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Alanezi T, Altoijry A, AlSheikh S, Al-Mubarak H, Alhamzah M, Alomran F, Abdulrahim O, Aljabri B, Greco E, Hussain MA, Al-Omran M. Predicting the need for subclavian artery revascularization in thoracic endovascular aortic repair: A systematic review and meta-analysis. J Vasc Surg 2024; 80:922-936.e5. [PMID: 38621636 DOI: 10.1016/j.jvs.2024.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/21/2024] [Accepted: 04/09/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVE This systematic review and meta-analysis aims to investigate the effectiveness of left subclavian artery revascularization compared with non-revascularization in thoracic endovascular aortic repair, and to summarize the current evidence on its indications. METHODS A computerized search was conducted across multiple databases, including MEDLINE, SCOPUS, Cochrane Library, and Web of Science, for studies published up to November 2023. Study selection, data abstraction, and quality assessment (using the Newcastle-Ottawa Scale) were independently conducted by two reviewers, with a third author resolving discrepancies. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models and publication bias was assessed using funnel plots. RESULTS In the 76 included studies, left subclavian artery revascularization was associated with reduced risks of stroke (OR, 0.67; 95% CI, 0.45-0.98; n = 15,331), spinal cord ischemia (OR, 0.75; 95% CI, 0.56-0.99; n = 11,995), and arm ischemia (OR, 0.09; 95% CI, 0.01-0.59; n = 8438). No significant reduction in paraplegia (OR, 0.56; 95% CI, 0.21-1.47; n = 1802) or mortality (OR, 0.77; 95% CI, 0.53-1.12; n = 11,831) was observed. Moreover, the risk of endoleak was comparable in both groups (OR, 1.25; 95% CI, 0.55-2.84; P = .60; n = 793), whereas the risk of reintervention was significantly higher in the revascularization group (OR, 1.98; 95% CI, 1.03-3.83; P = .04; n = 272). Both groups had similar risks of major (OR, 0.45; 95% CI, 0.19-1.09; P = .08; n = 1113), minor (OR, 0.21; 95% CI, 0.01-3.45; P = .27; n = 183), renal (OR, 0.61; 95% CI, 0.12-3.06; P = .55; n = 310), and pulmonary (OR, 0.59; 95% CI, 0.16-2.15; P = .42; n = 8083) complications. The most frequent indications for left subclavian artery revascularization were primary prevention of spinal cord ischemia, augmentation of the landing zone, and primary stroke prevention. CONCLUSIONS Left subclavian artery revascularization in thoracic endovascular aortic repair was associated with reduced neurological complications but was not found to impact mortality. The study highlights important indications for revascularization as well as significant predictors of complications, providing a basis for clinical decision-making and future research.
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Affiliation(s)
- Tariq Alanezi
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulmajeed Altoijry
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Sultan AlSheikh
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Husain Al-Mubarak
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Musaad Alhamzah
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Faris Alomran
- Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Omer Abdulrahim
- Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Badr Aljabri
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Elisa Greco
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Mohamad A Hussain
- Harvard Medical School, Boston, MA; Division of Vascular and Endovascular Surgery and the Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston
| | - Mohammed Al-Omran
- Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
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Buczkowski P, Puslecki M, Ligowski M, Dabrowski M, Stefaniak S, Fryska Z, Kulesza J, Juszkat R, Jemielity M, Perek B. Emergency Endovascular Interventions on Descending Thoracic Aorta: A Single-Center Experience. Emerg Med Int 2023; 2023:6600035. [PMID: 36636029 PMCID: PMC9831698 DOI: 10.1155/2023/6600035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/15/2022] [Accepted: 12/22/2022] [Indexed: 01/05/2023] Open
Abstract
Background Implementation of emergency endovascular aortic repair provides an attractive opportunity in the treatment of complicated acute aortic syndromes involving descending aorta. Aim The aim of this study was to analyze the effectiveness of thoracic endovascular aortic repair (TEVAR) for the treatment of acute surgical emergencies involving the descending thoracic aorta. Methods A retrospective review of the medical records of all patients undergoing TEVAR in a single center since 2007 was undertaken. Patients with the aortic disease treated on emergency inclusion criteria were complicated spontaneous acute aortic syndrome (csAAS), traumatic aortic acute injuries (TAIs), and other indications requiring emergent intervention. Technical and clinical success with patient mortality, survival, and reoperation rate was evaluated according to Society for Vascular Surgery reporting standards for thoracic endovascular aortic repair (TEVAR). Results The emergency interventions were necessary in 74 cases (51.0%), including patients with the complicated spontaneous acute aortic syndrome (csAAS) (64.8%; n = 48) and traumatic aortic acute injuries (TAIs) (31.1%). In addition, in one case aortic iatrogenic dissection (AID) and in 2 other fistulas after the previous stent graft, implantations were diagnosed. All procedures were done through surgically exposed femoral arteries while 2 hybrid procedures required additional approaches. The primary technical success rate was 95.9%, in 3 cases endoleak was reported. The primary clinical success occurred in 94.5%. All patients survived the endovascular interventions, whereas during in-hospital stay one of them died due to multiorgan failure (early mortality 1.3%). During the follow-up period, lasting 6 through 164 months (median 67), 11 patients died. Annual, five- and ten-year probability of survival was 86.4 ± 0.04%, 80.0 ± 0.05%, and 76.6 ± 0.06%, respectively. However, the rate of 5-year survivors was significantly higher after TAI (95.2%) than scAAS (63.4%) (p=0.008). Early after the procedure, one individual developed transient paraparesis (1.3%). No other serious stent-graft-related adverse events were noted within the postdischarge follow-up period. Conclusions Descending aortic pathologies requiring emergent interventions can be treated by endovascular techniques with optimal results and low morbidity and mortality in an experienced and dedicated team.
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Affiliation(s)
- Piotr Buczkowski
- Department of Cardiac Surgery and Transplantology, Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Dluga Street 1/2, Poznan 61–848, Poland
| | - Mateusz Puslecki
- Department of Cardiac Surgery and Transplantology, Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Dluga Street 1/2, Poznan 61–848, Poland
- Department of Medical Rescue, Emergency Medicine, Poznan University of Medical Sciences, Collegium Adama Wrzoska, Rokietnicka Street 7, Poznan 60-806, Poland
- Polish Society of Medical Simulation, Slupca, Poland
| | - Marcin Ligowski
- Department of Cardiac Surgery and Transplantology, Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Dluga Street 1/2, Poznan 61–848, Poland
| | - Marek Dabrowski
- Polish Society of Medical Simulation, Slupca, Poland
- Department of Medical Education, Poznan University of Medical Sciences, Collegium Adama Wrzoska, Rokietnicka Street 7, Poznan 60-806, Poland
| | - Sebastian Stefaniak
- Department of Cardiac Surgery and Transplantology, Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Dluga Street 1/2, Poznan 61–848, Poland
| | - Zuzanna Fryska
- Faculty of Medicine, Poznan University of Medical Sciences, Poland
| | - Jerzy Kulesza
- Department of Radiology, Poznan University of Medical Sciences, Dluga Street 1/2, Poznan 61–848, Poland
| | - Robert Juszkat
- Department of Radiology, Poznan University of Medical Sciences, Dluga Street 1/2, Poznan 61–848, Poland
| | - Marek Jemielity
- Department of Cardiac Surgery and Transplantology, Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Dluga Street 1/2, Poznan 61–848, Poland
| | - Bartlomiej Perek
- Department of Cardiac Surgery and Transplantology, Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Dluga Street 1/2, Poznan 61–848, Poland
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Benk J, Siepe M, Berger T, Beyersdorf F, Kondov S, Rylski B, Czerny M, Kreibich M. Early and mid-term outcomes of thoracic endovascular aortic repair to treat aortic rupture in patients with aneurysms, dissections and trauma. Interact Cardiovasc Thorac Surg 2022; 35:ivac042. [PMID: 35167665 PMCID: PMC9714596 DOI: 10.1093/icvts/ivac042] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/27/2022] [Accepted: 01/31/2022] [Indexed: 09/10/2023] Open
Abstract
OBJECTIVES The aim of this study was to analyse outcomes of thoracic endovascular aortic repair to treat aortic rupture. METHODS Patient and outcome characteristics of all emergent endovascular treatments for thoracic aortic rupture between January 2009 and December 2019 were analysed. RESULTS Thoracic aortic rupture occurred in patients with aortic aneurysms (n = 42, 49%), aortic dissection (n = 13, 16%) or after trauma (n = 30, 35%). Preoperative cerebrospinal fluid drainage was placed in 9 patients (11%) and 18 patients (21%) underwent perioperative supra-aortic transposition. The proximal landing zones were: zone 1 (n = 1, 1%), zone 2 (n = 23, 27%), zone 3 (n = 52, 61%) and zone 4 (n = 9, 11%). Temporary spinal cord injury occurred in 1 patient (1%), permanent spinal cord injury in 7 patients (8%). Two patients (2%) experienced a postoperative stroke. Seventeen patients (20%) expired in-hospital. Aortic dissection (odds ratio: 16.246, p = 0.001), aneurysm (odds ratio: 9.090, P = 0.003) and preoperative shock (odds ratio: 4.646, P < 0.001) were predictive for mortality. Eighteen patients (21%) required a stent-graft-related aortic reintervention for symptomatic supra-aortic malperfusion (n = 3, 4%), endoleaks (n = 6, 7%), a second aortic rupture (n = 4, 5%), retrograde type A aortic dissection (n = 2, 2%), aortic-oesophageal fistulation (n = 2, 2%) and stent-graft kinking (n = 1, 1%). CONCLUSIONS Thoracic endovascular aortic repair in patients with aortic rupture has become a valuable treatment modality to stabilize patients. However, a significant risk of postoperative morbidity and mortality remains, particularly in patients with aortic dissections, aneurysms or shock. Patients require thorough follow-up ideally in an aortic clinic with a staff having the entire spectrum of cardiovascular and thoracic surgical expertise.
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Affiliation(s)
- Julia Benk
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Tim Berger
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
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Patel PB, Marcaccio CL, de Guerre LEVM, Patel VI, Wang G, Giles K, Schermerhorn ML. Complications after thoracic endovascular aortic repair for ruptured thoracic aortic aneurysms remain high compared with elective repair. J Vasc Surg 2022; 75:842-850. [PMID: 34655686 PMCID: PMC8863631 DOI: 10.1016/j.jvs.2021.09.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 09/29/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Thoracic endovascular aortic repair (TEVAR) for ruptured thoracic aortic aneurysms is associated with increased perioperative mortality and morbidity compared with intact repair. The purpose of our study was to evaluate the factors associated with the presentation of ruptured aneurysms and adverse outcomes after repair. METHODS The Vascular Quality Initiative (VQI) registry was queried (2010-2020) to identify patients who had undergone TEVAR for ruptured and intact thoracic aortic aneurysms. The primary outcome was to identify the factors associated with ruptured thoracic aortic aneurysms. The secondary outcomes included perioperative mortality and morbidity, 5-year survival, and the identification of factors associated with adverse outcomes after TEVAR. RESULTS Of the 3039 patients identified with a thoracic aortic aneurysm, 2806 (92%) had undergone repair for an intact aneurysm and 233 (8%) had undergone repair for a ruptured aneurysm. Chronic kidney disease was associated with a greater odds of a presentation with a ruptured aneurysm (odds ratio [OR], 3.1; 95% confidence interval [CI], 2.0-4.9; P < .001). The factors associated with a lower odds of rupture included prior aortic aneurysm repair (OR, 0.71; 95% CI, 0.49-0.97; P = .05), prior smoker (OR, 0.36; 95% CI, 0.24-0.53; P < .001), preoperative beta-blocker therapy (OR, 0.57; 95% CI, 0.41-0.80; P = .001), and preoperative statin therapy (OR, 0.68; 95% CI, 0.49-0.94; P = .020). TEVAR for ruptured thoracic aortic aneurysms was associated with higher perioperative mortality (rupture vs intact, 27% vs 4.6%; OR, 6.6; 95% CI 4.3-10; P < .001) and the composite outcome of mortality, new dialysis, paralysis, and stroke (38% vs 9.5%; OR, 5.1; 95% CI, 3.5-7.4; P < .001). The 5-year survival was significantly lower after TEVAR for ruptured thoracic aortic aneurysms (50% vs 76%; P < .001; hazard ratio, 0.39; 95% CI, 0.29-0.52; P < .001). Preoperative statin therapy was associated with higher 5-year survival (hazard ratio, 1.3; 95% CI, 1.0-1.6; P = .021). CONCLUSIONS TEVAR for ruptured thoracic aortic aneurysms results in increased perioperative mortality and morbidity and lower 5-year survival compared with TEVAR for intact aneurysms. Patients with prior aortic aneurysm repair, prior smoking, and preoperative beta-blocker or statin therapy were less likely to present with ruptured thoracic aneurysms. This correlation might be attributed to increased exposure to cardiovascular healthcare providers and, thus, subsequently increased screening and surveillance, allowing for elective repair of thoracic aortic aneurysms.
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Affiliation(s)
- Priya B Patel
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Livia E V M de Guerre
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Virendra I Patel
- Division of Vascular Surgery and Endovascular Interventions, Columbia University Medical Center, New York, NY
| | - Grace Wang
- Division of Vascular and Endovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Kristina Giles
- Division of Vascular and Endovascular Surgery, Maine Medical Center, Portland, Me
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
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Zhang Z, Zhou Y, Lin S, Xiao J, Ai W, Zhang WW. Systematic review and meta-analysis of association of prophylactic cerebrospinal fluid drainage in preventing spinal cord ischemia after thoracic endovascular aortic repair. J Vasc Surg 2021; 75:1478-1489.e5. [PMID: 34793925 DOI: 10.1016/j.jvs.2021.10.050] [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: 01/31/2021] [Accepted: 10/27/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We conducted a systemic review and meta-analysis to compare the association between prophylactic cerebrospinal fluid drainage (CSFD) vs non-CSFD in preventing spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) for aneurysm and dissection. METHODS The MEDLINE, Embase, and Cochrane databases were systematically searched to identify all relevant studies reported before April 1, 2020. A systematic review and meta-analysis were performed. We assessed the association between CSFD strategies, including routine CSFD vs selective CSFD or no CSFD, and the SCI rates after TEVAR for patients with aortic dissection (AD), solitary thoracic aortic aneurysm (TAA), or thoracoabdominal aortic aneurysm (TAAA). Subgroup analyses were conducted to assess the association between different aortic pathologies, including AD and thoracic aneurysms, and SCI rates after TEVAR with and without prophylactic CSFD. The data are presented as the pooled event rates (ERs) and 95% confidence intervals (CIs). RESULTS A total of 34 studies of 3561 patients (2671 with TAA or TAAA and 890 with type B AD) were included in the present analysis. The data are presented as the pooled ERs and 95% CIs. The overall SCI rate for patients who had undergone TEVAR with prophylactic CSFD for AD (ER, 1.80%; 95% CI, 0.88%-2.72%) was significantly lower than that for the aortic aneurysm group (ER, 5.73%; 95% CI, 4.20%-7.27%; P < .0001). The SCI rate after TEVAR with prophylactic CSFD was not significantly different from that without CSFD for AD (P = .51). No association was found between the rates of SCI after TEVAR with routine prophylactic CSFD vs selective prophylactic CSFD for aortic aneurysms (P = .76) and AD (P = .70). The SCI rate after TEVAR without CSFD for aortic aneurysms, including isolated TAA and TAAA (ER, 3.49%; 95% CI, 0.23%-6.76%) was not significantly different from that for AD (ER, 3.20%; 95% CI, 0.00%-7.20%; P = .91). For the patients with TAAAs, the rate of SCI after TEVAR with routine prophylactic CSFD was significantly lower than that with selective prophylactic CSFD (P = .04). CONCLUSIONS Our systematic review and meta-analysis has shown that SCI occurs more often after TEVAR for aortic aneurysms than for AD. Routine prophylactic CSFD, compared with selective CSFD, was associated with a lower rate of postoperative SCI after TEVAR for TAAAs. No significant association was found between the SCI rate and routine prophylactic CSFD for patients undergoing TEVAR for isolated TAA or AD.
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Affiliation(s)
- Zhihui Zhang
- Department of Vascular Surgery, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yang Zhou
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Shaomang Lin
- Department of Vascular Surgery, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jianbin Xiao
- Department of Vascular Surgery, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wenjia Ai
- Department of Vascular Surgery, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wayne W Zhang
- Division of Vascular and Endovascular Surgery, University of Washington and Puget Sound Veterans Affairs Health Care System, Seattle, Wash.
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López Espada C, Linares Palomino JP, Domínguez González JM, Iborra Ortega E, Lozano Vilardell P, Solanich Valldaura T, Volo Pérez G, Blanco Cañibano E, Álvarez Salgado A, Fernández Fernández JC, Hernando Rydings M, Miralles Hernández M. A multicenter study of emergency endovascular repair of the thoracic aorta: Indications and outcomes. Med Intensiva 2021; 45:280-288. [PMID: 34059218 DOI: 10.1016/j.medine.2021.04.008] [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: 09/11/2019] [Accepted: 10/28/2019] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Endovascular techniques have become an essential tool for the treatment of descending thoracic aortic disease (thoracic endovascular aneurysm repair [TEVAR]). The aim is to analyze the indications and outcomes of emergency TEVAR at national level in relation to elective surgery. STUDY DESIGN AND SCOPE A retrospective multicenter registry of patients with descending thoracic aortic disease treated on an emergency basis using endovascular techniques between 2012-2016, in 11 clinical units. PATIENTS, INCLUSION CRITERIA 1) Ruptured descending thoracic aortic aneurysms (RTAA); 2) Blunt traumatic thoracic aortic injury (TAI); and 3) Complicated acute type B aortic dissections (TBADc). PRIMARY VARIABLES Patient mortality, survival and reoperation rate. SECONDARY VARIABLES Demographic data, cardiovascular risk factors, specific data by indication, technical resources and postoperative complications. RESULTS A total of 135 urgent TEVARs were included (111 men, mean age 60.4 ± 16.3 years): 43 ruptured thoracic aortic aneurysms (31.9%), 54 type B dissections (40%) and 32 traumatic aortic injuries (23.7%), and other etiologies 4.4%. The overall mortality rate at 30 days was 18.5%, and proved higher in the RTAA group (27.9%). The mean actuarial survival rate was 67 ± 6% at 5 years. The postoperative stroke rate was 5.2%, and the paraplegia rate was 5.9%. Aortic reoperations proved necessary in 12 patients (9%). CONCLUSIONS Emergency descending thoracic aortic diseases can be treated by endovascular techniques with optimal results and low morbidity and mortality - though the figures are slightly higher than in elective cases. This registry provides, for the first time, real information on the daily clinical practice of emergency TEVAR in Spain.
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Affiliation(s)
- C López Espada
- Servicio de Cirugía Vascular, Hospital Universitario Virgen de las Nieves, Granada, Spain.
| | - J P Linares Palomino
- Servicio de Cirugía Vascular, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | | | - E Iborra Ortega
- Servicio de Cirugía Vascular, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - P Lozano Vilardell
- Servicio de Cirugía Vascular, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | | | - G Volo Pérez
- Servicio de Cirugía Vascular, Hospital Universitario Dr. Negrín, Gran Canaria, Spain
| | - E Blanco Cañibano
- Servicio de Cirugía Vascular, Hospital Universitario de Guadalajara, Guadalajara, Spain
| | - A Álvarez Salgado
- Servicio de Cirugía Vascular, Hospital Universitario de Cabueñes, Spain
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Patel PB, Schermerhorn ML. Emergent thoracic endovascular aortic aneurysm repair for ruptured aneurysm: in-hospital and long-term results. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:675-680. [PMID: 33185076 DOI: 10.23736/s0021-9509.20.11595-7] [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
The use of thoracic endovascular aortic repair (TEVAR) has rapidly increased following Food and Drug Administration (FDA) approval in 2005. Initially used for the repair of intact thoracic aneurysms and aortic dissections, TEVAR is now routinely used for the treatment of ruptured thoracic aortic aneurysm as well. Emergent TEVAR for the repair of ruptured aneurysm has demonstrated improved perioperative mortality and morbidity compared to traditional open repair. Spinal cord ischemia and permanent paraplegia rates are also lower following TEVAR compared to open repair. However, TEVAR requires routine surveillance and has demonstrated the need for reintervention compared to open repair. Furthermore, the perioperative survival benefits of TEVAR were attenuated on mid-term and long-term survival analysis.
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Affiliation(s)
- Priya B Patel
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA -
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Iqbal R, Alom S, BinSaeid J, Harky A. Loeys-Dietz syndrome pathology and aspects of cardiovascular management: A systematic review. Vascular 2020; 29:3-14. [PMID: 32559129 DOI: 10.1177/1708538120934582] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Loeys-Dietz syndrome is an autosomal dominant genetic disorder which is associated with significant and often crucial vascular manifestations. This review is aimed to examine current evidence on pathophysiology and management of Loeys-Dietz syndrome in current era. A comprehensive electronic search was done to identify the articles that discussed all the aspects of Loeys-Dietz syndrome, combined key words and Medical Subject Headings (MeSH) terms were used. Relevant articles have been summarized in each relevant section. Loeys-Dietz syndrome is an autosomal dominant genetic disorder which has combined and multi-systemic manifestations. The increased breakdown of extracellular matrix predisposes an individual to developing aneurysms in the aortic tree which is undoubtedly the most significant complication of this disorder. Understanding the pathophysiology and natural history of Loeys-Dietz syndrome and regular surveillance is important to plan prophylactic interventions to prevent life-threatening aortic emergencies which can be fatal. Loeys-Dietz syndrome is an aggressive genetic condition that predisposes an individual to the development of life-threatening aortic aneurysms. Our understanding of Loeys-Dietz syndrome remains ever-changing and it is likely that the knowledge regarding its diagnosis and treatment will become more clearly defined in the coming years with deeper genetic studies.
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Affiliation(s)
| | - Samiha Alom
- School of Public Health, Imperial College London, London, UK
| | - Jalal BinSaeid
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
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Thoracic Endovascular Aneurysm Repair Trends and Outcomes in Over 27,000 Medicare Patients for Descending Thoracic Aneurysms. Ann Thorac Surg 2020; 109:1757-1764. [DOI: 10.1016/j.athoracsur.2019.12.054] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 10/21/2019] [Accepted: 12/19/2019] [Indexed: 11/19/2022]
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10
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López Espada C, Linares Palomino JP, Domínguez González JM, Iborra Ortega E, Lozano Vilardell P, Solanich Valldaura T, Volo Pérez G, Blanco Cañibano E, Álvarez Salgado A, Fernández Fernández JC, Hernando Rydings M, Miralles Hernández M. A multicenter study of emergency endovascular repair of the thoracic aorta: indications and outcomes. Med Intensiva 2019; 45:280-288. [PMID: 31836259 DOI: 10.1016/j.medin.2019.10.008] [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: 09/11/2019] [Revised: 10/22/2019] [Accepted: 10/28/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Endovascular techniques have become an essential tool for the treatment of descending thoracic aortic disease (thoracic endovascular aneurysm repair [TEVAR]). The aim is to analyze the indications and outcomes of emergency TEVAR at national level in relation to elective surgery. STUDY DESIGN AND SCOPE A retrospective multicenter registry of patients with descending thoracic aortic disease treated on an emergency basis using endovascular techniques between 2012-2016, in 11 clinical units. PATIENTS, INCLUSION CRITERIA 1) Ruptured descending thoracic aortic aneurysms; 2) Blunt traumatic thoracic aortic injury; and 3) Complicated acute type B aortic dissections (TBADc). PRIMARY VARIABLES Patient mortality, survival and reoperation rate. SECONDARY VARIABLES Demographic data, cardiovascular risk factors, specific data by indication, technical resources and postoperative complications. RESULTS A total of 135 urgent TEVARs were included (111 men, mean age 60.4 ± 16.3 years): 43 ruptured thoracic aortic aneurysms (31.9%), 54 type B dissections (40%) and 32 traumatic aortic injuries (23.7%), and other etiologies 4.4%. The overall mortality rate at 30 days was 18.5%, and proved higher in the ruptured descending thoracic aortic aneurysms group (27.9%). The mean actuarial survival rate was 67± 6% at 5 years. The postoperative stroke rate was 5.2%, and the paraplegia rate was 5.9%. Aortic reoperations proved necessary in 12 patients (9%). CONCLUSIONS Emergency descending thoracic aortic diseases can be treated by endovascular techniques with optimal results and low morbidity and mortality - though the figures are slightly higher than in elective cases. This registry provides, for the first time, real information on the daily clinical practice of emergency TEVAR in Spain.
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Affiliation(s)
- C López Espada
- Servicio de Cirugía Vascular, Hospital Universitario Virgen de las Nieves, Granada, España.
| | - J P Linares Palomino
- Servicio de Cirugía Vascular, Hospital Universitario Virgen de las Nieves, Granada, España
| | | | - E Iborra Ortega
- Servicio de Cirugía Vascular, Hospital Universitari de Bellvitge, Barcelona, España
| | - P Lozano Vilardell
- Servicio de Cirugía Vascular, Hospital Universitari Son Espases, Palma de Mallorca, España
| | | | - G Volo Pérez
- Servicio de Cirugía Vascular, Hospital Universitario Dr. Negrín, Gran Canaria, España
| | - E Blanco Cañibano
- Servicio de Cirugía Vascular, Hospital Universitario de Guadalajara, Guadalajara, España
| | - A Álvarez Salgado
- Servicio de Cirugía Vascular, Hospital Universitario de Cabueñes, España
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11
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Hammo S, Larzon T, Hultgren R, Wanhainen A, Mani K, Resch T, Falkenberg M, Forssell C, Sonesson B, Pirouzram A, Roos H, Hellgren T, Khan S, Höijer J, Wahlgren CM. Outcome After Endovascular Repair of Ruptured Descending Thoracic Aortic Aneurysm: A National Multicentre Study. Eur J Vasc Endovasc Surg 2019; 57:788-794. [PMID: 30910493 DOI: 10.1016/j.ejvs.2018.10.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 10/25/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The purpose of this multicentre study was to analyse the outcome of thoracic endovascular aortic repair (TEVAR) in patients with ruptured descending thoracic aortic aneurysm (rDTAA). METHODS This is a nationwide retrospective study including all patients who underwent TEVAR for rDTAA at six major vascular university centres in Sweden between January 2000 and December 2015. Outcome measures were analysed using Kaplan-Meier estimator and multivariable Cox regression. RESULTS There were 140 patients (age [mean ± SD] 74.1 ± 8.8 years; 56% men; aneurysm size 64.8 ± 19 mm), with rDTAA. In 53 patients (37.9%), the left subclavian artery was covered, and in 25 patients (17.9%) arch vessel revascularisation was performed. In total, 61/136 patients (45%) had a major complication within 30 days post TEVAR. Stroke (n = 20; 14.7%) was the most common complication, followed by paraplegia (n = 13; 9.6%) and major bleeding (n = 13; 9.6%). TEVAR related complications during follow up included endoleaks 22.1% (30/136; 14 type 1a, six type 1b, 10 not defined). In total, re-interventions (n = 31) were required in 27/137 (19.7%) patients. The median follow up time was 17.0 months (range 0-132 months). The Kaplan-Meier estimated survival was 80.0% at one month, 71.7% at three months, 65.3% at one year, 45.9% at three years, and 31.9% at five years. Age (HR 1.03; 95% CI 1.00-1.07; p = .046), history of stroke (HR 2.35; 95% CI 1.19-4.63; p = .014), previous aortic surgery (HR 2.11; 95% CI 1.15-3.87; p = .016) as well as post-operative major bleeding (HR 4.40; 95% CI 2.20-8.81; p = .001), stroke (HR 2.63; 95% CI 1.37-5.03; p = .004), and renal failure (HR 8.25; 95% CI 2.69-25.35; p = .001) were all associated with mortality. CONCLUSIONS This nationwide multicentre study of patients with rDTAA undergoing TEVAR showed acceptable short- but poor long-term survival. Adequate proximal and distal aortic sealing zones are important for technical success. High risk patients and post-operative complications need to be further addressed in an effort to improve outcome.
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Affiliation(s)
- Sari Hammo
- Department of Vascular Surgery, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Larzon
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Vascular Surgery, Örebro University Hospital, Örebro, Sweden
| | - Rebecka Hultgren
- Department of Vascular Surgery, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Timothy Resch
- Vascular Centre, Skåne University Hospital, Malmö, Sweden
| | - Mårten Falkenberg
- Unit of Vascular Surgery, Department of Hybrid and Interventional Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Claes Forssell
- Department of Thoracic and Vascular Surgery, Linköping University, Linköping, Sweden; Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Björn Sonesson
- Vascular Centre, Skåne University Hospital, Malmö, Sweden
| | - Artai Pirouzram
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Vascular Surgery, Örebro University Hospital, Örebro, Sweden
| | - Håkan Roos
- Unit of Vascular Surgery, Department of Hybrid and Interventional Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Tina Hellgren
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Shazhad Khan
- Vascular Centre, Skåne University Hospital, Malmö, Sweden
| | - Jonas Höijer
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Carl-Magnus Wahlgren
- Department of Vascular Surgery, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.
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12
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Hsu DY, Gabel E. Rigid Esophagoscopy-Induced Aortic Rupture During Oral Gastric Tube Placement in Patient With Esophageal Stricture: A Case Report. A A Pract 2018; 11:14-15. [PMID: 29634568 DOI: 10.1213/xaa.0000000000000721] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
This is the first account of significant aortic injury during diagnostic rigid esophagoscopy in an adult with an esophageal stricture. We describe the resultant hemothorax and hemodynamic collapse and the successful treatment with massive volume resuscitation, vasopressors, and timely surgical intervention including thoracic endovascular aortic repair. We discuss the importance of rapid diagnosis, relevant anatomy, treatment modalities, and communication as cornerstones for learning.
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Affiliation(s)
- Derek Y Hsu
- From the Department of Anesthesiology, Ronald Reagan UCLA Medical Center, Los Angeles, California
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13
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Lau C, Leonard JR, Iannacone E, Gaudino M, Girardi LN. Surgery for Acute Presentation of Thoracoabdominal Aortic Disease. Semin Thorac Cardiovasc Surg 2018; 31:11-16. [PMID: 30071280 DOI: 10.1053/j.semtcvs.2018.07.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 07/24/2018] [Indexed: 01/16/2023]
Abstract
Thoracoabdominal aortic aneurysms are most commonly asymptomatic until there is either an impending aortic catastrophe or one that has already occurred. While open surgery remains the gold-standard method for repair, modern technology has led to the development of less invasive endovascular devices and techniques. We provide an expert review of open and endovascular therapies for 3 highly lethal thoracoabdominal aortic emergencies in order to highlight expectations for both short- and long-term outcomes in an era of evolving technology and improvements in patient evaluation and postoperative care. Open repair of ruptured thoracoabdominal aortic aneurysms is associated with a dramatic increase in all postoperative complications, even in specialized aortic surgery centers. Mycotic thoracic aortic aneurysms are highly lethal if surgical treatment is not initiated quickly as they have a propensity toward rapid growth and fatal rupture. Thoracic endovascular aortic repair is well-suited for the treatment of acute complicated type B aortic dissection with outcomes superior to open repair in some centers. Acute aortic events associated with thoracoabdominal aneurysms represent technically challenging situations that require rapid diagnosis and treatment to avoid a fatal outcome. Endovascular techniques have evolved as a viable alternative therapy for acute complicated type B aortic dissection or as a bridge to more definitive repair in the setting of infection or rupture.
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Affiliation(s)
- Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Jeremy R Leonard
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Erin Iannacone
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York.
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14
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Thomas RP, Amin SS, Eldergash O, Kowald T, Bremer S, Easo J, Weymann A, Book M, Szczechowicz M, Schmuck B, Chavan A. Urgent Endovascular Treatment for Non-traumatic Descending Thoracic Aortic Rupture. Cardiovasc Intervent Radiol 2018; 41:1318-1323. [PMID: 29948006 DOI: 10.1007/s00270-018-2006-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 06/04/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the efficacy of endovascular repair of non-traumatic rupture of the descending thoracic aorta. MATERIALS AND METHODS From January 2011 to August 2017, 22 consecutive patients (16 men, mean age 73.7 years, range 63-92 years) with non-traumatic rupture of the descending thoracic aorta were treated endovascularly. Thirty-day mortality as well as procedure-related morbidity including stroke, renal, pulmonary and spinal complications were retrospectively assessed. Median follow-up was 29 months (range 6-65 months). RESULTS Nine patients had type B dissections, and 13 had atherosclerotic aortic aneurysms. The technical success was 100%; 86.3% of patients (19/22) were treated percutaneously. Thirteen patients (59%) received a single endograft, 8 (36%) received 2 endografts, and 1 received 3 endografts. The endograft diameters ranged between 28 and 46 mm. Two dissection patients received additional distal bare metal true lumen stents. Eleven patients required additional drainage of thoracic hematoma. Three primary percutaneous sites (15.7%) required surgical revision. No spinal cord ischemic or renal complications were observed. Stroke was observed in 2 patients (9%), both with full coverage of left subclavian artery origin. Four patients (18%) required tracheostomy with prolonged respiratory support (range 10-15 days). The median intensive care unit stay was 5 days (range 1-27 days). The 30-day mortality was 18.1% (4/22). CONCLUSION Endoluminal repair of non-traumatic rupture of the descending thoracic aorta can be performed percutaneously. It showed a 30-day mortality of 18.1%, and no spinal cord injury or renal complications were observed in surviving patients at follow-up. LEVEL OF EVIDENCE Level 4, case series.
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Affiliation(s)
- Rohit Philip Thomas
- Institute of Diagnostic and Interventional Radiology, Klinikum Oldenburg AöR, Rahel Straus Strasse 10, 26133, Oldenburg, Germany.
| | - Sandeep Sunder Amin
- Institute of Diagnostic and Interventional Radiology, Klinikum Oldenburg AöR, Rahel Straus Strasse 10, 26133, Oldenburg, Germany
| | - Osama Eldergash
- Institute of Diagnostic and Interventional Radiology, Klinikum Oldenburg AöR, Rahel Straus Strasse 10, 26133, Oldenburg, Germany
| | - Tobias Kowald
- Institute of Diagnostic and Interventional Radiology, Klinikum Oldenburg AöR, Rahel Straus Strasse 10, 26133, Oldenburg, Germany
| | - Sebastian Bremer
- Institute of Diagnostic and Interventional Radiology, Klinikum Oldenburg AöR, Rahel Straus Strasse 10, 26133, Oldenburg, Germany
| | - Jerry Easo
- Department of Cardiac Surgery, University Hospital, Klinikum Oldenburg AöR, Oldenburg, Germany
| | - Alexander Weymann
- Department of Cardiac Surgery, University Hospital, Klinikum Oldenburg AöR, Oldenburg, Germany
| | - Malte Book
- Department of Anesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, University Hospital, Klinikum Oldenburg AöR, Oldenburg, Germany
| | - Marcin Szczechowicz
- Department of Cardiac Surgery, University Hospital, Klinikum Oldenburg AöR, Oldenburg, Germany
| | - Bernhard Schmuck
- Institute of Diagnostic and Interventional Radiology, Klinikum Oldenburg AöR, Rahel Straus Strasse 10, 26133, Oldenburg, Germany
| | - Ajay Chavan
- Institute of Diagnostic and Interventional Radiology, Klinikum Oldenburg AöR, Rahel Straus Strasse 10, 26133, Oldenburg, Germany
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15
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Ju MH, Nooromid MJ, Rodriguez HE, Eskandari MK. Management of hemothorax after thoracic endovascular aortic repair for ruptured aneurysms. Vascular 2017; 26:39-46. [PMID: 28699426 DOI: 10.1177/1708538117718109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Thoracic aortic aneurysm rupture is often a fatal condition. Emergent thoracic endovascular aortic repair (TEVAR) has emerged as a suitable treatment option. Unfortunately, respiratory complications from hemothorax continue to be an important cause of morbidity and mortality even after successful management of the aortic rupture. We hypothesize that early hemothorax decompression after TEVAR for ruptured aneurysms decreases the rate of postoperative respiratory complications. Methods Single-center, retrospective eight-year review of ruptured thoracic aneurysms treated with TEVAR. Results Seventeen patients presented with ruptured degenerative thoracic aortic aneurysms, all of which were successfully treated emergently with TEVAR. The mean age was 74 years among the 12 (70.6%) men and 5 (29.4%) women treated. Inpatient and 30-day mortality rates for the entire cohort were both 17.6% (three patients). The 90-day mortality rate was 47.1% (eight patients). Thirty-day morbidities of the entire cohort included stroke ( n = 1, 5.9%), spinal cord ischemia ( n = 3, 17.6%; only one was temporary), cardiac arrest ( n = 4, 23.5%; 3 were fatal), respiratory failure ( n = 5, 29.4%), and renal failure ( n = 5, 29.4%). A large hemothorax was identified in the majority of patients ( n = 14, 82.4%). While six (42.9% of 14) patients had immediate chest tube decompression on the day of index procedure, three (21.4% of 14) patients had decompression on postoperative day 1, 4, and 7, respectively. Although not statistically significant, there were trends toward higher rates of respiratory failure (50.0% vs. 16.7%, P = 0.198) and 90-day mortality (62.5% vs. 33.3%, P = 0.280) for patients with delayed or no hemothorax decompression when compared to patients with immediate hemothorax decompression. Conclusions The morbidity and mortality of ruptured degenerative thoracic aortic aneurysms remains high despite the introduction of TEVAR. In this single-center experience, there was a trend toward decreased respiratory complications and increased survival with early chest decompression of hemothorax after TEVAR.
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Affiliation(s)
- Mila H Ju
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael J Nooromid
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Heron E Rodriguez
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mark K Eskandari
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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16
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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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17
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Ultee KHJ, Zettervall SL, Soden PA, Buck DB, Deery SE, Shean KE, Verhagen HJM, Schermerhorn ML. The impact of endovascular repair on management and outcome of ruptured thoracic aortic aneurysms. J Vasc Surg 2017; 66:343-352.e1. [PMID: 28366304 DOI: 10.1016/j.jvs.2017.01.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 01/09/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) has become an alternative to open repair for the treatment of ruptured thoracic aortic aneurysms (rTAAs). The aim of this study was to assess national trends in the use of TEVAR for the treatment of rTAA and to determine its impact on perioperative outcomes. METHODS Patients admitted with an rTAA between 1993 and 2012 were identified from the National Inpatient Sample. Patients were grouped in accordance with their treatment: TEVAR, open repair, or nonoperative treatment. The primary outcomes were treatment trends over time and in-hospital death. Secondary outcomes included perioperative complications and length of stay. Trend analyses were performed using the Cochran-Armitage test for trend, and adjusted mortality risks were established using multivariable logistic regression analysis. RESULTS A total of 12,399 patients were included, with 1622 (13%) undergoing TEVAR, 2808 (23%) undergoing open repair, and 7969 (64%) not undergoing surgical treatment. TEVAR has been increasingly used from 2% of total admissions in 2003-2004 to 43% in 2011-2012 (P < .001). Concurrently, there was a decline in the proportion of patients undergoing open repair (29% to 12%; P < .001) and nonoperative treatment (69% to 45%; P < .001). The proportion of patients undergoing surgical repair has increased for all age groups since 1993-1994 (P < .001 for all) but was most pronounced among those aged 80 years with a 7.5-fold increase. After TEVAR was introduced, procedural mortality decreased from 36% in 2003-2004 to 27% in 2011-2012 (P < .001); mortality among those undergoing nonoperative treatment remained stable between 63% and 60% (P = .167). Overall mortality after rTAA admission decreased from 55% to 42% (P < .001). Since 2005, mortality for open repair was 33% and 22% for TEVAR (P < .001). In adjusted analysis, open repair was associated with a twofold higher mortality than TEVAR (odds ratio, 2.0; 95% confidence interval, 1.7-2.5). CONCLUSIONS TEVAR has replaced open repair as primary surgical treatment for rTAA. The introduction of endovascular treatment appears to have broadened the eligibility of patients for surgical treatment, particularly among the elderly. Mortality after rTAA admission has declined since the introduction of TEVAR, which is the result of improved operative mortality as well as the increased proportion of patients undergoing surgical repair.
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Affiliation(s)
- Klaas H J Ultee
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Peter A Soden
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Dominique B Buck
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Sarah E Deery
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Katie E Shean
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass.
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18
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Bakoyiannis C, Moris D, Karaolanis G, Patelis N, Schizas D, Georgopoulos S, Liakakos T. Thoracic Aorta Aneurysm Repair in a Patient with a Solitary Kidney: Hybrid Surgery as a Bailout Procedure. Front Surg 2016; 3:62. [PMID: 27891504 PMCID: PMC5102893 DOI: 10.3389/fsurg.2016.00062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 10/27/2016] [Indexed: 11/15/2022] Open
Abstract
Thoracic endovascular aortic repair (TEVAR) is an emerging treatment option for thoracic aorta aneurysms (TAA). Endovascular access is a challenge. We present a novel TEVAR technique in a patient with single kidney and a 6.4 cm TAA. Attempting to place a sheath through iliac arteries was unsuccessful. The decision to proceed to hybrid TEVAR was made. The protection of the solitary kidney was achieved through axillo-femoral bypass, followed by an end-to-side anastomosis between the aorta and a bifurcated graft. Through the graft, a stent was introduced in the thoracic aorta. With the use of contrast material, the right position of the graft was confirmed.
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Affiliation(s)
| | - Demetrios Moris
- Lerner Research Institute, Cleveland Clinic , Cleveland, OH , USA
| | | | - Nikolaos Patelis
- Department of Surgery, Laikon General Hospital , Athens , Greece
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19
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Ultee KHJ, Soden PA, Chien V, Bensley RP, Zettervall SL, Verhagen HJM, Schermerhorn ML. National trends in utilization and outcome of thoracic endovascular aortic repair for traumatic thoracic aortic injuries. J Vasc Surg 2016; 63:1232-1239.e1. [PMID: 26776898 DOI: 10.1016/j.jvs.2015.11.034] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 11/03/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Endovascular repair of traumatic thoracic aortic injuries (TTAI) is an alternative to conventional open surgical repair. Single-institution studies have shown a survival benefit with thoracic endovascular aortic repair (TEVAR), but whether this is being realized nationally is not clear. The purpose of our study was to document trends in the increase in use of TEVAR and its effect on outcomes of TTAI nationally. METHODS Patients admitted with a TTAI between 2005 and 2011 were identified in the National Inpatient Sample. Patients were grouped by treatment into TEVAR, open repair, or nonoperative management. Primary outcomes were relative use over time and in-hospital mortality. Secondary outcomes included postoperative complications and length of stay. Multivariable logistic regression was performed to identify independent predictors of mortality. RESULTS Included were 8384 patients, with 2492 (29.7%) undergoing TEVAR, 848 (10.1%) open repair, and 5044 (60.2%) managed nonoperatively. TEVAR became the dominant treatment option for TTAI during the study period, starting at 6.5% of interventions in 2005 and accounting for 86.5% of interventions in 2011 (P < .001). Nonoperative management declined concurrently with the widespread of adoption TEVAR (79.8% to 53.7%; P < .001). In-hospital mortality after TEVAR decreased during the study period from 33.3% in 2005 to 4.9% in 2011 (P < .001), and an increase in mortality was observed for open repair from 13.9% to 19.2% (P < .001). Procedural mortality (TEVAR or open repair) decreased from 14.9% to 6.7% (P < .001), and mortality after any TTAI admission declined from 24.5% to 13.3% during the study period (P < .001). In addition to lower mortality, TEVAR was followed by fewer cardiac complications (4.1% vs 8.5%; P < .001), respiratory complications (47.5% vs 54.8%; P < .001), and shorter length of stay (18.4 vs 20.2 days; P = .012) compared with open repair. In adjusted mortality analyses, open repair proved to be associated with twice the mortality risk compared with TEVAR (odds ratio, 2.1; 95% confidence interval, 1.6-2.7), and nonoperative management was associated with more than a fourfold increase in mortality (odds ratio, 4.5; 95% confidence interval, 3.8-5.3). CONCLUSIONS TEVAR is now the dominant surgical approach in TTAI, with substantial perioperative morbidity and mortality benefits over open aortic repair. Overall mortality after admission for TTAI has declined, which is most likely the result of the replacement of open repair by TEVAR as well as the broadened eligibility for operative repair.
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Affiliation(s)
- Klaas H J Ultee
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Peter A Soden
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Victor Chien
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Rodney P Bensley
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass.
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20
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Serra R, de Franciscis S, Grande R, Butrico L, Perri P, Indolfi C, Mastroroberto P. Endovascular repair for acute traumatic transection of the descending thoracic aorta: experience of a single centre with a 12-years follow up. J Cardiothorac Surg 2015; 10:171. [PMID: 26590963 PMCID: PMC4655082 DOI: 10.1186/s13019-015-0388-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 11/18/2015] [Indexed: 11/24/2022] Open
Abstract
Background Most blunt aortic injuries occur in the proximal proximal descending aorta causing acute transection of this vessel. Generally, surgical repair of the ruptured segment of aorta is associated with high rates of morbidity and mortality and in this view endovascular treatment seems to be a valid and safer alternative. Aim of this article is to review our experience with endovascular approach for the treatment of acute traumatic rupture of descending thoracic aorta. Methods From April 2002 to November 2014, 11 patients (9 males and 2 females) were referred to our Department with a diagnosis of acute transection of thoracic aorta. Following preoperative Computed Tomography (CT) evaluation, thoracic endovascular aortic repair (TEVAR) with left subclavian artery coverage was performed. Follow-up consisted clinical and instrumental (CT, Duplex ultrasound) controls at discharge, 1, 3 and 6 months and yearly thereafter. Results At 12-year follow up, the overall survival for the entire patients cohort was 100 %, no major or minor neurological complications and no episode of left arm claudication occurred. Cardiovascular, respiratory and bleeding complications, in the early period, was represented by minor, non fatal events. No stent graft failure, collapse, leak or distal migration were detected at CT scan during the entire follow up period. Conclusions According to our experience, despite the small number of patient population, TEVAR procedure with with left subclavian artery coverage, performed in emergency settings, seems to provide excellent long term results. Trials registration The protocol was registered at a public trials registry, www.clinicaltrials.gov (trial identifier NCT02376998).
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Affiliation(s)
- Raffaele Serra
- Interuniversity Center of Phlebolymphology (CIFL). International Research and Educational Program in Clinical and Experimental Biotechnology. Headquarters: University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, 88100, Italy. .,Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, Germaneto, 88100, Italy.
| | - Stefano de Franciscis
- Interuniversity Center of Phlebolymphology (CIFL). International Research and Educational Program in Clinical and Experimental Biotechnology. Headquarters: University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, 88100, Italy. .,Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, Germaneto, 88100, Italy.
| | - Raffaele Grande
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, Germaneto, 88100, Italy.
| | - Lucia Butrico
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, Germaneto, 88100, Italy.
| | - Paolo Perri
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, Germaneto, 88100, Italy.
| | - Ciro Indolfi
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, Germaneto, 88100, Italy.
| | - Pasquale Mastroroberto
- Department of Experimental and Clinical Medicine, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, 88100, Italy.
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21
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Piffaretti G, Menegolo M, Kahlberg A, Mariscalco G, Rinaldi E, Castelli P, Grego F, Chiesa R, Antonello M. Hemothorax Management After Endovascular Treatment For Thoracic Aortic Rupture. Eur J Vasc Endovasc Surg 2015; 50:608-13. [DOI: 10.1016/j.ejvs.2015.07.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 07/08/2015] [Indexed: 01/19/2023]
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22
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Boufi M, Aouini F, Guivier-Curien C, Dona B, Loundou AD, Deplano V, Alimi YS. Examination of factors in type I endoleak development after thoracic endovascular repair. J Vasc Surg 2015; 61:317-23. [DOI: 10.1016/j.jvs.2014.08.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 08/05/2014] [Indexed: 11/16/2022]
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23
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Minami T, Imoto K, Uchida K, Karube N, Yasuda S, Choh T, Suzuki S, Masuda M. Thoracic Endovascular Aortic Repair for Ruptured Descending Thoracic Aortic Aneurysm. J Card Surg 2014; 30:163-9. [DOI: 10.1111/jocs.12499] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Tomoyuki Minami
- Cardiovascular Center; Yokohama City University Medical Center; Yokohama Kanagawa Japan
- Cardiovascular Surgery; Yokohama Municipal Citizen's Hospital; Yokohama Kanagawa Japan
| | - Kiyotaka Imoto
- Cardiovascular Center; Yokohama City University Medical Center; Yokohama Kanagawa Japan
| | - Keiji Uchida
- Cardiovascular Center; Yokohama City University Medical Center; Yokohama Kanagawa Japan
| | - Norihisa Karube
- Cardiovascular Center; Yokohama City University Medical Center; Yokohama Kanagawa Japan
| | - Shota Yasuda
- Cardiovascular Center; Yokohama City University Medical Center; Yokohama Kanagawa Japan
| | - Tomoki Choh
- Cardiovascular Center; Yokohama City University Medical Center; Yokohama Kanagawa Japan
| | - Shinichi Suzuki
- Department of Surgery; Yokohama City University Hospital; Yokohama Kanagawa Japan
| | - Munetaka Masuda
- Department of Surgery; Yokohama City University Hospital; Yokohama Kanagawa Japan
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24
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Yim NY, Kim YT, Kim HO, Kim JK, Kang YJ, Park YC, Park CY. Role of interventional radiology in trauma care: retrospective study from single trauma center experience. Am J Emerg Med 2014; 32:1315-8. [PMID: 25200505 DOI: 10.1016/j.ajem.2014.07.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2014] [Revised: 07/28/2014] [Accepted: 07/29/2014] [Indexed: 01/27/2023] Open
Abstract
PURPOSE Although interventional management is now regarded as essential in trauma care, the effect on clinical result remains uncertain. We conducted this retrospective study to figure out the role of interventional management in trauma care. MATERIALS AND METHODS Medical records of patients enrolled in the trauma database of our trauma center were reviewed for the period of January 2009 to December 2012. During this period, we have evaluated how many interventional procedures were conducted and the clinical effect of interventional procedure on trauma care. RESULTS Based on our institutional trauma database, medical records of 2017 patients were reviewed (male/female, 1475:542; mean age, 50.03 years). Their mean injury severity score was approximately 26.28. Among them, 111 patients have been treated with interventional procedure. The number of interventional procedures increased significantly over time, up to 15% (P < .005). During the same period, the overall survival rate did not show significant change. The survival rate of the patients, who have been treated with interventional procedures for traumatic vascular injury, was higher than possibility of survival from trauma injury severity score (86.4% vs 65.59%). CONCLUSION The need for interventional procedure in trauma care is increasing. Although interventional procedure could not affect the overall survival rate in trauma care, it can improve survival rate remarkably in patients with traumatic vascular injury.
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Affiliation(s)
- Nam Yeol Yim
- Department of Radiology, Chonnam National University Hospital, Gwangju, Republic of Korea.
| | - Yong Tae Kim
- Department of Radiology, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Hyoung Ook Kim
- Department of Radiology, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Jae Kyu Kim
- Department of Radiology, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Yang Jun Kang
- Department of Radiology, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Yun Chul Park
- Department of Trauma Surgery, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Chan Yong Park
- Department of Trauma Surgery, Pusan National University Hospital, Pusan, Republic of Korea
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25
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Chen T, Crozier JA. Endovascular repair of thoracic aortic pathologies: postoperative nursing implications. JOURNAL OF VASCULAR NURSING 2014; 32:63-9. [PMID: 24944173 DOI: 10.1016/j.jvn.2013.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 07/02/2013] [Accepted: 07/11/2013] [Indexed: 11/19/2022]
Abstract
Endovascular stent grafting is increasingly used to manage descending thoracic aortic pathologies. The procedure was introduced at the study hospital in 2001. We sought to examine the short-term clinical outcomes of patients who underwent this endovascular stent grafting, with the aim of using the result as baseline for development of an in-center clinical management protocol. We undertook a single-center, retrospective review of health care records of patients managed with thoracic stent grafts from 2001 to 2009. Patient characteristics, in-hospital data, and procedural data were obtained. SPSS was used to analyze the data. A total of 30 patients were treated with thoracic stent; 23 were male, 7 were female, and the mean age was 55.0. Aortic pathologies treated were traumatic aortic dissection/transection (n = 15), acute/chronic aortic dissection (n = 9), and degenerative aneurysms (n = 6). Endoleak occurred in 3 patients, with 1 requiring further endograft repair. Two patients underwent combined open and endovascular repair of acute thoracic aortic dissection; 1 died 4 days after the procedure, and the other developed stroke and acute renal failure not requiring dialysis. Of the 28 patients who underwent endovascular repair, paraplegia and paraparesis occurred in 2 patients but resolved with cerebrospinal fluid drainage. Stroke occurred in 1 patient. Patients who underwent combined procedure of open and endovascular repair of thoracic aortic dissection had a greater risk of developing major adverse events than patients who underwent endovascular repair alone (Fisher's exact test P = .023). There was no association between the risk of stroke and the coverage of left subclavian artery in this series (P = .483). Graft stenting treatment for descending thoracic aortic pathologies has been shown to result in high in-hospital survival rates. It is essential for nurses who work in acute care settings to have knowledge of this procedure and potential complications associated with the procedure to enable postoperative assessment and immediate action if any deviation is observed.
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Affiliation(s)
- Tanghua Chen
- Department of Vascular Surgery, Liverpool Hospital, Sydney, Australia.
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26
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Zicho D, Cartwright N, Bizzarri F, Malkin C, Cross M, Mcpherson S, Kaul P, Puppala S. Endovascular Stent Graft Repair of Suture-Line Pseudoaneurysm Following Ascending Aorta Replacement. Vasc Endovascular Surg 2013; 48:251-5. [DOI: 10.1177/1538574413513847] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Ascending aorta pseudoaneurysm (AAPA) is an uncommon complication following replacement of the ascending aorta with a prosthetic graft, carry a high risk of rupture, and warrant urgent intervention. The open surgical procedure “gold standard” of care is not always favorable, as the reoperations are technically more difficult or patient’s general condition doesn’t allow proceeding. Case discussed is an 80-year-old male patient who presented with worsening cough and hemoptysis. He underwent ascending aorta replacement 10 years ago. Computed tomography (CT) scan revealed a contrast-filled mediastinal mass communicating with the ascending aorta and extended into the right lung. Due to the patient’s advanced age, friability and clinical condition, combined with the position of the AAPA behind the sternum, surgery was deemed to be high risk. However, favorable anatomical conditions provided a safe landing zone for an endovascular stent. The patient underwent closed procedure. Postprocedure CT showed complete obliteration of the AAPA.
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Affiliation(s)
- David Zicho
- Leeds Teaching Hospital, Leeds, United Kingdom
| | | | | | | | | | | | - Pankaj Kaul
- Leeds Teaching Hospital, Leeds, United Kingdom
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27
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Sincos IR, da Silva ES, Belczak SQ, Baptista Sincos APW, de Lourdes Higuchi M, Gornati V, Otoch JP, Aun R. Histologic analysis of stent graft oversizing in the thoracic aorta. J Vasc Surg 2013; 58:1644-1651.e4. [DOI: 10.1016/j.jvs.2013.02.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 01/23/2013] [Accepted: 02/01/2013] [Indexed: 11/29/2022]
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28
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Ip EWK, Bourke VC, Stacey MC, Begley P, Ritter JC. Hard to diagnose and potentially fatal: slow aortic erosion post spinal fusion. J Emerg Med 2013; 46:335-40. [PMID: 24268895 DOI: 10.1016/j.jemermed.2013.08.075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Revised: 07/15/2013] [Accepted: 08/15/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Delayed aortic injuries are a rare, but well-recognized complication of spinal surgery. They are a result of slow erosion of osteosynthesis material into the aorta. Although this is a life-threatening complication, patients might present years later with nonspecific symptoms. OBJECTIVE A complex case of slow aortic injury after thoracic spinal surgery is presented, which highlights the challenges involved in diagnosis and treatment. CASE REPORT A 62-year-old man had a T6 vertebrectomy and T5-7 anterior spinal fusion for multiple myeloma 5 years earlier. Two years postoperatively, the patient developed intermittent hemoptysis that triggered several presentations to the emergency department and consecutive hospital admissions during a 3-year period. All investigations, including endoscopy, bronchoscopy, and repeated chest computed tomography (CT) scans, were unremarkable. Eventually, the patient presented with frank hemoptysis associated with severe left-sided chest pain. Urgent CT angiography revealed a pseudoaneurysm measuring 34 × 20 mm at the level of the vertebrectomy. The patient underwent emergency surgery and an endoluminal stent graft was successfully placed. The patient remains well after 6 months. CONCLUSIONS The close proximity of the aorta and spine entertains the risk of aortic injury associated with vertebral osteosynthesis. Long-term complications of slow aortic erosion are extremely difficult to diagnose. The presented patient suffered from an undetected bronchio-aortic fistula with consecutive pseudoaneurysm formation and rupture. Awareness of slow aortic erosion is important for correct diagnostic pathways and subsequent early diagnosis to ensure a positive outcome for the patient.
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Affiliation(s)
- Edmond W K Ip
- Department of Vascular and Endovascular Surgery, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Victor C Bourke
- Department of Vascular and Endovascular Surgery, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Michael C Stacey
- Department of Vascular and Endovascular Surgery, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Patrick Begley
- Emergency Department, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Jens C Ritter
- Department of Vascular and Endovascular Surgery, Fremantle Hospital, Fremantle, Western Australia, Australia
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29
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Petrilli G, Puppini G, Calzaferri D, Torre S, Bugana A, Faggian G. Emergency Thoracic Endovascular Aneurysm Repair in Acute Type B Dissection with Visceral Malperfusion. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2013; 1:206-9. [PMID: 26798696 DOI: 10.12945/j.aorta.2013.13-009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 08/30/2013] [Indexed: 11/18/2022]
Abstract
A 46-year-old female patient was admitted to the emergency room with the sudden onset of abdominal pain, back pain, and paresthesia in the right leg. An emergent chest computed tomography (CT) showed an acute Type B aortic dissection. An emergency thoracic endovascular aneurysm repair (TEVAR) procedure was subsequently performed, for an evolving visceral malperfusion syndrome. We performed the procedure using an axillary approach because the small diameter of the true lumen precluded transfemoral endovascular access. This case illustrates that TEVAR permits the treatment of complicated acute Type B aortic dissection; specifically, technical variations can expand the applicability of endovascular procedures.
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Affiliation(s)
| | | | | | - Salvo Torre
- Division of Cardiac Surgery, University of Verona, Verona, Italy
| | - Antonella Bugana
- Division of Cardiac Surgery, University of Verona, Verona, Italy
| | - Giuseppe Faggian
- Division of Cardiac Surgery, University of Verona, Verona, Italy
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30
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Hemoptysis as a first symptom of endoleak after thoracic endovascular aortic repair, which caused aortic rupture and required complex management. Wideochir Inne Tech Maloinwazyjne 2013; 8:178-81. [PMID: 23837105 PMCID: PMC3699777 DOI: 10.5114/wiitm.2011.33453] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 02/03/2013] [Accepted: 02/03/2013] [Indexed: 11/17/2022] Open
Abstract
Thoracic endovascular aortic repair (TEVAR) has become the most common procedure in the treatment of thoracic aorta aneurysms. However, potential long-term complications of this technique could be life-threatening. Hemoptysis is a common symptom of lung tumor, especially cancer. On the other hand, hemoptysis can also be caused by bronchitis, tuberculosis, mycosis, and trauma. In this case report, we present a patient with hemoptysis and lung tumor suggesting lung cancer, which was a unique symptom of type IA endoleak after TEVAR and led to rupture of the thoracic aneurysm. It was decided to perform next an endovascular procedure due to the severe state of the patient. Next the thoracotomy was performed because drainage of the left pleural cavity was unsuccessful. In the last stage bronchoscopy was needed to remove the thrombus, which occluded the left main bronchi. Successful management has led to the patient's full recovery. Despite justified popularity of endovascular procedures in the treatment of thoracic aorta aneurysms, we should remember about potential long-term complications. Hemoptysis could be a unique symptom of the endoleak after TEVAR and treatment of such complications could be complex and demanding.
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31
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Wong CS, Healy D, Canning C, Coffey JC, Boyle JR, Walsh SR. A systematic review of spinal cord injury and cerebrospinal fluid drainage after thoracic aortic endografting. J Vasc Surg 2012; 56:1438-47. [PMID: 22884456 DOI: 10.1016/j.jvs.2012.05.075] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 05/08/2012] [Accepted: 05/16/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND The use of thoracic endovascular aneurysm repair (TEVAR) is increasing. Similar to open repair, TEVAR carries a risk of spinal cord ischemia (SCI). We undertook a systematic review to determine whether preoperative cerebrospinal fluid (CSF) drainage reduces SCI. METHODS PubMed, the Cochrane Library, and conference abstracts were searched using the keywords thoracic endovascular aortic repair, cerebrospinal fluid, spinal cord ischaemia, TEVAR, and aneurysm. Studies reporting SCI rates and CSF drain rates for TEVAR patients were eligible for inclusion. SCI rates across studies were pooled using random-effects modeling. Study quality was evaluated using the Downs and Black score. RESULTS Study quality was generally poor to moderate (median Downs and Black score, 9). The systematic review identified 46 eligible studies comprising 4936 patients; overall, SCI affected 3.89% (95% confidence interval, 2.95.05%-4.95%). Series reporting routine prophylactic drain placement or no prophylactic drain placement reported pooled SCI rates of 3.2% and 3.47%, respectively. The pooled SCI rate from 24 series stating that prophylactic drainage was used selectively was 5.6%. CONCLUSIONS Spinal chord injury is uncommon after TEVAR. The role of prophylactic CSF drainage is difficult to establish from the available literature. High-quality studies are required to determine the role of prophylactic CSF drainage in TEVAR.
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Affiliation(s)
- Chee S Wong
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
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32
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Aortic dissection and renal failure in a patient with severe hypothyroidism. Case Rep Med 2012; 2012:842562. [PMID: 22829842 PMCID: PMC3399550 DOI: 10.1155/2012/842562] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 05/20/2012] [Accepted: 05/22/2012] [Indexed: 11/17/2022] Open
Abstract
Acute aortic dissection (AAD) is a life-threatening condition associated with high morbidity and mortality. The most important recognized acquired cause that leads to dissection is chronic arterial hypertension. With respect to the anuria and renal failure, aortic dissection is not something that is always considered and is still not a very common presentation unless both renal arteries come off the false lumen of the dissection. However, when present, preoperative renal failure in patients with acute type B dissection has been noted to be an independent predictor of mortality. Early recognition and diagnosis is the key and as noted by previous studies as well, almost a third of these patients are initially worked up for other causes until later when they are diagnosed with aortic dissection. Here we present a case of a patient presenting with severe hypothyroidism, long-standing hypertension, and anuria. Through the case, we highlight the importance of having aortic dissection as an important differential in patients presenting with anuria who have a long standing history of uncontrolled hypertension. Pathophysiology relating to severe hypothyroidism-induced renal dysfunction is also discussed.
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