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Kumins NH, Ambani RN, Bose S, King AH, Cho JS, Colvard B, Kashyap VS. Anatomic Utility of Single Branched Thoracic Endograft During Thoracic Endovascular Aortic Repair. Vasc Endovascular Surg 2023; 57:680-688. [PMID: 36961838 DOI: 10.1177/15385744231165988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
INTRODUCTION Single branched thoracic endografts (SBTEs) have been designed for pathology requiring zone 2 seal during thoracic endovascular aortic repair (TEVAR). Numerous criteria must be met to allow for their implantation. Our aim was to analyze anatomic suitability for a next generation SBTE. METHODS We reviewed 150 TEVAR procedures between 2015 and 2019. Proximal seal was: zone 0 in 21 (16%), zone 1 in 4 (3%), zone 2 in 52 (40%), zone 3 in 45 (35%), and zone 4 or distal in 7 (5%). We analyzed the Zone 2 patient's angiograms and CT angiograms using centerline software to measure arterial diameters and length in relation to the left common carotid artery (LCCA), left subclavian artery (LSA) and proximal extent of aortic disease to determine if patients met anatomic criteria of a novel SBTE. RESULTS Zone 2 average age was 64.4 ± 16.3 years; 34 patients were male (65%). Indications for repair were aneurysm (N = 9, 17%), acute dissection (N = 14, 27%), chronic dissection with aneurysmal degeneration (N = 7, 13%), intramural hematoma (N = 9, 17%), penetrating aortic ulcer (N = 5, 10%), and blunt traumatic aortic injury (BTAI, N = 8, 15%). LSA revascularization occurred in 27 patients (52%). Overall, 20 (38.5%) of the zone 2 patients met anatomic criteria. Patients with dissection met anatomic criteria less frequently than aneurysm (33% [10 of 30] vs 64% [9 of 14]). Patients treated for BTAI rarely met the anatomic criteria (1 of 8, 13%). The main anatomic constraints were an inadequate distance from the LCCA to the LSA takeoff and from the LCCA to the start of the aortic disease process. CONCLUSION Less than half of patients who require seal in zone 2 met criteria for this SBTE. Patients with aneurysms met anatomic criteria more often than those with dissection. The device would have little applicability in treating patients with BTAI.
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Affiliation(s)
- Norman H Kumins
- Department of Vascular Surgery, The Heart and Vascular Institute, The Cleveland Clinic, Cleveland, OH, USA
| | - Ravi N Ambani
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Saideep Bose
- Division of Vascular and Endovascular Surgery, Department of Surgery, St Louis University, St Louis, MO, USA
| | - Alexander H King
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Benjamin Colvard
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Vikram S Kashyap
- Division of Vascular Surgery, Frederik Meijer Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI, USA
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Geraghty PJ, Conte MS. A critical appraisal of registry-based objective performance goals in peripheral arterial disease. J Vasc Surg 2021; 74:1008-1012. [PMID: 34425942 DOI: 10.1016/j.jvs.2021.04.028] [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] [Received: 01/25/2021] [Accepted: 04/16/2021] [Indexed: 11/25/2022]
Abstract
The multidisciplinary Superficial Femoral Artery-Popliteal EvidencE Development (SPEED) Study Group, under the auspices of the Registry Assessment of Peripheral Interventional Devices (RAPID) partnership, recently published objective performance goals for peripheral vascular interventions in the femoropopliteal arteries. Retrospective outcomes from the Vascular Quality Initiative provided the sole study data source. Strengths and weaknesses of this landmark effort are examined. Critical concerns include the substantial risks of ascertainment bias, flawed end point selection, sparse and variable capture of midterm follow-up data, and lack of expected discrimination between treatment modalities. The current Vascular Quality Initiative registry data thus appear insufficiently robust for the generation of objective performance goals and practice benchmarks; suggestions for redesign are provided. The impact of the statutory framework of the US Food and Drug Administration on device approval pathways and the maturation of an evidence-based approach to peripheral vascular intervention is explored.
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Affiliation(s)
- Patrick J Geraghty
- Department of Surgery, Section of Vascular Surgery, Washington University Medical School, St. Louis, Calif.
| | - Michael S Conte
- Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco Medical School, University of California, San Francisco, Calif
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Benz RM, Makaloski V, Brönnimann M, Mertineit N, von Tengg-Kobligk H. [Diagnostics and treatment of traumatic aortic injuries]. Unfallchirurg 2021; 124:601-609. [PMID: 34254152 PMCID: PMC8370906 DOI: 10.1007/s00113-021-01044-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2021] [Indexed: 11/30/2022]
Abstract
Hintergrund Traumatische Aortenverletzungen (TAV) sind seltene Folgen von stumpfen Traumata, die eine hohe Mortalität und Morbidität aufweisen. Die schnelle und akkurate Diagnostik sowie die Wahl der korrekten Therapie sind für das Patientenüberleben elementar. Fragestellung Bestimmung des aktuellen Standards der Abklärung von TAV im akuten Trauma-Setting und Evaluation der aktuellen Leitlinien zur Therapie. Material und Methode Eine Literaturrecherche wurde durchgeführt, mit der Suche nach Publikationen, die die Abklärung und Diagnostik der TAV beschreiben. Außerdem wurden Leitlinien für die Behandlung und Nachsorge von TAV zusammengefasst. Ergebnisse In der Literatur wird trotz geringer Spezifität eine konventionelle Thoraxröntgenaufnahme als Initialdiagnostik genannt. Es sollte primär, als Modalität der Wahl, zur Diagnostik und zur Therapiestratifizierung eine Computertomographie (CT) aufgrund der hohen Sensitivität und Spezifität nachfolgen. In allen Leitlinien ist die thorakale endovaskuläre Aortenrekonstruktion („thoracic endovascular aortic repair“, TEVAR) die Therapie der Wahl bei höhergradigen TAV (Grade II–IV) und hat die offene Chirurgie in dem meisten Fällen abgelöst. Schlussfolgerung Nach einer kurzfristig erfolgten CT-Diagnostik und Einteilung wird die TEVAR der offenen Chirurgie bei therapiebedürftigen TAV vorgezogen.
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Affiliation(s)
- R M Benz
- Diagnostische, Interventionelle und Pädiatrische Radiologie, Inselspital, Universität Bern, Freiburgstr. 18, 3010, Bern, Schweiz.
| | - V Makaloski
- Universitätsklinik für Herz- und Gefäßchirurgie, Inselspital, Universität Bern, Freiburgstr. 18, 3010, Bern, Schweiz
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Kim HM, Cho YK, Kim JH, Seo TS, Song MG, Jeon YS, Cho SB, Im NY. Clinical Outcomes of the Seal® Thoracic Stent Graft for Traumatic Aortic Injury in a Korean Multicenter Retrospective Study. Ann Vasc Surg 2019; 61:400-409. [PMID: 31394246 DOI: 10.1016/j.avsg.2019.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 05/24/2019] [Accepted: 06/03/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Thoracic endovascular aneurysm repair (TEVAR) has been used as a primary treatment for blunt traumatic aortic injury (TAI). However, the outcomes of midterm surveillance of Seal® stent-graft durability for TAI have not been extensively studied. Thus, we aimed to report the midterm outcomes of TEVAR using the Seal® stent graft for blunt TAI. METHODS Patients with blunt TAI treated with TEVAR using the Seal® thoracic stent graft between 2007 and 2013 in Korea were included. Midterm outcomes included technical/clinical success, in-hospital death, aorta/procedure/device-related adverse events, secondary procedures, and 30-day and all-cause mortality. RESULTS A total of 99 patients (54% men; mean age, 48 years) were included. Grade III or higher injuries were present in 95% of patients, including 15 free ruptures of the thoracic aorta, and 64% of injuries were located in zone III. The median procedure and hospitalization duration were 90 min and 11 days, respectively. The technical success rate was 98%. The number of in-hospital mortalities (n = 8) and stroke (n = 2) were observed at 30 days. Late stroke and paraplegia (>30 days) were not observed during the mean 49 ± 26 months of follow-up (median, 48 months; range, 0-117 months). There were no aorta-related mortalities or conversions to open repair. Secondary procedures were performed in 8 patients, all of which were carotid-subclavian bypasses for delayed left subclavian occlusion. The all-cause mortality rate was 5% at 30 days and 8% at 1 year. The survival rate was 95% at 30 days, 92% at 1 year, 92% at 3 years, and 89% at 5 years. One type Ia endoleak occurred at 18 months after the procedure. CONCLUSIONS TEVAR with the Seal® stent graft for TAI showed favorable midterm outcomes. The incidence of major adverse events after the procedure was low.
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Affiliation(s)
- Han Myun Kim
- Department of Radiology, Kangnam Seong-Sim Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Young Kwon Cho
- Department of Radiology, Kangdong Seong-Sim Hospital, Hallym University College of Medicine, Seoul, Korea.
| | - Jeong Ho Kim
- Department of Radiology, Gachon University Gil Hospital, Gachon University College of Medicine, Incheon, Korea
| | - Tae-Seok Seo
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Myung Gyu Song
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Yong Sun Jeon
- Department of Radiology, Inha University Hospital, Inha University College of Medicine, Incheon, Korea
| | - Sung Bum Cho
- Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Nam Yeul Im
- Department of Radiology, Chonnam National University Hospital, Chonnam National University College of Medicine, Gwangju-si, Korea
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Al Shamsi S, Naiem A, Abdelhadi I, Al Manei K, Jose S, Al Sukaiti R, Al Hajeri M, Al Wahaibi K. Outcomes of Early versus Delayed Endovascular Repair of Blunt Traumatic Aortic Injuries. Oman Med J 2019; 34:283-289. [PMID: 31360315 PMCID: PMC6642713 DOI: 10.5001/omj.2019.57] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objectives Thoracic endovascular aortic repair (TEVAR) has surpassed open surgical repair in the management of blunt traumatic aortic injuries (BTAIs) over the past two decades. It is a less morbid procedure associated with lower mortality. We sought to determine the outcomes of early versus delayed TEVAR of BTAI in our population. Methods We conducted a retrospective analysis of a prospectively collected registry that looked at patients presenting with an image-proven diagnosis of BTAI at three tertiary health care facilities in Muscat, Oman. Forty consecutive patients were identified between January 2012 and July 2017, of which four were excluded for incomplete data. The remaining 36 patients were divided based on the timing of repair into early (< 7 days) or delayed (3 7 days) repair. In both cohorts, variables analyzed included patient demographics, mechanism of injury, injury severity score, need for blood products transfusion, use of anti-impulse medications, anticoagulation, intensive care unit (ICU) stay, and total hospital stay. Primary endpoints included: in-hospital mortality, TEVAR-related morbidity, and the need for reintervention. Results Our study subjects were young with a mean age of 33.5±14.8 and 29.9±11.0 years in the early and delayed repair cohorts, respectively. Motor vehicle collisions accounted for the majority of cases (82.6% and 76.9% in early and delayed repair, respectively). Thoracic injuries were the most commonly associated injuries in both early and delayed repair cohorts. Compared to early repair, the delayed repair cohort had a higher incidence of exploratory laparotomies, but the difference was not statistically significant (p = 0.161). There were four incidences of cerebrovascular accidents (CVAs) post-TEVAR; three in the early repair cohort and one in the delayed repair cohort (p = 1.000). There was no statistically significant correlation between left subclavian total or partial coverage and the incidence of CVA (p = 0.220) and type 1 (p = 0.466) or type 2 endoleak (p = 0.102). The early repair cohort had a longer but not statistically significant ICU stay (7.8±6.8 vs. 5.3±10.7, p = 0.386). Prolonged ICU stay was associated with more blood transfusion requirement (p < 0.001), and higher respiratory (p = 0.010) and gastrointestinal complications (p = 0.026). Conclusions The short-term outcomes for TEVAR of BTAI continue to show its feasibility in managing BTAI in severely injured patients. There was no clear statistical significance in mortality and morbidity comparing early versus delayed repair. However, our experience is based on a small sample size and short median follow-up but provides a good platform for further analysis.
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Affiliation(s)
- Sulaiman Al Shamsi
- Vascular Surgery Unit, Department of Surgery, Royal Hospital, Muscat, Oman
| | - Ahmed Naiem
- General Surgery Residency Program, Oman Medical Specialty Board, Muscat, Oman.,Division of Vascular Surgery, McGill University, Quebec, Canada
| | - Ibrahim Abdelhadi
- Vascular Surgery Unit, Department of Surgery, Sultan Qaboos University Hospital, Muscat, Oman
| | - Khalid Al Manei
- Radiology Residency Program, Oman Medical Specialty Board, Muscat, Oman
| | - Sachin Jose
- Research Section, Planning and Studies Department, Oman Medical Specialty Board, Muscat, Oman
| | - Rashid Al Sukaiti
- Department of Radiology and Molecular Imaging, Sultan Qaboos University Hospital, Muscat, Oman
| | | | - Khalifa Al Wahaibi
- Vascular Surgery Unit, Department of Surgery, Sultan Qaboos University Hospital, Muscat, Oman
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Tobey DJ, Reynolds TS, Kopchok GE, Donayre CE, Khoynezhad A, White RA. In Vivo Assessment of Ascending and Arch Aortic Compliance. Ann Vasc Surg 2019; 57:22-28. [PMID: 30710630 DOI: 10.1016/j.avsg.2018.12.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 10/21/2018] [Accepted: 12/11/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Dynamic compliance (Cd) of the adult thoracic ascending and arch aorta has had limited in vivo evaluation in patients with aortic disease. This study evaluates aortic compliance using intravascular ultrasound (IVUS) across a range of thoracic aortic diseases. METHODS Seventy-nine patients undergoing thoracic aortic endovascular procedures had Cd measurements of the ascending aorta proximal to the origin of the brachiocephalic trunk and distal to the origin of the left common carotid artery using IVUS before endograft deployment. Cd was calculated for each segment using the following equation, Cd = ΔD/(D • ΔP) where ΔD = change in aortic diameter, D = diameter in diastole, and ΔP = pulse pressure. RESULTS Mean Cd of the ascending aorta in all patients (18.4%/mm Hg) and aortic arch (16.5 %/100 mm Hg) did not differ significantly. Compliance was significantly lower in patients being treated for thoracic aortic aneurysm and penetrating ulcer than in patients with traumatic rupture, acute and chronic dissection (P = 0.009). Compliance was significantly higher in patients with aortic transection compared with thoracic aneurysm or penetrating ulcer (P = 0.001). Compliance decreased with age by 0.44 ± 0.06 (P = 0.001) per year in the ascending aorta and 0.41 ± 0.05 (P = 0.001) per year in the aortic arch. Compliance did not increase with diameter when adjusted for age (P = 0.65). Compliance measured in the ascending aorta in 7 patients after descending thoracic aortic endograft repair decreased to 12.6%/100 mm Hg, although not significant (P = 0.18). CONCLUSIONS Ascending and aortic arch compliance is significantly higher than reported for peripheral vessels. Thoracic aortic compliance decreases with age and is not related to aortic diameter. The results of the present study are important when considering the development of endoprosthesis devices and long-term effects on the thoracic aorta.
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Affiliation(s)
- David J Tobey
- Division of Vascular Surgery, Harbor-UCLA Medical Center, Torrance, CA.
| | | | | | | | - Ali Khoynezhad
- Division of Vascular Surgery, Long Beach Memorial Heart & Vascular Institute, Long Beach, CA
| | - Rodney A White
- Division of Vascular Surgery, Harbor-UCLA Medical Center, Torrance, CA; Division of Vascular Surgery, Long Beach Memorial Heart & Vascular Institute, Long Beach, CA
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Chou EL, Twerdahl EH, Eagleton MJ. Endovascular management of penetrating and non-penetrating aortic injury. VASA 2018; 48:23-33. [PMID: 30227809 DOI: 10.1024/0301-1526/a000740] [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: 11/19/2022]
Abstract
Aortic trauma is a devastating injury often associated with significant polytrauma. Penetrating injury of the aorta is highly lethal and therefore rarely encountered in the hospital setting. The management of blunt trauma of the aorta has changed significantly over the past decade, principally due to improved imaging technology and the development of endovascular therapy. The most common site of injury is the proximal descending thoracic aorta. The degree of aortic wall injury guides the indication for therapy, while a combination of the degree of injury and the extent of co-morbid injuries drives the timing of repair. Lower grade injuries frequently do not require any surgical intervention. Thoracic aortic endograft repair can be performed in a safe, expeditious fashion. Short-term and mid-term outcomes appear excellent, with patient survival based mainly on concomitant traumatic injuries. Long-term outcomes are less well known. Future endeavors will be guided toward gaining a better understanding of the indications for repair and the long-term outcomes for endograft devices designed for this purpose.
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Affiliation(s)
- Elizabeth L Chou
- 1 Massachusetts General Hospital, Division of Vascular and Endovascular Surgery, Boston, USA
| | - Eric H Twerdahl
- 1 Massachusetts General Hospital, Division of Vascular and Endovascular Surgery, Boston, USA
| | - Matthew J Eagleton
- 1 Massachusetts General Hospital, Division of Vascular and Endovascular Surgery, Boston, USA
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Kovari VZ, Pecsi F, Cs Janvari M, Veres R. Initial experience with the treatment of concomitant aortic pseudoaneurysm and thoracolumbar spinal fracture: Case report. Trauma Case Rep 2018; 12:48-53. [PMID: 29644285 PMCID: PMC5887094 DOI: 10.1016/j.tcr.2017.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2017] [Indexed: 11/26/2022] Open
Abstract
One blunt abdominal aortic disruption (BAAD) and one blunt thoracic aortic injury (BTAI) case are presented. Both aortic injuries were combined with spinal fractures. In the BAAD case the aortic pseudoaneurysm manifested just above the lumbar fracture while in the BTAI case the aortic injury appeared several vertebras below the thoracal fracture site, suggesting different mechanisms in the aortic wall damage. In both cases the aortic wall first was sealed, successfully, by endovascularly-placed stents, meaning the risks of open aortic reconstructive surgery could be avoided. The adjacent crucial vessel's preservation, despite the stent covering the left subclavian artery and the left common carotid artery in one of the cases was verified by post-operative computed tomography angiography (CTA) examination. In second stage those spinal fractures which were deemed unstable were stabilized by the fixateur interne (a transpedicular screw-rod system). With this treatment sequence we wanted to avoid the unnecessary risk of a possible rupture of the unsealed aortic wall during positioning for the spinal procedure and during the spinal surgery. Both patients recovered from their aortic and spinal injuries.
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Affiliation(s)
- Viktor Zsolt Kovari
- Hungarian Defense Forces Medical Centre, Department of Neurosurgery, Robert Karoly krt. 44, 1134 Budapest, Hungary
| | - Ferenc Pecsi
- Spinal Surgery and Scolisos Centre, Schön Klinik Neustadt, Am Kiebitzberg 10, 23730 Neustadt in Holstein, Germany
| | - Mate Cs Janvari
- Hungarian Defense Forces Medical Centre, Department of Radiology, Robert Karoly krt. 44, 1134 Budapest, Hungary
| | - Robert Veres
- Mafraq Hospital, Department of Neurosurgery, P.O. Box. 2951, Abu Dhabi, United Arab Emirates
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van der Zee CP, Vainas T, van Brussel FA, Tielliu IF, Zeebregts CJ, van der Laan MJ. Endovascular treatment of traumatic thoracic aortic lesions: a systematic review and meta-analysis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2017; 60:100-110. [PMID: 28471152 DOI: 10.23736/s0021-9509.17.09942-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION To provide an overview of the experience of endovascular treatment for traumatic thoracic aortic lesions (TTAL). Thoracic aortic injury secondary to high-energy chest trauma constitutes an emergency situation with potentially devastating outcome. In the present time, the majority of patients are treated with thoracic endovascular aortic repair. The aim of this study was to provide a systematic overview of endovascular aortic repair in patients with TTAL with special attention to perioperative mortality, paraplegia, stroke, influence of left subclavian artery (LSA) coverage herein, and long-term stent-related complications. EVIDENCE ACQUISITION PubMed and Embase were searched for studies describing endovascular treatment of TTAL in the period between January 1st, 2000 and January 30th, 2016. The methodological quality of articles was assessed using the MINORS score and PRISMA guidelines. Data on early mortality, perioperative complications, and long-term stent-related complications were extracted. EVIDENCE SYNTHESIS A total of 2005 reports were screened, and 74 publications were finally included in the analysis describing treatment of 1882 patients. Early mortality rate, paraplegia rate, and stroke rate were 7.5%, 0.4%, and 1.5%, respectively. LSA coverage did not increase the risk of stroke. The severity of injuries had a positive association on early mortality. Late stent related mortality and morbidity were uncommon. CONCLUSIONS TTAL can be treated endovascularly with low mortality and (neurological) morbidity. LSA coverage does not increase the risk of neurological complications but is associated with a moderate risk of left arm ischemia. Long-term stent-related complications are rare, but the available data is limited.
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Affiliation(s)
- Cornelis P van der Zee
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands -
| | - Tryfon Vainas
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Ignace F Tielliu
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten J van der Laan
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Challoumas D, Dimitrakakis G. Advances in the treatment of blunt thoracic aortic injuries. Injury 2015; 46:1431-9. [PMID: 25467824 DOI: 10.1016/j.injury.2014.10.065] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 10/27/2014] [Accepted: 10/29/2014] [Indexed: 02/02/2023]
Abstract
Blunt thoracic aortic injuries, even though rare in incidence, carry significant mortality rates and their management still remains challenging. There have been major shifts in diagnosing and treating these injuries in the last 5 decades, which proved to be beneficial in terms of mortality and complications. Endovascular repair has been increasingly used for definitive treatment and its outcomes appear to be at least equally safe and effective as those of open repair. We present a balanced review of the relevant literature regarding the most appropriate approach and definitive treatment of these pathological entities. Based on the studies analyzed, endovascular repair is increasingly being established as the choice of treatment, however, the conventional open surgical approach still remains a safe method for severe injuries; the mortality, complication rates and proven longterm results of the latter are continuously improving. Additionally, delayed repair, where appropriate, seems to be a safe option with very low mortality rates. Despite the encouraging short and midterm outcomes reported, endovascular treatment needs to be assessed in the longterm for more accurate conclusions to be drawn about its durability and safety.
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Affiliation(s)
- Dimitrios Challoumas
- Cardiff University School of Medicine, Heath Park Campus, University Hospital of Wales, Cardiff CF14 4XW, UK.
| | - Georgios Dimitrakakis
- Department of Cardiothoracic Surgery, University Hospital of Wales, Heath Park Campus, Cardiff CF14 4XW, UK
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11
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Noly PE, Mercier O, Angel C, Fabre D, Mussot S, Brenot P, Riou JY, Bourkaib R, Planché O, Dartevelle P, Fadel E. [Management of the traumatic aortic blunt injury in 2014]. Presse Med 2014; 44:305-16. [PMID: 25542710 DOI: 10.1016/j.lpm.2014.06.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Revised: 05/08/2014] [Accepted: 06/03/2014] [Indexed: 11/28/2022] Open
Abstract
Diagnosis of blunt thoracic aortic injury (BAI) should be considered in any serious polytrauma. The diagnosis is mainly based on the CT scan at baseline. Life-threatening lesions are often associated with BAI. Hospital mortality is mainly due to associated lesions. Except the complete rupture of the aorta, treatment should be initiated after hemodynamic and respiratory stabilization of the patient and after the treatment of a lesion involving the immediate prognosis. Endovascular treatment of BAI became the treatment of choice, especially for patients with severe associated injuries and bleeding risk. Additional data on the long-term stents are necessary in these young patients. Conventional surgical treatment is always indicated for young subjects with stable hemodynamic, low risk of bleeding and when surgery may be delayed several hours.
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Affiliation(s)
- Pierre-Emmanuel Noly
- Centre chirurgical Marie-Lannelongue, service de chirurgie thoracique et vasculaire, 92350 Le Plessis Robinson, France
| | - Olaf Mercier
- Centre chirurgical Marie-Lannelongue, service de chirurgie thoracique et vasculaire, 92350 Le Plessis Robinson, France.
| | - Claude Angel
- Centre chirurgical Marie-Lannelongue, service de cardiologie et radiologie interventionnelle, 92350 Le Plessis Robinson, France
| | - Dominique Fabre
- Centre chirurgical Marie-Lannelongue, service de chirurgie thoracique et vasculaire, 92350 Le Plessis Robinson, France
| | - Sacha Mussot
- Centre chirurgical Marie-Lannelongue, service de chirurgie thoracique et vasculaire, 92350 Le Plessis Robinson, France
| | - Philippe Brenot
- Centre chirurgical Marie-Lannelongue, service de cardiologie et radiologie interventionnelle, 92350 Le Plessis Robinson, France
| | - Jean-Yves Riou
- Centre chirurgical Marie-Lannelongue, service de cardiologie et radiologie interventionnelle, 92350 Le Plessis Robinson, France
| | - Riad Bourkaib
- Centre chirurgical Marie-Lannelongue, service de cardiologie et radiologie interventionnelle, 92350 Le Plessis Robinson, France
| | - Olivier Planché
- Centre chirurgical Marie-Lannelongue, service de cardiologie et radiologie interventionnelle, 92350 Le Plessis Robinson, France
| | - Philippe Dartevelle
- Centre chirurgical Marie-Lannelongue, service de chirurgie thoracique et vasculaire, 92350 Le Plessis Robinson, France
| | - Elie Fadel
- Centre chirurgical Marie-Lannelongue, service de chirurgie thoracique et vasculaire, 92350 Le Plessis Robinson, France
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12
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Khoynezhad A, Donayre CE, Azizzadeh A, White R. One-year results of thoracic endovascular aortic repair for blunt thoracic aortic injury (RESCUE trial). J Thorac Cardiovasc Surg 2014; 149:155-61.e4. [PMID: 25439771 DOI: 10.1016/j.jtcvs.2014.09.026] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 09/02/2014] [Accepted: 09/10/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE One-year outcomes of the RESCUE trial (endovascular aortic repair using Valiant Captivia for blunt thoracic aortic injury) are reported. METHODS RESCUE is a prospective, nonrandomized, multicenter trial. Fifty patients with blunt thoracic aortic injury were enrolled between April 2010 and January 2012. One-year outcomes included secondary procedures, device-, procedure-, and/or aorta-related adverse events, and all-cause mortality. RESULTS Mean patient age was 40.7 ± 17.4 years; 76% of patients were male. Fifty-two thoracic stent grafts were implanted within a median of 1 day of injury. Seventy percent (35 of 50) of aortic injuries were grade III or higher, including 1 free rupture. The mean Injury Severity Score was 37.6 ± 14.3. Vascular access, device delivery, and deployment were successful in all patients. The left subclavian artery was completely covered in 40% (20 of 50) and partially covered in 18% of patients (9 of 50). There were no strokes or spinal cord injuries. Median procedure time was 90.5 minutes; median hospital stay was 11 days. All-cause mortality within 1 year was 12%. There were no conversions to open repair. Four patients (8%) had subclavian artery revascularization; 1 preoperatively; 3 others postoperatively on days 8, 36, and 103. There were no device-related adverse events. During follow-up, 1 patient (2%) had aortic-related and 9 patients (18%) had procedure-related adverse events. CONCLUSIONS TEVAR has favorable early midterm outcomes in the treatment of blunt thoracic aortic injury, and remains the treatment modality of choice. Longevity of the stent grafts in this young patient population has yet to be established.
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Affiliation(s)
- Ali Khoynezhad
- Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif.
| | | | - Ali Azizzadeh
- Memorial Hermann Heart and Vascular Institute, University of Texas Medical Center, Houston, Tex
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Franzen D, Genoni M. Analysis of risk factors for death after blunt traumatic rupture of the thoracic aorta. Emerg Med J 2013; 32:124-9. [DOI: 10.1136/emermed-2013-202639] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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14
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Kitagawa RS, Van Haren RM, Yokobori S, Cohen D, Beckerman SR, Ahmad F, Bullock MR. Management of simultaneous traumatic brain injury and aortic injury. J Neurosurg 2013; 119:324-31. [DOI: 10.3171/2013.5.jns1397] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Simultaneous traumatic brain injury (TBI) and aortic injury has been considered unsurvivable for many years because treatments such as sedation and blood pressure goals conflict for these 2 conditions. Additionally, surgical interventions for aortic injury often require full anticoagulation, which is contraindicated in patients with TBI. For these reasons, and due to the relative rarity of aortic injury/TBI, little data are available to guide treating physicians.
Methods
A retrospective review was performed on all simultaneous TBI and aortic injury cases from 2000 to 2012 at a university-affiliated, Level I trauma center. Patient demographics, imaging studies, interventions, and outcomes were analyzed. Traumatic brain injury/aortic injury cases treated with endovascular stenting were specifically studied to determine trends in procedure timing, use of anticoagulation, and neurological outcome.
Results
Thirty-three patients with concurrent TBI and aortic injury were identified over a 12-year period. The median patient age was 44 years (range 16–86 years) and the overall mortality rate after imaging diagnosis was 46%. All surviving patients were awake and neurologically functional at discharge, and 83% were discharged home or to rehabilitation facilities. Patients who died had a higher Injury Severity Scale score (p = 0.006). Severe TBI (p = 0.045) or hemodynamic instability (p = 0.015) upon arrival to the hospital was also correlated with increased mortality rates. Thirty-three percent of aortic injury/TBI patients (n = 11) underwent endovascular stenting, and 7 of these patients received intravenous anticoagulation therapy at the time of surgery. Six of these 7 anticoagulation-treated patients experienced no significant progression on postoperative brain CT, whereas 1 patient died of hemodynamic instability prior to undergoing further imaging.
Conclusions
Simultaneous TBI and aortic injury is a rare condition with a historically poor prognosis. However, these results suggest that many patients can survive with a good quality of life. Technological advances such as endovascular aortic stenting may improve patient outcome, and anticoagulation is not absolutely contraindicated after TBI.
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Affiliation(s)
| | - Robert M. Van Haren
- 2Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; and
| | - Shoji Yokobori
- 1Department of Neurosurgery,
- 3Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
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Khoynezhad A, Azizzadeh A, Donayre CE, Matsumoto A, Velazquez O, White R. Results of a multicenter, prospective trial of thoracic endovascular aortic repair for blunt thoracic aortic injury (RESCUE trial). J Vasc Surg 2013; 57:899-905.e1. [PMID: 23384495 DOI: 10.1016/j.jvs.2012.10.099] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 10/16/2012] [Accepted: 10/18/2012] [Indexed: 11/25/2022]
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Patel JH, Wayangankar SA, Zacharias S, Stowell D, Saucedo JF. Endovascular Repair of Traumatic Aortic Injury: A Novel Arena in Interventional Cardiology. J Interv Cardiol 2012; 26:77-83. [DOI: 10.1111/j.1540-8183.2012.00761.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- Jigar H Patel
- Department of Internal Medicine, Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
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Jánosi RA, Erbel R, Konorza TF. Recent advances in the diagnosis of acute aortic syndromes. ACTA ACUST UNITED AC 2012; 6:529-40. [PMID: 23480835 DOI: 10.1517/17530059.2012.704362] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Acute aortic syndrome (AAS) is an acute lesion of the aortic wall involving the aortic media. In patients presenting with AAS, establishing a timely diagnosis is of paramount importance as mortality from AAS increases by 1 - 2% per hour. Acute aortic syndrome comprises a variety of pathologically distinct life-threatening conditions such as aortic dissection, intramural hematoma (IMH) of the aorta, penetrating aortic ulcer (PAU), traumatic transection and symptomatic aortic aneurysm. AREAS COVERED The aim of this article was to review recent progress in the diagnosis and therapeutic management of these syndromes. In the past few years, imaging techniques have increased our understanding of the natural history of these disease entities. Patients presenting with AAS require immediate diagnosis in order to rapidly initiate adequate therapeutic measures. Diagnostic imaging modalities that can be used for diagnosing this condition are transthoracic and transesophageal echocardiography (TTE and TEE, respectively), computed tomography angiography (CTA), magnetic resonance imaging and angiography in combination with intravascular ultrasound (IVUS). EXPERT OPINION Patients presenting with AAS require immediate diagnosis for rapid initiation of adequate therapeutic measures. The best method to correctly diagnose acute aortic dissection and its complications is complementary use of CTA, TEE and angiography in combination with IVUS to improve visualization of aortic syndromes and to guide aortic stent graft implantation.
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Affiliation(s)
- Rolf Alexander Jánosi
- University of Duisburg- Essen, West-German Heart Center Essen, Department of Cardiology , Hufelandstraße 55, 45122 Essen , Germany +49 201 723 4807 ; +49 201 723 5931 ;
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Grabenwöger M, Alfonso F, Bachet J, Bonser R, Czerny M, Eggebrecht H, Evangelista A, Fattori R, Jakob H, Lönn L, Nienaber CA, Rocchi G, Rousseau H, Thompson M, Weigang E, Erbel R. Thoracic Endovascular Aortic Repair (TEVAR) for the treatment of aortic diseases: a position statement from the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur J Cardiothorac Surg 2012; 42:17-24. [PMID: 22561652 DOI: 10.1093/ejcts/ezs107] [Citation(s) in RCA: 167] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Martin Grabenwöger
- Department of Cardiovascular Surgery, Hospital Hietzing, Vienna, Austria
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Grabenwöger M, Alfonso F, Bachet J, Bonser R, Czerny M, Eggebrecht H, Evangelista A, Fattori R, Jakob H, Lönn L, Nienaber CA, Rocchi G, Rousseau H, Thompson M, Weigang E, Erbel R. Thoracic Endovascular Aortic Repair (TEVAR) for the treatment of aortic diseases: a position statement from the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2012; 33:1558-63. [PMID: 22561257 DOI: 10.1093/eurheartj/ehs074] [Citation(s) in RCA: 162] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Martin Grabenwöger
- Department of Cardiovascular Surgery, Hospital Hietzing, Vienna, Austria
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Lioupis C, MacKenzie KS, Corriveau MM, Obrand DI, Abraham CZ, Steinmetz OK. Midterm results following endovascular repair of blunt thoracic aortic injuries. Vasc Endovascular Surg 2012; 46:109-16. [PMID: 22308206 DOI: 10.1177/1538574411431648] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Previous studies have focused on early outcomes of thoracic endovascular repair (TEVAR) of blunt thoracic aortic injuries (BTAIs). Late results remain ill-defined. The purpose of this study is to review the midterm results of our experience with endovascular repair of BTAIs. METHODS A retrospective analysis was performed reviewing all endovascular repairs of BTAIs from 2002 to present. Preoperative, operative, and postoperative variables were recorded. Clinical end points included aortic-related mortality, stroke and paraplegia, hospital length of stay, procedure-related complications, endoleaks, and reinterventions. Computed tomography data sets were postprocessed for assessing integrity of stent grafts and late complications. RESULTS A total of 24 cases of BTAIs treated with TEVAR were identified. Thoracic endovascular repair was successful in treating BTAIs in all patients and there were no instances of procedure-related death, stroke, or paraplegia. One access complication occurred, requiring an iliofemoral bypass. Actuarial survival estimates and freedom from reintervention at 5 years were 88.7% and 95.8%, respectively. No late endoleaks, stent fractures, or device migration were identified. One patient required a secondary intervention 1 year following the initial repair to treat a pseudocoarctation syndrome caused by a diaphragm at the distal half of the stented aorta. This was treated successfully with repeated endografting. CONCLUSIONS Thoracic endovascular repair for BTAIs can be performed safely with low periprocedural mortality and morbidity. Midterm follow-up data presented in this report further support the therapeutic role of endoluminal approach for treating BTAIs in anatomically suitable patients.
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Affiliation(s)
- Christos Lioupis
- Division of Vascular Surgery, Jewish General Hospital, McGill University, Montreal, QC, Canada
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