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Awiwi MO, Kandemirli VB, Kokash D, Hossain F, Gjoni M, Odisio E, Ocazionez D, Ferguson E, Hanna M, Duran C. Complications of thoracic endovascular aneurysm repair (TEVAR): A pictorial review. Curr Probl Diagn Radiol 2024; 53:648-661. [PMID: 38777715 DOI: 10.1067/j.cpradiol.2024.05.018] [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: 12/10/2023] [Revised: 05/06/2024] [Accepted: 05/06/2024] [Indexed: 05/25/2024]
Abstract
Thoracic endovascular aneurysm repair (TEVAR) has replaced open surgical repair as the treatment of choice for several aortic conditions. Despite its lower morbidity and mortality, several TEVAR-related complications can occur and some of which may necessitate surgical or endovascular re-intervention. The current article reviews common and rare complications of TEVAR procedure with emphasis on complications identifiable on cross-sectional imaging and potential pitfalls of pre-procedural planning.
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Affiliation(s)
- Muhammad O Awiwi
- Division of Diagnostic Imaging, The University of Texas Health Science Center at Houston, Texas, USA.
| | | | - Diana Kokash
- Division of Diagnostic Imaging, Dubai Academic Health Corporation, UAE
| | - Ferzana Hossain
- Division of Diagnostic Imaging, The University of Texas Health Science Center at Houston, Texas, USA
| | - Migena Gjoni
- Department of Medicine, Istanbul University-Cerrahpasa Hospital, Istanbul, Turkey
| | - Erika Odisio
- Division of Diagnostic Imaging, The University of Texas Health Science Center at Houston, Texas, USA
| | - Daniel Ocazionez
- Division of Diagnostic Imaging, The University of Texas Health Science Center at Houston, Texas, USA
| | - Emma Ferguson
- Division of Diagnostic Imaging, The University of Texas Health Science Center at Houston, Texas, USA
| | - Mina Hanna
- Division of Diagnostic Imaging, The University of Texas Health Science Center at Houston, Texas, USA
| | - Cihan Duran
- Division of Diagnostic Imaging, The University of Texas Health Science Center at Houston, Texas, USA
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Deniz G, Kasımzade F, Ozcınar E, Yazicioglu L, Eryılmaz S. Long-term outcomes of TEVAR for thoracic aortic diseases: a retrospective single-center study. J Cardiothorac Surg 2024; 19:405. [PMID: 38951901 PMCID: PMC11218359 DOI: 10.1186/s13019-024-02886-6] [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: 03/09/2024] [Accepted: 06/15/2024] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND The outcomes of Thoracic Endovascular Aortic Repair (TEVAR) vary depending on thoracic aortic pathologies, comorbidities. This study presents our comprehensive endovascular experience, focusing on exploring the outcome in long term follow-up. METHODS From 2006 to 2018, we conducted TEVAR on 97 patients presenting with various aortic pathologies. This retrospective cohort study was designed primarily to assess graft durability and secondarily to evaluate mortality causes, complications, reinterventions, and the impact of comorbidities on survival using Kaplan-Meier and Cox regression analyses. RESULTS The most common indication was thoracic aortic aneurysm (n = 52). Ten patients had aortic arch variations and anomalies, and the bovine arch was observed in eight patients. Endoleaks were the main complications encountered, and 10 of 15 endoleaks were type I endoleaks. There were 18 reinterventions; the most of which was TEVAR (n = 5). The overall mortality was 20 patients, with TEVAR-related causes accounting for 12 of these deaths, including intracranial bleeding in three patients. Multivariant Cox regression revealed chronic renal diseases (OR = 11.73; 95% CI: 2.04-67.2; p = 0.006), previous cardiac operation (OR = 14.26; 95% CI: 1.59-127.36; p = 0.01), and chronic obstructive pulmonary diseases (OR = 7.82; 95% CI: 1.43-42.78; p = 0.001) to be independent risk factors for 10-year survival. There was no significant difference in the survival curves of the various aortic pathologies. In the follow-up period, two non-symptomatic intragraft thromboses and one graft infection were found. CONCLUSION Comorbidities can increase the risk of TEVAR-related mortality without significantly impacting endoleak rates. TEVAR is effective for severe aortic pathologies, though long-term graft durability may be compromised by its thrombosis and infection.
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Affiliation(s)
- Gokay Deniz
- Cardiovascular Department, Ankara Bilkent City Hospital, Bilkent Blvd. 1, Çankaya/Ankara, 06800 , Turkey.
| | - Ferit Kasımzade
- Cardiovascular Department, Ankara Bilkent City Hospital, Bilkent Blvd. 1, Çankaya/Ankara, 06800 , Turkey
| | - Evren Ozcınar
- Cardiovascular Department, Ankara University, Bilkent Blvd. 1, Çankaya/Ankara, Turkey
| | - Levent Yazicioglu
- Cardiovascular Department, Ankara University, Bilkent Blvd. 1, Çankaya/Ankara, Turkey
| | - Sadik Eryılmaz
- Cardiovascular Department, Ankara University, Bilkent Blvd. 1, Çankaya/Ankara, Turkey
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Gross BD, Zhu J, Rao A, Ilonzo N, Storch J, Faries PL, Marin ML, George JM, Tadros RO. Use of Spinal Anesthesia during Thoracic Endovascular Aortic Repair. Ann Vasc Surg 2024; 99:242-251. [PMID: 37802146 DOI: 10.1016/j.avsg.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/06/2023] [Accepted: 08/07/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND The purpose of this study was to assess outcomes after spinal anesthesia (SA) versus general anesthesia (GA) in patients undergoing thoracic endograft placement and to evaluate the adjunctive use of cerebrospinal fluid drainage (CSFD) placement. METHODS A single-center retrospective review of patients that underwent thoracic endograft placement from 2001 to 2019 was performed. Patients were stratified based on the type of anesthesia they received: GA, SA or epidural, GA with CSFD, and SA with CSFD. Primary outcomes included 30-day mortality and length of stay (LOS). Baseline characteristics were analyzed with Student's t-test and Pearson's chi-squared test. Multivariate logistic regression analysis was performed to identify risk factors for 30-day mortality and longer LOS. RESULTS A total of 333 patients underwent thoracic endograft placement; 104 patients received SA, 180 patients received GA, 30 patients received GA and CSFD, and 19 patients received SA and CSFD. Of the total patients, 16.2% underwent thoracic endograft placement for type B aortic dissection, 3.3% for type A aortic dissection, and 12.3% for penetrating ulcer. The mean age of the study population was 68.7 years old. Patients undergoing SA were older with a mean age of 73.4 years versus 64.7 years for patients undergoing GA (P < 0.001). Spinal anesthesia (SA) was preferred in patients at high risk for GA (>75 years old: 52.9% vs. 33.3%, P < 0.001; renal comorbidities: 20.6% vs. 10.6%, P = 0.03, and current smokers: 26.7% vs. 9.6%, P < 0.001). Length of stay (LOS) was decreased in the SA group (4.29 days vs. 9.70 days, P < 0.001). There was a lower incidence of spinal cord ischemia in the SA group (1.0% vs. 2.2%, P = 0.44), as well as significantly decreased 30-day mortality (0% vs. 5.6%, P = 0.01), reintervention (19.2% vs. 26.8%, P = 0.02), and return to the operating room (6.8% vs. 12.7%, P = 0.02). Of the 19 patients that had SA + CSFD, there were no signs and symptoms of spinal cord ischemia and decreased incidence of perioperative complications (0% vs. 33.3%, P = 0.01). There was no difference in the risk for intraoperative complications, neurologic complications, or 30-day mortality between GA + CSFD patients versus SA + CSFD patients. Age >75 (P = 0.002), intraoperative complications (P < 0.001), and perioperative complications (P = 0.02) were associated with increased mortality after thoracic endograft placement per multivariate logistic regression analysis. CONCLUSIONS Spinal anesthesia (SA) in select high-risk patients was associated with reduced 30-day mortality, neurologic complications, and LOS compared to GA. The concurrent use of spinal drainage and SA had satisfactory results compared to spinal drainage and GA.
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Affiliation(s)
- Benjamin D Gross
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jerry Zhu
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Ajit Rao
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nicole Ilonzo
- Division of Vascular and Endovascular Surgery, Weil Cornell Medical College, New York, NY
| | - Jason Storch
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Peter L Faries
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael L Marin
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Justin M George
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rami O Tadros
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de Las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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5
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Amabile A, Lewis E, Costa V, Tadros RO, Han DK, Di Luozzo G. Spinal cord protection in open and endovascular approaches to thoracoabdominal aortic aneurysms. Vascular 2023; 31:874-883. [PMID: 35507464 DOI: 10.1177/17085381221094411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite advancements in surgical and postoperative management, spinal cord injury has been a persistent complication of both open and endovascular repair of thoracoabdominal and descending thoracic aortic aneurysm. Spinal cord injury can be explained with an ischemia-infarction model which results in local edema of the spinal cord, damaging its structure and leading to reversible or irreversible loss of its function. Perfusion of the spinal cord during aortic procedures can be enhanced by several adjuncts which have been described with a broad variety of evidence in their support. These adjuncts include systemic hypothermia, cerebrospinal fluid drainage, extracorporeal circulation and distal aortic perfusion, segmental arteries reimplantation, left subclavian artery revascularization, and staged aortic repair. The Authors here reviewed and discussed the role of such adjuncts in preventing spinal cord injury from occurring, pinpointing current evidence and outlining future perspectives.
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Affiliation(s)
- Andrea Amabile
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Erin Lewis
- Department of Surgery, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Victor Costa
- Department of Surgery, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Rami O Tadros
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniel K Han
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gabriele Di Luozzo
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Kothari P, Bodmer NJ, Ellis S, Kiwakyou LM, Choi C. Highlights and Perioperative Implications from the 2022 American College of Cardiology and American Heart Association Guidelines for Diagnosis and Management of Aortic Disease. J Cardiothorac Vasc Anesth 2023; 37:1870-1883. [PMID: 37353422 DOI: 10.1053/j.jvca.2023.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/10/2023] [Accepted: 05/22/2023] [Indexed: 06/25/2023]
Abstract
As the understanding of aortic diseases and their complications grow, increasing importance of uniformity in diagnosis and management is crucial for optimal care of this patient population. The 2022 American College of Cardiology and American Heart Association Guidelines for Diagnosis and Management of Aortic Disease discusses these considerations in detail. The purpose of this review is to highlight essential recommendations that are of relevance to the perioperative physician who manages these patients. A few notable points include, shared decision-making with patients, creation of multidisciplinary aortic teams, lower diameter thresholds for surgery in certain situations, and increased testing for patients with heritable aortic diseases. In addition to briefly reviewing basics of aortic diseases, the authors discuss changes to guidelines that are especially relevant to perioperative care.
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Affiliation(s)
- Perin Kothari
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA.
| | - Natalie J Bodmer
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Sarah Ellis
- Department of Anesthesiology, the University of California-San Diego, La Jolla, CA
| | - Larissa Miyachi Kiwakyou
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Christine Choi
- Department of Anesthesiology, the University of California-San Diego, La Jolla, CA
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7
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Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
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8
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Yoshitani K, Ogata S, Kato S, Tsukinaga A, Takatani T, Kin N, Ezaka M, Shimizu J, Furuichi Y, Uezono S, Kida K, Seo K, Kakumoto S, Miyawaki H, Kawamata M, Tanaka S, Kakinohana M, Izumi S, Uchino H, Kakinuma T, Nishiwaki K, Hasegawa K, Matsumoto M, Ishida K, Yamashita A, Yamakage M, Yoshikawa Y, Morimoto Y, Saito H, Goto T, Masubuchi T, Kawaguchi M, Tsubaki K, Mizobuchi S, Obata N, Inagaki Y, Funaki K, Ishiguro Y, Sanui M, Taniguchi K, Nishimura K, Ohnishi Y. Effect of cerebrospinal fluid drainage pressure in descending and thoracoabdominal aortic repair: a prospective multicenter observational study. J Anesth 2023; 37:408-415. [PMID: 36944824 DOI: 10.1007/s00540-023-03179-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/06/2023] [Indexed: 03/23/2023]
Abstract
PURPOSE Cerebrospinal fluid drainage (CSFD) is recommended during open or endovascular thoracic aortic repair. However, the incidence of CSFD complications is still high. Recently, CSF pressure has been kept high to avoid complications, but the efficacy of CSFD at higher pressures has not been confirmed. We hypothesize that CSFD at higher pressures is effective for preventing motor deficits. METHODS This prospective observational study included 14 hospitals that are members of the Japanese Society of Cardiovascular Anesthesiologists. Patients who underwent thoracic and thoracoabdominal aortic repair were divided into four groups: Group 1, CSF pressure around 10 mmHg; Group 2, CSF pressure around 15 mmHg; Group 3, CSFD initiated when motor evoked potential amplitudes decreased; and Group 4, no CSFD. We assessed the association between the CSFD group and motor deficits using mixed-effects logistic regression with a random intercept for the institution. RESULTS Of 1072 patients in the study, 84 patients (open surgery, 51; thoracic endovascular aortic repair, 33) had motor deficits at discharge. Groups 1 and 2 were not associated with motor deficits (Group 1, odds ratio (OR): 1.53, 95% confidence interval (95% CI): 0.71-3.29, p = 0.276; Group 2, OR: 1.73, 95% CI: 0.62-4.82) when compared with Group 4. Group 3 was significantly more prone to motor deficits than Group 4 (OR: 2.56, 95% CI: 1.27-5.17, p = 0.009). CONCLUSION CSFD is not associated with motor deficits in thoracic and thoracoabdominal aortic repair with CSF pressure around 10 or 15 mmHg.
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Affiliation(s)
- Kenji Yoshitani
- Department of Transfusion, National Cerebral and Cardiovascular Center, 6-1 Kishibeshimmachi, Suita, Osaka, 564-8565, Japan.
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Soshiro Ogata
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Shinya Kato
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Akito Tsukinaga
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
- Department of Anesthesiology, School of Medicine, Yokohama City University, Yokohama, Japan
| | - Tsunenori Takatani
- Division of Central Clinical Laboratory, Nara Medical University, Kashihara, Nara, Japan
| | - Nobuhide Kin
- Department of Anesthesia, New Tokyo Hospital, Matsudo, Japan
| | - Mariko Ezaka
- Department of Anesthesia, New Tokyo Hospital, Matsudo, Japan
| | - Jun Shimizu
- Department of Anesthesiology, Sakakibara Heart Institute, Futyu, Japan
| | - Yuko Furuichi
- Department of Anesthesiology, Sakakibara Heart Institute, Futyu, Japan
| | - Shoichi Uezono
- Department of Anesthesiology, The Jikei University School of Medicine, Minato-ku, Japan
| | - Kotaro Kida
- Department of Anesthesiology, The Jikei University School of Medicine, Minato-ku, Japan
| | - Katsuhiro Seo
- Department of Emergency, Kokura Memorial Hospital, Fukuoka, Japan
| | - Shinichi Kakumoto
- Department of Anesthesiology, Kokura Memorial Hospital, Fukuoka, Japan
| | - Hiroshi Miyawaki
- Department of Anesthesiology, Kokura Memorial Hospital, Fukuoka, Japan
| | - Mikito Kawamata
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Satoshi Tanaka
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Manabu Kakinohana
- Department of Anesthesiology, Faculty of Medicine, University of Ryukyu, Nishihara, Japan
| | - Shunsuke Izumi
- Department of Anesthesiology, Faculty of Medicine, University of Ryukyu, Nishihara, Japan
| | - Hiroyuki Uchino
- Department of Anesthesiology, Tokyo Medical University, Shinjuku-ku, Japan
| | - Takayasu Kakinuma
- Department of Anesthesiology, Tokyo Medical University, Shinjuku-ku, Japan
| | - Kimitoshi Nishiwaki
- Department of Anesthesiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuko Hasegawa
- Department of Anesthesiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mishiya Matsumoto
- Department of Anesthesiology, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Kazuyoshi Ishida
- Department of Anesthesiology, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Atsuo Yamashita
- Department of Anesthesiology, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Michiaki Yamakage
- Department of Anesthesiology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Yusuke Yoshikawa
- Department of Anesthesiology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Yuji Morimoto
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hitoshi Saito
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takahisa Goto
- Department of Anesthesiology, School of Medicine, Yokohama City University, Yokohama, Japan
- Department of Anesthesiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Tetsuhito Masubuchi
- Department of Anesthesiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Masahiko Kawaguchi
- Department of Anesthesiology, Nara Medical University, Kashihara, Nara, Japan
| | - Kosuke Tsubaki
- Department of Anesthesiology, Nara Medical University, Kashihara, Nara, Japan
| | - Satoshi Mizobuchi
- Division of Anesthesiology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Norihiko Obata
- Division of Anesthesiology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshimi Inagaki
- Division of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Kazumi Funaki
- Division of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Yoshiki Ishiguro
- Department of Anesthesiology, The Jikei University School of Medicine, Minato-ku, Japan
- Department of Anesthesiology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | | | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yoshihiko Ohnishi
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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9
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Zarrintan S, Yei KS, Moacdieh MP, Schermerhorn M, Clouse WD, Malas MB. Preoperative Spinal Drain Placement is Associated with Reduced Risk of Spinal Cord Ischemia in Patients Undergoing Thoracic Endovascular Aortic Repair for Aortic Dissection. Ann Vasc Surg 2023; 90:17-26. [PMID: 36442708 DOI: 10.1016/j.avsg.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 10/31/2022] [Accepted: 11/05/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Spinal cord ischemia (SCI) is a rare but serious complication of Thoracic Endovascular Aortic Repair (TEVAR). Several measures including spinal drain (SD) placement have been proposed to reduce the risk of SCI in TEVARs performed for aneurysms. However, there are no specific large-scale data on potential benefits of SD placement in Stanford Type B aortic dissection (TBAD). We aimed to assess the impact of preoperative SD placement on preventing SCI during TEVARs performed for TBAD. METHODS We included all TEVAR cases performed for TBAD in Vascular Quality Initiative (VQI) from 2012 to 2021. Patients with connective tissue disease, open conversion, rupture, proximal disease > zone 5, proximal landing zone <2 or SCI on presentation were excluded. One-to-one propensity score matching was used to balance patients on 34 dimensions by the nearest neighbor principle to compare patients based on preoperative SD placement. The primary outcome was SCI. Secondary outcomes included 30-day and 90-day mortality, perioperative complications, and 90-day2intervention. RESULTS A total of 2,683 TEVARs were performed for TBAD with 1,227 (45.7%) undergoing preoperative SD placement. Propensity matching produced 672 well-matched pairs. In the matched cohort, SD placement was not associated with significant reduction in temporary SCI (3.0% vs. 3.7%, P = 0.45). However, SD placement was associated with significant reduction of the risk of permanent SCI at discharge (1.3% vs. 3.4%, P = 0.012). SD was also associated with lower risk of 30-day mortality (3.7% vs 6.4%, P = 0.025) and shorter length of stay but not 90-day mortality or 90-day reintervention. CONCLUSIONS Our study suggests that preoperative SD placement in patients undergoing TEVAR for TBAD is beneficial in reducing the risk of permanent SCI without increasing risks of perioperative complications. Further prospective studies are necessary to confirm these findings.
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Affiliation(s)
- Sina Zarrintan
- Department of Surgery, Division of Vascular & Endovascular Surgery, UC San Diego, San Diego, CA
| | - Kevin S Yei
- Department of Surgery, Division of Vascular & Endovascular Surgery, UC San Diego, San Diego, CA
| | - Munir P Moacdieh
- Department of Surgery, Division of Vascular & Endovascular Surgery, UC San Diego, San Diego, CA
| | - Marc Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - W Darrin Clouse
- Division of Vascular & Endovascular Surgery, University of Virginia Health System, Charlottesville, VA
| | - Mahmoud B Malas
- Department of Surgery, Division of Vascular & Endovascular Surgery, UC San Diego, San Diego, CA.
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10
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Oberhuber A, Raddatz A, Betge S, Ploenes C, Ito W, Janosi RA, Ott C, Langheim E, Czerny M, Puls R, Maßmann A, Zeyer K, Schelzig H. Interdisciplinary German clinical practice guidelines on the management of type B aortic dissection. GEFASSCHIRURGIE 2023; 28:1-28. [PMCID: PMC10123596 DOI: 10.1007/s00772-023-00995-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 08/13/2023]
Affiliation(s)
- A. Oberhuber
- German Society of Vascular Surgery and Vascular Medicine (DGG); Department of Vascular and Endovascular Surgery, University Hospital of Münster, Münster, Germany
| | - A. Raddatz
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI); Department of Anaesthesiology, Critical Care and Pain Medicine, Saarland University Hospital, Homburg, Germany
| | - S. Betge
- German Society of Angiology and Vascular Medicine (DGG); Department of Internal Medicine and Angiology, Helios Hospital Salzgitter, Salzgitter, Germany
| | - C. Ploenes
- German Society of Geriatrics (DGG); Department of Angiology, Schön Klinik Düsseldorf, Düsseldorf, Germany
| | - W. Ito
- German Society of Internal Medicine (GSIM) (DGIM); cardiovascular center Oberallgäu Kempten, Hospital Kempten, Kempten, Germany
| | - R. A. Janosi
- German Cardiac Society (DGK); Department of Cardiology and Angiology, University Hospital Essen, Essen, Germany
| | - C. Ott
- German Society of Nephrology (DGfN); Department of Nephrology and Hypertension, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
- Department of Nephrology and Hypertension, Paracelsus Medical University, Nürnberg, Germany
| | - E. Langheim
- German Society of prevention and rehabilitation of cardiovascular diseaese (DGPR), Reha Center Seehof, Teltow, Germany
| | - M. Czerny
- German Society of Thoracic and Cardiovascular Surgery (DGTHG), Department University Heart Center Freiburg – Bad Krozingen, Freiburg, Germany
- Albert Ludwigs University Freiburg, Freiburg, Germany
| | - R. Puls
- German Radiologic Society (DRG); Institute of Diagnostic an Interventional Radiology and Neuroradiology, Helios Klinikum Erfurt, Erfurt, Germany
| | - A. Maßmann
- German Society of Interventional Radiology (DeGIR); Department of Diagnostic an Interventional Radiology, Saarland University Hospital, Homburg, Germany
| | - K. Zeyer
- Marfanhilfe e. V., Weiden, Germany
| | - H. Schelzig
- German Society of Surgery (DGCH); Department of Vascular and Endovascular Surgery, University Hospital of Düsseldorf, Düsseldorf, Germany
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11
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Matsumoto R, Nishi S, Yoshimoto A, Suematsu Y. Inverted Thoracic Stent Graft Technique for Separation of a Stent Graft and Bare Stent Caused by Aortic Elongation. Vasc Endovascular Surg 2022; 57:402-405. [PMID: 36525510 DOI: 10.1177/15385744221143226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction Component separation (CS) of the Zenith Dissection Endovascular Graft and Stent have been reported with some causes. However, CS caused by aortic elongation has not yet been reported. A long treatment range with the sacrifice of some intercostal arteries (ICAs) is sometimes needed when repairing CS because of the large difference in the diameter between the proximal and distal landing zones with a reverse taper. Case presentation A 78-year-old man, who underwent thoracic endovascular aortic repair (TEVAR) using a Zenith Dissection Graft and stents for acute type B aortic dissection 3 years and 8 months previously was admitted to our hospital with severe back pain. Contrast-enhanced computed tomography (CT) showed separation of the SG and bare stent, and aortic elongation. As there was a large difference in the diameter of the proximal and distal landing zones with a reverse taper, a long treatment range with the sacrifice of two large ICAs was needed. Thus, TEVAR using an inverted thoracic SG technique was performed in order to shorten the treatment range to preserve a large ICA and reduce the risk of paraplegia. Completion angiography showed that the separation was repaired with preservation of the large ICA. The postoperative course was uneventful, and he was discharged on postoperative day 10 with relief of his severe pain. At 1 year after secondary TEVAR, CT showed that the diameter of the descending aorta had decreased with no separation of the SGs. Conclusion Deployment of an inverted thoracic SG for the treatment of CS of the Zenith Dissection Endovascular Graft and Stent is a feasible and effective procedure to preserve ICAs. An overlapping range of >1.5 times the length of a bare stent within an SG is needed to prevent CS of the Zenith Dissection Endovascular Graft and Stent caused by aortic elongation.
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Affiliation(s)
- Ryumon Matsumoto
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Satoshi Nishi
- Department of Cardiovascular Surgery, Tsukuba Memorial Hospital, Ibaraki, Japan
- Tsukuba Endovascular Aortic Repair Center, Tsukuba Memorial Hospital, Ibaraki, Japan
| | - Akihiro Yoshimoto
- Department of Cardiovascular Surgery, Tsukuba Memorial Hospital, Ibaraki, Japan
| | - Yoshihiro Suematsu
- Department of Cardiovascular Surgery, Tsukuba Memorial Hospital, Ibaraki, Japan
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12
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2022; 146:e334-e482. [PMID: 36322642 PMCID: PMC9876736 DOI: 10.1161/cir.0000000000001106] [Citation(s) in RCA: 424] [Impact Index Per Article: 212.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce E Bray
- AHA/ACC Joint Committee on Clinical Data Standards liaison
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Y Joseph Woo
- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
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13
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Isselbacher EM, Preventza O, Hamilton Black Iii J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Jones WS, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Times SS, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 80:e223-e393. [PMID: 36334952 PMCID: PMC9860464 DOI: 10.1016/j.jacc.2022.08.004] [Citation(s) in RCA: 138] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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14
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Ellauzi H, Arora H, Elefteriades JA, Zaffar MA, Ellauzi R, Popescu WM. Cerebrospinal Fluid Drainage for Prevention of Spinal Cord Ischemia in Thoracic Endovascular Aortic Surgery-Pros and Cons. AORTA (STAMFORD, CONN.) 2022; 10:290-297. [PMID: 36539146 PMCID: PMC9767776 DOI: 10.1055/s-0042-1757792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 04/14/2022] [Indexed: 06/17/2023]
Abstract
Thoracic endovascular aortic repair (TEVAR) carries a risk of spinal cord ischemia (SCI) which exerts a devastating impact on patient's quality of life and life expectancy. Although routine prophylactic cerebrospinal fluid (CSF) drainage is not unequivocally supported by current data, several studies have demonstrated favorable outcomes. Patients at high risk for SCI following TEVAR likely will benefit from prophylactic CSF drains. However, the intervention is not risk free, and thorough risk/benefit analysis should be individualized to each patient.
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Affiliation(s)
- Hesham Ellauzi
- Aortic Institute at Yale New-Haven, Department of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
- Department of Surgery, Istishari Hospital, Amman, Jordan
| | - Harendra Arora
- Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - John A. Elefteriades
- Aortic Institute at Yale New-Haven, Department of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Mohammad A. Zaffar
- Aortic Institute at Yale New-Haven, Department of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Rama Ellauzi
- Department of Surgery, Istishari Hospital, Amman, Jordan
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan.
| | - Wanda M. Popescu
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
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15
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Dias-Neto M, Tenorio ER, Baumgardt Barbosa Lima G, Baghbani-Oskouei A, Oderich GS. Postoperative management in patients with complex aortic aneurysms. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:587-596. [PMID: 35687066 DOI: 10.23736/s0021-9509.22.12359-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Patients with complex aortic aneurysms (CAA) are often high risk due to advanced age and widespread atherosclerosis affecting numerous vascular territories. Therefore, a thorough perioperative evaluation is needed prior to performing in any type of aortic repair, regardless of whether an endovascular or open surgical approach is selected. Because these operations are technically demanding and often result in end organ ischemia, it is not surprising that complex aortic repair carries significant risk of morbidity and mortality. Disabling complications such as dialysis, major stroke and paraplegia constitute the main limitation of complex aortic repair. The aim of this article was to review postoperative management to mitigate complications after CAA repair.
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Affiliation(s)
- Marina Dias-Neto
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Emanuel R Tenorio
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Guilherme Baumgardt Barbosa Lima
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Aidin Baghbani-Oskouei
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Gustavo S Oderich
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA -
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16
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Leone A, Di Marco L, Murana G, Pacini D. How much should be covered a type B aortic dissection? Just do it, but don't forget about spinal cord protection. Indian J Thorac Cardiovasc Surg 2022; 38:466-468. [PMID: 36050966 PMCID: PMC9424459 DOI: 10.1007/s12055-022-01387-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 10/17/2022] Open
Abstract
Revascularization of the left subclavian artery (LSA) is considered a method of spinal cord protection from ischemia during thoracic endovascular aortic repair (TEVAR). Coverage of the artery of Adamkiewicz with TEVAR is usually well tolerated because of collateral pathways to this vessel, but on the other side, the LSA is crucial in this regard since it represents the primary source of collateral pathways. In our commentary, we wish to focus the discussion on the LSA revascularization and about the complexity of the anatomy of spinal cord supply in order to underline what have been already studied, analyzed, and recommended from the current guidelines.
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Affiliation(s)
- Alessandro Leone
- Division of Cardiac Surgery, Cardiac Surgery Dept., IRCCS Azienda Ospedaliero-Universitaria Di Bologna, S. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
| | - Luca Di Marco
- Division of Cardiac Surgery, Cardiac Surgery Dept., IRCCS Azienda Ospedaliero-Universitaria Di Bologna, S. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
| | - Giacomo Murana
- Division of Cardiac Surgery, Cardiac Surgery Dept., IRCCS Azienda Ospedaliero-Universitaria Di Bologna, S. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
| | - Davide Pacini
- Division of Cardiac Surgery, Cardiac Surgery Dept., IRCCS Azienda Ospedaliero-Universitaria Di Bologna, S. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
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17
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Spinal cord ischemia following simultaneous EVAR and TEVAR for concomitant thoracic and abdominal aortic aneurysms. Ann Vasc Surg 2022; 87:343-350. [PMID: 35926790 DOI: 10.1016/j.avsg.2022.06.018] [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: 03/09/2022] [Revised: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES In patients with abdominal aortic aneurysms, 10-20% have concomitant thoracic aortic pathologies. These are typically managed with staged endovascular aneurysm repair (EVAR) and thoracic endovascular aortic repair (TEVAR) due to a perceived higher risk of spinal cord ischemia from a simultaneous intervention. We aimed to determine the outcomes of patients undergoing simultaneous EVAR and TEVAR for concomitant aneurysms. METHODS A retrospective cohort study was performed using the Vascular Quality Initiative registry from December 2003 to January 2021. Patients undergoing same-day EVAR and TEVAR were included and analyzed in accordance with the Society for Vascular Surgery reporting standards. Primary outcomes were technical success and spinal cord ischemia. RESULTS Simultaneous EVAR and TEVAR was performed in 25 patients. Median age was 75.0 (IQR 63.0-79.0) years and 20 (80.0%) patients were male. Two (4.0%) patients were symptomatic and four (16.0%) presented with rupture. Median maximum infrarenal and thoracic aortic diameter was 57.0 (IQR 52.0-65.0). Infrarenal aortic neck length was 15.0mm (IQR 10.0-25.0), and diameter was 27.0mm (IQR 24.5-30.0). Median procedure time was 185.0 minutes (IQR, 117.8-251.3), fluoroscopy time 32.7 minutes (IQR, 21.8-63.1), and contrast volume 165 ml (IQR 115.0-207.0). There were three (12.0%) Type Ia endoleaks and three (12.0%) Type II endoleaks in EVAR's, with one (4.0%) Type Ia and one (4.0%) Type II endoleak in TEVARs. In-hospital mortality occurred in three (12.0%) patients (one elective, two ruptures). Spinal cord ischemia occurred in one (4.0%) patient. This patient had a symptomatic aneurysm. Thoracic coverage extended from Zone 4 to Zone 5 and an emergent spinal drain was placed postoperatively. Symptoms were present on discharge. There was one (4.0%) conversion to open repair which occurred in a ruptured aneurysm. Technical success was achieved in 19 (76.0%) patients, however when excluding ruptured aneurysms, was achieved in 17 (81.0%) patients. Follow-up data was available for 19 (76.0%) patients at a median of 426.0 (IQR 329.0-592.5) days postoperatively. A total of 3 (12.0%) patients died during the late mortality period, at a mean of 509.0 (±503.7) days. Median change in abdominal and thoracic aortic sac diameter was -1.35mm (IQR -11.5-2.5) and 8.0 (IQR -10.5-12.0) respectively. CONCLUSIONS Simultaneous EVAR and TEVAR for concomitant abdominal and thoracic aortic aneurysms can be performed with low rates of spinal cord ischemia. Short- and mid-term outcomes are acceptable.
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18
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Fleischmann D, Afifi RO, Casanegra AI, Elefteriades JA, Gleason TG, Hanneman K, Roselli EE, Willemink MJ, Fischbein MP. Imaging and Surveillance of Chronic Aortic Dissection: A Scientific Statement From the American Heart Association. Circ Cardiovasc Imaging 2022; 15:e000075. [PMID: 35172599 DOI: 10.1161/hci.0000000000000075] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
All patients surviving an acute aortic dissection require continued lifelong surveillance of their diseased aorta. Late complications, driven predominantly by chronic false lumen degeneration and aneurysm formation, often require surgical, endovascular, or hybrid interventions to treat or prevent aortic rupture. Imaging plays a central role in the medical decision-making of patients with chronic aortic dissection. Accurate aortic diameter measurements and rigorous, systematic documentation of diameter changes over time with different imaging equipment and modalities pose a range of practical challenges in these complex patients. Currently, no guidelines or recommendations for imaging surveillance in patients with chronic aortic dissection exist. In this document, we present state-of-the-art imaging and measurement techniques for patients with chronic aortic dissection and clarify the need for standardized measurements and reporting for lifelong surveillance. We also examine the emerging role of imaging and computer simulations to predict aortic false lumen degeneration, remodeling, and biomechanical failure from morphological and hemodynamic features. These insights may improve risk stratification, individualize contemporary treatment options, and potentially aid in the conception of novel treatment strategies in the future.
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19
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Augoustides JG. Protecting the Central Nervous System During Cardiac Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00022-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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20
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CHAN CH, DESAI SR, HWANG NC. Cerebrospinal Fluid Drains: Risks in Contemporary Practice. J Cardiothorac Vasc Anesth 2022; 36:2685-2699. [DOI: 10.1053/j.jvca.2022.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 01/03/2022] [Accepted: 01/12/2022] [Indexed: 11/11/2022]
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21
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Matar A, Arnaoutakis DJ. Endovascular treatment of thoracoabdominal aortic aneurysms. Semin Vasc Surg 2021; 34:205-214. [PMID: 34911626 DOI: 10.1053/j.semvascsurg.2021.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 10/08/2021] [Accepted: 10/10/2021] [Indexed: 11/11/2022]
Abstract
Endovascular repair of thoracoabdominal aneurysms using fenestrated and/or branched stent grafts is technically feasible and efficacious but carries a steep learning curve. This innovative surgical approach is associated with less perioperative morbidity than traditional open repair and its early and mid-term outcomes are very favorable. Spinal cord ischemia remains a devastating complication after these procedures, hence the importance of various neuroprotective strategies. Widespread applicability remains limited in the United States, as no custom-made or off-the-shelf endografts are commercially available. Access to these devices remains limited to physician-sponsored or industry-sponsored clinical trials, but results from the Cook p-Branch and Gore Thoracoabdominal Branch Endoprosthesis trials are on the horizon.
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Affiliation(s)
- Andrew Matar
- Division of Vascular Surgery, University of South Florida, 2 Tampa General Circle, 7th Floor, Room 7007, Tampa, FL 33629
| | - Dean J Arnaoutakis
- Division of Vascular Surgery, University of South Florida, 2 Tampa General Circle, 7th Floor, Room 7007, Tampa, FL 33629.
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22
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Rizk MAEMAES, Ismail MIM, Gohar KS. Stroke, spinal cord ischemia and upper limb ischemia in patients undergoing TEVAR with coverage of the left subclavian artery: a case series study. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2021. [DOI: 10.1186/s43055-021-00654-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
We performed routine spinal fluid drainage for patients who underwent TEVAR for thoracic aortic pathology together with left subclavian artery coverage, which was needed for achievement of a safe proximal sealing zone. We assessed the occurrence of spinal cord ischemia as well the rate of occurrence of other complications such as stroke, and upper limb ischemia.
Results
This was a case series study done between July 2014 and April 2020, in them all the left subclavian artery was covered to ensure a proximal safe seal zone. Routine spinal fluid drainage was done, keeping the spinal fluid pressure < 10–15 mmHg with catheter in place for 48 h. Data was obtained from twenty-three patients who underwent TEVAR for thoracic aortic dissection (73.91%), thoracic aortic aneurysm (21.74%), or ulcer (4.35%). Planning was based upon multi-slice computed tomographic angiography and covering the left subclavian was mandatory to achieve a proximal sealing zone. Technical success was achieved in 100% of cases. 4.35% of patients had three endograft, 56.52% had two endografts, 39.13% had one endograft. All patients lost their radial pulsations immediately after implantation, 8.70% developed post implantation syndrome(fever) that was managed conservatively, 4.35% developed stroke related to the anterior circulation, 4.35% developed signs of spinal cord ischemia. During the follow up, one patient died within 6 h after the procedure due to extensive myocardial infarction (patient was scheduled for CABG after our procedure). 17.40% developed upper limb symptoms that were tolerable and were managed conservatively.
Conclusion
By adopting routine spinal cord drainage and pressure monitoring, we can consider not to revascularize the left subclavian artery prior to TEVAR if it will be covered.
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23
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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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Khemlani KH, Schurink GW, Buhre W, Schreiber JU. Cerebrospinal Fluid Drainage in Thoracic and Thoracoabdominal Endovascular Aortic Repair: A Survey of Current Clinical Practice in European Medical Centers. J Cardiothorac Vasc Anesth 2021; 36:1318-1325. [PMID: 34507885 DOI: 10.1053/j.jvca.2021.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/17/2021] [Accepted: 08/01/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVES The aim of this survey was to evaluate the daily clinical practice in European hospitals regarding the modalities to prevent spinal cord ischemia, with an emphasis on cerebrospinal fluid drainage (CSFD), in patients undergoing thoracic and thoracoabdominal endovascular repair. DESIGN A 21-item online survey on current practice of spinal cord protection with an emphasis on CSFD. SETTING Online service using Castor EDC software. PARTICIPANTS Members of the European Association of Cardiothoracic Anaesthesiology and Intensive Care and European Society of Vascular Surgeons. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One hundred eighty invitations were sent and 104 were used for analysis. A majority of respondents used a written protocol for spinal cord protection during endovascular thoracic and thoracoabdominal repair (81/104 = 78%). The most common protective measures used were CSFD (79/81 = 98%), controlled hypertension (59/81 = 73%), drugs (11/81 = 14%), and hypothermia (6/81 = 7%). The two most common indications for placement of a spinal catheter were the length of the stent (83/104 = 80%) and location of aneurysm (71/104 = 68%). Preventive placement of the spinal drain (96/104) is the most common approach. In the subgroup of high-volume centers, 86% (12/14) of the respondents used a written protocol and all protocols include CSFD. Ninety-two percent (11/12) had included controlled arterial hypertension in the protocol compared with 70% (48/69) of the non-high-volume centers respondents. CONCLUSIONS The majority of European centers use a written protocol that includes CSFD. This survey showed the similarities and differences in the management of CSFD in patients undergoing endovascular thoracic and thoracoabdominal repair.
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Affiliation(s)
- Kavita Houthoff Khemlani
- Department of Anesthesia and Pain Management, Maastricht University Medical Center, Maastricht, The Netherlands; Department of Anesthesia, Maxima Medical Center, Veldhoven, The Netherlands.
| | - Geert Willem Schurink
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Wolfgang Buhre
- Department of Anesthesia and Pain Management, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan Uwe Schreiber
- Department of Anesthesia and Pain Management, Maastricht University Medical Center, Maastricht, The Netherlands
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Monga A, Patil SB, Cherian M, Poyyamoli S, Mehta P. Thoracic Trauma: Aortic Injuries. Semin Intervent Radiol 2021; 38:84-95. [PMID: 33883805 DOI: 10.1055/s-0041-1724009] [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: 10/21/2022]
Abstract
Thoracic aortic injuries caused by high impact trauma are life-threatening and require emergent diagnosis and management. With improvement in the acute care services, an increasing number of such injuries are being managed such that patients survive to undergo definitive therapies. A high index of clinical suspicion is required to order appropriate imaging. Computed tomography angiography is used to classify the injuries and guide treatment strategy. While low-grade injuries might be managed conservatively, high-grade injuries require urgent surgical or endovascular intervention. Over the past decade, endovascular repair of the thoracic aorta with or without a surgical bypass has become the preferred treatment with reduced mortality and morbidity. Rapid advancements in the stent graft technology have reduced the anatomic barriers to endovascular therapy and increased the confidence of the operators. Detailed planning prior to the procedure, understanding of the anatomy, correct choice of hardware, and adherence to technical protocol are essential for a successful endovascular procedure. These patients are often young and the limited data on the long-term outcome of aortic stent grafts make a case for a robust follow-up protocol.
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Affiliation(s)
- Akhil Monga
- Department of Radiology, Kovai Medical Centre and Hospitals, Coimbatore, Tamil Nadu, India
| | - Santosh B Patil
- Department of Radiology, Kovai Medical Centre and Hospitals, Coimbatore, Tamil Nadu, India
| | - Mathew Cherian
- Department of Radiology, Kovai Medical Centre and Hospitals, Coimbatore, Tamil Nadu, India
| | - Santhosh Poyyamoli
- Department of Radiology, Kovai Medical Centre and Hospitals, Coimbatore, Tamil Nadu, India
| | - Pankaj Mehta
- Department of Radiology, KMCH IHSR, Coimbatore, Tamil Nadu, India
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Blanco Amil CL, Mestres Alomar G, Guarnaccia G, Luoni G, Yugueros Castellnou X, Vigliotti RC, Ramses R, Riambau V. The Initial Experience on Branched and Fenestrated Endografts in the Aortic Arch. A Systematic Review. Ann Vasc Surg 2021; 75:29-44. [PMID: 33831530 DOI: 10.1016/j.avsg.2021.03.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/01/2021] [Accepted: 03/11/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Branched and fenestrated endografts (fEVAR/bEVAR) are complex techniques used to treat thoracic aorta pathologies involving the aortic arch. This systematic review aims to determine all the reported results regarding these techniques in the aortic arch, in order to describe their clinical outcomes. METHODS A systematic review of the literature was performed, considering all articles published until October 2019. PubMed, Cochrane database resources were used. The protocol of the study was previously registered in the Prospero database (CRD42020147037). Primary exclusion criteria included opinion articles, merely technique descriptions, articles without the follow-up of at least 1 month, studies conducted on animals, mixed treatments, and ongoing trials without published data. Included variables were study design, aortic pathology, type of endovascular technique (fEVAR/bEVAR), endograft manufacturing, number of fenestrations/branches and type of bridge stents. Technical success, complications during surgery and follow-up were also described. RESULTS From a total of 164 articles, 29 (28 retrospective, 1 prospective) were analyzed with a total of 693 cases (341 fEVAR and 352 bEVAR). The most common indications for repair were aneurysm (54.8%) and dissection (40%). Only fEVAR and bEVAR were considered, but different endograft materials and techniques were used and, therefore, reported upon in the current review. Zenith Alpha Thoracic Endovascular Graft was the most representative (24% of cases). Custom made, off-the-shelf, physician modified and in situ fenestrated endografts were also used in 39%, 22.4%, 18.6% and 18.9% of cases, respectively. Bridge stents were implanted in the 50.5% of cases. Technical success rate was 96%. The main intraoperative complication was the endoleak (5.2%) followed by stroke (4.8%). The in-hospital mortality was 2.5%. The mean follow-up was 18.5 months. The mortality related to the main operation during follow-up was 3.2% and not directly related to the main operation was 11.3%. During the follow-up, 92 cases (13.3%) in total had to undergo through a reintervention, 46.7% with endovascular repair and 26.1% with open surgical repair (the rest were not specified). CONCLUSION published experience with bEVAR and fEVAR in the aortic arch showed acceptable short-term effectiveness and safety. More well-conducted prospective clinical studies with long term follow-up, combined with comparative meta-analysis, are needed to elucidate the real benefit of those endovascular techniques in the aortic arch pathology.
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Affiliation(s)
- Carla Lorena Blanco Amil
- Division of Vascular Surgery, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain.
| | - Gaspar Mestres Alomar
- Division of Vascular Surgery, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Giorgio Guarnaccia
- Division of Vascular Surgery, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Giorgio Luoni
- Division of Vascular Surgery, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Xavier Yugueros Castellnou
- Division of Vascular Surgery, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Rossella Chiara Vigliotti
- Division of Vascular Surgery, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Rafic Ramses
- Division of Vascular Surgery, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Vincent Riambau
- Division of Vascular Surgery, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
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Protocolized Based Management of Cerebrospinal Fluid Drains in Thoracic Endovascular Aortic Aneurysm Repair Procedures. Ann Vasc Surg 2021; 72:409-418. [DOI: 10.1016/j.avsg.2020.08.134] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 08/12/2020] [Accepted: 08/17/2020] [Indexed: 01/04/2023]
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28
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Upchurch GR, Escobar GA, Azizzadeh A, Beck AW, Conrad MF, Matsumura JS, Murad MH, Perry RJ, Singh MJ, Veeraswamy RK, Wang GJ. Society for Vascular Surgery clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms. J Vasc Surg 2021; 73:55S-83S. [DOI: 10.1016/j.jvs.2020.05.076] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 12/17/2022]
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29
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Protocolized Based Management of CSF Drains in TEVAR Procedures. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2020.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Currie LA. Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management. Crit Care Nurse 2020; 40:75-80. [PMID: 33257969 DOI: 10.4037/ccn2020684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Linda Ann Currie
- Linda Ann Currie is a clinical nurse specialist in the cardiac surgery intensive care unit at the Virginia Commonwealth University Health System, Richmond, Virginia
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Neri E, Muzzi L, Tucci E, Cini M, Barabesi L, Tommasino G, Ricci C. Arch replacement with collared elephant trunks: The Siena approach. JTCVS Tech 2020; 6:13-27. [PMID: 34318130 PMCID: PMC8300570 DOI: 10.1016/j.xjtc.2020.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 11/18/2020] [Indexed: 11/19/2022] Open
Abstract
Objective To illustrate our experience and results in patients with diffuse aneurysmal disease treated with arch replacement using the Siena collared graft, a device designed in 2002 to improve the elephant trunk technique. Results of the first step surgical implant and the subsequent treatment strategies, with extensive use of endovascular techniques, are reported. Methods All aortic arch–replacement procedures using the Siena graft between February 2002 and January 2020 were retrospectively analyzed for early and late clinical outcomes. Results Of 146 patients (54 women, 36.9%) with a median age of 69.1 years (interquartile range 58.4-75.0 years), 55 (37.6%) had acute/chronic dissection with false lumen aneurysmal dilatation, 91 (62.3%) had degenerative aneurysms, 45 (30.8%) were redo operations, and 14 (9.5%) had connective tissue disease. First-stage outcomes: 10.9% 30-day mortality (n = 16); 5.4% stroke (n = 8, 6 disabling, 2 nondisabling; 3 fatal); and 0.6% paraplegia. Outcomes for 113 second-stage procedures (77.3%, n = 97 endovascular [66.4%], n = 16 surgical [10.9%]) were 5.3% and 8.8% 30-day and 180-day mortality; no stroke; 10.6% paraplegia. Median follow-up was 5.7 years (range: 0-18.02 years) median survival was 16.65 years (95% lower confidence limit, 10.06 years) with no significant difference between aneurysm and dissection patients. Freedom from further treatment was 87.0% (95% confidence interval, 79.9%-94.7%) at 5 years and 71.4% (95% confidence interval, 71.4%-84.7%) at 10 years; median time to reintervention was 2.59 years (interquartile range, 0.52-5.20 years) with no difference (P = .22) between dissection and aneurysm groups. Conclusions Siena collared graft represents a reliable platform for the treatment of diffuse aneurysmal disease. This device offers the flexibility required in the treatment of extended aortic lesions and guarantees the choice of the most appropriate approach for treatment completion. In this context, the availability of hybrid grafts has not modified the role of this device in arch surgery.
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Key Words
- CI, confidence interval
- CSF, cerebrospinal spinal fluid
- CT, computed tomography
- ET, elephant trunk
- IQR, interquartile range
- LCL, lower confidence limit
- OR, odds ratio
- OSR, open surgical repair
- PAU, penetrating aortic ulcer
- SINE, stent graft–induced new entry tear
- TEVAR, thoracic endovascular aortic repair
- aorta
- aortic arch surgery
- elephant trunk technique
- thoracic endovascular repair
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Affiliation(s)
- Eugenio Neri
- Aortic Surgery Unit, Siena University Hospital, Siena, Italy
- Address for reprints: Eugenio Neri, MD, Azienda Ospedaliera Universitaria Senese, Policlinico “Santa Maria alle Scotte,” Viale M. Bracci, 53100 Siena, Italy.
| | - Luigi Muzzi
- Aortic Surgery Unit, Siena University Hospital, Siena, Italy
| | - Enrico Tucci
- Aortic Surgery Unit, Siena University Hospital, Siena, Italy
| | - Marco Cini
- Interventional Radiology Unit, Siena University Hospital, Siena, Italy
| | - Lucio Barabesi
- Department of Statistics, Università degli Studi di Siena, Siena, Italy
| | | | - Carmelo Ricci
- Interventional Radiology Unit, Siena University Hospital, Siena, Italy
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Chen SW, Lee KB, Napolitano MA, Murillo-Berlioz AE, Sattah AP, Sarin S, Trachiotis G. Complications and Management of the Thoracic Endovascular Aortic Repair. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2020; 8:49-58. [PMID: 33152785 PMCID: PMC7644296 DOI: 10.1055/s-0040-1714089] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Endovascular treatment in thoracic aortic diseases has increased in use exponentially since Dake and colleagues first described the use of a home-made transluminal endovascular graft on 13 patients with descending thoracic aortic aneurysm at Stanford University in the early 1990s. Thoracic endovascular aneurysm repair (TEVAR) was initially developed for therapy in patients deemed unfit for open surgery. Innovations in endograft engineering design and popularization of endovascular techniques have transformed TEVAR to the predominant treatment choice in elective thoracic aortic repair. The number of TEVARs performed in the United States increased by 600% from 1998 to 2007, while the total number of thoracic aortic repairs increased by 60%. As larger multicenter trials and meta-analysis studies in the 2000s demonstrate the significant decrease in perioperative morbidity and mortality of TEVAR over open repair, TEVAR became incorporated into standard guidelines. The 2010 American consensus guidelines recommend TEVAR to be “strongly considered” when feasible for patients with degenerative or traumatic aneurysms of the descending thoracic aorta exceeding 5.5 cm, saccular aneurysms, or postoperative pseudoaneurysms. Nowadays, TEVAR is the predominant treatment for degenerative and traumatic descending thoracic aortic aneurysm repair. Although TEVAR has been shown to have decreased early morbidity and mortality compared with open surgical repair, endovascular manipulation of a diseased aorta with endovascular devices continues to have significant risks. Despite continued advancement in endovascular technique and devices since the first prospective trial examined the complications associated with TEVAR, common complications, two decades later, still include stroke, spinal cord ischemia, device failure, unintentional great vessel coverage, access site complications, and renal injury. In this article, we review common TEVAR complications with some corresponding radiographic imaging and their management.
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Affiliation(s)
- Sheena W Chen
- George Washington University Hospital, Washington, District of Columbia
| | - Kyongjune B Lee
- George Washington University Hospital, Washington, District of Columbia
| | | | | | | | - Shawn Sarin
- George Washington University Hospital, Washington, District of Columbia
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Yoshitani K, Kawaguchi M, Kawamata M, Kakinohana M, Kato S, Hasuwa K, Yamakage M, Yoshikawa Y, Nishiwaki K, Hasegawa K, Inagaki Y, Funaki K, Matsumoto M, Ishida K, Yamashita A, Seo K, Kakumoto S, Tsubaki K, Tanaka S, Ishida T, Uchino H, Kakinuma T, Yamada Y, Mori Y, Izumi S, Shimizu J, Furuichi Y, Kin N, Uezono S, Kida K, Nishimura K, Nakai M, Ohnishi Y. Cerebrospinal fluid drainage to prevent postoperative spinal cord injury in thoracic aortic repair. J Anesth 2020; 35:43-50. [PMID: 32980925 DOI: 10.1007/s00540-020-02857-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 09/15/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cerebrospinal fluid drainage (CSFD) is recommended as a spinal cord protective strategy in open and endovascular thoracic aortic repair. Although small studies support the use of CSFD, systematic reviews have not suggested definite conclusion and a large-scale study is needed. Therefore, we reviewed medical records of patients who had undergone descending and thoracoabdominal aortic repair (both open and endovascular repair) at multiple institutions to assess the association between CSFD and postoperative motor deficits. METHODS Patients included in this study underwent descending or thoracoabdominal aortic repair between 2000 and 2013 at 12 hospitals belonging to the Japanese Association of Spinal Cord Protection in Aortic Surgery. We conducted a retrospective study to investigate whether motor-evoked potential monitoring is effective in reducing motor deficits in thoracic aortic aneurysm repair. We use the same dataset to examine whether CSFD reduces motor deficits after propensity score matching. RESULTS We reviewed data from 1214 patients [open surgery, 601 (49.5%); endovascular repair, 613 (50.5%)]. CSFD was performed in 417 patients and not performed in the remaining 797 patients. Postoperative motor deficits were observed in 75 (6.2%) patients at discharge. After propensity score matching (n = 700), mixed-effects logistic regression performed revealed that CSFD is associated with postoperative motor deficits at discharge [adjusted odds ratio (OR), 3.87; 95% confidence interval (CI), 2.30-6.51]. CONCLUSION CSFD may not be effective for postoperative motor deficits at discharge.
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Affiliation(s)
- Kenji Yoshitani
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, Japan.
| | | | - Mikito Kawamata
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Manabu Kakinohana
- Department of Anesthesiology, Faculty of Medicine, University of Ryukyu, Naha, Japan
| | - Shinya Kato
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, Japan
| | - Kyoko Hasuwa
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, Japan
| | - Michiaki Yamakage
- Department of Anesthesiology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Yusuke Yoshikawa
- Department of Anesthesiology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Kimitoshi Nishiwaki
- Department of Anesthesiology, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Kazuko Hasegawa
- Department of Anesthesiology, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Yoshimi Inagaki
- Department of Anesthesiology and Critical Care, Medicine, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Kazumi Funaki
- Department of Anesthesiology and Critical Care, Medicine, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Mishiya Matsumoto
- Department of Anesthesiology, Graduate School of Medicine, Yamaguchi University, Ube, Japan
| | - Kazuyoshi Ishida
- Department of Anesthesiology, Graduate School of Medicine, Yamaguchi University, Ube, Japan
| | - Atsuo Yamashita
- Department of Anesthesiology, Graduate School of Medicine, Yamaguchi University, Ube, Japan
| | - Katsuhiro Seo
- Department of Anesthesiology and Intensive Care Medicine, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Shinichi Kakumoto
- Department of Anesthesiology and Intensive Care Medicine, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Kosuke Tsubaki
- Department of Anesthesiology, Nara Medical University, Kashihara, Japan
| | - Satoshi Tanaka
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takashi Ishida
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hiroyuki Uchino
- Department of Anesthesiology, Tokyo Medical University, Shinjuku Ku, Japan
| | - Takayasu Kakinuma
- Department of Anesthesiology, Tokyo Medical University, Shinjuku Ku, Japan
| | - Yoshitsugu Yamada
- Department of Anesthesiology, Faculty of Vital Care Medicine, The Graduate School of Medicine, The University of Tokyo, Bunkyo Ku, Japan
| | - Yoshiteru Mori
- Department of Anesthesiology, Faculty of Vital Care Medicine, The Graduate School of Medicine, The University of Tokyo, Bunkyo Ku, Japan
| | - Shunsuke Izumi
- Department of Anesthesiology, Faculty of Medicine, University of Ryukyu, Naha, Japan
| | - Jun Shimizu
- Department of Anesthesiology, Sakakibara Heart Institute, Fuchu, Japan
| | - Yuko Furuichi
- Department of Anesthesiology, Sakakibara Heart Institute, Fuchu, Japan
| | - Nobuhide Kin
- Department of Anesthesiology, New Tokyo Hospital, Matsudo, Japan
| | - Shoichi Uezono
- Department of Anesthesiology, School of Medicine, The Jikei University, Minato Ku, Japan
| | - Kotaro Kida
- Department of Anesthesiology, School of Medicine, The Jikei University, Minato Ku, Japan
| | - Kunihiko Nishimura
- Department of Statistics and Data Analysis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Michikazu Nakai
- Department of Statistics and Data Analysis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshihiko Ohnishi
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, Japan
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Vandiver MS, Vacas S. Interventions to improve perioperative neurologic outcomes. Curr Opin Anaesthesiol 2020; 33:661-667. [PMID: 32769748 DOI: 10.1097/aco.0000000000000905] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE OF REVIEW Few outcomes in surgery are as important to patients as that of their neurologic status. The purpose of this review is to discuss and categorize the most common perioperative neurologic complications. We will also discuss strategies to help prevent and mitigate these complications for our patients. RECENT FINDINGS There are several strategies the anesthesiologist can undertake to prevent or treat conditions, such as perioperative neurocognitive disorders, spinal cord ischemia, perioperative stroke, and postoperative visual loss. SUMMARY A thorough understanding of threats to patients' neurologic well-being is essential to excellent clinical practice.
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Affiliation(s)
- Matthew S Vandiver
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, CA, USA
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Mousa AY, Morcos R, Broce M, Bates MC, AbuRahma AF. New Preoperative Spinal Cord Ischemia Risk Stratification Model for Patients Undergoing Thoracic Endovascular Aortic Repair. Vasc Endovascular Surg 2020; 54:487-496. [PMID: 32495704 DOI: 10.1177/1538574420929135] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Our objective was to determine significant predictors of spinal cord ischemia (SCI) following Thoracic Endovascular Aortic Repair (TEVAR) and to further develop a simple and clinically orientated risk score model. METHODS A retrospective review of data from the Society of Vascular Surgery/Vascular Quality Initiative national data set was performed for all patients undergoing TEVAR from January, 2014 to June 2018. Preoperative demographics, procedure-related variables, and clinical details related to SCI were examined. A SCI risk score was developed utilizing a multivariable logistic regression model. RESULTS For the 7889 patients in the final analysis who underwent TEVAR during the study period, the mean age was 67.6 ± 13.9, range 18 to 90 years, and the majority was male (65%). Postoperative outcomes included stroke (3.0%), myocardial infarction (2.9%), inhospital mortality (5.4%), transient SCI (1.5%), and permanent SCI (2.1%). Nearly half of the overall cases were performed in high volume centers. Predictors of increased risk for SCI included age by decade (odds ratio [OR]: 1.2), celiac coverage (OR: 1.5), current smoker (OR: 1.6), dialysis (OR: 1.9), 3 or more aortic implanted devices (OR: 1.7), emergent or urgent surgery (OR: 1.5), adjunct aorta-related procedure (OR: 2.5), adjunct not related (OR: 2.6), total estimated length of aortic device (19-31 cm, OR: 1.9 and ≥32 cm, OR: 3.0), ASA class 4 or 5 (OR: 1.6), and procedure time ≥154 minutes (OR: 1.8). Two predictors decreased the risk of SCI, cases from high-volume centers (OR: 0.6) and eGFR ≥ 60 (OR: 0.6). To evaluate the risk score model, probabilities of SCI from the original regression, raw score, and raw score categories resulted in area under the curve statistics of 0.792, 0.786, and 0.738, respectively. CONCLUSIONS Spinal cord ischemia remains one of the most feared complications of TEVAR. Incidence of SCI in this large series of patients with TEVAR was 3.6% with nearly 60% being permanent. The proposed model provides an assessment tool to guide clinical decisions, patient consent process, risk-assessment, and procedural strategy.
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Affiliation(s)
- Albeir Y Mousa
- Department of Surgery, Robert C. Byrd Health Sciences Center/West Virginia University, Charleston Area Medical Center, Vascular Center of Excellence, WV, USA
| | - Ramez Morcos
- Charles E. Schmidt College of Medicine Florida Atlantic University, Boca Raton, FL, USA
| | - Mike Broce
- Center for Health Services and Outcomes Research, Charleston Area Medical Center Health Education and Research Institute, Charleston, WV, USA
| | - Mark C Bates
- Department of Surgery, Robert C. Byrd Health Sciences Center/West Virginia University, Charleston Area Medical Center, Vascular Center of Excellence, WV, USA
| | - Ali F AbuRahma
- Department of Surgery, Robert C. Byrd Health Sciences Center/West Virginia University, Charleston Area Medical Center, Vascular Center of Excellence, WV, USA
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Cavalcanti LRP, Sá MPBO, Campos JCS, Braga PGB, Perazzo ÁM, Escorel de A. Neto AC, Wanderley LC, Holz BS, Soares AMMN, Zhigalov K, Tsagakis K, Ruhparwar A, Weymann A. Acute Aortic Dissection: an Update. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2020. [DOI: 10.1007/s40138-020-00216-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Spinal cord injury after open and endovascular repair of descending thoracic and thoracoabdominal aortic aneurysms: A meta-analysis. J Thorac Cardiovasc Surg 2020; 163:552-564. [PMID: 32561196 DOI: 10.1016/j.jtcvs.2020.04.126] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/23/2020] [Accepted: 04/23/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVE An inclusive contemporary analysis of spinal cord injury (SCI) rates in patients undergoing aneurysm repair and the factors associated with complications has not been performed. METHODS Following a systematic literature search, studies from 2008 to 2018 on repair of descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) were pooled in a meta-analysis performed using the generic inverse variance method. The primary outcome was permanent SCI. Secondary outcomes were temporary SCI, operative mortality, long-term mortality, postoperative stroke, and cerebrospinal fluid (CSF) drain-related complications. RESULTS One-hundred sixty-nine studies (22,634 patients) were included. The pooled rate of permanent SCI was 4.5% (95% confidence interval [CI], 3.8-5.4); 3.5% (95% CI, 1.8-6.7) for DTA and 7.6% (96% CI, 6.2-9.3) for TAAA repair (P for subgroups = .02), 5.7% (95% CI, 4.3-7.5) for open repair and 3.9% (95% CI, 3.1-4.8) for endovascular repair (P for subgroups = .03). Rates for Crawford extents I, II, III, IV, and V aneurysms were 4.0% (95% CI, 3.0-5.0), 15.0% (95% CI, 10.0-22.0), 7.0% (95% CI, 6.0-9.0), 2.0% (95% CI, 2.0-4.0), and 7.0% (95% CI, 2.0-23.0) respectively (P for subgroups <.001). The pooled rates for operative mortality, late mortality at a mean follow-up of 5.0 years, stroke, and temporary SCI were 7.4% (95% CI, 6.1-9.4), 1.0% (95% CI, 0.0-1.0), 4.2% (95% CI, 3.6-4.8), and 3.7% (95% CI, 3.0-4.6), respectively. The pooled rates for severe, moderate, and minor CSF-drain related complications were 5.1% (95% CI, 2.23-11.1), 4.1% (95% CI, 0.6-22.0), and 3.6% (95% CI, 1.2-8.0) respectively. CONCLUSIONS Despite improvement, both open and endovascular aneurysm repair remain associated with a substantial risk of permanent SCI. The risk is greater for TAAA repair, especially extent II, III, and V.
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Pasqualucci A, Al-Sibaie A, Vaidyan KPT, Paladini A, Nadhari MY, Gori F, Greiss HF, Properzi M, Al Ani OSM, Godwin A, Syedkazmi AH, Elhanf OA, Varrassi G. Epidural Corticosteroids, Lumbar Spinal Drainage, and Selective Hemodynamic Control for the Prevention of Spinal Cord Ischemia in Thoracoabdominal Endovascular Aortic Repair: A New Clinical Protocol. Adv Ther 2020; 37:272-287. [PMID: 31721112 DOI: 10.1007/s12325-019-01146-7] [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: 08/30/2019] [Indexed: 12/16/2022]
Abstract
INTRODUCTION In patients undergoing thoracoabdominal aorta repair, spinal cord ischemia (SCI) remains one of the most common and important complications resulting in transient paraparesis through to permanent flaccid paraplegia. In this manuscript, after a brief introduction to spinal cord ischemia complication and its prevention in thoracoabdominal endovascular aortic repair (TEVAR), we propose a new clinical protocol potentially able to prevent such complication. METHODS The proposed protocol suggests the use of high dosages of corticosteroids by epidural route, along with drainage of cerebrospinal fluid and controlled vascular hypertension, to reduce the incidence of SCI in TEVAR. Moreover, we paid particular attention to the control of the hemodynamic parameters to obtain adequate peripheral tissue perfusion (oxygen delivery), including in the spinal cord. RESULTS We applied this new protocol in 50 consecutive patients treated with TEVAR for thoracoabdominal aortic aneurysms (TAAs); 47 patients completed the procedure: 27 patients Crawford type I and 20 Crawford type II. Three patients died during surgery because of untreatable aneurysm rupture. The results show that in all patients there were no cases of SCI, after 5 days from TEVAR. DISCUSSION To the best of our knowledge, there are no clinical studies on the use of epidural corticosteroids in patients undergoing treatment of aortic syndrome (both in "open surgery" and endovascular aortic repair). This initial study on 50 consecutive patients has shown that the clinical protocol used could be of great interest to prevent one of the worse complications of TEVAR. Its limitations are the low number of patients studied till now, and the non-randomized protocol adopted. Further studies would be necessary. CONCLUSION Our experience and the results obtained with this new perioperative protocol with epidural corticosteroid and accurate hemodynamic control have been encouraging and it seems a valid proposal to be explored in future by well-structured prospective, randomized protocols.
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Affiliation(s)
- Alberto Pasqualucci
- Department of Surgical and Biomedical Science, University Hospital of Perugia, 06100, Perugia, Italy
- Rashid Hospital, Trauma and Emergency Center (Dubai Health Authority), Dubai, UAE
| | - Ayman Al-Sibaie
- Rashid Hospital, Trauma and Emergency Center (Dubai Health Authority), Dubai, UAE
| | | | | | | | - Fabio Gori
- Department of Surgical and Biomedical Science, University Hospital of Perugia, 06100, Perugia, Italy
| | - Hany Fawzy Greiss
- Rashid Hospital, Trauma and Emergency Center (Dubai Health Authority), Dubai, UAE
| | - Marina Properzi
- Department of Surgical and Biomedical Science, University Hospital of Perugia, 06100, Perugia, Italy
| | | | - Aruna Godwin
- Rashid Hospital, Trauma and Emergency Center (Dubai Health Authority), Dubai, UAE
| | | | - Osama Ahmed Elhanf
- Rashid Hospital, Trauma and Emergency Center (Dubai Health Authority), Dubai, UAE
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Malloy PC, Raghavan A, Elder T, Wright J, Wright CH, Burant C, Sajatovic M, Hoffer A. Cerebrospinal Fluid Drainage During Endovascular Aortic Aneurysm Repair: A Systematic Review of the Literature and Treatment Recommendations. Vasc Endovascular Surg 2019; 54:205-213. [DOI: 10.1177/1538574419896525] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction: Spinal cord injury (SCI) is a known complication of aortic aneurysm repair. Previous reports indicate that cerebrospinal fluid drainage (CSFD) may reduce incidence of SCI during open aortic aneurysm repair but its utility in endovascular repair remains poorly understood. We performed a systematic review of the literature to examine the protocols and outcomes of CSFD in patients undergoing endovascular aortic aneurysm repair. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were utilized to conduct a systematic literature review. PubMed, Scopus, Ovid, Cochrane, and EMBASE were queried for articles published since 2016 using search terms “(cerebrospinal fluid diversion OR CSF diversion OR lumbar drain OR subarachnoid drain OR spinal) AND (aortic aneurysm AND thoracic AND endovascular OR TEVAR).” Ninety-two articles were identified and screened by 2 independent reviewers, and 23 studies met criteria for full-text review after initial screening. Results: A total of 8 studies met full inclusion criteria for final analysis. Six studies reported incidence of SCI in patients with CSFD and 2 compared SCI incidence between patients with and without CSFD. Protocols for drainage most commonly included draining to a target pressure intra- and postoperatively, between 8 and 12 mm Hg. Incidence of SCI ranged from 0% to 17% in patients with CSFD, and from 0% to 50% in those without CSFD. Rates of CSFD-related complications ranged from <1% to 28%. Conclusion: There may be a protective benefit of CSFD in preventing SCI, but there remains significant variation in drain placement protocols. Significant potential bias exists in the reviewed data. Higher quality studies on the role of CSFD in endovascular aortic aneurysm repair are needed.
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Affiliation(s)
- Patrick C. Malloy
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
- Patrick C. Malloy and Alankrita Raghavan contributed equally to the content
| | - Alankrita Raghavan
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
- Patrick C. Malloy and Alankrita Raghavan contributed equally to the content
| | - Theresa Elder
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - James Wright
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Christina Huang Wright
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Christopher Burant
- Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, OH, USA
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - Martha Sajatovic
- Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Alan Hoffer
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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Matsuzaki Y, Yamasaki T, Hohri Y, Hiramatsu T. Surgical Strategies for Type B Aortic Dissection by Frozen Elephant Trunk. Ann Vasc Dis 2019; 12:473-479. [PMID: 31942204 PMCID: PMC6957904 DOI: 10.3400/avd.oa.19-00094] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The timing and choice of surgical method for type B aortic dissection, is still a topic of much debate. We performed total arch replacement using frozen elephant trunk (TAR-FET) as a means of preventing distant aortic events, such as retrograde type A aortic dissection (RTAD). We conducted analysis of 142 patients with acute type B dissection who were admitted between January of 2010 and July of 2017. Fifty-five cases required surgical intervention to treat enlargement of the false lumen diameter and ULP formation 2 weeks after the onset of symptoms. 17 TAR-FET were performed with a mean of 42±26 days period from onset to surgery. There were no complications of RTAD or paraplegic, and 90% of patient demonstrated aortic event free survival (5 years) and false lumen reduction ratio of 35%. Based on our analysis, using TAR-FET properly avoids serious complications like RTAD, and is a viable treatment option for type B dissection. (This is a translation of J Jpn Coll Angiol 2018; 58: 151-157.).
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Affiliation(s)
- Yuichi Matsuzaki
- Department of Cardiovascular Surgery, Kyoto Daini Red Cross Hospital, Kyoto, Kyoto, Japan
| | - Takuma Yamasaki
- Department of Cardiovascular Surgery, Kyoto Daini Red Cross Hospital, Kyoto, Kyoto, Japan
| | - Yu Hohri
- Department of Cardiovascular Surgery, Kyoto Daini Red Cross Hospital, Kyoto, Kyoto, Japan
| | - Takeshi Hiramatsu
- Department of Cardiovascular Surgery, Kyoto Daini Red Cross Hospital, Kyoto, Kyoto, Japan
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A practical guide for anesthetic management during intraoperative motor evoked potential monitoring. J Anesth 2019; 34:5-28. [PMID: 31630259 DOI: 10.1007/s00540-019-02698-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 10/05/2019] [Indexed: 12/19/2022]
Abstract
Postoperative motor dysfunction can develop after spinal surgery, neurosurgery and aortic surgery, in which there is a risk of injury of motor pathway. In order to prevent such devastating complication, intraoperative monitoring of motor evoked potentials (MEP) has been conducted. However, to prevent postoperative motor dysfunction, proper understanding of MEP monitoring and proper anesthetic managements are required. Especially, a variety of anesthetics and neuromuscular blocking agent are known to attenuate MEP responses. In addition to the selection of anesthetic regime to record the baseline and control MEP, the measures to keep the level of hypnosis and muscular relaxation at constant are crucial to detect the changes of MEP responses after the surgical manipulation. Once the changes of MEP are observed based on the institutional alarm criteria, multidisciplinary team members should share the results of MEP monitoring and respond to check the status of monitoring and recover the possible motor nerve injury. Prevention of MEP-related adverse effects is also important to be considered. The Working Group of Japanese Society of Anesthesiologists (JSA) developed this practical guide aimed to help ensure safe and successful surgery through appropriate anesthetic management during intraoperative MEP monitoring.
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Suarez-Pierre A, Zhou X, Gonzalez JE, Rizwan M, Fraser CD, Lui C, Malas MB, Abularrage CJ, Black JH. Association of preoperative spinal drain placement with spinal cord ischemia among patients undergoing thoracic and thoracoabdominal endovascular aortic repair. J Vasc Surg 2019; 70:393-403. [DOI: 10.1016/j.jvs.2018.10.112] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/22/2018] [Indexed: 11/24/2022]
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Yang GK, Misskey J, Arsenault K, Gagnon J, Janusz M, Faulds J. Outcomes of a Spinal Drain and Intraoperative Neurophysiologic Monitoring Protocol in Thoracic Endovascular Aortic Repair. Ann Vasc Surg 2019; 61:124-133. [PMID: 31344465 DOI: 10.1016/j.avsg.2019.04.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 04/09/2019] [Accepted: 04/10/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Adjuncts for early detection and treatment of spinal cord ischemia (SCI) in thoracic aortic surgery are supported by robust clinical experience in open repair. The utility of cerebrospinal fluid (CSF) drainage and neurophysiologic monitoring (NPM) in thoracic endovascular aortic repair (TEVAR) is less clear. The purpose of this investigation is to determine the influence of a selective institutional spinal cord protection protocol using prophylactic NPM and CSF on outcomes for standard TEVAR. METHODS Patients undergoing standard TEVAR entered into a prospectively maintained database from a single institution from 2007 to 2016 were retrospectively reviewed. Preoperative characteristics, aneurysm extent, and etiology were reviewed. Utilization of CSF drains including volume of fluid removed, duration of drainage, and catheter-related complications were collected. NPM data were reviewed to determine the influence on intraoperative management. Exact logistic regression was used to identify independent predictors of SCI. RESULTS Of 223 patients undergoing TEVAR, 130 met inclusion criteria for the study. CSF drains were used in 71 patients (54.6%), and 56 of 130 (43%) had NPM. SCI occurred in 7 patients (5.4%), of whom 5 had partial or complete recovery. Median time to symptoms of SCI was delayed in all cases (median 52 hr, range 8-312), and none of the 4 of 7 patients with adjunct NPM demonstrated intraoperative changes. Intraoperative changes in NPM occurred in 26 (46%), and represented unilateral leg ischemia in all but 2 cases. In both patients, changes consistent with SCI were associated with intraoperative hypotension and resolved with blood pressure augmentation. Neither patient developed postoperative SCI. Median length of stay (22 vs. 9 days, P = 0.012), operative room time (262 vs. 209, P = 0.040), and perioperative mortality (28.6% vs. 4.1%, P = 0.046) were significantly higher for patients with SCI versus those without. Length of aortic coverage was found to be the sole independent predictor of SCI (odds ratio 8.2, P = 0.026). Complications related to CSF drainage occurred in 4 patients (5.6%) with major complications occurring in 2 patients (2.8%), including 1 with an intrathecal hematoma and permanent bilateral paraparesis. CONCLUSIONS Selective use of prophylactic CSF drainage in TEVAR was associated with moderate risk and questionable benefit. The use of neurophysiological monitoring allowed for early detection and treatment of spinal ischemia, but its utility is limited by logistical factors and to the minority of patients with intraoperative spinal ischemic events.
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Affiliation(s)
- Gary K Yang
- Division of Vascular Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Jonathan Misskey
- Division of Vascular Surgery, University of British Columbia, Vancouver, BC, Canada.
| | - Kyle Arsenault
- Division of Vascular Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Joel Gagnon
- Division of Vascular Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Michael Janusz
- Division of Cardiac Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Jason Faulds
- Division of Vascular Surgery, University of British Columbia, Vancouver, BC, Canada
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Fairman AS, Beck AW, Malas MB, Goodney PP, Osborne NH, Schermerhorn ML, Wang GJ. Reinterventions in the modern era of thoracic endovascular aortic repair. J Vasc Surg 2019; 71:408-422. [PMID: 31327616 DOI: 10.1016/j.jvs.2019.04.484] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 04/20/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Using a national data set, we sought to describe the population of patients and the nature and timing of reinterventions after thoracic endovascular aortic repair (TEVAR) by aortic disease as well as their impact on survival. METHODS We evaluated the national data set for TEVAR in the Vascular Quality Initiative from 2010 to 2017. Student t-test and χ2 analysis were used to compare continuous and categorical variables in the reintervention and no reintervention groups, respectively. Freedom from reintervention and survival analysis was performed using Kaplan-Meier methods. RESULTS A total of 7006 patients were evaluated: 51.2% thoracic aortic aneurysm, 33.5% type B dissection (TBD), 7.0% penetrating aortic ulcer, 6.7% trauma, and 1.6% intramural hematoma. Overall, 553 patients (7.9%) underwent at least one reintervention, with an in-hospital reintervention rate of 3.5%. Reinterventions were most commonly performed for TBD (11.5%), with reinterventions for other diseases occurring at lower rates: thoracic aortic aneurysm, 6.7%; intramural hematoma, 5.4%; penetrating aortic ulcer, 4.8%; and trauma, 1.8%. The most common cause of reintervention across all aortic diseases was type I endoleak. The most common long-term reinterventions were placement of endovascular stent graft (65%), other surgical treatments (15.9%), other endovascular treatment (13%), endovascular branch treatment (12.4%), surgical treatment with no device removal (11.0%), and surgical branch treatment (10.4%). Freedom from reintervention was decreased for TBD compared with other diseases (P < .001). There was no difference in survival comparing patients undergoing reinterventions and those without (P = .87). However, patients undergoing in-hospital reintervention trended toward increased mortality (P = .075). CONCLUSIONS Whereas reinterventions were not rare after TEVAR, there was no difference in mortality between patients undergoing reintervention and those without. Patients undergoing TEVAR for TBD demonstrated the highest reintervention rate. This study highlights the importance of long-term follow-up to address disease-specific patterns of reintervention.
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Affiliation(s)
- Alexander S Fairman
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama Birmingham Hospital, Birmingham, Ala
| | - Mahmoud B Malas
- Divison of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego Health System, San Diego, Calif
| | - Philip P Goodney
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Nicholas H Osborne
- Section of Vascular Surgery, University of Michigan Medical Center, Ann Arbor, Mich
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa.
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Commentary: Left subclavian artery revascularization during zone 2 thoracic endovascular aortic repair: Bypass versus transposition? Just do it! J Thorac Cardiovasc Surg 2019; 159:1228-1230. [PMID: 31280896 DOI: 10.1016/j.jtcvs.2019.05.050] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 05/03/2019] [Indexed: 11/22/2022]
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Mhamdi S, Nakhli M, Chelly M, Chouchene A, Chaouch A, Naija W, Said R. Postendovascular thoracic aortic repair subclavian steal syndrome revealed by severe headache. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2015.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- S. Mhamdi
- Department of anesthesia and intensive care, Sahloul Academic Hospital, Sousse, Tunisia
| | - M.S. Nakhli
- Department of anesthesia and intensive care, Sahloul Academic Hospital, Sousse, Tunisia
| | - M. Chelly
- Department of anesthesia and intensive care, Sahloul Academic Hospital, Sousse, Tunisia
| | - A. Chouchene
- Department of anesthesia and intensive care, Sahloul Academic Hospital, Sousse, Tunisia
| | - A. Chaouch
- Department of anesthesia and intensive care, Sahloul Academic Hospital, Sousse, Tunisia
| | - W. Naija
- Department of anesthesia and intensive care, Sahloul Academic Hospital, Sousse, Tunisia
| | - R. Said
- Faculty of Medicine Ibn El Jazzar, University Of Sousse, Tunisia
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D’Oria M, Chiarandini S, Pipitone M, Calvagna C, Ziani B. Coverage of visible intercostal and lumbar segmental arteries can predict the volume of cerebrospinal fluid drainage in elective endovascular repair of descending thoracic and thoracoabdominal aortic disease: a pilot study. Eur J Cardiothorac Surg 2018; 55:646-652. [DOI: 10.1093/ejcts/ezy371] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 09/23/2018] [Accepted: 09/26/2018] [Indexed: 12/22/2022] Open
Affiliation(s)
- Mario D’Oria
- Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
| | - Stefano Chiarandini
- Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
| | - Marco Pipitone
- Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
| | - Cristiano Calvagna
- Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
| | - Barbara Ziani
- Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
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González-Urquijo M, Dominguez-Porras VA, Tellez-Martinez LG, Lozano-Balderas G, Flores-Villalba E, Fabiani MA. A case report of successful endovascular repair of a giant 15 cm diameter asymptomatic thoracic aortic aneurysm. Int J Surg Case Rep 2018; 51:344-348. [PMID: 30248627 PMCID: PMC6153185 DOI: 10.1016/j.ijscr.2018.08.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 08/06/2018] [Accepted: 08/20/2018] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Giant thoracic aortic aneurysms (TAA) are extremely uncommon, and there are only a few cases reported in the literature. Most patients presented with symptoms before the size of the aneurysm reached a magnitude >10 cm, and most of the reported cases were treated with open repair. PRESENTATION OF CASE Here we report a 15 cm asymptomatic thoracic aortic aneurysm of a 72-year-old male patient, treated successfully with thoracic endovascular aortic repair (TEVAR). The patient was discharged asymptomatic on postoperative day 2. DISCUSSION Only 20 case reports of giant TAAs were found in the literature, and this is the biggest TAA reported treated with TEVAR. This procedure is a promising treatment as morbidity and mortality is lower when compared with open aortic repair (OAR). CONCLUSION Even though there is limited documented experience, use of TEVAR seems a safe and promising option in the treatment of giant thoracic aneurysms as presented in this case.
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Arora H, Kumar PA. Prophylactic Cerebrospinal Fluid Drainage for High-Risk Thoracic Endovascular Aortic Repair: Safe and Effective? J Cardiothorac Vasc Anesth 2018; 32:890-892. [DOI: 10.1053/j.jvca.2018.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Mazzeffi M, Abuelkasem E, Drucker CB, Kalsi R, Toursavadkohi S, Harris DG, Rock P, Tanaka K, Taylor B, Crawford R. Contemporary Single-Center Experience With Prophylactic Cerebrospinal Fluid Drainage for Thoracic Endovascular Aortic Repair in Patients at High Risk for Ischemic Spinal Cord Injury. J Cardiothorac Vasc Anesth 2018; 32:883-889. [DOI: 10.1053/j.jvca.2017.12.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Indexed: 11/11/2022]
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