEVAR compared with the recommended open repair to appropriately weigh the risks and benefits of endovascular treatment in patients with GA.
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Affiliation(s)
- Jorge L Gomez-Mayorga
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sai Divya Yadavalli
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sara Allievi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Section of Vascular Surgery, Cardio Thoracic Vascular Department, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Sophie X Wang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vinamr Rastogi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sabrina Straus
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego (UCSD), San Diego, CA
| | - Tim J Mandigers
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Section of Vascular Surgery, Cardio Thoracic Vascular Department, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, University of Washington, Seattle, WA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Nucera M, Kreibich M, Yildiz M, Berger T, Kolb RK, Kondov S, Kunzmann S, Rylski B, Makaloski V, Siepe M, Czerny M, Schoenhoff FS. Endovascular aortic repair in patients with Marfan and Loeys-Dietz syndrome is safe and durable when employed by a multi-disciplinary aortic team. Eur J Cardiothorac Surg 2024; 65:ezae069. [PMID: 38430465 DOI: 10.1093/ejcts/ezae069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 02/12/2024] [Accepted: 02/29/2024] [Indexed: 03/03/2024] Open
Abstract
OBJECTIVES The aim of this study was to report on mid-term outcomes after endovascular aortic repair (EVAR) in patients with Marfan (MFS) or Loeys-Dietz (LDS) syndrome. METHODS We analysed data from 2 European centres of patients with MFS and LDS undergoing EVAR. Patients were analysed based on (i) timing of the procedure (planned versus emergency procedure) and (ii) the nature of the landing zone (safe versus non-safe). The primary end-point was freedom from reintervention. Secondary end-points were freedom from stroke, bleeding and death. RESULTS A population of 419 patients with MFS (n = 352) or LDS (n = 67) was analysed for the purpose of this study. Thirty-nine patients (9%) underwent EVAR. Indications for thoracic endovascular aortic repair or EVAR were aortic dissection in 13 (33%) patients, aortic aneurysm in 22 (57%) patients and others (intercostal patch aneurysm, penetrating atherosclerotic ulcer, pseudoaneurysm, kinking of frozen elephant trunk (FET)) in 4 (10%) patients. Thoracic endovascular repair was performed in 34 patients, and abdominal endovascular aortic repair was performed in 5 patients. Mean age at 1st thoracic endovascular aortic repair/EVAR was 48.5 ± 15.4 years. Mean follow-up after 1st thoracic endovascular aortic repair/EVAR was 5.9 ± 4.4 years. There was no statistically significant difference in the rate of reinterventions between patients with non-safe landing zone and the patients with safe proximal landing zone (P = 0.609). Furthermore, there was no increased probability for reintervention after planned endovascular intervention compared to emergency procedures (P = 0.916). Mean time to reintervention, either open surgical or endovascular, after planned endovascular intervention was in median 3.9 years (95% confidence interval 2.0-5.9 years) and 2.0 years (95% confidence interval -1.1 to 5.1 years) (P = 0.23) after emergency procedures. CONCLUSIONS EVAR in patients with MFS and LDS and a safe landing zone is feasible and safe. Endovascular treatment is a viable option when employed by a multi-disciplinary aortic team even if the landing zone is in native tissue.
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Affiliation(s)
- Maria Nucera
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Cardiovascular Surgery, University Heart Centre Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, University Heart Centre Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Murat Yildiz
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tim Berger
- Department of Cardiovascular Surgery, University Heart Centre Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Rosa Klara Kolb
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, University Heart Centre Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sophie Kunzmann
- Department of Cardiovascular Surgery, University Heart Centre Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, University Heart Centre Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Vladimir Makaloski
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias Siepe
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Centre Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Florian S Schoenhoff
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
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Al-Tawil M, Geragotellis A, Jubouri M, Tan SZ, Mohammed I, Williams I, Bashir M. Population risk profile analysis of acute uncomplicated type B aortic dissection patients undergoing thoracic endovascular aortic repair. Asian Cardiovasc Thorac Ann 2023; 31:549-556. [PMID: 35532028 DOI: 10.1177/02184923221099771] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
BACKGROUND Uncomplicated type B aortic dissection (unTBAD) comprises the estimated majority of type B aortic dissection (TBAD), presenting without any of the complications associated with complicated TBAD (coTBAD). Although first-line treatment for coTBAD is thoracic endovascular aortic repair (TEVAR), and despite the fact that TEVAR has proven its safety and effectiveness in the treatment of unTBAD, unTBAD is still being predominantly managed conservatively with medical therapy, with a small proportion of patients being offered TEVAR. AIMS The main scope of this review is to highlight the evidence in the literature of the demographic characteristics and associated co-morbidities of unTBAD patients undergoing TEVAR in order to produce a risk stratification system to achieve favourable outcomes. METHODS A comprehensive literature search was conducted using multiple electronic databases including PubMed, Ovid, Scopus, and EMBASE. RESULTS Multiple demographic characteristics and associated co-morbidities of unTBAD patients affecting TEVAR outcomes were identified, assessed, and investigated, including age, gender, race, genetics, medical conditions, such as hypertension and diabetes, and lifestyle factors such as smoking. Most factors were associated with increased risks of mortality and morbidity, while others, such as race, were identified as being protective against those when it comes to TEVAR. CONCLUSION Despite the favourable results yielded by TEVAR in unTBAD, there remains a grey area concerning its management. Thus, it is important to incorporate the demographics and co-morbidities of unTBAD patients' when into clinical judgement when assessing indications for TEVAR intervention to ensure optimum results can be achieved.
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Affiliation(s)
| | | | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Sven Zcp Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, UK
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Ian Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Mohamad Bashir
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
- Vascular & Endovascular Surgery, Velindre University NHS Trust, Health Education & Improvement Wales (HEIW), Cardiff, UK
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Asta L, D’Angelo GA, Marinelli D, Benedetto U. Genetic Basis, New Diagnostic Approaches, and Updated Therapeutic Strategies of the Syndromic Aortic Diseases: Marfan, Loeys-Dietz, and Vascular Ehlers-Danlos Syndrome. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6615. [PMID: 37623198 PMCID: PMC10454608 DOI: 10.3390/ijerph20166615] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 08/08/2023] [Accepted: 08/11/2023] [Indexed: 08/26/2023]
Abstract
Syndromic aortic diseases (SADs) encompass various pathological manifestations affecting the aorta caused by known genetic factors, such as aneurysms, dissections, and ruptures. However, the genetic mutation underlying aortic pathology also gives rise to clinical manifestations affecting other vessels and systems. As a consequence, the main syndromes currently identified as Marfan, Loeys-Dietz, and vascular Ehlers-Danlos are characterized by a complex clinical picture. In this contribution, we provide an overview of the genetic mutations currently identified in order to have a better understanding of the pathogenic mechanisms. Moreover, an update is presented on the basis of the most recent diagnostic criteria, which enable an early diagnosis. Finally, therapeutic strategies are proposed with the goal of improving the rates of patient survival and the quality of life of those affected by these SADs.
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Affiliation(s)
- Laura Asta
- Department of Cardiac Surgery, Tor Vergata University Hospital, 00133 Rome, Italy
| | - Gianluca A. D’Angelo
- Department of Cardiac Surgery, SS Annunziata Hospital, 66100 Chieti, Italy; (G.A.D.); (D.M.); (U.B.)
| | - Daniele Marinelli
- Department of Cardiac Surgery, SS Annunziata Hospital, 66100 Chieti, Italy; (G.A.D.); (D.M.); (U.B.)
| | - Umberto Benedetto
- Department of Cardiac Surgery, SS Annunziata Hospital, 66100 Chieti, Italy; (G.A.D.); (D.M.); (U.B.)
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Azogui R, Porto A, Castelli M, Omnes V, De Masi M, Bartoli M, Piquet P, Gariboldi V, Busa T, Jacquier A, Bal L, Gaudry M. In Marfan Syndrome and Related Diseases, STABILISE Technique Should Be Used with Care: Results from a Volumetric Comparative Study of Endovascular Treatment for Aortic Dissection. J Clin Med 2023; 12:4378. [PMID: 37445413 DOI: 10.3390/jcm12134378] [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: 05/25/2023] [Revised: 06/20/2023] [Accepted: 06/24/2023] [Indexed: 07/15/2023] Open
Abstract
Objectives: Aortic dissection in patients with Marfan and related syndromes (HTAD) is a serious pathology whose treatment by thoracic endovascular repair (TEVAR) is still under debate. The aim of this study was to assess the results of the TEVAR for aortic dissection in patients with HTAD as compared to a young population without HTAD. Methods: The study received the proper ethical oversight. We performed an observational exposed (confirmed HTAD) vs. non-exposed (<65 years old) study of TEVAR-treated patients. The preoperative, 1 year, and last available CT scans were analyzed. The thoracic and abdominal aortic diameters, aortic length, and volumes were measured. The entry tears and false lumen (FL) status were assessed. The demographic, clinical, and anatomic data were collected during the follow-up. Results: Between 2011 and 2021, 17 patients were included in the HTAD group and 22 in the non-HTAD group. At 1 year, the whole aortic volume increased by +21.2% in the HTAD group and by +0.2% the non-HTAD groups, p = 0.005. An increase in the whole aortic volume > 10% was observed in ten cases (58.8%) in the HTAD group and in five cases (22.7%) in the non-HTAD group (p = 0.022). FL thrombosis was achieved in nine cases (52.9%) in the HTAD group vs. twenty (90.9%) cases in the non-HTAD group (p < 0.01). The risk factors for unfavorable anatomical evolution were male gender and the STABILISE technique. With a linear model, we observed a significantly different aortic volume evolution between the two groups (p < 0.01) with the STABILISE technique; this statistical difference was not found in the TEVAR subgroup. In the HTAD patients, there was a significant difference in the total aortic volume evolution progression between the patients treated with the STABILISE technique and the patients treated with TEVAR (+160.1 ± 52.3% vs. +47 ± 22.5%, p < 0.01 and +189.5 ± 92.5% vs. +58.6 ± 34.8%, p < 0.01 at 1 year and at the end of follow-up, respectively). Conclusions: TEVAR in the HTAD patients seemed to be associated with poorer anatomical outcomes at 1 year. This result was strongly related to the STABILISE technique which should be considered with care in these specific patients.
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Affiliation(s)
- Ron Azogui
- Timone Aortic Center, Department of Vascular Surgery, APHM, Timone Hospital, 13005 Marseille, France
| | - Alizee Porto
- Department of Cardiac Surgery, APHM, Timone Hospital, 13005 Marseille, France
| | - Maxime Castelli
- Department of Radiology, APHM, Timone Hospital, 13005 Marseille, France
| | - Virgile Omnes
- Timone Aortic Center, Department of Vascular Surgery, APHM, Timone Hospital, 13005 Marseille, France
| | - Mariangela De Masi
- Timone Aortic Center, Department of Vascular Surgery, APHM, Timone Hospital, 13005 Marseille, France
| | - Michel Bartoli
- Timone Aortic Center, Department of Vascular Surgery, APHM, Timone Hospital, 13005 Marseille, France
| | - Philippe Piquet
- Timone Aortic Center, Department of Vascular Surgery, APHM, Timone Hospital, 13005 Marseille, France
| | - Vlad Gariboldi
- Department of Cardiac Surgery, APHM, Timone Hospital, 13005 Marseille, France
| | - Tiffany Busa
- Department of Genetic, APHM, Timone Hospital, 13005 Marseille, France
| | - Alexis Jacquier
- Timone Aortic Center, Department of Vascular Surgery, APHM, Timone Hospital, 13005 Marseille, France
- Department of Radiology, APHM, Timone Hospital, 13005 Marseille, France
| | - Laurence Bal
- Timone Aortic Center, Department of Vascular Surgery, APHM, Timone Hospital, 13005 Marseille, France
- Timone Aortic Center, APHM, Centre de Référence Marfan et Apparentés, 13005 Marseille, France
| | - Marine Gaudry
- Timone Aortic Center, Department of Vascular Surgery, APHM, Timone Hospital, 13005 Marseille, France
- Timone Aortic Center, APHM, Centre de Référence Marfan et Apparentés, 13005 Marseille, France
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Yokoyama Y, Tsukagoshi J, Hamlin S, Takagi H, Kuno T, Takayama H. Endovascular therapy for Stanford B aortic dissection for patients with Marfan Syndrome: systematic review and meta-analysis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:41-47. [PMID: 36239929 DOI: 10.23736/s0021-9509.22.12441-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION The role of thoracic endovascular aortic repair (TEVAR) in patients with Marfan Syndrome with Stanford type B aortic dissection (TBAD) remains under debate. EVIDENCE ACQUISITION MEDLINE and EMBASE were searched through December 2021 to identify studies that investigated outcomes in MFS patients with TBAD who underwent TEVAR. Data regarding patient characteristics, perioperative and late outcomes were extracted. EVIDENCE SYNTHESIS Twelve studies were identified including 120 patients. The mean age was 40.2 years (95% confidence interval [CI], 36.8-43.6). 40.4% (95% CI: 10.8-70.0) of cases were performed emergently. 76.2% (95% CI: 64.6-87.8) of patients had a history of previous aortic surgery. In-hospital mortality was 3.7% (95% CI: 0.6-6.8). Primary endoleak occurred in 15.2% (95% CI: 8.6-21.8), which was comprised of type 1 (9.3% [95% CI: 3.9-14.6]) and type 2 (7.1% [95% CI: 2.3-12.0]) endoleaks. During mean follow-up period of 37.4 months (95% CI: 24.1-50.7), secondary endoleak was reported in 14.1% (95% CI: 7.1-21.1), which was comprised of type 1 (7.4% [95% CI: 2.4-12.5]) and type 2 (4.0% [95% CI: 0.3-7.7]) endoleak. Repeat TEVAR was performed in 15.5% (95% CI: 9.3-21.8) and open aortic surgery in 18.6% (95% CI: 9.6-27.5). Long-term mortality was 11.9% (95% CI: 6.5-17.3). CONCLUSIONS Our analysis showed that TEVAR for TBAD in patients with MFS has low perioperative morbidity and mortality but was associated with a high rate of late reintervention. This treatment option should be limited to emergent cases and to patients deemed unsuitable for open repair. Lifelong follow-up with imaging is mandatory in this population.
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Affiliation(s)
- Yujiro Yokoyama
- Department of Surgery, St. Luke's University Health Network, Fountain Hill, PA, USA
| | - Junji Tsukagoshi
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Sean Hamlin
- Department of Surgery, St. Luke's University Health Network, Fountain Hill, PA, USA
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Toshiki Kuno
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Hiroo Takayama
- Department of Surgery, Columbia Medical Center, New Yourk, NY, USA -
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Jonsson M, Blohmé L, Daryapeyma A, Günther A, Lundberg G, Nilsson L, Wahlgren CM, Franco-Cereceda A, Olsson C. Outcomes of descending and thoracoabdominal aortic repair in connective tissue disorder patients. SCAND CARDIOVASC J 2022; 56:352-359. [PMID: 36151718 DOI: 10.1080/14017431.2022.2125174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 08/17/2022] [Accepted: 09/10/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES Open surgical repair (OSR) of descending and thoracoabdominal aortic aneurysms carries risks of mortality and major complications. Patients with connective tissue disorders (CTD) are younger and require safe, efficient treatment with long-term durability. This study provides current outcome data to help inform treatment decisions. METHODS All OSRs of descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) from January 2011 to July 2021 were included in a retrospective cohort study. Primary outcome measures were early and follow-up mortality and reintervention. Secondary outcome measures were major complications. Kaplan-Meier methods were used to estimate reintervention-free survival. RESULTS A total of 26 OSRs (7 DTAA, 19 TAAA) were performed in 23 patients: 20 (77%) Marfan and 6 (23%) Loeys-Dietz syndrome; median age 43 years. Aortic dissection was present in 100% and 3/26 (12%) were urgent. Early mortality was 1/26 (3.8%). No patient suffered spinal cord ischemia, stroke, vocal cord paralysis, or re-exploration for bleeding. The transient respiratory failure occurred in 19% (5/26) and transient renal replacement therapy in 15% (4/26). Renal function normalized in all patients within 3 months. During follow-up (median 4.6, range 0-11 years) there were no deaths and only one re-intervention on a previously operated aortic segment, resulting in 92% reintervention-free survival at 5 years. CONCLUSIONS In dedicated units, open surgical DTAA and TAAA repair in patients with CTD can be performed with a very low risk of death, severe complications and, late re-intervention. For CTD patients with reasonable risk, OSR should remain the first line of treatment.
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Affiliation(s)
- Magnus Jonsson
- Department of Vascular Surgery, Karolinska University Hospital,, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Linus Blohmé
- Department of Vascular Surgery, Karolinska University Hospital,, Stockholm, Sweden
| | - Alireza Daryapeyma
- Department of Vascular Surgery, Karolinska University Hospital,, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Anders Günther
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiothoracic Anesthesia, Karolinska University Hospital, Stockholm, Sweden
| | - Göran Lundberg
- Department of Vascular Surgery, Karolinska University Hospital,, Stockholm, Sweden
| | - Lena Nilsson
- Department of Cardiothoracic Anesthesia, Karolinska University Hospital, Stockholm, Sweden
| | - Carl-Magnus Wahlgren
- Department of Vascular Surgery, Karolinska University Hospital,, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Anders Franco-Cereceda
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Sweden
| | - Christian Olsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Sweden
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9
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Spanos K, Kodolitsch Y, Detter NC, Panuccio G, Rohlffs F, Eleshra A, Kölbel T. Endovascular treatment of aortic aneurysms and dissections in patients with genetically triggered aortic diseases. Semin Vasc Surg 2022; 35:320-333. [DOI: 10.1053/j.semvascsurg.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/20/2022] [Accepted: 06/27/2022] [Indexed: 11/11/2022]
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10
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Endovascular and Hybrid Repair in Patients with Heritable Thoracic Aortic Disease. Ann Vasc Surg 2022; 87:124-139. [PMID: 35691461 DOI: 10.1016/j.avsg.2022.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/23/2022] [Accepted: 05/25/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE In individuals with heritable thoracic aortic disease (HTAD), endovascular repair for treatment of aortic aneurysm and dissection may be lifesaving but is associated with increased risk of failure of endovascular repair and adverse outcomes. This study reports our experience with early and late outcomes of endovascular aortic and branch vessel repair in patients with HTAD. METHODS A retrospective case series was performed by chart review of individuals with HTAD followed at Washington University School of Medicine/Barnes-Jewish Hospital who underwent endovascular aortic and/or branch vessel repair. Clinical features, imaging characteristics, and short- and long-term outcomes were collected. RESULTS Twenty-nine patients with HTAD (20 male; mean age 45 ± 13 years) underwent thirty-seven endovascular procedures between 2006 and 2020 with mean follow up of 54 ± 41 months. Seven patients underwent two or more separate endovascular procedures. Each procedure was considered separate for data collection and analysis. Underlying conditions included Marfan syndrome (n=16 procedures), Loeys-Dietz syndrome (n=14 procedures), vascular Ehlers-Danlos syndrome (n=3 procedures), and nonsyndromic HTAD (n=4 procedures). Twenty patients (69%) had prior open surgical aortic repair. Indications for endovascular aortic repair (n=31) included urgent repairs of acute complications of aortic dissection (n=10) or aneurysm rupture (n=3), and elective aortic repair (n=18; 10 chronic dissections and 8 chronic aneurysms). Six patients underwent elective endovascular repair of six branch vessel aneurysms or dissections. Six patients underwent hybrid open surgical and endovascular repair. Of the 37 procedures, twenty-five (68%) proximal landing zones were in the native aorta or branch vessel, eleven (30%) were in a surgical graft or elephant trunk and one was in a previously placed endograft. Thirty-six (97%) procedures were technically successful, and none required emergency surgical conversion. Two patients died: one from sepsis and one from presumed late pseudoaneurysm rupture, for a 5% per-procedure mortality rate. Two procedures were complicated by stroke and one patient developed paraparesis. Of the 31 aortic procedures, seven aortic endografts (23%) developed a stent-induced new entry (SINE) discovered with imaging at 20 ± 15 days post-procedure. Seven endografts (23%) developed a Type I endoleak and eight (26%) developed a Type II endoleak. No Type III endoleaks were seen. Within 30 days, two endografts (of 37, 5%) required reintervention. After 30 days, fifteen additional endografts (of 37, 41%) required reintervention. Two patients (of 6, 33%) who underwent hybrid repair required reintervention. CONCLUSIONS This study is the largest single-center case series examining outcomes of HTAD patients following endovascular repair. Urgent and elective endovascular repairs in patients with HTAD can manage acute and chronic complications of aortic aneurysm and dissection with relatively low risk. However, risk of early and late endoleaks and SINE is high. Close post-procedural surveillance is required, and many individuals will require additional interventions. Hybrid repair shows promise and requires further investigation.
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11
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Muncan B, Sangari A, Liu SH, Price LZ. Midterm Outcomes of Endovascular versus Open Surgical Repair of Intact Descending Thoracic Aneurysms in Patients with Connective Tissue Disorders. Ann Vasc Surg 2022; 87:40-46. [PMID: 35460854 DOI: 10.1016/j.avsg.2022.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/07/2022] [Accepted: 04/07/2022] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Data on the efficacy of endovascular (TEVAR) vs open surgical repair for chronic aortic pathology in patients with connective tissue disorders are limited. In particular, few studies have examined outcomes of TEVAR vs. open repair for intact aneurysms of the descending thoracic aorta (DTAAs) in this subset of patients beyond index hospitalization. Therefore, we investigate and five-year outcomes of TEVAR and open surgical repair of intact DTAAs in patients with known connective tissue disorders. METHODS Using the TriNetX Data Network, a global federated database of over 75 million patients, we conducted a retrospective cohort study of patients with connective tissue disorders and intact DTAAs, treated initially with either TEVAR or open surgery. Eligible patients were 1:1 propensity score-matched for several preoperative covariates including demographics, surgical history, and comorbidities. We calculated and compared five-year cumulative incidence and hazard of death, reintervention, aortic dissection, renal failure, stroke, intracranial hemorrhage, paraplegia and limb ischemia using the Kaplan-Meier method and Cox proportional hazards models. RESULTS We identified 55 patients treated with TEVAR and 200 treated with open surgery. After matching, we compared 46 patients in each cohort. After matching, only incidence of reintervention via endovascular approach was significantly higher among patients in the TEVAR cohort (27.1% vs. 4.8%, p = 0.009). Rates and hazards of other outcomes were higher in the TEVAR group, however differences were not statistically significant. CONCLUSION Patients treated with TEVAR had numerically higher rates of adverse outcomes compared to open surgical patients, however only the difference in reintervention rate was statistically significant. Given the evolving landscape of endovascular intervention, greater-powered studies are needed to determine the safety and efficacy of TEVAR for intact DTAAs in a select subset of connective tissue disorder patients.
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Affiliation(s)
- Brandon Muncan
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA.
| | - Ayush Sangari
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Steven H Liu
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Lucyna Z Price
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
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12
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Eleshra A, Panuccio G, Spanos K, Rohlffs F, von Kodolitsch Y, Kolbel T. Safety and Effectiveness of TEVAR in Native Proximal Landing Zone 2 for Chronic Type B Aortic Dissection in Patients with Genetic Aortic Syndrome. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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13
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Pellenc Q, Boitet A, Roussel A, Milleron O, Mordant P, Senemaud J, Cerceau P, Jondeau G, Castier Y. Non-Dissecting Distal Aortic and Peripheral Arterial Aneurysms in Patients With Marfan Syndrome. Front Cardiovasc Med 2022; 9:827357. [PMID: 35360038 PMCID: PMC8962944 DOI: 10.3389/fcvm.2022.827357] [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: 12/01/2021] [Accepted: 01/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background In Marfan syndrome (MFS), an aortic or peripheral arterial dilatation is usually the consequence of aortic dissection. Non-dissecting distal aortic and peripheral aneurysms (DAPA) are barely described. We sought to determine the incidence and prognostic impact of non-dissecting DAPA, requiring a surgical repair in a large population of patients with MFS. Methods The patients referred to the French MFS reference center were included in a prospective database, and the patients treated for a non-dissecting DAPA between 2013 and 2020 were retrospectively reviewed. The first-line therapy was open surgery. The patients unfit for open repair or experiencing life-threatening complications underwent endovascular repair. Results Among 1,575 patients with MFS, 19 (1.2%) were operated for 25 non-dissecting DAPA. The mean age was 42.4 ± 11.5 years. Non-dissecting DAPA involved the subclavian or axillary artery (n = 12), the descending or thoracoabdominal aorta (n = 6), the abdominal aorta andiliac arteries (n = 6), and the popliteal artery (n = 1). Open and endovascular repairs were performed in 22 and three cases, respectively. After a median follow-up of 54.2 months, no local recurrence was noticed and no secondary procedure was performed. Eight patients presented a new aortic event, including two aortic dissections and seven new aortic surgeries. Compared to the overall MFS population, the non-dissecting DAPA group presented a significantly higher risk of an aortic event (100 vs. 28%, p < 0.0001), a higher risk of aortic dissection (53 vs. 8%, p < 0.0001), and a higher rate of pejorative genetic mutations (68 vs. 40%, p = 0.011). Conclusion Among the patients with MFS, the diagnosis of non-dissecting DAPA is infrequent but is associated with a significant adverse outcome, thus, advocating for a specific follow-up.
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Affiliation(s)
- Quentin Pellenc
- Department of Vascular and Thoracic Surgery, Bichat Hospital, Assistance Publique–Hopitaux de Paris (AP-HP), Paris, France
- Centre de Référence pour le Syndrome de Marfan et apparentés, Bichat Hospital, Assistance Publique–Hopitaux de Paris (AP-HP), Paris, France
- INSERM U 1148, LVTS, Bichat Hospital, Paris, France
- Université de Paris, Paris, France
- *Correspondence: Quentin Pellenc
| | - Auréline Boitet
- Department of Vascular and Thoracic Surgery, Bichat Hospital, Assistance Publique–Hopitaux de Paris (AP-HP), Paris, France
| | - Arnaud Roussel
- Department of Vascular and Thoracic Surgery, Bichat Hospital, Assistance Publique–Hopitaux de Paris (AP-HP), Paris, France
- Université de Paris, Paris, France
| | - Olivier Milleron
- Centre de Référence pour le Syndrome de Marfan et apparentés, Bichat Hospital, Assistance Publique–Hopitaux de Paris (AP-HP), Paris, France
- INSERM U 1148, LVTS, Bichat Hospital, Paris, France
- Department of Cardiology, Bichat Hospital, Assistance Publique–Hopitaux de Paris (AP-HP), Paris, France
| | - Pierre Mordant
- Department of Vascular and Thoracic Surgery, Bichat Hospital, Assistance Publique–Hopitaux de Paris (AP-HP), Paris, France
- Université de Paris, Paris, France
| | - Jean Senemaud
- Department of Vascular and Thoracic Surgery, Bichat Hospital, Assistance Publique–Hopitaux de Paris (AP-HP), Paris, France
- INSERM U 1148, LVTS, Bichat Hospital, Paris, France
- Université de Paris, Paris, France
| | - Pierre Cerceau
- Department of Vascular and Thoracic Surgery, Bichat Hospital, Assistance Publique–Hopitaux de Paris (AP-HP), Paris, France
| | - Guillaume Jondeau
- Centre de Référence pour le Syndrome de Marfan et apparentés, Bichat Hospital, Assistance Publique–Hopitaux de Paris (AP-HP), Paris, France
- INSERM U 1148, LVTS, Bichat Hospital, Paris, France
- Université de Paris, Paris, France
- Department of Cardiology, Bichat Hospital, Assistance Publique–Hopitaux de Paris (AP-HP), Paris, France
| | - Yves Castier
- Department of Vascular and Thoracic Surgery, Bichat Hospital, Assistance Publique–Hopitaux de Paris (AP-HP), Paris, France
- INSERM U 1148, LVTS, Bichat Hospital, Paris, France
- Université de Paris, Paris, France
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Le Huu A, Olive JK, Cekmecelioglu D, Chatterjee S, Amarasekara HS, Green SY, Coselli JS, Preventza O. Endovascular therapy for patients with heritable thoracic aortic disease. Ann Cardiothorac Surg 2022; 11:31-36. [PMID: 35211383 PMCID: PMC8807421 DOI: 10.21037/acs-2021-taes-109] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 10/04/2021] [Indexed: 02/13/2024]
Abstract
BACKGROUND Patients with genetic or heritable aortic conditions and thoracic aortic aneurysm syndrome often develop cardiovascular abnormalities originating at the aortic root and affecting the entire thoracoabdominal aorta. Although thoracic endovascular aortic repair (TEVAR) is usually avoided in these patients, TEVAR may be worthwhile for those at high risk for surgical complications and in certain emergency circumstances. We explored indications for TEVAR in patients with suspected or confirmed genetic or heritable aortic conditions and investigated early and mid-term outcomes. METHODS Our institutional aortic surgery database was queried for patients with suspected or confirmed Marfan syndrome, Loeys-Dietz syndrome, Ehlers-Danlos syndrome, Turner syndrome, neurofibromatosis, or familial aortic aneurysm and dissection who underwent TEVAR between February 1, 2002 and October 31, 2020. We extracted operative details and in-hospital, follow-up, and survival data. RESULTS Thirty-seven patients who underwent 40 endovascular interventions met the inclusion criteria; 25 previously underwent ascending aorta or aortic root surgery, and 21 previously underwent open thoracoabdominal surgery. Postoperative complications included respiratory failure (24.3%), cardiac complications (16.2%), renal failure (13.5%), tracheostomy (8.1%), and spinal cord ischemia (paraplegia/paraparesis) (8.1%). Follow-up ranged from 1.3 to 8.5 years (median: 3.6 years), with 15 deaths overall (three early/in-hospital). Thirteen patients (35.1%) had 22 repeat interventions (open and endovascular) post-TEVAR; five had the endograft removed. CONCLUSIONS Despite consensus that thoracic aneurysms in patients with genetic or heritable aortic conditions should be treated with conventional open surgery, the outcomes from our study suggest that TEVAR might be suitable in emergency settings or for patients in this population who are not candidates for open surgery, who are at high risk for reintervention, or who have a previously implanted Dacron graft. Nonetheless, lifelong surveillance is important for these patients after TEVAR to monitor for new dissection at distal or proximal landing zones, as repeat interventions are frequent.
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Affiliation(s)
- Alice Le Huu
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Jacqueline K. Olive
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Davut Cekmecelioglu
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
| | - Subhasis Chatterjee
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
| | - Hiruni S. Amarasekara
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Susan Y. Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Joseph S. Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
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15
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Eleshra A, Panuccio G, Spanos K, Rohlffs F, von Kodolitsch Y, Kölbel T. Safety and Effectiveness of TEVAR in Native Proximal Landing Zone 2 for Chronic Type B Aortic Dissection in Patients With Genetic Aortic Syndrome. J Endovasc Ther 2021; 29:717-723. [PMID: 34894819 DOI: 10.1177/15266028211061276] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The aim of this study is to report the safety and effectiveness of thoracic endovascular aortic repair (TEVAR) in a native proximal landing zone (PLZ) 2 for chronic type B aortic dissection (TBAD) patients with genetic aortic syndrome (GAS). METHODS A retrospective review of a single center database to identify patients with GAS treated with TEVAR in native PLZ 2 for chronic TBAD and thoracic false lumen aneurysm between February 2012 and February 2018 was undertaken. RESULTS In total, 31 patients with GAS (24 Marfan syndrome [MFS], 5 Loeys-Dietz syndrome [LDS], and 2 vascular Ehlers-Danlos syndrome [vEDS]) were treated by endovascular repair. Nineteen patients were treated by TEVAR as index procedures with 8 patients (5 females, mean age = 55, range = 36-79 years old) receiving TEVAR in native PLZ 2. Left subclavian artery (LSA) perfusion was preserved in all 8 patients: by left common carotid artery-LSA bypass in 6 patients, chimney stenting of the LSA in 1 patient, and partial coverage of LSA ostium in 1 patient. Technical success was achieved in all patients (100%). There was no 30 day mortality (0%). The 30 day morbidity (0%) was free from major complications. The median follow-up was 40 months (range = 7-79). One patient died due to non-aortic-related cause. Native PLZ 2 was free from complications in MFS patients (5/8). Two patients with LDS developed type Ia endoleak with aneurysmal progression. One patient was treated by proximal extension with a double inner branched arch stent-graft landing in the replaced ascending aorta. The other one was treated with frozen elephant trunk. CONCLUSION Thoracic endovascular aortic repair in native PLZ 2 was safe and effective with no early or midterm PLZ complications in patients with MFS with chronic TBAD in this limited series. Native PLZ 2 is not safe in patients with LDS and should only be used in emergencies as a bridging to open repair.
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Affiliation(s)
- Ahmed Eleshra
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Konstantinos Spanos
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Yskert von Kodolitsch
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany
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16
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Zeigler SM, Sloan B, Jones JA. Pathophysiology and Pathogenesis of Marfan Syndrome. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1348:185-206. [PMID: 34807420 DOI: 10.1007/978-3-030-80614-9_8] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Marfan syndrome (MFS) is a systemic connective tissue disorder that is inherited in an autosomal dominant pattern with variable penetrance. While clinically this disease manifests in many different ways, the most life-threatening manifestations are related to cardiovascular complications including mitral valve prolapse, aortic insufficiency, dilatation of the aortic root, and aortic dissection. In the past 30 years, research efforts have not only identified the genetic locus responsible but have begun to elucidate the molecular pathogenesis underlying this disorder, allowing for the development of seemingly rational therapeutic strategies for treating affected individuals. In spite of these advancements, the cardiovascular complications still remain as the most life-threatening clinical manifestations. The present chapter will focus on the pathophysiology and clinical treatment of Marfan syndrome, providing an updated overview of the recent advancements in molecular genetics research and clinical trials, with an emphasis on how this information can focus future efforts toward finding betters ways to detect, diagnose, and treat this devastating condition.
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Affiliation(s)
- Sanford M Zeigler
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Brandon Sloan
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Jeffrey A Jones
- Division of Cardiothoracic Surgery, Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA.
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17
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Delaney CL, Milner R, Loa J. The Impact of Degenerative Connective Tissue Disorders on Outcomes Following Endovascular Aortic Intervention in the Global Registry for Endovascular Aortic Treatment. Ann Vasc Surg 2021; 79:81-90. [PMID: 34644638 DOI: 10.1016/j.avsg.2021.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 07/05/2021] [Accepted: 07/05/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Endovascular therapy for the management of aortic pathology in patients with degenerative connective tissue disorder (DCTD) is controversial. Current guidelines are based on a paucity of literature and registry data are lacking. This study reports on medium term outcomes of patients with diagnosed DCTD compared to those without DCTD who were included in the W.L. Gore Global Registry for Endovascular Aortic Treatment (GREAT). METHODS Patients included in the GREAT registry who underwent treatment for any thoracic or abdominal aortic pathology were included and grouped according to the presence or absence of a DCTD. Baseline demographic and procedural data were collected as well as data relating to key outcomes within 5 years follow-up, including all-cause mortality, aortic-related mortality, reinterventions and serious adverse events (SAE). Multivariable Cox proportional hazards models were built to determine if any association existed between the presence of DCTD and any key outcomes. RESULTS The analysis included 92 (1.9%) with DCTD and 4741 (98.1%) without DCTD. Patients with DCTD were more likely to be female (34.8% vs. 18.5%, P < .0001) and younger (66.8 [15.1] vs. 71.7 [10.3] years, P = .013) than those without DCTD. They were also more likely to have had prior aortic intervention (22.8% vs. 13.9%, P = .015) and an associated branch vessel procedure with the index operation (30.3% vs. 18.6%, P = .005). The majority of reinterventions in both groups occurred within the first 2 years and multivariable models demonstrated that the presence of DCTD was not predictive of all-cause mortality, aortic-related mortality, reinterventions or SAE within 5 years. CONCLUSIONS Within the limitations of registry data, this work demonstrates the medium term safety and durability of endovascular stent-grafts across a spectrum of aortic pathology in some patients with DCTD. More work is required to determine the applicability of these findings to specific sub-types of DCTD and aortic pathology.
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Affiliation(s)
- Christopher L Delaney
- Department of Vascular and Endovascular Surgery, Flinders Medical Centre and Flinders University, Adelaide, Australia.
| | - Ross Milner
- Division of Vascular Surgery and Endovascular Therapy, University of Chicago Pritzker School of Medicine, Chicago
| | - Jack Loa
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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Jiang X, Chen B, Jiang J, Shi Y, Ma T, Fu W, Dong Z. Outcomes of endovascular therapy for Stanford type B aortic dissection in patients with Marfan syndrome. J Thorac Cardiovasc Surg 2021; 165:1999-2007.e1. [PMID: 34176615 DOI: 10.1016/j.jtcvs.2021.05.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 05/13/2021] [Accepted: 05/18/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To evaluate the mid-term outcomes of thoracic endovascular aorta repair (TEVAR) for Stanford type B aortic dissection (TBAD) in patients with Marfan syndrome (MFS). METHODS Between January 2009 and December 2019, patients with MFS who underwent TEVAR for TBAD were enrolled. Demographic data, preoperative and perioperative clinical profiles, and follow-up data were collected and analyzed. The cumulative survival and freedom from reintervention rates were calculated with Kaplan-Meier analysis. RESULTS A total of 26 patients were enrolled. The mean age was 38.5 ± 10.7 (range, 24-64 years). The in-hospital mortality was 0. The cumulative survival rate was 88.1% (95% confidence interval [CI], 67.5%-98.5%) at 5 years and 82.9% (95% CI, 60.2%-93.3%) at 10 years. Patients with a thrombosed false lumen (FL) along the length of the stent had a significantly higher cumulative survival rate (P < .05) and freedom from reintervention (P = .01) than patients with patent FL. The freedom from reintervention was 83.4% (95% CI, 61.4% to 93.4%) at 5 years and 50.3% (95% CI, 21.4%-97.3%) at 10 years. There was no significant difference freedom from reintervention in freedom from reintervention between patients with and those without a previous aortic root procedure (P = .46). CONCLUSIONS TEVAR can be performed safely and effectively for TBAD in patients with MFS. Perioperative mortality and morbidity were low; however, lifelong close follow-up in the clinic and imaging are mandatory to prevent aortic rupture. Patients with a patent FL were at high risk of late death.
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Affiliation(s)
- Xiaolang Jiang
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Bin Chen
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Junhao Jiang
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yun Shi
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tao Ma
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Weiguo Fu
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Zhihui Dong
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.
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A novel technique for the treatment of a ruptured para-anastomotic thoracic aortic aneurysm in the presence of a chronic abdominal aortic dissection. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2021; 7:350-353. [PMID: 34095640 PMCID: PMC8163864 DOI: 10.1016/j.jvscit.2021.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 03/19/2021] [Indexed: 11/22/2022]
Abstract
We report the case of a 69-year-old woman with Marfan syndrome and a history of multiple thoracic aortic surgeries and a coexisting dissection of her abdominal aorta. She had presented with a ruptured para-anastomotic thoracic aortic aneurysm due to an infected graft. She was treated with two parallel Nellix endografts that were placed in the true and false lumens. The surrounding endobags were inflated with a polymer that completely sealed the ruptured aorta and preserved blood flow to the visceral arteries. Postoperative imaging showed complete exclusion of the aneurysm with patency of all aortic branches and no evidence of endoleak.
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20
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Shalhub S, Wallace S, Okunbor O, Newhall K. Genetic aortic disease epidemiology, management principles, and disparities in care. Semin Vasc Surg 2021; 34:79-88. [PMID: 33757640 DOI: 10.1053/j.semvascsurg.2021.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Patients with syndromic and nonsyndromic heritable aortopathies (also known as genetic aortic disease) are a heterogeneous group of patients who present at younger ages with more rapid growth of aortic aneurysms and/or increased frequency of dissections compared with patients with atherosclerotic aortopathies. In this review, we describe the etiology, epidemiology, and appropriate care delivery for these conditions at each stage of management. Within each section, we discuss sex, gender, and race differences and highlight disparities in care and knowledge. We then discuss the role of the vascular team throughout the cycle of care and the evolving inclusion of patient input in research. This understanding is essential to the creation of effective health care policies that support equitable, appropriate, and patient-centered clinical practices.
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Affiliation(s)
- Sherene Shalhub
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195.
| | - Stephanie Wallace
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195
| | - Osa Okunbor
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195
| | - Karina Newhall
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195
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21
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Odofin X, Houbby N, Hagana A, Nasser I, Ahmed A, Harky A. Thoracic aortic aneurysms in patients with heritable connective tissue disease. J Card Surg 2021; 36:1083-1090. [PMID: 33476431 DOI: 10.1111/jocs.15340] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 12/26/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Patients with connective tissue diseases are at high lifetime risk of developing thoracic aortic aneurysms (TAAs) due to defects in extracellular matrix composition which compromise the structural integrity of the aortic wall. It is vital to identify and manage aneurysms early to prevent fatal complications such as dissection or rupture. METHOD This review synthesises information obtained from a thorough literature search regarding the pathophysiology of TAAs in those with heritable connective tissue diseases (HCTDs), the investigations for timely diagnosis and current operative strategies. RESULTS Major complications of open repair (OR) include pneumonia (32%), haemorrhage (31%) and tracheostomy (18%), with a minor risk of vocal cord paresis (9%). For thoracic endovascular aortic repair (TEVAR), high rates of endoleak were documented (38-66.6%). Reintervention rates for TEVAR are also high at 38-44%. Mortality rates were documented as 25% for open repair and vary from 14% to 44% for TEVAR. CONCLUSION OR remains the mainstay of surgical management. While TEVAR use is expanding, it remains the alternative choice due to concerns over endograft durability, limited long-term outcome data and the lack of high-quality evidence regarding its use in HCTD patients.
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Affiliation(s)
- Xuan Odofin
- Faculty of Medicine, Imperial College School of Medicine, Imperial College London, London, UK
| | - Nour Houbby
- Faculty of Medicine, Imperial College School of Medicine, Imperial College London, London, UK
| | - Arwa Hagana
- Faculty of Medicine, Imperial College School of Medicine, Imperial College London, London, UK
| | - Ibrahim Nasser
- Faculty of Medicine, Imperial College School of Medicine, Imperial College London, London, UK.,Leicester Medical School, College of Life Sciences, University of Leicester, Leicester, UK
| | | | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.,Department of Integrative Biology, Faculty of Life Sciences, University of Liverpool, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, Liverpool, UK
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Harky A, Hussain SMA, MacCarthy-Ofosu B, Ahmad MU. The Role of Thoracic Endovascular Aortic Repair (TEVAR) of Thoracic Aortic Diseases in Patients with Connective Tissue Disorders - A Literature Review. Braz J Cardiovasc Surg 2020; 35:977-985. [PMID: 33306324 PMCID: PMC7731863 DOI: 10.21470/1678-9741-2019-0367] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To review the currently available literature to define the role of thoracic endovascular aortic repair (TEVAR) in patients with connective tissue disorders (CTD). METHODS A comprehensive electronic database search was performed in PubMed, SCOPUS, Embase, Google scholar, and OVID to identify all the articles that reported on outcomes of utilizing TEVAR in patients with CTD during elective and emergency settings. The search was not limited to time or language of the published study. RESULTS All the relevant studies have been summarized in its correspondence section. The outcomes were analyzed in narrative format. The role of TEVAR has been elaborated as per each study. Currently, there is limited large cohort size studies outlining the use of TEVAR in patients with CTD. The use of endovascular repair in patients with CTD is limited due to progressive aortic dilatations and high possibility of further reinterventions at later stage of life. CONCLUSION Open repair remains the gold standard method of intervention in young patients with progressive CTD, especially in the setting of acute type A aortic dissection. However, TEVAR can be sought as a reliable alternative in emergency setting of diseases involving the descending thoracic aorta; yet the long-term data needs to be published to support such practice.
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Affiliation(s)
- Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK
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Shalhub S, Rah JY, Campbell R, Sweet MP, Quiroga E, Starnes BW. Characterization of syndromic, nonsyndromic familial, and sporadic type B aortic dissection. J Vasc Surg 2020; 73:1906-1914.e2. [PMID: 33249204 DOI: 10.1016/j.jvs.2020.10.080] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 10/25/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Type B aortic dissection (TBAD) is commonly thought of as a sporadic event. However, an increasing body of data has suggested that genetic factors can influence TBAD. Our aim was to determine the prevalence of heritable TBAD, defined as either syndromic TBAD or nonsyndromic familial TBAD and to detail the natural history and long-term clinical outcomes compared with patients with "sporadic" TBAD without an identified syndrome or family history. METHODS The clinical records of 389 patients with TBAD who had presented to a single health care system from 1995 to 2017 were reviewed. A family history was obtained by interview and/or medical record review. Syndromic TBAD was defined as TBAD in patients with Marfan, Loeys-Dietz, or vascular Ehlers-Danlos syndrome. Nonsyndromic familial TBAD was defined as a family history of aortic or arterial aneurysm or dissection and/or sudden death in a first- or second-degree relative in the absence of a known syndrome. Patients with syndromic and nonsyndromic familial TBAD were compared with patients with sporadic TBAD in terms of the comorbid conditions, aortic repair, and mortality. RESULTS Of 389 patients (71.2% male) with TBAD, the etiology of TBAD was heritable in 27.9% (9.6% syndromic; 18.3% nonsyndromic familial TBAD) and 72.1% sporadic of the cases. Patients with syndromic and nonsyndromic familial TBAD had been more frequently referred in the chronic phase than were the patients with sporadic TBAD (35.5% vs 44.1% vs 25.8%; P = .014) and had presented at a younger age (40.6 ± 10.9 years vs 55.2 ± 11.3 years vs 62 ± 12.9 years; P < .001) and with lower blood pressure at acute TBAD (systolic, 159.2 ± 21 mm Hg vs 178.9 ± 39.3 mm Hg vs 186.1 ± 38.4, P = .01; diastolic, 84.3 ± 17.3 mm Hg vs 91.4 ± 24.1 mm Hg vs 101.6 ± 22.3 mm Hg, P = .001). Among patients with acute TBAD surviving to discharge from the initial hospitalization, thoracic endovascular aortic repair (TEVAR) had been performed in 115 patients, with no significant differences in TEVAR usage in the three groups. However, those with syndromic and nonsyndromic familial TBAD had had a greater incidence of retrograde aortic dissection after TEVAR (33.3% vs 15% vs 3%; P = .006). They had also required a greater number of arch repairs (30% vs 10.5% vs 3.6%; P < .001) and had died at a younger age (47.7 ± 13.1 years vs 65.7 ± 13.7 years vs 72.8 ± 12.7 years; P < .001). Aortic-related mortality was more common among patients with syndromic TBAD (36.7% vs 12.3% vs 17.6%; P = .016). CONCLUSIONS In our single-institutional experience, heritable TBAD accounted for one in four patients with TBAD. Nonsyndromic familial TBAD was twice as common as syndromic TBAD and appeared to share many clinical features. Identifying these patients early in their disease course and personalizing their care might improve their survival.
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Affiliation(s)
- Sherene Shalhub
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, Wash.
| | - Jasmine Y Rah
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Rebecca Campbell
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Matthew P Sweet
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Elina Quiroga
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Benjamin W Starnes
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, Wash
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Management of the aortic arch in patients with Loeys–Dietz syndrome. J Thorac Cardiovasc Surg 2020; 160:1166-1175. [DOI: 10.1016/j.jtcvs.2019.07.130] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 07/05/2019] [Accepted: 07/11/2019] [Indexed: 01/14/2023]
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Chassin-Trubert L, Ozdemir BA, Roussel A, Dessertenne G, Castier Y, Ludovic C, Alric P. Prevention of Retrograde Ascending Aortic Dissection by Cardiac Pacing During Hybrid Surgery for Zone 0 Aortic Arch Repair. Ann Vasc Surg 2020; 71:48-55. [PMID: 32927033 DOI: 10.1016/j.avsg.2020.08.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/15/2020] [Accepted: 08/18/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Retrograde type A dissection (RTAD) after zone 0 hybrid aortic arch repair is highly lethal and not infrequent complication. The aim of this study was to assess the safety and effectiveness of rapid cardiac pacing as an adjunctive tool to prevent RTAD during or after hybrid procedures for zone 0 disease. METHODS We performed a retrospective review of 42 consecutive patients with zone 0 hybrid aortic arch repair between November 2004 and January 2018. Right ventricular pacing was carried out through unipolar electrodes attached to the epicardium of the right ventricle through the sternotomy (the indifferent electrode was in the subcutaneous tissue). Pacing was utilised during the clamping of the ascending aorta, release of the aortic clamp, and stent-graft deployment. RESULTS Operative indications were aortic arch aneurysm 45% (n = 19), aortic arch dissection 45% (n = 19), traumatic rupture of isthmus 7% (n = 3), and type IA endoleak 2% (n = 1). Urgent procedures 48% (n = 20). The mean proximal aortic diameter was 34.14 ± 2.9 mm. Mean stent-graft oversizing was 12.97 ± 3.4%. The 30-day mortality rate was 14% (n = 6). RTAD was observed in 7% (n = 3). The actuarial survival rate was 74% over a mean follow-up of 50 ± 30.2 months. Since January 2013, rapid right ventricular pacing (overdrive pacing at a rate of 200 beats/min) was systematically used (n = 24). No RTAD was observed in this group of patients. Rapid right ventricular pacing reduced significatively the risk of RTAD (P = 0.038). CONCLUSIONS Rapid right ventricular pacing is an effective method of inducing hypotension and appears to decrease the risk of retrograde type A dissection after zone 0 hybrid aortic arch repair.
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Affiliation(s)
- Lucien Chassin-Trubert
- Department of Vascular and Thoracic Surgery, Arnaud de Villeneuve Hospital, Montpellier, France; Clínica Universidad de los Andes, Servicio de Cirugía Vascular y Endovascular, Santiago, Chile.
| | - Baris Ata Ozdemir
- Department of Vascular and Thoracic Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Arnaud Roussel
- Department of Vascular and Thoracic Surgery, Bichat Hospital, Paris, France
| | | | - Yves Castier
- Department of Vascular and Thoracic Surgery, Bichat Hospital, Paris, France
| | - Canaud Ludovic
- Department of Vascular and Thoracic Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Pierre Alric
- Department of Vascular and Thoracic Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
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Lovato L, Cefarelli M, Gatta E, Di Eusanio M, Fattori R. Devices for thoracic endovascular aortic repair of type B aortic dissection: is there any chance for Marfan syndrome? Expert Rev Med Devices 2020; 17:683-696. [DOI: 10.1080/17434440.2020.1782735] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Luigi Lovato
- Cardio-Thoracic-Vascular Department, Cardiovascular Radiology Unit and Marfan Center; S.Orsola-Malpighi Hospital; University of Bologna, Italy
| | - Mariano Cefarelli
- Cardiovascular Department, Cardiac Surgery Unit and Marfan Center; Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Emanuele Gatta
- Cardiovascular Department, Vascular Surgery Unit and Marfan Center; Lancisi Cardiovascular Center, Ancona, Italy
| | - Marco Di Eusanio
- Cardiovascular Department, Cardiac Surgery Unit and Marfan Center; Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Rossella Fattori
- Cardiovascular Department, Marfan Center; Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
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27
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Qato K, Conway A, Lu E, Tran NN, Giangola G, Carroccio A. Outcomes of Thoracic Endovascular Aneurysm Repair (TEVAR) in Patients With Connective Tissue Disorders. Vasc Endovascular Surg 2020; 54:676-680. [DOI: 10.1177/1538574420945070] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: Thoracic endovascular aortic repair (TEVAR) remains controversial in patients with connective tissue disorders given the concern for durability. We report on the largest series to date on outcomes of patients with thoracic aortic disease and connective tissue disorders treated with TEVAR. Methods: The Vascular Quality Initiative registry identified 12 207 patients treated with TEVAR from January 2010 to December 2018, including 102 with Marfans, Ehlers-Danlos, or Loey-Dietz syndrome. Outcomes were analyzed per the Society for Vascular Surgery reporting standards. Results: Median age was 50.6 years (interquartile range: 57.0-75.0), and 62 (60.7%) were male. Eighty-eight (86.3%) patients had Marfan, 9 (8.8%) had Ehlers-Danlos, and 5 (4.9%) had Loey-Dietz syndrome. Twenty-six (25.5%) patients were treated for degenerative aneurysmal disease and 76 (74.5%) patients for type B dissections (33 acute, 31 chronic). Most common indications for interventions in patients with type B dissection were pain (n = 41), aneurysmal degeneration (n = 16), and malperfusion (n = 8), with 3 patients who presented ruptured. There was no significant difference in perioperative complications between acute/chronic dissections and aneurysms ( P = .14). Percutaneous access was utilized in 61.7% of patients, with a 2.9% rate of arterial injury requiring reintervention. Follow-up data were available for 75 (73.3%) patients at a mean follow-up of 15.6 months. Overall mortality was 5.3%. There were 30 patients with follow-up endoleak data, and 8 (26.7%) endoleaks were identified. All endoleaks were in patients treated for acute type B dissection, and all resolved after a mean of 2.1 reinterventions. Three patients treated for acute Type B Aortic Dissection (TBAD) had retrograde dissections requiring intervention. Discussion: Thoracic endovascular aortic repair for patients with connective tissue disorders can be performed with low perioperative mortality, spinal cord ischemia, or Cerebrovascular Accident (CVA). On follow-up, acute type B aortic dissections represent a higher risk subgroup with increased rates of endoleak and retrograde dissection. Closer follow-up for these patients and early reintervention may be beneficial.
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Affiliation(s)
- Khalil Qato
- Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Allan Conway
- Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Eileen Lu
- Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | | | - Gary Giangola
- Northwell Health, Lenox Hill Hospital, New York, NY, USA
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Jayarajan SN, Downing BD, Sanchez LA, Jim J. Trends of vascular surgery procedures in Marfan syndrome and Ehlers-Danlos syndrome. Vascular 2020; 28:834-841. [DOI: 10.1177/1708538120925597] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives Marfan syndrome and Ehlers-Danlos syndrome represent two connective tissue vascular diseases requiring unique consideration in their vascular surgical care. A comprehensive national review encompassing all hospitalizations for the Marfan Syndrome and Ehlers-Danlos syndrome patient population is lacking. Methods The National (Nationwide) Inpatient Sample from 2010 to 2014 was reviewed for all inpatient vascular surgery procedures including those with a diagnosis of Marfan syndrome and Ehlers-Danlos syndrome. National estimates of vascular surgery rates were generated from provided weights. Patient demographics, procedure type, and outcomes were assessed. Results There were 3103 Marfan syndrome and 476 Ehlers-Danlos syndrome vascular procedures identified as well as 3,895,381 vascular procedures in the remainder of population (control group). The percent of aortic procedures from all vascular procedures in Marfan syndrome (23.5%) and Ehlers-Danlos syndrome (23.5%) were 2.5-fold higher than controls (9.1%), p < 0.0001. Open aortic aneurysm repair was also significantly greater in both Marfan syndrome (16.8%) and Ehlers-Danlos syndrome (11.2%) compared to controls (4.4%), p < 0.0001. Endovascular aortic repair ( p < 0.2302) was similar among the groups. Marfan syndrome (7.7%) and Ehlers-Danlos syndrome (5.1%) had more thoracic endovascular aortic repair performed than controls (0.7%), p < 0.0001. Percutaneous procedures were fewer in Marfan syndrome (6.3%) than controls (31.3%) and Ehlers-Danlos syndrome (26.3%), p < 0.0001, while repair of peripheral arteries was greater in Marfan syndrome (5.9%) and Ehlers-Danlos syndrome (4.1%) than controls (1.5%), p < 0.0001. For total aortic procedures, the mean age of aortic procedures was 68.2 years in controls vs 45.8 years in Marfan syndrome and 55.3 years in Ehlers-Danlos syndrome, p < 0.0001. Marfan syndrome and Ehlers-Danlos syndrome had fewer comorbidities overall, while controls had significantly higher rates of coronary artery disease (controls 39.9% vs Marfan syndrome 8.3% and Ehlers-Danlos syndrome 13.0%, p < 0.0001), peripheral vascular disease (controls 34.5% vs Marfan syndrome 4.2% and Ehlers-Danlos syndrome 8.7%, p < 0.0001), and diabetes (controls 20.6% vs Marfan syndrome 6.6 and Ehlers-Danlos syndrome 4.4%, p < 0.0001). Marfan syndrome and Ehlers-Danlos syndrome had higher overall complication rate (65.5% and 52.2%) compared to controls (44.6%), p < 0.0001. Postoperative hemorrhage was more likely in Marfan syndrome (42.9%) and Ehlers-Danlos syndrome (39.1%) than controls (22.2%), p < 0.0001. Increased respiratory failure was noted in Marfan syndrome (20.2%) vs controls (10.7%) and Ehlers-Danlos syndrome (8.7%), p = .0003. Finally, length of stay was increased in Marfan syndrome 12.5 days vs Ehlers-Danlos syndrome 7.4 days and controls 7.2 days ( p < 0.0001) as well as a higher median costs of index hospitalization in Marfan syndrome ($57,084 vs Ehlers-Danlos syndrome $22,032 and controls $26,520, p < 0.0001). Conclusions Patients with Marfan syndrome and Ehlers-Danlos syndrome differ from other patients undergoing vascular surgical procedures, with a significantly higher proportion of aortic procedures including open aneurysm repair and thoracic endovascular aortic repair. While they are younger with fewer comorbidities, due to the unique pathogenesis of their underlying connective tissue disorder, there is an overall higher rate of procedural complications and increased length of stay and cost for Marfan syndrome patients undergoing aortic surgery.
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Affiliation(s)
- Senthil N Jayarajan
- Section of Vascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Brandon D Downing
- Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Luis A Sanchez
- Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jeffrey Jim
- Section of Vascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA
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Pellenc Q, Girault A, Roussel A, De Blic R, Cerceau P, Raffoul R, Milleron O, Jondeau G, Castier Y. Optimising Aortic Endovascular Repair in Patients with Marfan Syndrome. Eur J Vasc Endovasc Surg 2020; 59:577-585. [DOI: 10.1016/j.ejvs.2019.09.501] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 09/10/2019] [Accepted: 09/20/2019] [Indexed: 12/20/2022]
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Chou EL, Lindsay ME. The genetics of aortopathies: Hereditary thoracic aortic aneurysms and dissections. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2020; 184:136-148. [PMID: 32034893 DOI: 10.1002/ajmg.c.31771] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 01/28/2020] [Indexed: 12/15/2022]
Abstract
Aortopathies encompass a variety of inherited and acquired pathologies that increase risk of life-threatening dissection or rupture. Identifying individuals with hereditary thoracic aortic aneurysm and dissection (HTAAD) for longitudinal monitoring, medical therapy, or elective and preventative repair is paramount to reduce risk of cardiovascular-related mortality and complications from dissection and rupture. Over the past couple of decades, pathogenic variants in numerous genes have been identified in relation to HTAAD. The genetic diagnosis can help stratify patient risk and provide guidance on medical treatment, timing of prophylactic surgical repair, as well as longitudinal surveillance and imaging. Implicated genes and their associated proteins have been found to act on a diverse variety of pathways, cells and structural components linked to transforming growth factor beta (TGF-β) signaling pathways, disruption of the vascular smooth muscle cell contractile apparatus, and primary disruption of extracellular matrix homeostasis. This review describes relevant genetic variants that may help identify and guide the management of hereditary thoracic aortic aneurysms and dissections.
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Affiliation(s)
- Elizabeth L Chou
- Division of Vascular Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Thoracic Aortic Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark E Lindsay
- Thoracic Aortic Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Cardiovascular Genetics Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Pediatric Cardiology Division, Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Open Descending and Thoracoabdominal Aortic Repairs in Patients Younger Than 50 Years Old. Ann Thorac Surg 2019; 108:693-699. [DOI: 10.1016/j.athoracsur.2019.03.058] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 03/05/2019] [Accepted: 03/18/2019] [Indexed: 11/22/2022]
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Harky A, Iqbal R, Giordano V, Al-Adhami A. Aortic endovascular stenting in patients with systemic connective tissue disorders: does the prohibitive dogma still stand tall? J Int Med Res 2019; 48:300060519863963. [PMID: 31354092 PMCID: PMC7579328 DOI: 10.1177/0300060519863963] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Endovascular repair of thoracic aortic diseases can provide satisfactory
outcomes in elective and certain emergency cases involving the
descending thoracic and aortic arch. However, open repair remains the
gold standard method of aortic root pathologies and certain aortic
arch pathologies, such as extended dissection. Nevertheless, the use
of endovascular stenting in patients with connective tissue disorders
has not been fully explored because the aortic tissues are fragile and
the likelihood of keeping the stent in place is low because of its
progressive dilatation and subsequent requirement for open repair at a
later stage when the stent graft fails. Our brief review focuses on
current evidence of the use of stents in patients with connective
tissue disorders and whether such practice can be expanded
further.
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Affiliation(s)
- Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK
| | - Rizwan Iqbal
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Vincenzo Giordano
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ahmed Al-Adhami
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
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Treatment of thoracoabdominal aortic disease in patients with connective tissue disorders. J Vasc Surg 2018; 68:1257-1267. [DOI: 10.1016/j.jvs.2018.06.199] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 06/21/2018] [Indexed: 11/21/2022]
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Endovascular thoracic aortic repair in confirmed or suspected genetically triggered thoracic aortic dissection. J Vasc Surg 2018; 68:364-371. [DOI: 10.1016/j.jvs.2017.11.095] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 11/26/2017] [Indexed: 01/16/2023]
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Tinelli G, Ferraresi M, Watkins AC, Hertault A, Soler R, Azzaoui R, Fabre D, Sobocinski J, Haulon S. Aortic treatment in connective tissue disease. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 60:518-525. [PMID: 29943958 DOI: 10.23736/s0021-9509.18.10443-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Connective tissue disease (CTD) represents a group of genetic conditions characterized by disruptive matrix remodeling. When this process involves aortic and vascular wall, patients with CTD have a high risk of developing arterial aneurysms, dissections and ruptures. Open surgical repair is still the gold standard therapy for patients with CTD with reasonable morbidity and mortality risk. The surgical treatment of CTD often requires multiple operations. In the endovascular era, fenestrated and branched stent grafts may play a role in reducing the complications of multiple open operations. Although the long-term results of endovascular treatment in the setting of CTD are unknown, it is generally accepted that endovascular treatment is restricted to selected patients with high surgical risk. In an emergency setting, endovascular intervention can serve as a lifesaving bridge to elective open aortic repair. Aortic centers performing a large volume of complex open and endovascular aortic repairs have started to combine these two techniques in a staged fashion. The goal is to reduce the morbidity and mortality associated with extensive aortic repairs in CTD patients. For this reason, recommend endovascular therapy when a "graft-to-graft" approach is possible. In this scenario, the surgeon who performs the open repair must take into consideration future interventions. Surgical repair in any aortic segment should allow creation of proximal and distal landing zones over 4 cm to secure the sealing of a future stent graft. Connective tissue disease should be treated with a multidisciplinary approach, in high volume centers. Endovascular treatment represents a potential option in patients at high risk for open repair. Staged hybrid procedures have emerged as a way to reduce spinal cord ischemia and avoid multiple open surgeries. The aim of this article is to discuss the management of aortic diseases in CTD, focusing on to the role of standard open surgery and emerging endovascular treatment, and to give an overview of the few series published regarding this topic with a small number of patients.
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Affiliation(s)
- Giovanni Tinelli
- Vascular Unit, Department of Cardiovascular Surgery, Gemelli Foundation IRCCS, School of Medicine, Sacred Heart Catholic University, Rome, Italy -
| | - Marco Ferraresi
- Vascular Unit, Department of Cardiovascular Surgery, Gemelli Foundation IRCCS, School of Medicine, Sacred Heart Catholic University, Rome, Italy
| | - Amelia C Watkins
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | | | - Raphael Soler
- Aortic Center, Marie Lannelongue Hospital, Paris Sud University, Le Plessis Robinson, France
| | | | - Dominique Fabre
- Aortic Center, Marie Lannelongue Hospital, Paris Sud University, Le Plessis Robinson, France
| | | | - Stéphan Haulon
- Aortic Center, Marie Lannelongue Hospital, Paris Sud University, Le Plessis Robinson, France
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Kölbel T, Tsilimparis N, Mani K, Rohlffs F, Wipper S, Debus ES, Kodolitsch YV, Wanhainen A. Physician-Modified Thoracic Stent-Graft With Low Distal Radial Force to Prevent Distal Stent-Graft–Induced New Entry Tears in Patients With Genetic Aortic Syndromes and Aortic Dissection. J Endovasc Ther 2018; 25:456-463. [DOI: 10.1177/1526602818774795] [Citation(s) in RCA: 14] [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 describe a novel modification technique to lower the distal radial force of a thoracic stent-graft so as to avert stent-graft–induced new entry tears (SINE) in the fragile aorta of patients with genetic aortic disease and aortic dissection. Technique: A commercially available thoracic stent-graft is partially deployed on a back table. The most distal Z-stent is removed, the distal fabric is marked by vascular clips, and the modified stent-graft is reloaded and deployed in the true lumen of an aortic dissection. The technique is demonstrated in 3 patients with aortic dissection related to genetic aortic diseases. Conclusion: Creating a low distal radial force stent-graft is easy and can be done in a short time. Endovascular implantation appears feasible and safe.
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Affiliation(s)
- Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, Hamburg, Germany
| | - Nikolaos Tsilimparis
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, Hamburg, Germany
| | - Kevin Mani
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Fiona Rohlffs
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, Hamburg, Germany
| | - Sabine Wipper
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, Hamburg, Germany
| | - E. Sebastian Debus
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, Hamburg, Germany
| | - Yskert von Kodolitsch
- German Aortic Center Hamburg, Department of Cardiology, University Heart Center, Hamburg, Germany
| | - Anders Wanhainen
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Ouzounian M, LeMaire SA. How can genetic diagnosis inform the decision of when to operate? J Vis Surg 2018; 4:68. [PMID: 29780714 DOI: 10.21037/jovs.2018.03.08] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 03/07/2018] [Indexed: 12/16/2022]
Abstract
Genetic discovery for heritable thoracic aortic disease (HTAD) has been progressing at a brisk pace. Surgical management of thoracic aortic aneurysms and dissections has become more personalized, with genetic factors increasingly informing the decision of when to operate on patients. An improved understanding of genotype-phenotype correlations in patients with HTAD will ultimately lead to gene- and mutation-specific recommendations for surgical repair. Until more robust data from larger cohorts can inform our decisions, patients with HTAD should be seen by an aortic specialist for a tailored approach to elective surgical repair.
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Affiliation(s)
- Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, and the Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas, USA.,Cardiovascular Surgery Service, The Texas Heart Institute, Houston, Texas, USA
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Puluca N, Burri M, Cleuziou J, Krane M, Lange R. Consecutive operative procedures in patients with Marfan syndrome up to 28 years after initial aortic root surgery. Eur J Cardiothorac Surg 2018; 54:504-509. [DOI: 10.1093/ejcts/ezy065] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 01/17/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Nazan Puluca
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Department of Cardiovascular Surgery, Institute for Translational Cardiac Surgery (INSURE), German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Department of Cardiovascular Surgery, Institute for Translational Cardiac Surgery (INSURE), German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Julie Cleuziou
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Department of Cardiovascular Surgery, Institute for Translational Cardiac Surgery (INSURE), German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Markus Krane
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Department of Cardiovascular Surgery, Institute for Translational Cardiac Surgery (INSURE), German Heart Center Munich, Technische Universität München, Munich, Germany
- German Heart Center Munich-DZHK Partner Site Munich Heart Alliance, Munich, Germany
| | - Rüdiger Lange
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Department of Cardiovascular Surgery, Institute for Translational Cardiac Surgery (INSURE), German Heart Center Munich, Technische Universität München, Munich, Germany
- German Heart Center Munich-DZHK Partner Site Munich Heart Alliance, Munich, Germany
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39
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Canaud L, Alric P. [Endovascular repair of the thoracic aorta]. Presse Med 2018; 47:153-160. [PMID: 29482890 DOI: 10.1016/j.lpm.2017.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 12/04/2017] [Accepted: 12/13/2017] [Indexed: 10/18/2022] Open
Abstract
Degenerative aneurysms of the thoracic aorta are increasing in prevalence. The recognition of the decreased morbidity of this approach compared with open repair was readily apparent, as it avoided left thoracotomy, aortic cross-clamping, and left heart bypass. Repair of isolated descending thoracic aortic aneurysms using stent grafts was introduced in 1995, and in an anatomically suitable subgroup of patients with thoracic aortic aneurysm, repair with endovascular stent graft provides favorable outcomes, with decreased perioperative morbidity and mortality relative to open repair. The cornerstones of successful thoracic endovascular aneurysm repair are appropriate patient selection, thorough preprocedural planning, and cautious procedural execution. Since then, TEVAR is increasingly being used for other aortic pathologies such as complicated type B dissection, traumatic aortic transection, and aneurysmal disease extending into the arch or visceral segment, requiring debranching procedures.
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Affiliation(s)
- Ludovic Canaud
- CHU de Montpellier, hôpital Arnaud-de-Villeneuve, service de chirurgie thoracique et vasculaire, 191, avenue Doyen-Gaston-Giraud, 34090 Montpellier, France.
| | - Pierre Alric
- CHU de Montpellier, hôpital Arnaud-de-Villeneuve, service de chirurgie thoracique et vasculaire, 191, avenue Doyen-Gaston-Giraud, 34090 Montpellier, France
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40
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Bin Mahmood SU, Velasquez CA, Zafar MA, Saeyeldin AA, Brownstein AJ, Ziganshin BA, Elefteriades JA, Mukherjee SK. Medical management of aortic disease in Marfan syndrome. Ann Cardiothorac Surg 2017; 6:654-661. [PMID: 29270377 DOI: 10.21037/acs.2017.11.09] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Marfan syndrome (MFS) is a hereditary disorder with numerous pathophysiological effects, some specifically creating elastic dysfunction in cardiovascular organs. Aortic dilatation, dissection and rupture are major concerns in the management of MFS patients. Predilection to form aneurysms is an indication for prophylactic medical management of thoracic aortic aneurysm disease in these patients. The current guidelines describe β-blockers as the standard of care with angiotensin receptor blockers (ARBs) emerging as an equal, if not better alternative. We elaborate current evidence for and against different medical regimens used for the medical management of MFS patients.
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Affiliation(s)
- Syed Usman Bin Mahmood
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Camilo A Velasquez
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Mohammad A Zafar
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Ayman A Saeyeldin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Adam J Brownstein
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Bulat A Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA.,Department of Surgical Disease #2, Kazan State Medical University, Kazan, Russia
| | - John A Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Sandip K Mukherjee
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
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Schoenhoff FS, Carrel TP. Re-interventions on the thoracic and thoracoabdominal aorta in patients with Marfan syndrome. Ann Cardiothorac Surg 2017; 6:662-671. [PMID: 29270378 DOI: 10.21037/acs.2017.09.14] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The advent of multi-gene panel genetic testing and the discovery of new syndromic and non-syndromic forms of connective tissue disorders have established thoracic aortic aneurysms as a genetically mediated disease. Surgical results in patients with Marfan syndrome (MFS) provide an important benchmark for this patient population. Prophylactic aortic root surgery prevents acute dissection and has contributed to the improved survival of MFS patients. In the majority of patients, re-interventions are driven by a history of dissection. Patients undergoing elective root repair have a low risk for re-interventions on the root itself. Experienced centers have results after valve-sparing procedures at 10 years comparable with those seen after a modified Bentall procedure. In patients where only the ascending aorta was replaced during the initial surgery, re-intervention rates are high as the root continues to dilate. The fate of the aortic arch in MFS patients presenting with dissection is strongly correlated with the extent of the initial surgery. Not replacing the entire ascending aorta and proximal aortic arch results in a high rate of re-interventions. Nevertheless, the additional burden of replacing the entire aortic arch during emergent proximal repair is not very well defined and makes comparisons with patients undergoing elective arch replacement difficult. Interestingly, replacing the entire aortic arch during initial surgery for acute dissection does not protect from re-interventions on downstream aortic segments. MFS patients suffering from type B dissection have a high risk for re-interventions ultimately leading up to replacement of the entire thoracoabdominal aorta even if the dissection was deemed uncomplicated by conventional criteria. While current guidelines do not recommend the implantation of stent grafts in MFS patients, implantation of a frozen-elephant-trunk to create a stable proximal landing zone for future endovascular or open procedures has emerged as a means to address aortic arch and descending aortic pathologies.
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Affiliation(s)
- Florian S Schoenhoff
- Department of Cardiovascular Surgery, University Hospital Bern, Bern, Switzerland
| | - Thierry P Carrel
- Department of Cardiovascular Surgery, University Hospital Bern, Bern, Switzerland
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42
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Clough RE, Martin-Gonzalez T, Van Calster K, Hertault A, Spear R, Azzaoui R, Sobocinski J, Haulon S. Endovascular Repair of Thoracoabdominal and Arch Aneurysms in Patients with Connective Tissue Disease Using Branched and Fenestrated Devices. Ann Vasc Surg 2017; 44:158-163. [DOI: 10.1016/j.avsg.2017.05.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 04/18/2017] [Accepted: 05/11/2017] [Indexed: 10/19/2022]
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Hinojosa CA, Anaya-Ayala JE, Laparra-Escareno H, Lizola R, Torres-Machorro A. Sequential Hybrid Repair of Aorta and Bilateral Common Iliac Arteries Secondary to Chronic Aortic Dissection with Extensive Aneurysmal Degeneration in a Marfan Patient. Vasc Specialist Int 2017; 33:112-116. [PMID: 28955701 PMCID: PMC5614380 DOI: 10.5758/vsi.2017.33.3.112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 06/09/2017] [Accepted: 06/19/2017] [Indexed: 11/20/2022] Open
Abstract
Marfan syndrome is a connective tissue disorder associated with aortic dissection, aneurysmal degeneration and rupture. These cardiovascular complications represent the main cause of mortality, therefore repair is indicated. We present a 35-year-old woman who experienced acute onset of chest pain. Her imaging revealed a chronic DeBakey type I dissection with aortic root dilation and descending thoracic aneurysmal degeneration. She underwent a Bentall procedure and endovascular exclusion of the descending thoracic aortic aneurysm. She was closely followed and 2 years later a computed tomography angiography (CTA) revealed the aneurysmal degeneration of the thoracoabominal aorta and bilateral iliac arteries. The patient underwent a composite reconstruction using multi-visceral branched and bifurcated Dacron grafts. At 5 years from her last surgery, a CTA revealed no new dissection or further aneurysmal degenerations. Aortic disease in Marfan patients is a complex clinical problem that may lead to secondary or tertiary aortic reconstructions; close follow-up is mandatory.
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Affiliation(s)
- Carlos A Hinojosa
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Javier E Anaya-Ayala
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Hugo Laparra-Escareno
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Rene Lizola
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Adriana Torres-Machorro
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Riambau V, Böckler D, Brunkwall J, Cao P, Chiesa R, Coppi G, Czerny M, Fraedrich G, Haulon S, Jacobs M, Lachat M, Moll F, Setacci C, Taylor P, Thompson M, Trimarchi S, Verhagen H, Verhoeven E, ESVS Guidelines Committee, Kolh P, de Borst G, Chakfé N, Debus E, Hinchliffe R, Kakkos S, Koncar I, Lindholt J, Vega de Ceniga M, Vermassen F, Verzini F, Document Reviewers, Kolh P, Black J, Busund R, Björck M, Dake M, Dick F, Eggebrecht H, Evangelista A, Grabenwöger M, Milner R, Naylor A, Ricco JB, Rousseau H, Schmidli J. Editor's Choice – Management of Descending Thoracic Aorta Diseases. Eur J Vasc Endovasc Surg 2017; 53:4-52. [DOI: 10.1016/j.ejvs.2016.06.005] [Citation(s) in RCA: 598] [Impact Index Per Article: 85.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Rylski B, Czerny M, Südkamp M, Russe M, Siep M, Beyersdorf F. Fenestrated and Branched Aortic Grafts. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 112:816-22. [PMID: 26667980 DOI: 10.3238/arztebl.2015.0816] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 08/10/2015] [Accepted: 08/10/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Abdominal and thoracic aortic aneurysms are diagnosed in 40 and 10 to 15 out of 100 000 persons per year, respectively. Fenestrated (fEVAR) and branched (bEVAR) stent grafts have been developed for abdominal juxtarenal and thoracoabdominal aneurysms. We discuss the patency and complication rates of fEVAR and bEVAR procedures and compare them with the outcome of open surgery. METHODS This review is based on pertinent publications from 2011 to 2014 that were retrieved by a selective literature search. The clinical outcomes of case series involving a total of more than 1500 patients are presented. The discussion takes account of recommendations contained in the literature and the authors' own experience. RESULTS Open surgery and aortic stent grafting have not been compared in any randomized trial to date. We identified 7 clinical series that included a total of 1270 fEVAR patients and 5 with a total of 408 bEVAR patients. The perioperative mortality after fEVAR procedures was 0-4%. Spinal cord ischemia arose in 1% of cases. The stent patency rate in visceral vessels ranged from 93 to 98%. bEVAR procedures were associated with both higher mortality (4-7%) and more common spinal cord ischemia (4-13%). 5-8% of all patients needed dialysis perioperatively, and the stent patency rate in visceral vessels was 94-97%. Preoperative renal insufficiency was a risk factor for peri-interventional death. Impaired renal function after fEVAR/bEVAR procedures was mainly associated with intermittent lower limb ischemia. CONCLUSION The results of fEVAR/bEVAR procedures in the last 5 years are similar to those of open surgery. The high postoperative rate of spinal cord ischemia remains a serious problem in the endovascular treatment of thoracoabdominal aortic aneurysms. The decision to implant a stent graft by an endovascular approach or to treat surgically should be made on a case-to-case basis in an interdisciplinary vascular conference.
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Affiliation(s)
- Bartosz Rylski
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Center for Diagnostic and Therapeutic Radiology, Medical Center-University of Freiburg
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Chimneys and sandwiches for endovascular arch repair in patients with Marfan syndrome: Are we snorkeling in cloudy waters? J Thorac Cardiovasc Surg 2016; 152:1195-6. [DOI: 10.1016/j.jtcvs.2016.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Accepted: 07/06/2016] [Indexed: 11/21/2022]
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Yamane Y, Uchida N, Mochizuki S, Furukawa T, Yamada K. Endovascular Repair by Graft-to-Graft Bridging in a Patient with Marfan Syndrome. Ann Vasc Dis 2016; 9:111-3. [PMID: 27375805 DOI: 10.3400/avd.cr.16-00005] [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] [Received: 01/14/2016] [Accepted: 02/25/2016] [Indexed: 11/13/2022] Open
Abstract
We report a case of chronic aortic dissection in a patient with Marfan syndrome in which we performed thoracic endovascular repair after aortic root replacement, total arch replacement with open stent grafting and thoracoabdominal aortic repair. We consider that endovascular repair of the dissected descending aorta in a patient with Marfan syndrome can be effective when graft-to-graft bridging is performed as the "finishing procedure".
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Affiliation(s)
- Yoshitaka Yamane
- Department of Cardiovascular Surgery, Cardiovascular Center, Akane-Foundation Tsuchiya General Hospital, Hiroshima, Hiroshima, Japan
| | - Naomichi Uchida
- Department of Cardiovascular Surgery, Cardiovascular Center, Akane-Foundation Tsuchiya General Hospital, Hiroshima, Hiroshima, Japan
| | - Shingo Mochizuki
- Department of Cardiovascular Surgery, Cardiovascular Center, Akane-Foundation Tsuchiya General Hospital, Hiroshima, Hiroshima, Japan
| | - Tomokuni Furukawa
- Department of Cardiovascular Surgery, Cardiovascular Center, Akane-Foundation Tsuchiya General Hospital, Hiroshima, Hiroshima, Japan
| | - Kazunori Yamada
- Department of Cardiovascular Surgery, Cardiovascular Center, Akane-Foundation Tsuchiya General Hospital, Hiroshima, Hiroshima, Japan
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Nauta FJH, Trimarchi S, Kamman AV, Moll FL, van Herwaarden JA, Patel HJ, Figueroa CA, Eagle KA, Froehlich JB. Update in the management of type B aortic dissection. Vasc Med 2016; 21:251-63. [DOI: 10.1177/1358863x16642318] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Stanford type B aortic dissection (TBAD) is a life-threatening aortic disease. The initial management goal is to prevent aortic rupture, propagation of the dissection, and symptoms by reducing the heart rate and blood pressure. Uncomplicated TBAD patients require prompt medical management to prevent aortic dilatation or rupture during subsequent follow-up. Complicated TBAD patients require immediate invasive management to prevent death or injury caused by rupture or malperfusion. Recent developments in diagnosis and management have reduced mortality related to TBAD considerably. In particular, the introduction of thoracic stent-grafts has shifted the management from surgical to endovascular repair, contributing to a fourfold increase in early survival in complicated TBAD. Furthermore, endovascular repair is now considered in some uncomplicated TBAD patients in addition to optimal medical therapy. For more challenging aortic dissection patients with involvement of the aortic arch, hybrid approaches, combining open and endovascular repair, have had promising results. Regardless of the chosen management strategy, strict antihypertensive control should be administered to all TBAD patients in addition to close imaging surveillance. Future developments in stent-graft design, medical therapy, surgical and hybrid techniques, imaging, and genetic screening may improve the outcomes of TBAD patients even further. We present a comprehensive review of the recommended management strategy based on current evidence in the literature.
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Affiliation(s)
- Foeke JH Nauta
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA
| | - Santi Trimarchi
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy
| | - Arnoud V Kamman
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy
| | - Frans L Moll
- Vascular Surgery Department, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joost A van Herwaarden
- Vascular Surgery Department, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - C Alberto Figueroa
- Departments of Biomedical Engineering and Surgery, University of Michigan, USA
| | - Kim A Eagle
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA
| | - James B Froehlich
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA
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49
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Beyond the Aortic Root: Staged Open and Endovascular Repair of Arch and Descending Aorta in Patients With Connective Tissue Disorders. Ann Thorac Surg 2016; 101:906-12. [DOI: 10.1016/j.athoracsur.2015.08.011] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 07/30/2015] [Accepted: 08/07/2015] [Indexed: 11/21/2022]
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50
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Gagné-Loranger M, Voisine P, Dagenais F. Should Endovascular Therapy Be Considered for Patients With Connective Tissue Disorder? Can J Cardiol 2016; 32:1-3. [DOI: 10.1016/j.cjca.2015.06.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 06/29/2015] [Accepted: 06/29/2015] [Indexed: 11/28/2022] Open
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