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Sultan S, Acharya Y, Chua Vi Long K, Hatem M, Hezima M, Veerasingham D, Soliman O, Hynes N. Management of acute aortic syndrome with evolving individualized precision medicine solutions: Lessons learned over two decades and literature review. Front Surg 2023; 10:1157457. [PMID: 37065997 PMCID: PMC10097442 DOI: 10.3389/fsurg.2023.1157457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
BackgroundThoracoabdominal acute aortic syndrome is associated with high morbidity and mortality. We aim to scrutinize our evolving strategies for acute aortic syndrome (AAS) management using minimally invasive and adaptive surgical techniques over two decades.MethodsThis is a longitudinal observational study at our tertiary vascular centre from 2002 to 2021. Out of 22,349 aortic referrals, we performed 1,555 aortic interventions over twenty years. Amongst 96 presented with symptomatic aortic thoracic pathology, 71 patients had AAS. Our primary endpoint is combined aneurysm-related and cardiovascular-related mortality.ResultsThere were 43 males and 28 females (5 Traumatic Aortic Transection (TAT), 8 Acute Aortic Intramural Hematoma (IMH), 27 Symptomatic Aortic Dissection (SAD) and 31 Thoracic Aortic Aneurysm (TAA) post-SAD) with a mean age of 69. All the patients with AAS received optimal medical therapy (OMT), but TAT patients underwent emergency thoracic endovascular aortic repair (TEVAR). Fifty-eight patients had an aortic dissection, of which 31 developed TAA. These 31 patients with SAD and TAA received OMT initially and interval surgical intervention with TEVAR or sTaged hybrId sinGle lumEn Reconstruction (TIGER). To increase our landing area, we performed a left subclavian chimney graft with TEVAR in twelve patients. The average follow-up duration was 78.2 months, and eleven patients (15.5%) had combined aneurysm and cardiovascular-related mortality. Twenty-six percentage of the patients developed endoleaks (EL), of which 15% required re-intervention for type II and III. Four patients who had paraplegia (5.7%) and developed renal failure died. None of our patients had a stroke or bowel ischaemia. Twenty patients had OMT, eight of these were patients with acute aortic hematoma, and all eight died within 30 days of presentation.ConclusionAcute aortic hematoma is a sinister finding, which must be closely monitored, and consideration is given to early intervention. Paraplegia and renal failure result in an increased mortality rate. TIGER technique with interval TEVAR has salvaged complex situations in young patients. Left subclavian chimney increases our landing area and abolishes SINE. Our experience shows that minimally invasive techniques could be a viable option for AAS.
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Affiliation(s)
- Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
- Correspondence: Sherif Sultan
| | - Yogesh Acharya
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
| | - Keegan Chua Vi Long
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
| | - Mohamed Hatem
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
| | - Mohieldin Hezima
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
| | - David Veerasingham
- Department of Cardiothoracic Surgery, University Hospital Galway, University of Galway, Galway, Ireland
| | - Osama Soliman
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
| | - Niamh Hynes
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
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Saw LJ, Lim‐Cooke M, Woodward B, Othman A, Harky A. The surgical management of acute type A aortic dissection: Current options and future trends. J Card Surg 2020; 35:2286-2296. [DOI: 10.1111/jocs.14733] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Li Jing Saw
- School of MedicineUniversity of Liverpool Liverpool UK
| | | | - Beth Woodward
- College of Medical and Dental SciencesUniversity of Birmingham Birmingham UK
| | - Ahmed Othman
- Department of Cardiothoracic SurgeryLiverpool Heart and Chest Hospital Liverpool UK
| | - Amer Harky
- School of MedicineUniversity of Liverpool Liverpool UK
- Department of Cardiothoracic SurgeryLiverpool Heart and Chest Hospital Liverpool UK
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Hosseini S, Rezaei Y, Alizadeh Ghavidel A. Challenges and experience of setting up an aortic service. Asian Cardiovasc Thorac Ann 2020; 29:669-676. [PMID: 32469677 DOI: 10.1177/0218492320930841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Aortic surgery is a complex procedure posing high risks in comparison to other adult cardiac surgeries. Novel surgical approaches including minimally invasive procedures, sutureless aortic valve replacement, and transcatheter aortic valve implantation have been found to be acceptable alternatives to conventional surgeries. In addition, novel endovascular repair techniques and hybrid procedures have been introduced for the management of patients with thoracoabdominal aortic pathologies. However, these modalities are not readily available in every center, and such novel procedures impose a learning curve for surgeons and high costs for affected patients. In this review, we discuss the challenges of setting up an aortic service, having regard to the Iranian experience.
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Affiliation(s)
- Saeid Hosseini
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Yousef Rezaei
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Alizadeh Ghavidel
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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Arnaoutakis DJ, Scali ST, Beck AW, Kubilis P, Huber TS, Martin AJ, Laquian L, Back M, Giles KA, Fatima J, Beaver TM, Upchurch GR. Comparative outcomes of open, hybrid, and fenestrated branched endovascular repair of extent II and III thoracoabdominal aortic aneurysms. J Vasc Surg 2020; 71:1503-1514. [DOI: 10.1016/j.jvs.2019.08.236] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 08/02/2019] [Indexed: 11/26/2022]
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Mariscalco G, Maselli D, Zanobini M, Ahmed A, Bruno VD, Benedetto U, Gherli R, Gherli T, Nicolini F. Aortic centres should represent the standard of care for acute aortic syndrome. Eur J Prev Cardiol 2019; 25:3-14. [PMID: 29708034 DOI: 10.1177/2047487318764963] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background Existing evidence suggests that patients affected by acute aortic syndromes (AAS) may benefit from treatment at dedicated specialized aortic centres. The purpose of the present study was to perform a meta-analysis to evaluate the impact aortic service configuration has in clinical outcomes in AAS patients. Methods The design was a quantitative and qualitative review of observational studies. We searched PubMed/ MEDLINE, EMBASE, and Cochrane Library from inception to the end of December 2017 to identify eligible articles. Areas of interest included hospital and surgeon volume activity, presence of a multidisciplinary thoracic aortic surgery program, and a dedicated on-call aortic team. Participants were patients undergoing repair for AAS, and odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were adopted for synthesizing hospital/30-day mortality. Results A total of 79,131 adult patients from a total of 30 studies were obtained. No randomized studies were identified. Pooled unadjusted ORs showed that patients treated in high-volume centres or by high-volume surgeons were associated with lower mortality rates (OR 0.51; 95% CI 0.46-0.56, and OR 0.41, 95% CI 0.25-0.66, respectively). Pooled adjusted estimates for both high-volume centres and surgeons confirmed these survival benefits (adjusted OR, 0.56; 95% CI 0.45-0.70, respectively). Patients treated in centres that introduced a specific multidisciplinary aortic program and a dedicated on-call aortic team also showed a significant reduction in mortality (OR 0.31; 95% CI 0.19-0.5, and OR 0.37; 95% CI 0.15-0.87, respectively). Conclusions We found that specialist aortic care improves outcomes and decreases mortality in patients affected by AAS.
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Affiliation(s)
- Giovanni Mariscalco
- 1 Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Daniele Maselli
- 2 Department of Cardiac Surgery, St. Anna Hospital, Catanzaro, Italy
| | - Marco Zanobini
- 3 Department of Cardiac Surgery, Centro Cardiologico-Fondazione Monzino IRCCS, University of Milan, Italy
| | - Aamer Ahmed
- 4 Department of Anaesthesia and Critical Care, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | | | - Riccardo Gherli
- 6 Department of Cardiovascular Sciences, Cardiac Surgery Unit, San Camillo Hospital, Rome, Italy
| | - Tiziano Gherli
- 7 Division of Cardiac Surgery, University of Parma, Parma, Italy
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Davies MG. Invited commentary. J Vasc Surg 2018; 68:415. [DOI: 10.1016/j.jvs.2018.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 02/06/2018] [Indexed: 10/28/2022]
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Decoding the volume–outcome relationship in Type A aortic dissection. Gen Thorac Cardiovasc Surg 2018; 67:32-36. [DOI: 10.1007/s11748-018-0939-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 05/08/2018] [Indexed: 10/16/2022]
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Bin Mahmood SU, Ulrich A, Safdar B, Geirsson A, Mangi AA. Spontaneous rupture of the ascending aorta. J Card Surg 2018; 33:107-114. [PMID: 29405382 DOI: 10.1111/jocs.13535] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Nontraumatic, spontaneous rupture of the ascending aorta is rare and the etiology is largely unknown. METHODS We reviewed seven patients from our institution, with no known aortic disease or hereditary connective tissue disorder that presented with spontaneous ascending aortic rupture from 2012 to 2017. RESULTS Most patients presented with non-radiating chest pain along with hypertension (71.4%). The mean ascending aortic diameter at rupture was 4.60 ± 0.62 cm. The median door-to-operating room time was 2.58 h, resulting from effective implementation of an aortic emergency protocol. There were no operative mortalities. CONCLUSIONS In patients with ascending aortic rupture, aortic diameter may not always correlate with the risk of rupture. Rapid diagnosis combined with a multidisciplinary approach is vital for the successful management of these high-risk patients.
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Affiliation(s)
| | - Andrew Ulrich
- Section of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Basmah Safdar
- Section of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Arnar Geirsson
- Section of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Abeel A Mangi
- Section of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
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Defining the burden, scope, and future of vascular acute care surgery. J Vasc Surg 2017; 66:1511-1517. [PMID: 28662926 DOI: 10.1016/j.jvs.2017.04.060] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 04/26/2017] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The paradigm of acute care surgery has revolutionized nonelective general surgery. Similarly, nonelective vascular surgery may benefit from specific management and resource capabilities. To establish the burden and scope of vascular acute care surgery, we analyzed the characteristics and outcomes of patients hospitalized for vascular surgical procedures in Maryland. METHODS A retrospective analysis of a statewide inpatient database was performed to identify patients undergoing noncardiac vascular procedures in Maryland from 2009 to 2013. Patients were stratified by admission acuity as elective, urgent, or emergent, with the last two groups defined as acute. The primary outcome was inpatient mortality, and secondary outcomes were critical care and hospital resource requirements. Groups were compared by univariate analyses, with multivariable analysis of mortality based on acuity level and other potential risk factors for death. RESULTS Of 3,157,499 adult hospital admissions, 154,004 (5%) patients underwent a vascular procedure; most were acute (54% emergent, 13% urgent), whereas 33% were elective. Acute patients had higher rates of critical care morbidity and required more hospital resource utilization. Admission for acute vascular surgery was independently associated with mortality (urgent odds ratio, 2.1; emergent odds ratio, 3.0). CONCLUSIONS The majority of inpatient vascular care in Maryland is for acute vascular surgery, which is an independent risk factor for mortality. Acute vascular surgical care entails greater critical care and hospital resource utilization and-similar to emergency general surgery-may benefit from dedicated training and practice models.
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Bottle A, Mariscalco G, Shaw MA, Benedetto U, Saratzis A, Mariani S, Bashir M, Aylin P, Jenkins D, Oo AY, Murphy GJ. Unwarranted Variation in the Quality of Care for Patients With Diseases of the Thoracic Aorta. J Am Heart Assoc 2017; 6:JAHA.116.004913. [PMID: 28292748 PMCID: PMC5524021 DOI: 10.1161/jaha.116.004913] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Thoracic aortic disease has a high mortality. We sought to establish the contribution of unwarranted variation in care to regional differences in outcomes observed in patients with thoracic aortic disease in England. METHODS AND RESULTS Data from the Hospital Episode Statistics (HES) and the National Adult Cardiac Surgery Audit (NACSA) were extracted. A parallel systematic review/meta-analysis through December 2015, and structure and process questionnaire of English cardiac surgery units were also accomplished. Treatment and mortality rates were investigated. A total of 24 548 adult patients in the HES study, 8058 in the NACSA study, and 103 543 from a total of 33 studies in the systematic review were obtained. Treatment rates for thoracic aortic disease within 6 months of index admission ranged from 7.6% to 31.5% between English counties. Risk-adjusted 6-month mortality in untreated patients ranged from 19.4% to 36.3%. Regional variation persisted after adjustment for disease or patient factors. Regional cardiac units with higher case volumes treated more-complex patients and had significantly lower risk-adjusted mortality relative to low-volume units. The results of the systematic review indicated that the delivery of care by multidisciplinary teams in high-volume units resulted in better outcomes. The observational analyses and the online survey indicated that this is not how services are configured in most units in England. CONCLUSIONS Changes in the organization of services that address unwarranted variation in the provision of care for patients with thoracic aortic disease in England may result in more-equitable access to treatment and improved outcomes.
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Affiliation(s)
- Alex Bottle
- Dr Foster Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College, London, United Kingdom
| | - Giovanni Mariscalco
- Leicester Cardiovascular Biomedical Research Unit & Department of Cardiovascular Sciences, Glenfield Hospital, University of Leicester, United Kingdom
| | - Matthew A Shaw
- Information Department, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Umberto Benedetto
- School of Clinical Sciences, Bristol Heart Institute, University of Bristol, United Kingdom
| | - Athanasios Saratzis
- Leicester Cardiovascular Biomedical Research Unit & Department of Cardiovascular Sciences, Glenfield Hospital, University of Leicester, United Kingdom
| | - Silvia Mariani
- Leicester Cardiovascular Biomedical Research Unit & Department of Cardiovascular Sciences, Glenfield Hospital, University of Leicester, United Kingdom
| | - Mohamad Bashir
- Department of Health Economics, University of Liverpool, United Kingdom
| | - Paul Aylin
- Dr Foster Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College, London, United Kingdom
| | - David Jenkins
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, United Kingdom
| | - Aung Y Oo
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Gavin J Murphy
- Leicester Cardiovascular Biomedical Research Unit & Department of Cardiovascular Sciences, Glenfield Hospital, University of Leicester, United Kingdom
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Mell MW, Starnes BW, Kraiss LW, Schneider PA, Pevec WC. Western Vascular Society guidelines for transfer of patients with ruptured abdominal aortic aneurysm. J Vasc Surg 2017; 65:603-608. [DOI: 10.1016/j.jvs.2016.10.097] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 10/08/2016] [Indexed: 11/29/2022]
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Andersen ND, Benrashid E, Ross AK, Pickett LC, Smith PK, Daneshmand MA, Schroder JN, Gaca JG, Hughes GC. The utility of the aortic dissection team: outcomes and insights after a decade of experience. Ann Cardiothorac Surg 2016; 5:194-201. [PMID: 27386406 DOI: 10.21037/acs.2016.05.12] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Mortality rates following acute type A aortic dissection (ATAAD) repair are reduced when operations are performed by a high-volume acute aortic dissection (AAD) team, leading to efforts to centralize ATAAD care. Here, we describe our experience with ATAAD repair by our AAD team over the last 10 years, with a focus on patient selection, transfer protocols, operative approach, and volume trends over time. METHODS An AAD team was implemented at our institution in 2005, with dedicated high-volume AAD surgeons, a multidisciplinary approach to thoracic aortic disease management, and a standardized protocol for ATAAD repair. Further process improvements were made in 2013 to facilitate the rapid transfer of ATAAD patients to our institution using stream-lined triage, diagnostic, and transfer protocols for patients with suspected ATAAD (RACE-AD protocol). Volume trends and outcomes were assessed longitudinally over this period. RESULTS Institutional ATAAD repair volume remained constant at 12±2 cases per year from 2005-2013, but increased nearly two-fold to 22±6 cases per year (P=0.004) from 2013-2015 following implementation of the RACE-AD protocol. To accommodate this increased volume, two additional surgeons were added to the AAD team. Surgeon ATAAD repair volume was unchanged over the 10-year interval (7.9±3.9 cases per year from 2005-2013 versus 5.5±1.5 cases per year from 2013-2015; P=0.36), and all AAD team surgeons consistently met or exceeded the high-volume surgeon threshold of 5 ATAAD repairs per year. Thirty-day/in-hospital mortality rates of less than 10% were maintained over the study period. CONCLUSIONS Centralization of ATAAD care has begun to occur at our center, with maintenance of low mortality rates for ATAAD repair. These data confirm a net positive impact on regional ATAAD outcomes through transfer of patients to a high-volume center with dedicated AAD surgeons.
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Affiliation(s)
- Nicholas D Andersen
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Ehsan Benrashid
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Adia K Ross
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Lisa C Pickett
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Peter K Smith
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Mani A Daneshmand
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Jacob N Schroder
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey G Gaca
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - G Chad Hughes
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
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Shin KC, Lee HS, Park JM, Joo HC, Ko YG, Park I, Kim MJ. Outcomes before and after the Implementation of a Critical Pathway for Patients with Acute Aortic Disease. Yonsei Med J 2016; 57:626-34. [PMID: 26996561 PMCID: PMC4800351 DOI: 10.3349/ymj.2016.57.3.626] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 08/14/2015] [Accepted: 09/25/2015] [Indexed: 01/14/2023] Open
Abstract
PURPOSE Acute aortic diseases, such as aortic dissection and aortic aneurysm, can be life-threatening vascular conditions. In this study, we compared outcomes before and after the implementation of a critical pathway (CP) for patients with acute aortic disease at the emergency department (ED). MATERIALS AND METHODS This was a retrospective observational cohort study. The CP was composed of two phases: PRE-AORTA for early diagnosis and AORTA for prompt treatment. We compared patients who were diagnosed with acute aortic disease between pre-period (January 2010 to December 2011) and post-period (July 2012 to June 2014). RESULTS Ninety-four and 104 patients were diagnosed with acute aortic disease in the pre- and post-periods, respectively. After the implementation of the CP, 38.7% of acute aortic disease cases were diagnosed via PRE-AORTA. The door-to-CT time was reduced more in PRE-AORTA-activated patients [71.0 (61.0, 115.0) min vs. 113.0 (56.0, 170.5) min; p=0.026]. During the post-period, more patients received emergency intervention than during the pre-period (22.3% vs. 36.5%; p=0.029). Time until emergency intervention was reduced in patients, who visited the ED directly, from 378.0 (302.0, 489.0) min in the pre-period to 200.0 (170.0, 299.0) min in the post-period (p=0.001). The number of patients who died in the ED declined from 11 to 4 from the pre-period to the post-period. Hospital mortality decreased from 26.6% to 14.4% in the post-period (p=0.033). CONCLUSION After the implementation of a CP for patients with acute aortic disease, more patients received emergency intervention within a shorter time, resulting in improved hospital mortality.
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Affiliation(s)
- Kyu Chul Shin
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Lee
- Department of Biostatistics, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Min Park
- Department of Emergency Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Hyun-Chel Joo
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Young-Guk Ko
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea
| | - Incheol Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Min Joung Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea.
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Uğuz E, Canyiğit M, Hıdıroğlu M, Şener E. Treatment of acute thoracic aortic syndromes using endovascular techniques. Diagn Interv Radiol 2016; 22:365-70. [PMID: 27113420 DOI: 10.5152/dir.2015.15270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE Acute thoracic aortic syndrome (ATAS) is a novel term to define emergency aortic conditions with common clinical features and challenges. Traditional management of ATAS includes surgical replacement of the aorta and is correlated with high perioperative mortality and morbidity. We aimed to evaluate our experience and outcomes in patients presenting with ATAS, managed by endovascular techniques. METHODS This cohort consisted of 31 consecutive patients (24 males; mean age, 57.5±13.81 years; range, 19-84 years) with acute thoracic aortic pathologies who underwent endovascular repair between January 2011 and January 2015. The study was designed as a retrospective analysis of prospectively maintained data. RESULTS Complicated acute type-B aortic dissection was the most common pathology (35.5%). All aortic stent-grafts (n=37) and dissection stents (n=9) were implanted with 100% procedural success. The overall in-hospital mortality was 9.7%. The mean follow-up duration of patients who were alive at 30 days was 25.9±11.49 months (3-53 months). So far, there have been no late deaths after 30 days. CONCLUSION In the high-risk setting of ATAS, endovascular procedures come forward as novel therapeutic strategies with promising results. Endovascular repair of ATAS can be considered as a first-line treatment alternative under emergency conditions with encouraging results, particularly when conventional surgical repair cannot be implemented due to prohibitive comorbidities.
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Affiliation(s)
- Emrah Uğuz
- Department of Cardiovascular Surgery, Ankara Atatürk Training and Research Hospital, Ankara, Turkey.
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Outcomes of surgeon-modified fenestrated-branched endograft repair for acute aortic pathology. J Vasc Surg 2015; 62:1148-59.e2. [PMID: 26254453 DOI: 10.1016/j.jvs.2015.06.133] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 06/03/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Open surgical repair for acute aortic pathologies involving the visceral vessels is associated with morbidity and mortality rates of 40% to 70% and 30% to 60%, respectively. Due to these poor outcomes, the application of fenestrated/branched endovascular aortic repair (F/B-EVAR) has been expanded in this setting; however, durability remains unknown. The purpose of this analysis was to describe outcomes after F/B-EVAR for acute aortic disease. METHODS A single center retrospective review of all F/B-EVARs for acute aortic disease was completed. Primary end points included mortality and reintervention-free survival. Secondary end points were patency and freedom from endoleak, as well as change in aneurysm diameter and estimated glomerular filtration rate. Life-tables were used to estimate end points, while mixed statistical models were used to determine aneurysm diameter change. RESULTS Thirty-seven patients (mean age ± standard deviation, 67 ± 10 years; 75% male) underwent F/B-EVAR for acute aortic disease, and median follow-up time was 10.3 months (range, 0.5-31.4 months). Indications included thoracoabdominal aneurysm (65%; n = 24), pararenal aneurysm (17%; n = 6), postsurgical anastomotic pseudoaneurysm (8%; n = 3), dissection (5%; n = 2), and penetrating ulcer (5%; n = 2). Mean preoperative aneurysm diameter was 7.3 ± 1.8 cm. All patients were American Society of Anesthesiologists class IV or IV-E, and 38% (n = 14) had history of aortic repair. There were 105 visceral vessels revascularized (celiac, 26; superior mesenteric artery, 29; renal, 50) and 24 (65%) patients underwent three- or four-vessel repair. Technical success was 92% (n = 34), with no intraoperative deaths and one conversion (3%). Median length of stay was 6 days (range, 2-60 days), and postoperative morbidity was 41% (n = 15; spinal cord ischemia, 14% [8% permanent]; pulmonary, 14%; renal, 14%; extremity ischemia, 8%; stroke, 5%; cardiac, 3%; bleeding, 3%) with 30-day mortality of 19% (n = 7; in-hospital, 8%; n = 3). Endoleak was detected at some point in follow-up in 27% (n = 10), and a majority were type II (n = 7). Six (16%) patients underwent reintervention, and no late conversions occurred. Postoperative imaging was available in 27 (73%), and one celiac fenestration lost patency at 12 months. One-year branch vessel patency and freedom from reintervention was 98% ± 6% and 70% ± 9%, respectively. Estimated 1- and 4-year survival were 70% ± 8% and 67% ± 8%, respectively. During follow-up, aortic diameter decreased 0.5 cm (95% confidence interval, 1.1-0.2; P = .1) while estimated glomerular filtration rate decreased by 2 mL/min/1.73 m(2). CONCLUSIONS F/B-EVAR can be performed to treat a variety of symptomatic and/or ruptured paravisceral aortic pathologies. Perioperative morbidity and mortality can be significant; however, it is less than literature-based outcomes of open repair. Short-term fenestrated/branched graft patency is excellent, but reintervention is frequent, highlighting the need for diligent follow-up. Patients surviving the initial hospitalization for F/B-EVAR of acute aortic disease can anticipate good long-term survival.
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Williams KB, Belyansky I, Dacey KT, Yurko Y, Augenstein VA, Lincourt AE, Horton J, Kercher KW, Heniford BT. Impact of the Establishment of a Specialty Hernia Referral Center. Surg Innov 2014; 21:572-9. [DOI: 10.1177/1553350614528579] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. Creating a surgical specialty referral center requires a strong interest, expertise, and a market demand in that particular field, as well as some form of promotion. In 2004, we established a tertiary hernia referral center. Our goal in this study was to examine its impact on institutional volume and economics. Materials and methods. The database of all hernia repairs (2004-2011) was reviewed comparing hernia repair type and volume and center financial performance. The ventral hernia repair (VHR) patient subset was further analyzed with particular attention paid to previous repairs, comorbidities, referral patterns, and the concomitant involvement of plastic surgery. Results. From 2004 to 2011, 4927 hernia repairs were performed: 39.3% inguinal, 35.5% ventral or incisional, 16.2% umbilical, 5.8% diaphragmatic, 1.6% femoral, and 1.5% other. Annual billing increased yearly from 7% to 85% and averaged 37% per year. Comparing 2004 with 2011, procedural volume increased 234%, and billing increased 713%. During that period, there was a 2.5-fold increase in open VHRs, and plastic surgeon involvement increased almost 8-fold, ( P = .004). In 2005, 51 VHR patients had a previous repair, 27.0% with mesh, versus 114 previous VHR in 2011, 58.3% with mesh ( P < .0001). For VHR, in-state referrals from 2004 to 2011 increased 340% while out-of-state referrals jumped 580%. In 2011, 21% of all patients had more than 4 comorbidities, significantly increased from 2004 ( P = .02). Conclusion. The establishment of a tertiary, regional referral center for hernia repair has led to a substantial increase in surgical volume, complexity, referral geography, and financial benefit to the institution.
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Naughton PA, Park MS, Morasch MD, Rodriguez HE, Garcia-Toca M, Wang CE, Eskandari MK. Emergent repair of acute thoracic aortic catastrophes: a comparative analysis. ACTA ACUST UNITED AC 2012; 147:243-9. [PMID: 22430904 DOI: 10.1001/archsurg.2011.1476] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To provide a contemporary institutional comparative analysis of expedient correction of acute catastrophes of the descending thoracic aorta (ACDTA) by traditional direct thoracic aortic repair (DTAR) or thoracic endovascular aortic repair (TEVAR). DESIGN Single-center retrospective review (April 2001-January 2010). SETTING Academic medical center. PATIENTS One hundred patients with ACDTA treated with either TEVAR (n = 76) or DTAR (n = 24). Indications for repair included ruptured degenerative aneurysm (n = 41), traumatic transection (n = 27), complicated acute type B dissection (n = 20), penetrating ulcer (n = 4), intramural hematoma (n = 3), penetrating injury (n = 3), and embolizing lesion (n = 2). MAIN OUTCOME MEASURES Demographics and 30-day and late outcomes were analyzed using multivariate analysis over a mean follow-up of 33.8 months. RESULTS Among the 100 patients, mean (SD) age was 58.5 (17.3) years (range, 18-87 years). Demographics and comorbid conditions were similar between the 2 groups, except more patients in the DTAR group had prior aortic surgery (P = .02) and were older (P = .01). Overall 30-day mortality was significantly better among the TEVAR group (8% vs 29%; P = .007). Incidence of postoperative myocardial infarction, acute renal failure, stroke, and paraplegia/paresis was similar between the 2 treatment groups (TEVAR, 5%, 12%, 8%, and 8% vs DTAR, 13%, 13%, 9%, and 13%, respectively). Major respiratory complications were lower in the TEVAR group (16% vs 48%; P < .05). Mean length of hospital stay was also shorter after TEVAR (13.5 vs 16.3 days; P = .30). Independent predictors of patient mortality included age (P = .004) and DTAR (P = .001). CONCLUSION Patients presenting with ACDTA are best treated with TEVAR whenever feasible.
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Affiliation(s)
- Peter A Naughton
- Division of Vascular Surgery, Northwestern University, 676 N St Clair, Ste 650, Chicago, IL 60611, USA
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Araújo PV, Joviliano EE, Ribeiro MS, Dalio MB, Piccinato CE, Moriya T. Endovascular Treatment for Acute Aortic Syndrome. Ann Vasc Surg 2012; 26:516-20. [DOI: 10.1016/j.avsg.2011.07.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2011] [Revised: 07/18/2011] [Accepted: 07/27/2011] [Indexed: 11/28/2022]
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Clough RE, Mani K, Lyons OT, Bell RE, Zayed HA, Waltham M, Carrell TW, Taylor PR. Endovascular treatment of acute aortic syndrome. J Vasc Surg 2011; 54:1580-7. [DOI: 10.1016/j.jvs.2011.07.034] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Revised: 06/16/2011] [Accepted: 07/01/2011] [Indexed: 11/25/2022]
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Scali ST, Goodney PP, Walsh DB, Travis LL, Nolan BW, Goodman DC, Lucas FL, Stone DH. National trends and regional variation of open and endovascular repair of thoracic and thoracoabdominal aneurysms in contemporary practice. J Vasc Surg 2011; 53:1499-505. [PMID: 21609795 DOI: 10.1016/j.jvs.2011.02.014] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Revised: 02/08/2011] [Accepted: 02/08/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Successful surgical management of thoracic aortic aneurysms (TAA) and thoracoabdominal aortic aneurysms (TAAA) has historically relied upon open surgical repair (OSR). More recently, the advent and application of thoracic endovascular stent graft aneurysm repair (TEVAR) permutations have become increasingly performed in contemporary practice. To better determine the effect of TEVAR techniques on OSR, we examined national and regional trends in treatment use. METHODS All Medicare patients from 1998 through 2007 undergoing isolated TAA and TAAA repair were analyzed using a clinically validated algorithm using diagnostic International Classification of Disease 9th revision (ICD-9; 441.1, 441.2, 441.6, 441.7, 441.9) codes and procedural (ICD-9 OSR: 38.35, 38.45 and TEVAR: 39.73, 39.79) codes. Differential rates of OSR and TEVAR were compared across census tract regions during the study interval. RESULTS Total complex aortic repairs increased by 60%, from 10.8 to 17.8/100,000, between 1998 and 2007 (P < .001). A dramatic increase occurred in TEVAR (not performed in 1998, 5.8/100,000 in 2007) during the study period, but OSR rates remained stable during the same interval (10.7 to 12.0/100,000 in 2007, P = NS). There was substantial regional variation for both OSR and TEVAR. This regional variation was greater in OSR (range, 8.8-16.7/100,000) than in TEVAR (range, 4.5-6.9/100,000). CONCLUSIONS Degenerative TAA and TAAA aneurysms are being repaired in the United States at an increasing rate. This reflects the rapid acceptance of TEVAR, which apparently supplements rather than supplants OSR. There appears to be greater regional variation in OSR compared with TEVAR. These data may have significant implications for those interested in the effect of new technologies on health care and cost containment.
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Affiliation(s)
- Salvatore T Scali
- Section of Vascular Surgery, Shands Hospital-University of Florida, Gainesville, FL 32610-0128, USA.
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