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Banks CA, Novak Z, Spangler EL, Schanzer A, Farber MA, Sweet MP, Oderich G, Timaran CH, Lee A, Schneider DB, Eagleton MJ, Gasper W, Beck AW. Preoperative risk factors for 1-year mortality in patients undergoing fenestrated endovascular aortic aneurysm repair in the US Aortic Research Consortium. J Vasc Surg 2024; 80:724-735.e3. [PMID: 38718849 DOI: 10.1016/j.jvs.2024.04.063] [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: 02/20/2024] [Revised: 04/03/2024] [Accepted: 04/15/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Early survival (1-year) after elective repair of complex abdominal aortic aneurysms (AAA) or thoracoabdominal aortic aneurysms (TAAA) can be used as an indicator of successful repair and provides a reasonable countermeasure to the annual rupture risk based on diameter. We aimed to identify preoperative factors associated with 1-year mortality after fenestrated or branched endovascular aortic repair (F/BEVAR) and develop a predictive model for 1-year mortality based on patient-specific risk profiles. METHODS The US-Aortic Research Consortium database was queried for all patients undergoing elective F/BEVAR for complex AAA (cAAA) or TAAA from 2005 to 2022. The primary outcome was 1-year survival based on preoperative risk profile. Multivariable Cox regression was used to determine preoperative variables associated with 1-year mortality overall and by extent of aortic pathology. Logistic regression was performed to build a predictive model for 1-year mortality based on number of risk factors present. RESULTS A total of 2099 patients met the inclusion criteria for this study (cAAA: n = 709 [34.3%]; type 1-3 TAAA: n = 777 [37.6%]; type 4-5 TAAA: n = 580 [28.1%]). Multivariable Cox regression identified the following significant risk factors associated with 1-year mortality: current smoker, chronic obstructive pulmonary disease, congestive heart failure (CHF), aortic diameter >7 cm, age >75 years, extent 1-3, creatinine >1.7 mg/dL, and hematocrit <36%. When stratified by extent of aortic involvement, multivariable Cox regression revealed risk factors for 1-year mortality in cAAA (CHF maximum aortic diameter >7 cm, hematocrit <36 mg/dL, and current smoking status), type 1-3 TAAA (chronic obstructive pulmonary disease, CHF, and age >75 years), and type 4-5 TAAA (age >75 years, creatinine >1.7 mg/dL, and hematocrit <36 mg/dL). Logistic regression was then used to develop a predictive model for 1-year mortality based on patient risk profile. Appraisal of the model revealed an area under the curve of 0.64 (P < .001), and an observed to expected ratio of 0.85. CONCLUSIONS This study describes multiple risk factors associated with an increase in 1-year mortality after F/BEVAR. Given that elective repair of cAAA or TAAA is offered to some patients in whom future rupture risk outweighs operative risk, these findings suggest that highly comorbid patients with smaller aneurysms may not benefit from repair. Descriptive and predictive models for 1-year mortality based on patient risk profiles can serve as an adjunct in clinical decision-making when considering elective F/BEVAR.
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Affiliation(s)
- Charles A Banks
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Zdenek Novak
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Emily L Spangler
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Andres Schanzer
- Division of Vascular and Endovascular Surgery, University of Massachusetts Memorial Hospital, Worcester, MA
| | - Mark A Farber
- Division of Vascular Surgery, University of North Carolina, Chapel Hill, NC
| | - Matthew P Sweet
- Division of Vascular and Endovascular Surgery, University of Washington, Seattle, WA
| | - Gustavo Oderich
- Division of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center, Houston, TX
| | - Carlos H Timaran
- Division of Vascular Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Anothny Lee
- Division of Vascular Surgery, Boca Raton Regional Hospital, Boca Raton, FL
| | - Darren B Schneider
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania, Philadelphia, PA
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Warren Gasper
- Division of Vascular and Endovascular Surgery, University of California San Francisco, San Francisco, CA
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL.
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Ozcinar E, Dikmen N, Baran C, Buyukcakir O, Kandemir M, Yazicioglu L. Comparative Retrospective Cohort Study of Carotid-Subclavian Bypass versus In Situ Fenestration for Left Subclavian Artery Revascularization during Zone 2 Thoracic Endovascular Aortic Repair: A Single-Center Experience. J Clin Med 2024; 13:5043. [PMID: 39274259 PMCID: PMC11396557 DOI: 10.3390/jcm13175043] [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: 07/30/2024] [Revised: 08/23/2024] [Accepted: 08/23/2024] [Indexed: 09/16/2024] Open
Abstract
Background: Thoracic endovascular aortic repair (TEVAR) has become the first-line therapy for descending aortic disease. Recent studies have demonstrated that preventive revascularization of the left subclavian artery (LSA) in zone 2 TEVAR cases reduces the risk of neurological complications. However, there is no uniform consensus on the choice of revascularization techniques. Although carotid-subclavian bypass is considered the gold standard method, in situ fenestration techniques have also shown encouraging results. This study aims to compare the carotid-LSA bypass with in situ fenestration (ISF) for LSA revascularization and to discuss our treatment approach. Methods: We conducted a retrospective review of all patients undergoing zone 2 TEVAR with in situ fenestration (ISF) or carotid-subclavian artery bypasses for LSA revascularization at our institution between February 2011 and February 2024. Preoperative patient characteristics and primary outcomes, such as operative mortality, transient ischemic attack, stroke, and spinal cord ischemia, were analyzed between the groups. Results: During the 13-year study period, 185 patients underwent TEVAR procedures. Of these, 51 patients had LSA revascularization with zone 2 TEVAR; 32 patients underwent carotid-subclavian artery bypasses, and 19 underwent in situ fenestration. The technical success rate was 100%. Statistically, there was no significant difference between the groups in terms of primary outcomes such as stroke, transient ischemic attack, spinal cord ischemia, and death (p > 0.05). Conclusions: In situ fenestration (ISF) may be an effective and feasible method for LSA revascularization. With precise patient selection and in experienced hands, ISF appears to be associated with similar perioperative outcomes and mortality rates to the carotid-subclavian bypass.
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Affiliation(s)
- Evren Ozcinar
- Cardiovascular Surgery Department, Heart Center, Cebeci Hospitals, Ankara University School of Medicine, Mamak, Ankara 06340, Turkey
| | - Nur Dikmen
- Cardiovascular Surgery Department, Heart Center, Cebeci Hospitals, Ankara University School of Medicine, Mamak, Ankara 06340, Turkey
| | - Cagdas Baran
- Cardiovascular Surgery Department, Heart Center, Cebeci Hospitals, Ankara University School of Medicine, Mamak, Ankara 06340, Turkey
| | - Onur Buyukcakir
- Cardiovascular Surgery Department, Heart Center, Cebeci Hospitals, Ankara University School of Medicine, Mamak, Ankara 06340, Turkey
| | - Melisa Kandemir
- Cardiovascular Surgery Department, Heart Center, Cebeci Hospitals, Ankara University School of Medicine, Mamak, Ankara 06340, Turkey
| | - Levent Yazicioglu
- Cardiovascular Surgery Department, Heart Center, Cebeci Hospitals, Ankara University School of Medicine, Mamak, Ankara 06340, Turkey
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Tricarico R, Berceli SA, Tran-Son-Tay R, He Y. Non-invasive estimation of the parameters of a three-element windkessel model of aortic arch arteries in patients undergoing thoracic endovascular aortic repair. Front Bioeng Biotechnol 2023; 11:1127855. [PMID: 36926690 PMCID: PMC10011467 DOI: 10.3389/fbioe.2023.1127855] [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: 12/20/2022] [Accepted: 02/17/2023] [Indexed: 03/08/2023] Open
Abstract
Background: Image-based computational hemodynamic modeling and simulations are important for personalized diagnosis and treatment of cardiovascular diseases. However, the required patient-specific boundary conditions are often not available and need to be estimated. Methods: We propose a pipeline for estimating the parameters of the popular three-element Windkessel (WK3) models (a proximal resistor in series with a parallel combination of a distal resistor and a capacitor) of the aortic arch arteries in patients receiving thoracic endovascular aortic repair of aneurysms. Pre-operative and post-operative 1-week duplex ultrasound scans were performed to obtain blood flow rates, and intra-operative pressure measurements were also performed invasively using a pressure transducer pre- and post-stent graft deployment in arch arteries. The patient-specific WK3 model parameters were derived from the flow rate and pressure waveforms using an optimization algorithm reducing the error between simulated and measured pressure data. The resistors were normalized by total resistance, and the capacitor was normalized by total resistance and heart rate. The normalized WK3 parameters can be combined with readily available vessel diameter, brachial blood pressure, and heart rate data to estimate WK3 parameters of other patients non-invasively. Results: Ten patients were studied. The medians (interquartile range) of the normalized proximal resistor, distal resistor, and capacitor parameters are 0.10 (0.07-0.15), 0.90 (0.84-0.93), and 0.46 (0.33-0.58), respectively, for common carotid artery; 0.03 (0.02-0.04), 0.97 (0.96-0.98), and 1.91 (1.63-2.26) for subclavian artery; 0.18 (0.08-0.41), 0.82 (0.59-0.92), and 0.47 (0.32-0.85) for vertebral artery. The estimated pressure showed fairly high tolerance to patient-specific inlet flow rate waveforms using the WK3 parameters estimated from the medians of the normalized parameters. Conclusion: When patient-specific outflow boundary conditions are not available, our proposed pipeline can be used to estimate the WK3 parameters of arch arteries.
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Affiliation(s)
- Rosamaria Tricarico
- Department of Biomedical Engineering, University of Florida, Gainesville, FL, United States
| | - Scott A Berceli
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL, United States.,North Florida/South Georgia Veterans Health System, Gainesville, FL, United States
| | - Roger Tran-Son-Tay
- Department of Biomedical Engineering, University of Florida, Gainesville, FL, United States.,Department of Mechanical and Aerospace Engineering, University of Florida, Gainesville, FL, United States
| | - Yong He
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL, United States
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MacGillivray TE, Gleason TG, Patel HJ, Aldea GS, Bavaria JE, Beaver TM, Chen EP, Czerny M, Estrera AL, Firestone S, Fischbein MP, Hughes GC, Hui DS, Kissoon K, Lawton JS, Pacini D, Reece TB, Roselli EE, Stulak J. The Society of Thoracic Surgeons/American Association for Thoracic Surgery clinical practice guidelines on the management of type B aortic dissection. J Thorac Cardiovasc Surg 2022; 163:1231-1249. [PMID: 35090765 DOI: 10.1016/j.jtcvs.2021.11.091] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 01/16/2023]
Affiliation(s)
| | - Thomas G Gleason
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | | | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Md
| | - Davide Pacini
- Department of Cardiac Surgery, University of Bologna, Bologna, Italy
| | - T Brett Reece
- Department of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
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5
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MacGillivray TE, Gleason TG, Patel HJ, Aldea GS, Bavaria JE, Beaver TM, Chen EP, Czerny M, Estrera AL, Firestone S, Fischbein MP, Hughes GC, Hui DS, Kissoon K, Lawton JS, Pacini D, Reece TB, Roselli EE, Stulak J. The Society of Thoracic Surgeons/American Association for Thoracic Surgery Clinical Practice Guidelines on the Management of Type B Aortic Dissection. Ann Thorac Surg 2022; 113:1073-1092. [PMID: 35090687 DOI: 10.1016/j.athoracsur.2021.11.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 02/07/2023]
Affiliation(s)
| | - Thomas G Gleason
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Florida
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Texas
| | | | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, California
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Davide Pacini
- Department of Cardiac Surgery, University of Bologna, Bologna, Italy
| | - T Brett Reece
- Department of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
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Naazie IN, Gupta JD, Azizzadeh A, Arbabi C, Zarkowsky D, Malas MB. Prediction of thirty-day mortality risk after thoracic endovascular aortic repair for intact descending thoracic aortic aneurysms: Derivation of risk calculator in the Vascular Quality Initiative. J Vasc Surg 2021; 75:833-841.e1. [PMID: 34506896 DOI: 10.1016/j.jvs.2021.08.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 08/05/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm (DTAA) is associated with high perioperative survival, although mortality is a possible outcome. However, no risk score has been developed to predict mortality after TEVAR for intact DTAA to aid in risk discussion and preoperative patient selection. Our objective was to use a multi-institutional database to develop a 30-day mortality risk calculator for TEVAR after DTAA repair. METHODS The Vascular Quality Initiative database was queried for patients treated with TEVAR for intact DTAA between August 2014 and August 2020. Univariable and multivariable analyses aided in developing a 30-day mortality risk score. Internal validation was done with K-fold cross-validation and calibration curve analysis. RESULTS Of 2141 patients included in the analysis, 90 (4.2%) died within 30 days after the procedure. Clinically relevant variables identified to be independently associated with 30-day mortality and therefore used to derive the predictive model included age 75 years or greater (odds ratio [OR], 2.27; 95% confidence interval [CI], 1.50-3.44; P < .001), coronary artery disease (OR, 1.60; 95% CI, 1.03-2.47; P = .036), American Society of Anesthesiologists class IV/V (OR, 2.39; 95% CI, 1.39-4.10; P = .002), urgent vs elective procedure (OR, 3.47; 95% CI, 1.90-6.33; P < .001), emergent vs elective procedure (OR, 5.27; 95% CI, 2.36-11.75; P < .001), prior carotid revascularization (OR, 3.24; 95% CI, 1.64-6.39; P = .001), and proximal landing zone <3 (OR, 2.51; 95% CI, 1.65-3.81; P < .001). The model showed an area under the receiver operating characteristic curve of 0.75. Internal validation demonstrated a bias-corrected area under the receiver operating characteristic curve of 0.73 (95% CI, 0.66-0.79) and a calibration slope of 1.00 with a corresponding intercept of 0.00. CONCLUSIONS This study provides a novel clinically relevant risk prediction model to estimate 30-day mortality risk after TEVAR for DTAA. The TEVAR Mortality Risk Calculator provides useful prognostic information to guide patient selection and facilitate preoperative discussions and shared decision making. An easily accessible online version of the TEVAR Mortality Risk Score is available to facilitate ease of use.
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Affiliation(s)
- Isaac N Naazie
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, Calif
| | - Jaideep Das Gupta
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, Calif
| | - Ali Azizzadeh
- Division of Vascular Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Cassra Arbabi
- Division of Vascular Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Devin Zarkowsky
- Division of Vascular Surgery, Department of Surgery, University of Colorado, Aurora, Colo
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, Calif.
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Nadeswaran P, Ding L, Singh N, Plotkin A, Magee GA, Han SM, Garg PK. Functional performance status and risk of cardiovascular events and mortality following endovascular repair of thoracic and abdominal aortic pathology. Vascular 2021; 30:206-216. [PMID: 33900842 DOI: 10.1177/17085381211010545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To characterize the association of preoperative functional performance status based on Eastern Cooperative Oncology Group (ECOG) scoring with the risk of adverse cardiovascular events, vascular events, and mortality in patients undergoing EVAR and TEVAR. METHODS Retrospective review of the Society for Vascular Surgery Vascular Quality Initiative, a large, multi-center, registry database was performed. All individuals undergoing EVAR (n = 18,730) and TEVAR (n = 6595) for non-ruptured aortic pathologies between 2014 and 2018 were eligible for analysis. Multivariable logistic regression was used to determine the association of pre-procedure ECOG functional performance status on risk of in-hospital adverse cardiovascular events, vascular events, and mortality. RESULTS The number of operations complicated by adverse cardiovascular and vascular events was 480 (2.6%) and 190 (1.0%) for EVAR and 733 (11.1%) and 219 (3.3%) for TEVAR, respectively. There were 118 (0.6%) and 240 (3.6%) in-hospital deaths following EVAR and TEVAR, respectively. Patients with ECOG grades 3 or 4 undergoing EVAR were at increased risk of cardiovascular events (OR = 1.62; 95% CI = 1.09, 2.41) and one-year mortality (HR = 2.62; 95% CI = 1.92, 3.57) compared to those with ECOG grade 0. Patients undergoing TEVAR with ECOG grade 3 or 4 were at increased risk for both inpatient death (OR = 2.77; 95% CI = 1.56, 4.9) and one-year mortality (HR = 3.27, 95% CI = 2.06, 5.21). ECOG status was not associated with an increased risk of adverse vascular events following either EVAR or TEVAR. CONCLUSIONS Poor preoperative functional status as assessed by ECOG score is associated with an increased risk of adverse postoperative cardiovascular events following EVAR and a higher mortality risk following both EVAR and TEVAR. Functional status assessment may be useful for risk stratification and determining procedural candidacy prior to EVAR and TEVAR.
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Affiliation(s)
- Pradeep Nadeswaran
- Division of Cardiology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Li Ding
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Nikhil Singh
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Anastasia Plotkin
- Division of Vascular Surgery and Endovascular Therapy, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Sukgu M Han
- Division of Vascular Surgery and Endovascular Therapy, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Parveen K Garg
- Division of Cardiology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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Plotkin A, Ding L, Han SM, Oderich GS, Starnes BW, Lee JT, Malas MB, Weaver FA, Magee GA. Association of upper extremity and neck access with stroke in endovascular aortic repair. J Vasc Surg 2020; 72:1602-1609. [DOI: 10.1016/j.jvs.2020.02.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 02/06/2020] [Indexed: 11/28/2022]
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9
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Belkin N, Jackson BM, Foley PJ, Damrauer SM, Kalapatapu V, Golden MA, Fairman RM, Wang GJ. The use of intravascular ultrasound in the treatment of type B aortic dissection with thoracic endovascular aneurysm repair is associated with improved long-term survival. J Vasc Surg 2020; 72:490-497. [DOI: 10.1016/j.jvs.2019.10.073] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/14/2019] [Indexed: 11/25/2022]
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10
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Harris DG, Olson SL, Panthofer AM, Matsumura JS, DiMusto PD. A Frailty-Based Risk Score Predicts Morbidity and Mortality After Elective Endovascular Repair of Descending Thoracic Aortic Aneurysms. Ann Vasc Surg 2020; 67:90-99. [DOI: 10.1016/j.avsg.2019.10.090] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 10/29/2019] [Accepted: 10/29/2019] [Indexed: 12/21/2022]
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Tanious A, Boitano L, Canha L, Chou EL, Wang LJ, Latz C, Eagleton MJ, Conrad MF. Thoracic aortic remodeling with endografting after a decade of thoracic endovascular aortic repair experience. J Vasc Surg 2020; 73:844-849. [PMID: 32707385 DOI: 10.1016/j.jvs.2020.06.120] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/22/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Thoracic endovascular aortic repair (TEVAR) results have been studied in short-term time frames. This study aimed to evaluate midterm and long-term outcomes of TEVAR, emphasizing postoperative aortic remodeling and need for reintervention. METHODS This is an institutional retrospective review of TEVAR for isolated descending thoracic aortic aneurysms. Data were collected from 2004 to 2018. Primary outcomes studied included aneurysm sac remodeling, freedom from reintervention, and all-cause mortality. Other outcomes studied include endoleak rates, neurologic complication rates, and any overall postoperative complication rates. RESULTS During the study period, 219 patients underwent TEVAR for descending thoracic aortic aneurysms. The median effect of TEVAR on sac diameter was a 0.7-cm decrease in size (interquartile range, -1.4 to 0.0 cm). During the study period, 80% (n = 147) of patients experienced aneurysm sac regression or stability. Perioperative neurologic complications occurred in 16% (n = 34) of patients. Significant predictors of sac growth were endoleak (odds ratio [OR], 65; P < .001), preoperative carotid-subclavian bypass (OR, 8; P = .003), and graft oversizing <20% (OR, 15; P = .046). Every 1-mm increase in aortic diameter at the proximal TEVAR landing zone led to an increased odds of endoleak (OR, 2; P = .049). Access complications (OR, 8) and subclavian artery coverage (OR, 6) significantly increased the odds of reintervention, whereas every percentage of graft oversizing protected against reintervention (OR, 0.005). Life-table analysis revealed an overall survival of 78% (71%-83%) at median follow-up. At 3 years, survival was 88% (80%-93%) for those with aneurysm sac stability or regression, whereas it was 70% (49%-84%) for those with aneurysm sac growth (P = .0402). Cox proportional hazards model showed that the only protective factor for mortality was percentage oversizing, with every 1% of oversizing having a hazard ratio (HR) of <.001 (P = .032). This was counterbalanced by the fact that patients with graft oversizing >30% had an increased odds of mortality with HR >10 (P = .049). Other significant factors that increased the odds of mortality included endoleak (HR, 3.6; P = .033), diabetes (HR, 4.1; P = .048), age (every 1-year increase in age; HR, 1.2; P = .002), year of surgery (every year subsequent to 2004; HR, 1.3; P = .012), and peripheral artery disease (HR, 5.2; P = .041). CONCLUSIONS The majority of patients (80%) experience sac stability or regression after TEVAR, which offers a clear survival advantage. Endoleaks are predictive of sac growth, conferring increased mortality. Rigorous surveillance is necessary to prevent future aortic events through reintervention.
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Affiliation(s)
- Adam Tanious
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
| | - Laura Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Lauren Canha
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Elizabeth L Chou
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Linda J Wang
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Christopher Latz
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
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Acheampong DO, Paul P, Boateng P, Leitman IM. Predictors and Outcomes of Cardiac Events following Thoracic Endovascular Aortic Repair in Descending Thoracic Aortic Aneurysm and Dissection. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2020; 8:6-13. [PMID: 32599627 PMCID: PMC7324254 DOI: 10.1055/s-0040-1701606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Cardiac events following thoracic endovascular aortic repair (TEVAR) have been associated with significant morbidity and mortality. However, predictors of post-TEVAR cardiac events in descending thoracic aortic aneurysm or dissection are poorly understood. METHODS A retrospective analysis of completed TEVAR procedures performed from 2010 to 2016 was conducted using the ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) participant user file database. Adult patients (≥18 years) who underwent TEVAR for descending thoracic aortic aneurysm or dissection were identified and 30-day outcomes were examined. An initial univariate analysis was performed to determine associations between all patient variables and cardiac events, defined as myocardial infarction or cardiac arrest that occurred ≤30 days of surgery. Multivariate logistic regression was subsequently performed to identify independent risk factors for cardiac events following TEVAR. RESULTS The study identified 150 out of 2,905 (5.2%) patients who underwent TEVAR for descending thoracic aortic aneurysm or dissection who developed cardiac events. No significant difference in incidence of cardiac events was noted among patients presenting with aortic aneurysm or dissection (p = 0.339). The overall 30-day mortality rate for all patients was 9.1%. Independent preoperative predictors of post-TEVAR cardiac events included emergency procedure (odds ratio [OR] 2.80, 95% confidence interval [CI] 1.9-4.1, p < 0.01); American Society of Anesthesiologists score >3 (OR 1.71, 95% CI 1.1-2.6, p = 0.01), ventilator dependence (OR 2.33, 95% CI 1.3-4.2, p < 0.01), renal failure (OR 2.53, 95% CI 1.50-4.3, p < 0.01), blood transfusion (OR 1.84, 95% CI 1.1-3.2, p = 0.03), and preoperative leukocytosis (OR 2.45, 1.6-3.8, p < 0.01). After TEVAR, unplanned reintubation (OR 5.52, 95% CI 3.5-8.8, p < 0.01), prolonged mechanical ventilation (OR 1.94, 95% CI 1.2-3.2, p = 0.011), and postoperative blood transfusion (OR 4.02, 95% CI 2.70-6.0, p < 0.01) were independent predictors of cardiac events. Cardiac events greatly increased mortality (60.7 vs. 5.5%), total length of hospital stay (13.2 ± 14.7 days vs. 8.3 ± 9.3 days), and readmission rates (19.3 vs. 8.2%, p < 0.01). CONCLUSIONS Cardiac events following TEVAR are associated with significant mortality. Patients with these risk factors should be appropriately monitored to improve outcomes.
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Affiliation(s)
- Derrick O Acheampong
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Philip Paul
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Percy Boateng
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - I Michael Leitman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
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Marrocco-Trischitta MM, de Beaufort HW, Piffaretti G, Bonardelli S, Gargiulo M, Antonello M, van Herwaarden JA, Boveri S, Bellosta R, Trimarchi S, Castelli P, Gallitto E, Macchi E, Mazzeo G, Saviane G, Secchi F, Spampinato B, Xodo A. The Modified Arch Landing Areas Nomenclature predicts proximal endograft failure after thoracic endovascular aortic repair. Eur J Cardiothorac Surg 2020; 58:309-318. [DOI: 10.1093/ejcts/ezaa115] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 02/18/2020] [Accepted: 02/27/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
Our goal was to assess the value of the Modified Arch Landing Areas Nomenclature (MALAN) for thoracic endovascular aortic repair (TEVAR), in which each landing area (LA) is identified by a proximal landing zone and the type of arch (e.g. 0/I), as predictors of postoperative proximal endograft performance.
METHODS
A multicentre retrospective analysis was performed of patients treated with arch TEVAR (i.e. proximal landing zone 0–3) for various indications between 2007 and 2017. Patients were stratified by the MALAN classification into hostile LAs (i.e. 2/III and 3/III) and favourable LAs (i.e. 0/I–III, 1/I–III, 2/I–II and 3/I–II). Outcome criteria included composite proximal endograft failure (including type Ia endoleak, persistent false lumen perfusion at the level of the most proximal communication between the lumina in aortic dissections, endograft migration and retrograde dissection) and deaths from all causes. Competing risk analyses were performed.
RESULTS
A total of 359 patients (hostile LAs 133; favourable LAs 226) were identified. The median age was 71.0 (62.0–77.0); 78.3% were men. Proximal endograft failure occurred in 28/133 patients (21.1%) in the hostile LA group and in 12/226 (5.3%) in the favourable LA group. On multivariate analysis, hostile LAs were independently associated with proximal endograft failure (P < 0.0001). There was no other independent risk factor. Favourable LAs were associated with an increased mortality rate (P = 0.006), which could be attributed to the proximal LA subgroup (i.e. 0/I–III and 1/I–III) (P < 0.0001), in addition to age (P < 0.0001).
CONCLUSIONS
The MALAN classification identifies hostile proximal landing zones for TEVAR, namely 2/III and 3/III LAs, which are associated with dismal proximal endograft performance. The MALAN appears to be an intuitive and valuable tool to improve the preoperative decision-making process.
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Affiliation(s)
| | - Hector W de Beaufort
- Clinical Research Unit and Division of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Italy
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Gabriele Piffaretti
- Vascular Surgery, Department of Surgery and Morphological Sciences, Circolo University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
| | - Stefano Bonardelli
- Department of Vascular Surgery, A.O Spedali Civili di Brescia, University of Brescia, Brescia, Italy
| | - Mauro Gargiulo
- Vascular Surgery, DIMES, Policlinico Sant’Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - Michele Antonello
- Vascular and Endovascular Surgery Division, Padua University, School of Medicine, Padua, Italy
| | | | - Sara Boveri
- Scientific Directorate, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Raffaello Bellosta
- Vascular Surgery Unit, Cardiovascular Surgery Department, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Santi Trimarchi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical and Community Sciences, University of Milan, Milan, Italy
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King RW, Wooster MD, Ruddy JM, Genovese EA, Anderson JM, Brothers TE, Veeraswamy RK. Previous thoracic aortic repair is not associated with adverse outcomes after thoracic endovascular aortic repair. J Vasc Surg 2020; 71:1097-1108. [PMID: 31619351 PMCID: PMC7189752 DOI: 10.1016/j.jvs.2019.07.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 07/18/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND As many as 20% of patients who have undergone previous thoracic aortic repair will require reintervention, which could entail thoracic endovascular aortic repair (TEVAR). A paucity of data is available on mortality and the incidence of spinal cord ischemia (SCI) and other postoperative complications associated with TEVAR after previous aortic repairs exclusive to the thoracic aorta. The aim of the present study was to assess the effect of previous thoracic aortic repair on the 30-day mortality and SCI outcomes for patients after TEVAR. METHODS The Society for Vascular Surgery Vascular Quality Initiative database was queried for all cases of TEVAR from 2012 to 2018. Patients were excluded if they had undergone previous abdominal aortic repair, the TEVAR had extended beyond aortic zone 5, or SCI data were missing. The 3 cohorts compared were TEVAR with previous ascending aortic or aortic arch repair (group 1), TEVAR with previous descending thoracic aortic repair (group 2), and TEVAR without previous repair (group 3). The primary outcomes of interest were 30-day mortality and SCI. The secondary outcomes included stroke, myocardial infarction, cardiac complications, respiratory complications, postoperative length of stay, and reintervention. The patient variables were compared using χ2 tests, analysis of variance, or Kruskal-Wallis tests, as appropriate. Logistic regression analysis was performed to identify the predictors of 30-day mortality and SCI. RESULTS A total of 4010 patients met the inclusion criteria, with 470 in group 1, 132 in group 2, and 3408 in group 3. The 30-day mortality was 4% (19 of 470) in group 1, 6% (8 of 132) in group 2, and 6% (213 of 3408) in group 3 (P = .17). The incidence of SCI was 3% (14 of 470) in group 1, 3% (4 of 132) in group 2, and 3.8% (128 of 3408) in group 3 (P = .65). Stroke, reintervention, myocardial infarction, and cardiac complications were not significantly different among the 3 groups. The incidence of respiratory complications was greatest for group 3 (11%; 360 of 3408) compared with groups 1 (9%; 44 of 470) and 2 (4%; 5 of 132; P = .034). Similarly, the postoperative length of stay was longest for group 3 (9.6 ± 19.4 days vs 8.2 ± 18.3 days for group 1 and 5.9 ± 8.6 days for group 2; P = .038). The independent predictors of 30-day mortality for all TEVAR patients included units of packed red blood cells transfused intraoperatively, urgent or emergent repairs, older age, increasing serum creatinine level, inability to perform self-care, total procedure time, occlusion of the left subclavian artery intraoperatively, distal endograft landing zone 5, and diabetes. The predictors of SCI included the total procedure time, urgent and emergent repairs, and increasing serum creatinine level. CONCLUSIONS TEVAR after previous thoracic aortic repair was not associated with an increased risk of SCI or 30-day mortality compared with TEVAR without previous aortic repair.
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Affiliation(s)
- Ryan W King
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC.
| | - Mathew D Wooster
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC
| | - Jean M Ruddy
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC; Ralph H. Johnson Department of Veteran Affairs Medical Center, Charleston, SC
| | - Elizabeth A Genovese
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC; Ralph H. Johnson Department of Veteran Affairs Medical Center, Charleston, SC
| | - Joseph M Anderson
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC
| | - Thomas E Brothers
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC; Ralph H. Johnson Department of Veteran Affairs Medical Center, Charleston, SC
| | - Ravi K Veeraswamy
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC
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Liew LQ, Teo WW, Seet E, Lean LL, Paramasivan A, Tan J, Lim I, Wang J, Ti LK. Factors predicting one-year post-surgical mortality amongst older Asian patients undergoing moderate to major non-cardiac surgery - a retrospective cohort study. BMC Surg 2020; 20:11. [PMID: 31931774 PMCID: PMC6956490 DOI: 10.1186/s12893-019-0654-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 11/27/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND While short-term perioperative outcomes have been well studied in Western surgical populations, the aim of this study is to look at the one-year perioperative mortality and its associated factors in an Asian surgical population after non-cardiac surgery. METHODS A retrospective cohort study of 2163 patients aged above 45 undergoing non-cardiac surgery in a university-affiliated tertiary hospital from January to July 2015 was performed. Relevant demographic, clinical and surgical data were analysed to elicit their relationship to mortality at one year after surgery. A univariate analysis was first performed to identify significant variables with p-values ≤ 0.2, which were then analysed using Firth multiple logistic regression to calculate the adjusted odds ratio. RESULTS The one-year mortality in our surgical population was 5.9%. The significant factors that increased one-year mortality include smoking (adjusted OR 2.17 (1.02-4.45), p = 0.044), anaemia (adjusted OR 1.32 (1.16-1.47), p < 0.001, for every 1 g/dL drop in haemoglobin level), lower BMI (adjusted OR 0.93 (0.87-0.98), p = 0.005, for every 1 point increase in BMI), Malay and Indian ethnicity (adjusted OR 2.68 (1.53-4.65), p = 0.001), peripheral vascular disease (adjusted OR 4.21 (1.62-10.38), p = 0.004), advanced age (adjusted OR 1.04 (1.01-1.06), p = 0.004, for every one year increase in age), emergency surgery (adjusted OR 2.26 (1.29-3.15), p = 0.005) and malignancy (adjusted OR 3.20 (1.85-5.52), p < 0.001). CONCLUSIONS Our study shows that modifiable risk factors such as malnutrition, anaemia and smoking which affect short term mortality extend beyond the immediate perioperative period into longer term outcomes. Identification and optimization of this subset of patients are therefore vital. Further similar large studies should be done to develop a risk scoring system for post-operative long-term outcomes. This would aid clinicians in risk stratification, counselling and surgical planning, which will help in patients' decision making and care planning.
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Affiliation(s)
- Lydia Q. Liew
- Department of Anaesthesia, National University Health System, 5 Lower Kent Ridge Road, Singapore, 119074 Singapore
| | - Wei Wei Teo
- Department of Anaesthesia, National University Health System, 5 Lower Kent Ridge Road, Singapore, 119074 Singapore
| | - Edwin Seet
- Department of Anaesthesia, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828 Singapore
| | - Lyn Li Lean
- Department of Anaesthesia, National University Health System, 5 Lower Kent Ridge Road, Singapore, 119074 Singapore
| | - Ambika Paramasivan
- Department of Anaesthesia, National University Health System, 5 Lower Kent Ridge Road, Singapore, 119074 Singapore
| | - Joanna Tan
- Department of Anaesthesia, National University Health System, 5 Lower Kent Ridge Road, Singapore, 119074 Singapore
| | - Irene Lim
- Department of Anaesthesia, National University Health System, 5 Lower Kent Ridge Road, Singapore, 119074 Singapore
| | - Jiexun Wang
- Department of Anaesthesia, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828 Singapore
| | - Lian Kah Ti
- Department of Anaesthesia, National University Health System, 5 Lower Kent Ridge Road, Singapore, 119074 Singapore
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Senaratne JM, Norris CM, Youngson E, McClure RS, Nagendran J, Butler CR, Meyer SR, Anderson TJ, van Diepen S. Variables Associated With Cardiac Surgical Waitlist Mortality From a Population-Based Cohort. Can J Cardiol 2018; 35:61-67. [PMID: 30595184 DOI: 10.1016/j.cjca.2018.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 10/02/2018] [Accepted: 10/14/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Cardiac surgery waitlist recommendations, which were developed based on expert opinion, poorly predict preoperative mortality. Studies reporting risk factors for waitlist mortality have not evaluated the risks including nonadherence to waitlist benchmarks. METHODS In patients who underwent cardiac surgery or died on the waitlist between 2005 and 2015, we used a Fine and Gray competing risk model to identify independent predictors of waitlist mortality in 12,106 patients scheduled for urgent, semiurgent, or nonurgent surgery. The predictive variables were compared with Canadian Cardiovascular Society (CCS) waitlist recommendations using the Akaike information criterion. RESULTS A total of 101 (0.8%) patients died awaiting surgery. The median wait times and frequency waitlist deaths among emergent, urgent, semi-urgent, and nonurgent surgery were 0.6, 7.4, 69.0, 55.5 days (P < 0.001) and 6.3%, 0.8%, 0.3%, 0.6% (P < 0.001), respectively. Adherence to CCS waitlist recommendations was higher in patients who died on the waitlist (51.6% vs 70.8%, P = 0.001) and was not predictive of waitlist mortality (hazard ratio 1.48, 95% confidence interval 0.62-0.56). Independent predictors of waitlist mortality were age, aortic surgery, ejection fraction < 35%, urgent surgery, prior myocardial infarction, haemodynamic instability during cardiac catheterization, hypertension, and dyslipidemia. These variables were superior to current CCS guidelines (Akaike information criterion 1251 vs 1317, likelihood ratio test P < 0.001). CONCLUSIONS CCS waitlist recommendations were poorly predictive of waitlist mortality and the majority of waitlist deaths occur within recommended benchmarks. We identified variables associated with waitlist mortality with improved clinical performance. Our findings suggest a need to re-evaluate cardiac surgical triage criteria using evidence-based data.
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Affiliation(s)
- Janek M Senaratne
- Division of Cardiology, University of Alberta Hospital, Edmonton, Alberta, Canada; Department of Critical Care, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Colleen M Norris
- Division of Cardiology, University of Alberta Hospital, Edmonton, Alberta, Canada; Division of Cardiac Surgery, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada; Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease, Calgary Alberta, Canada; Cardiovascular Health and Stroke, Strategic Clinical Network, Alberta, Canada; Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Erik Youngson
- Alberta SPOR Support Unit Data Platform, University of Alberta, Edmonton, Alberta, Canada
| | - Robert S McClure
- Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary Alberta, Canada
| | - Jayan Nagendran
- Division of Cardiac Surgery, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Craig R Butler
- Division of Cardiology, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Steven R Meyer
- Division of Cardiac Surgery, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Todd J Anderson
- Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary Alberta, Canada
| | - Sean van Diepen
- Division of Cardiology, University of Alberta Hospital, Edmonton, Alberta, Canada; Department of Critical Care, University of Alberta Hospital, Edmonton, Alberta, Canada.
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Monnot A, Pochulu B, Doguet F, Godier S, Scherrer V, Plissonnier D. Operated descending thoracic and thoracoabdominal atherosclerotic aortic aneurysm prognosis. JOURNAL DE MÉDECINE VASCULAIRE 2018; 43:288-292. [PMID: 30217342 DOI: 10.1016/j.jdmv.2018.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 06/30/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The long-term survival of patients treated from descending thoracic aneurysm (DTA) is well known, more than those treated from a thoracoabdominal aortic aneurysm (TAAA). Moreover, studies are rarely focused on the aneurysmal etiology and include both degenerative and post dissecting aneurysms. The aim of this study is to compare the long-term survival of patients operated from DTA or TAAA due to degenerative atherosclerosis. METHODS Thirty-nine atherosclerotic aneurysm patients were operated between January 2007 and July 2015 at Rouen University Hospital. Eighteen DTA patients were operated by TEVAR and 21 TAAA patients (8 type I and 13 type III) by open approach. The main endpoint was remote survival patients. RESULTS Overall, the initial population was similar in the two groups. However, one third of DTA were treated in context of emergency for painful aneurysm versus 9.5% of patients with TAAA (P=0.066). Survival median of 18 DTA was 18 months (1-68). Survival median of 21 TAAA followed was 66 months (1-91). Survival in both groups was statistically different with the log-rank test (P=0.044). CONCLUSIONS Long-term prognosis of atherosclerotic DTA may be worse than that of TAAA's. This retrospective study reflects experience in the management of DTA and TAAA in a single-center. Prospective data in patients treated with endovascular procedures for DTA or TAAA, with fenesterated or branched endoprosthesis, are warranted to confirm these results.
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Affiliation(s)
- Antoine Monnot
- Service de chirurgie vasculaire, CHU de Rouen, 1, rue de Germont, 76031 Rouen cedex, France
| | - Bruno Pochulu
- Service de chirurgie vasculaire, CHU de Rouen, 1, rue de Germont, 76031 Rouen cedex, France
| | - Fabien Doguet
- Service de chirurgie cardiaque, CHU de Rouen, 1, rue de Germont, 76031 Rouen cedex, France
| | - Sylvie Godier
- Service d'anesthésie réanimation, CHU de Rouen, 1, rue de Germont, 76031 Rouen cedex, France
| | - Vincent Scherrer
- Service d'anesthésie réanimation, CHU de Rouen, 1, rue de Germont, 76031 Rouen cedex, France
| | - Didier Plissonnier
- Service de chirurgie vasculaire, CHU de Rouen, 1, rue de Germont, 76031 Rouen cedex, France.
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Hu FY, Fang ZB, Leshnower BG, Duwayri Y, Jordan WD, Gillespie TW, Veeraswamy RK. Contemporary evaluation of mortality and stroke risk after thoracic endovascular aortic repair. J Vasc Surg 2017; 66:718-727.e5. [PMID: 28502542 DOI: 10.1016/j.jvs.2017.01.069] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 01/29/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE During the past decade, thoracic endovascular aortic repair (TEVAR) has increased as a treatment option for a variety of aortic pathologic processes. Despite this rise in the use of thoracic stent grafts, real-world outcomes from a robust, adjudicated, contemporary data set have yet to be reported. Previous studies have shown periprocedural mortality rates between 1.5% and 9.5% and procedure-related stroke rates of 2.3% to 8.2%. With advances in device engineering and increased experience of physicians, we hypothesized that the rates of these complications would be reduced in a more recent sample set. The purpose of this study was to determine current rates of mortality and stroke after TEVAR, to identify risk factors that contribute to 30-day mortality, and to develop a simple scoring system that allows risk stratification of patients undergoing TEVAR. METHODS We examined the 30-day mortality rate after TEVAR using the 2013 to 2014 American College of Surgeons National Surgical Quality Improvement Program database. Patients undergoing TEVAR for all aortic disease were identified using procedure codes. Bivariate analyses were performed to evaluate the association of preoperative, intraoperative, and postoperative variables with 30-day mortality, followed by multivariable logistic analysis using preoperative variables only, with P < .10 as the criterion for model entry. The predictive logistic model was internally validated by cross-validation. Variables included in the multivariable model were used to develop a risk score. RESULTS There were 826 patients included. The 30-day mortality and stroke rates were 7.63% (n = 63) and 4.5% (n = 37), respectively. In regression analysis, mortality was independently associated with age ≥80 years (odds ratio [OR], 2.32; 95% confidence interval [CI], 1.25-4.31), emergency case (OR, 2.61; 95% CI, 1.39-4.90), American Society of Anesthesiologists classification >3 (OR, 2.89; 95% CI, 1.34-6.24), transfusion >4 units in the 72 hours before surgery (OR, 2.86; 95% CI, 1.30-6.28), preoperative creatinine concentration ≥1.8 mg/dL (OR, 2.07; 95% CI, 1.05-4.08), and preoperative white blood cell count ≥12 × 109/L (OR, 2.65; 95% CI, 1.41-4.96). Incorporating these factors, a 6-point risk score was generated and demonstrated high predictability for overall 30-day mortality. CONCLUSIONS Recent data from a national, retrospective data set demonstrate that high perioperative mortality and stroke rates have persisted during the last decade. The risk score derived from this data set is simple and convenient and serves as a prognostic tool in the preoperative risk stratification of patients being evaluated for TEVAR.
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Affiliation(s)
- Frances Y Hu
- Division of Vascular and Endovascular Therapy, Department of Surgery, Emory University, Atlanta, Ga
| | - Zachary B Fang
- Division of Vascular and Endovascular Therapy, Department of Surgery, Emory University, Atlanta, Ga
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University, Atlanta, Ga
| | - Yazan Duwayri
- Division of Vascular and Endovascular Therapy, Department of Surgery, Emory University, Atlanta, Ga
| | - William D Jordan
- Division of Vascular and Endovascular Therapy, Department of Surgery, Emory University, Atlanta, Ga
| | - Theresa W Gillespie
- Department of Surgery and Department of Hematology & Medical Oncology, Emory University, Atlanta, Ga
| | - Ravi K Veeraswamy
- Division of Vascular Surgery, Department of Surgery, the Medical University of South Carolina, Charleston, SC.
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Predicting Mid-term All-cause Mortality in Patients Undergoing Elective Endovascular Repair of a Descending Thoracic Aortic Aneurysm. Ann Surg 2016; 264:1162-1167. [DOI: 10.1097/sla.0000000000001577] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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20
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Crawford SA, Sanford RM, Forbes TL, Amon CH, Doyle MG. Clinical outcomes and material properties of in situ fenestration of endovascular stent grafts. J Vasc Surg 2016; 64:244-50. [DOI: 10.1016/j.jvs.2016.03.445] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 03/18/2016] [Indexed: 01/29/2023]
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Schraag S. Postoperative management. Best Pract Res Clin Anaesthesiol 2016; 30:381-93. [PMID: 27650347 DOI: 10.1016/j.bpa.2016.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 06/02/2016] [Indexed: 02/06/2023]
Abstract
Most patients undergoing major aortic surgery have multiple comorbidities and are at high risk of postoperative complications that affect multiple organ systems. Different aortic pathologies and surgical repair techniques have specific impact on the postoperative course. Ischemia-reperfusion injury is the common denominator in aortic surgery and influences the integrity of end-organ function. Common postoperative problems include hemodynamic instability due to the immediate inflammatory response, renal impairment, spinal cord ischemia, respiratory failure with prolonged mechanical ventilation, and gastrointestinal symptoms such as ileus or mesenteric ischemia. Focused care bundles to establish homeostasis and a team working toward an early functional recovery determine the success of effective rehabilitation and outcomes after aortic surgery.
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Affiliation(s)
- Stefan Schraag
- Department of Perioperative Medicine, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, Scotland, United Kingdom.
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Bosanquet DC, Twine CP, Tang TY, Boyle JR, Bell RE, Bicknell CD, Jenkins MP, Loftus IM, Modarai B, Vallabhaneni SR. Pragmatic Minimum Reporting Standards for Thoracic Endovascular Aortic Repair. J Endovasc Ther 2015; 22:356-67. [DOI: 10.1177/1526602815584925] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- David C. Bosanquet
- South East Wales Regional Vascular Network, Royal Gwent Hospital, Newport, Wales, UK
| | - Christopher P. Twine
- South East Wales Regional Vascular Network, Royal Gwent Hospital, Newport, Wales, UK
| | - Tjun Y. Tang
- Department of General Surgery, Changi General Hospital, Singapore
| | - Jonathan R. Boyle
- Regional Vascular Unit, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
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Knowles M, Nation DA, Timaran DE, Gomez LF, Baig MS, Valentine RJ, Timaran CH. Upper extremity access for fenestrated endovascular aortic aneurysm repair is not associated with increased morbidity. J Vasc Surg 2015; 61:80-7. [DOI: 10.1016/j.jvs.2014.06.113] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 06/19/2014] [Indexed: 11/24/2022]
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von Allmen RS, Anjum A, Powell JT. Outcomes after endovascular or open repair for degenerative descending thoracic aortic aneurysm using linked hospital data. Br J Surg 2014; 101:1244-51. [PMID: 25048981 DOI: 10.1002/bjs.9568] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 02/04/2014] [Accepted: 04/17/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND The population-based effectiveness of thoracic endovascular aortic repair (TEVAR) versus open surgery for descending thoracic aortic aneurysm remains in doubt. METHODS Patients aged over 50 years, without a history of aortic dissection, undergoing repair of a thoracic aortic aneurysm between 2006 and 2011 were assessed using mortality-linked individual patient data from Hospital Episode Statistics (England). The principal outcomes were 30-day operative mortality, long-term survival (5 years) and aortic-related reinterventions. TEVAR and open repair were compared using crude and multivariable models that adjusted for age and sex. RESULTS Overall, 759 patients underwent thoracic aortic aneurysm repair, mainly for intact aneurysms (618, 81·4 per cent). Median ages of TEVAR and open cohorts were 73 and 71 years respectively (P < 0·001), with more men undergoing TEVAR (P = 0·004). For intact aneurysms, the operative mortality rate was similar for TEVAR and open repair (6·5 versus 7·6 per cent; odds ratio 0·79, 95 per cent confidence interval (c.i.) 0·41 to 1·49), but the 5-year survival rate was significantly worse after TEVAR (54·2 versus 65·6 per cent; adjusted hazard ratio 1·45, 95 per cent c.i. 1·08 to 1·94). After 5 years, aortic-related mortality was similar in the two groups, but cardiopulmonary mortality was higher after TEVAR. TEVAR was associated with more aortic-related reinterventions (23·1 versus 14·3 per cent; adjusted HR 1·70, 95 per cent c.i. 1·11 to 2·60). There were 141 procedures for ruptured thoracic aneurysm (97 TEVAR, 44 open), with TEVAR showing no significant advantage in terms of operative mortality. CONCLUSION In England, operative mortality for degenerative descending thoracic aneurysm was similar after either TEVAR or open repair. Patients who had TEVAR appeared to have a higher reintervention rate and worse long-term survival, possibly owing to cardiopulmonary morbidity and other selection bias.
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Affiliation(s)
- R S von Allmen
- Vascular Surgery Research Group, Imperial College London, London, UK; Department of Cardiovascular Surgery, Swiss Cardiovascular Centre, University Hospital Berne and University of Berne, Berne, Switzerland
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Kilic A, Shah AS, Black JH, Whitman GJ, Yuh DD, Cameron DE, Conte JV. Trends in repair of intact and ruptured descending thoracic aortic aneurysms in the United States: A population-based analysis. J Thorac Cardiovasc Surg 2014; 147:1855-60. [DOI: 10.1016/j.jtcvs.2013.06.032] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 05/02/2013] [Accepted: 06/27/2013] [Indexed: 11/15/2022]
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Rudarakanchana N, Reeves BC, Bicknell CD, Heatley FM, Cheshire NJ, Powell JT. Treatment decisions for descending thoracic aneurysm: preferences for thoracic endovascular aneurysm repair or surveillance in a discrete choice experiment. Eur J Vasc Endovasc Surg 2014; 48:13-22. [PMID: 24785650 DOI: 10.1016/j.ejvs.2014.03.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 03/20/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate and rank factors that influence endovascular treatment decisions by specialists for patients with descending thoracic aortic aneurysm (dTAA). METHODS Specialists completed a diagrammatic survey describing uncertainty about the benefit of thoracic endovascular aneurysm repair (TEVAR) for dTAA with respect to age, sex, and aneurysm diameter. Subsequently, a detailed discrete choice experiment was designed. Specialists were recruited and asked to indicate treatment their preference (TEVAR or surveillance) in 25 hypothetical cases of dTAA, with variable patient attributes: age, sex, American Society of Anesthesiologists (ASA) grade, aneurysm diameter, adequate landing zone distal to left subclavian artery (LSA), and length of aortic coverage. Data were analysed using multiple logistic regression. RESULTS The diagrammatic survey, based on 50 respondents, showed that uncertainty about the benefits of TEVAR was greatest for patients aged 80-85 years (up to 47% of respondents were "unsure") and that uncertainty increased with increasing aneurysm diameter (for an 80-year-old man, 7% were unsure at 5.5 cm and 33% were unsure at 7.0 cm). Seventy-one specialists (mainly from Europe and North America, 86% vascular surgeons and 98% working in units offering TEVAR) completed the discrete choice experiment. Preference for TEVAR increased greatly with enlarging diameter: adjusted odds ratios (OR) >5.5-6.0 cm = 15.8 (95% confidence interval [CI] 9.83-25.40); >6.0-6.5 cm = 393.0 (95% CI 202.00-766.00); >6.5-7.0 cm = 1829.0 (95% CI 400.00-4,181.00). TEVAR was less likely to be preferred in patients older than 75 years (>75-80 years OR 0.32, 95% CI 0.21-0.49; >80-85 years = 0.18, 95% CI 0.11-0.28); in women (OR 0.52, 95% CI 0.37-0.74); in patients classified as ASA grade 4 (OR 0.44, 95% CI 0.36-0.57); and in patients with aorta coverage >25 cm (OR 0.48, 95% CI 0.32-0.74). The proximal landing zone did not influence preference. CONCLUSION Specialists' preferences for endovascular repair of degenerative dTAA vary widely, and demonstrate clinical uncertainty, especially in octogenarians, and a reluctance to offer TEVAR to women. Aneurysm diameter dominates treatment preferences, but patient fitness and length of aortic coverage (>25 cm) also were influential, although the landing zone distal to LSA was not.
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Affiliation(s)
- N Rudarakanchana
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK; Division of Surgery, Department of Surgery and Cancer, Imperial College, London, UK.
| | - B C Reeves
- Clinical Trials and Evaluation Unit, British Heart Institute, University of Bristol, Bristol, UK
| | - C D Bicknell
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK; Division of Surgery, Department of Surgery and Cancer, Imperial College, London, UK
| | - F M Heatley
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - N J Cheshire
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK; Division of Surgery, Department of Surgery and Cancer, Imperial College, London, UK
| | - J T Powell
- Division of Surgery, Department of Surgery and Cancer, Imperial College, London, UK
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Scali ST, Beck AW, Butler K, Feezor RJ, Martin TD, Hess PJ, Huber TS, Chang CK. Pathology-specific secondary aortic interventions after thoracic endovascular aortic repair. J Vasc Surg 2014; 59:599-607. [PMID: 24571937 DOI: 10.1016/j.jvs.2013.09.050] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 08/24/2013] [Accepted: 09/23/2013] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Despite improved short-term outcomes, concerns remain regarding durability of thoracic endovascular aortic repair (TEVAR). The purpose of this analysis was to evaluate the pathology-specific incidence of secondary aortic interventions (SAI) after TEVAR and their impact on survival. METHODS Retrospective review was performed of all TEVAR procedures and SAI at one institution from 2004-2011. Kaplan-Meier analysis was used to estimate survival. RESULTS Of 585 patients, 72 (12%) required SAI at a median of 5.6 months (interquartile range, 1.4-14.2) with 22 (3.7%) requiring multiple SAI. SAI incidence differed significantly by pathology (P = .002) [acute dissection (21.3%), postsurgical (20.0%), chronic dissection (16.7%), degenerative aneurysm (10.8%), traumatic transection (8.1%), penetrating ulcer (1.5%), and other etiologies (14.8%)]. Most common indications after dissection were persistent false lumen flow and proximal/distal extension of disease. For degenerative aneurysms, SAI was performed primarily to treat type I/III endoleaks. SAI patients had a greater mean number of comorbidities (P < .0005), stents placed (P = .0002), and postoperative complications after the index TEVAR (P < .0005) compared with those without SAI. Freedom from SAI at 1 and 5 years (95% confidence interval) was estimated to be 86% (82%-90%) and 68% (57%-76%), respectively. There were no differences in survival (95% confidence interval) between patients requiring SAI and those who did not [SAI 1-year, 88% (77%-93%); 5-year, 51% (37%-63%); and no SAI 1-year, 82% (79%-85%); 5-year, 67% (62%-71%) (log-rank, P = .2)]. CONCLUSIONS SAI after TEVAR is not uncommon, particularly in patients with dissection, but does not affect long-term survival. Aortic pathology is the most important variable impacting survival and dictated need, timing, and mode of SAI. The varying incidence of SAI by indication underscores the need for diligent surveillance protocols that should be pathology-specific.
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Affiliation(s)
- Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Khayree Butler
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Robert J Feezor
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Tomas D Martin
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Philip J Hess
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Catherine K Chang
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
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Marrocco-Trischitta MM, Chiesa R. Regarding "Preoperative prediction of mortality within 1 year after elective thoracic endovascular aortic aneurysm repair". J Vasc Surg 2013; 57:1176. [PMID: 23535047 DOI: 10.1016/j.jvs.2012.10.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 10/26/2012] [Accepted: 10/29/2012] [Indexed: 11/28/2022]
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Rylski B, Blanke P, Siepe M, Kari FA, Euringer W, Sudkamp M, Beyersdorf F. Results of high-risk endovascular procedures in patients with non-dissected thoracic aortic pathology: intermediate outcomes. Eur J Cardiothorac Surg 2013; 44:156-62. [DOI: 10.1093/ejcts/ezs694] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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von Allmen RS, Anjum A, Powell JT. Incidence of descending aortic pathology and evaluation of the impact of thoracic endovascular aortic repair: a population-based study in England and Wales from 1999 to 2010. Eur J Vasc Endovasc Surg 2012; 45:154-9. [PMID: 23280314 DOI: 10.1016/j.ejvs.2012.12.007] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 12/10/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate population trends in thoracic aortic disease (dissections and aneurysms) in England and Wales, with focus on the impact of thoracic endovascular aortic repair on procedure numbers and age at repair. MATERIALS AND METHODS Routine hospital statistics of England and Wales provided admission, procedure and mortality data from 1999 to 2010. All data were age-standardised, reported per 100,000 population, by age bands (>50 years or 50-74 years versus 75+ years) and gender. Only patients 50+ years were included, to focus on degenerative disease. RESULTS Between 1999 and 2010 hospital admissions for total (ascending and descending) have risen steadily for thoracic aortic dissection (TAD) from 7.2 to 8.8 and thoracic aortic aneurysm (TAA) from 4.4 to 9.0, principally attributable to increased admissions in those 75+ years. Total mortality declined steadily over the same period, for TAD from 4.4 to 3.2 and for TAA from 10.4 to 7.5. Procedure rates have risen sharply, driven by the implementation of TEVAR from 2006, for type B dissection from 0.06 to 0.53 and for descending TAA from 0.76 to 1.89. All figures are per 100,000 population with P <0.005. CONCLUSION Improvements in case ascertainment may have contributed to the increase in hospital admissions. The increased application of TEVAR, particularly for dissections, is mainly in those above 75 years and has not yet translated into an accelerated survival benefit.
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Affiliation(s)
- R S von Allmen
- Vascular Surgery Research Group, Imperial College, Charing Cross Campus, St Dunstan's Road, London W6 8RF, UK.
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