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Sica S, Pratesi G, Rossi G, Ferraresi M, Lovato L, Volpe P, Fadda GF, Ferri M, Rizza A, D'Oria M, Micheli R, Tshomba Y, Tinelli G. Proximal sealing in the aortic arch for inner curve disease using the Custom Relay® Scalloped and Fenestrated stent graft. J Vasc Surg 2024:S0741-5214(24)01657-4. [PMID: 39069017 DOI: 10.1016/j.jvs.2024.07.086] [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: 04/07/2024] [Revised: 06/30/2024] [Accepted: 07/21/2024] [Indexed: 07/30/2024]
Abstract
OBJECTIVE This study aims to analyze early and midterm results of custom-made proximal scallop and fenestrated stent-grafts for thoracic endovascular aortic repair (TEVAR) with proximal landing zone (PLZ) in the aortic arch. METHODS All consecutive patients treated with the custom made proximal scalloped and fenestrated Relay stent grafts (Terumo Aortic Bolton Medical Inc., Sunrise, USA) in ten Italian centers between January 2014 and December 2022 were included. The primary endpoints were technical success, incidence of intraoperative major adverse events (MAEs), deployment accuracy, and rate of early neurological complications, endoleaks (Els) and retrograde aortic dissection. RESULTS During the study period, 49 patients received TEVAR with Relay custom-made endograft in Italy were enrolled. The median patient age was 70.1 years (interquartile range, 23-86 years) and 65.3% were male. The indication for treatment was atherosclerotic aneurysms in 59.2% of cases and penetrating aortic ulcer in 22.4%. The endograft configuration was proximal fenestration in 55.1% and scallop in 44.9%. The PLZ was zone 0 in 25 cases (51%), zone 1 in 14 cases (28.6%), and zone 2 in 10 cases (20.4%). The supra-aortic debranching procedures were 38 (77.5%). Technical success was 97.9% (48/49) due to one case (2.0%) of inaccurate deployment. Intraoperatively, one (2.0%) type Ia and one (2.0%) type III Els were detected. There were no cases of in-hospital mortality, MAEs and retrograde dissection. Three (6.1%) minor strokes (National Institutes of Health Stroke Scale score≤4) were observed. At a mean follow-up time of 36.3 + 21.3 months the rate of type I-III Els and reintervention was 4.1%, respectively. Four patients (8.2%) died during the follow-up period, one (2.1%) from abdominal aortic rupture and three (6.1%) for non-aortic causes. CONCLUSIONS Our early and midterm outcomes suggest that scalloped and fenestrated TEVAR may provide an acceptable alternative treatment option for aortic arch pathologies. Large-scale studies are needed to assess the long-term durability of this technique.
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Affiliation(s)
- Simona Sica
- Università Cattolica del Sacro Cuore, Rome, Italy; Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy
| | - Giovanni Pratesi
- Department of Integrated Surgical and Diagnostic Sciences, University of Genoa; Clinic of Vascular and Endovascular Surgery, IRCCS Ospedale Policlinico San Martino, Genoa
| | | | - Marco Ferraresi
- School of Vascular Surgery, University of Milan, Milan, Italy
| | - Luigi Lovato
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Pediatric and Adult CardioThoracic and Vascular, Oncohematologic and Emergency Radiology Unit, Italy
| | - Pietro Volpe
- Unit of Vascular and Endovascular Surgery, Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Gian Franco Fadda
- Unit of Vascular and Endovascular Surgery, "Cliniche San Pietro" Hospital, AOU Sassari, Sassari, Italy
| | - Michelangelo Ferri
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Antonio Rizza
- Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana "G. Monasterio", Pisa, Italy
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Trieste, Italy
| | - Raimondo Micheli
- Unit of Vascular Surgery, Azienda Ospedaliera Santa Maria, Terni, Italy
| | - Yamume Tshomba
- Università Cattolica del Sacro Cuore, Rome, Italy; Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy
| | - Giovanni Tinelli
- Università Cattolica del Sacro Cuore, Rome, Italy; Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy.
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Melloni A, D’Oria M, Dioni P, Ongaro D, Badalamenti G, Lepidi S, Bonardelli S, Bertoglio L. Plug-Based Embolization Techniques of Aortic Side Branches during Standard and Complex Endovascular Aortic Repair. J Clin Med 2024; 13:2084. [PMID: 38610847 PMCID: PMC11012954 DOI: 10.3390/jcm13072084] [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: 02/24/2024] [Revised: 03/20/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
Vascular plugs are an evolving family of vessel occluders providing a single-device embolization system for large, high-flow arteries. Nitinol mesh plugs and polytetrafluoroethylene membrane plugs are available in different configurations and sizes to occlude arteries from 3 to 20 mm in diameter. Possible applications during complex endovascular aortic procedures are aortic branch embolization to prevent endoleak or to gain an adequate landing zone, directional branch occlusion, and false lumen embolization in aortic dissection. Plugs are delivered through catheters or introducers, and their technical and clinical results are comparable to those of coil embolization. Plugs are more accurate than coils as repositionable devices, less prone to migration, and have fewer blooming artifacts on postoperative computed tomography imaging. Their main drawback is the need for larger delivery systems. This narrative review describes up-to-date techniques and technology for plug embolization in complex aortic repair.
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Affiliation(s)
- Andrea Melloni
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University and ASST Spedali Civili Hospital of Brescia, 25123 Brescia, Italy; (P.D.); (D.O.); (S.B.); (L.B.)
| | - Mario D’Oria
- Division of Vascular and Endovascular Surgery, Cardiothoracovascular Department, University Hospital of Trieste ASUGI, 34139 Trieste, Italy; (M.D.); (G.B.); (S.L.)
| | - Pietro Dioni
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University and ASST Spedali Civili Hospital of Brescia, 25123 Brescia, Italy; (P.D.); (D.O.); (S.B.); (L.B.)
| | - Deborah Ongaro
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University and ASST Spedali Civili Hospital of Brescia, 25123 Brescia, Italy; (P.D.); (D.O.); (S.B.); (L.B.)
| | - Giovanni Badalamenti
- Division of Vascular and Endovascular Surgery, Cardiothoracovascular Department, University Hospital of Trieste ASUGI, 34139 Trieste, Italy; (M.D.); (G.B.); (S.L.)
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiothoracovascular Department, University Hospital of Trieste ASUGI, 34139 Trieste, Italy; (M.D.); (G.B.); (S.L.)
| | - Stefano Bonardelli
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University and ASST Spedali Civili Hospital of Brescia, 25123 Brescia, Italy; (P.D.); (D.O.); (S.B.); (L.B.)
| | - Luca Bertoglio
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University and ASST Spedali Civili Hospital of Brescia, 25123 Brescia, Italy; (P.D.); (D.O.); (S.B.); (L.B.)
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Stilo F, Catanese V, Montelione N, Nenna A, Pilato F, Gabellini T, Chello M, DI Lazzaro V, Spinelli F. Subclavian artery revascularization with subclavian-carotid transposition for TEVAR and non-TEVAR patients. THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:147-154. [PMID: 37162237 DOI: 10.23736/s0021-9509.23.11473-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
BACKGROUND Subclavian artery revascularization (SAR) has become an increasingly performed technique in patients undergoing thoracic endovascular aortic aneurysm repair (TEVAR), in order to optimize the proximal landing zone, or in patients with significant atherosclerotic diseases. SAR was usually achieved through carotid-subclavian bypass (CSB) which is daunted by graft and patency-related issues, or through subclavian carotid transposition (SCT) which has recently been reconsidered as a potential solution. Nowadays, multiple endovascular strategies including parallel grafts, chimney graft and branch-fenestrated repair, are available in patients unfit for open SAR. However, there is no consensus on the preferable technique in both TEVAR- and non TEVAR-patients. The purpose of this study was to evaluate our experience with SCT in terms of overall postoperative adverse events and mid-term patency rate. METHODS We performed a retrospective cohort study, including all patients who underwent SCT between June 2014 and March 2020 at our Division. Preoperative risk factors, symptoms, intraoperative details, postoperative outcomes and follow-up data were collected. RESULTS A total of 27 patients were included in this study. Indications for SCT included aortic arch debranching for TEVAR for thoracic aortic aneurysm and type B dissection and symptomatic subclavian steal syndrome (SSS). There were no major perioperative adverse events or major neurological complications; five minor adverse events occurred (18.5%) (3 Horner' Syndrome, 1 hematoma requiring reoperation,1 pneumothorax). Peripheral nerve injuries and lymphatic lesions were not recorded. On a mean follow-up of 21±16 months, SCT patency was confirmed in all patients and no deaths occurred. Comparison of baseline and operative characteristics and intraoperative details between groups of patients with or without adverse events did not found differences. CONCLUSIONS SCT should be considered a feasible, effective and safe technique for SAR, with low perioperative complications and optimal mid-term patency. This surgical technique appears to provide a lower risk of neurological events and mortality, particularly in TEVAR patients, reducing the complications caused by the coverage of the left subclavian artery.
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Affiliation(s)
- Francesco Stilo
- Department of Vascular Surgery, Campus Bio-Medico University, Rome, Italy
| | - Vincenzo Catanese
- Department of Vascular Surgery, Campus Bio-Medico University, Rome, Italy -
| | - Nunzio Montelione
- Department of Vascular Surgery, Campus Bio-Medico University, Rome, Italy
| | - Antonio Nenna
- Department of Cardiovascular Surgery, Campus Bio-Medico University, Rome, Italy
| | - Fabio Pilato
- Department of Neurology, Institute of Neurology, Sacred Heart Catholic University, Rome, Italy
| | | | - Massimo Chello
- Department of Cardiovascular Surgery, Campus Bio-Medico University, Rome, Italy
| | - Vincenzo DI Lazzaro
- Department of Neurology, Institute of Neurology, Campus Bio-Medico University, Rome, Italy
| | - Francesco Spinelli
- Department of Vascular Surgery, Campus Bio-Medico University, Rome, Italy
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Wang Z, Fang C, Song H, Wei D, Li B, Xu K, Ma Z, Zhao X. Short-term follow-up of proximal aorta remodeling after zone 2 thoracic endovascular aortic repair for acute type B aortic dissection. Int J Cardiol 2023; 393:131393. [PMID: 37748525 DOI: 10.1016/j.ijcard.2023.131393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 09/10/2023] [Accepted: 09/22/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND To evaluate the early remodeling of the proximal aorta in patients with acute type B aortic dissection (ATBAD) after zone 2 thoracic endovascular aortic repair (TEVAR). METHODS From January 2016 to May 2022, 53 ATBAD patients underwent zone 2 TEVAR were divided into two groups, the Castor single-branched stent-graft (CSS) group (n = 26) and the common stent-graft group (n = 27). Three-dimensional imaging created by computed tomography angiography was used to measure different parameters of the aorta, such as angulation, cross-sectional area (CSA), length and tortuosity. Early remodeling of the proximal aorta was evaluated by comparing geometric parameters of the proximal aorta before and 3 months after surgery. RESULTS In terms of angle, the postoperative angle of aortic arch to ascending aorta, descending aorta increased in all patients compared with that before surgery (all P < 0.05), while the angle of aortic arch to left subclavian artery increased after surgery only in the CSS group (P < 0.001); As for CSA, the CSA of distal aortic arch and true lumen increased (all P < 0.05), while the CSA of false lumen decreased in both groups after operation (all P < 0.05); Only in CSS group, the CSA of the ascending aorta, proximal aortic arch and total descending thoracic aorta decreased after surgery (all P < 0.05); In terms of length, the aortic arch prolonged after operation in both groups (P = 0.018 and P = 0.004, respectively). In addition, the ascending aorta tortuosity decreased in the CSS group after surgery (P = 0.011). There was no significant difference in the alterations of other aortic parameters after operation (P > 0.05). CONCLUSIONS The CSS implantation provided a more relatively safe and effective treatment for acute type B aortic dissection patients with unfavorable proximal landing zone. It can promote the earlier remodeling of the proximal aorta compared with the common stent-graft implantation after zone 2 TEVAR.
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Affiliation(s)
- Zhenhua Wang
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, No. 107, West Wenhua Road, Jinan 250012, Shandong, China; Institute of Thoracoscopy in Cardiac Surgery, Shandong University, China
| | - Changcun Fang
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, No. 107, West Wenhua Road, Jinan 250012, Shandong, China; Institute of Thoracoscopy in Cardiac Surgery, Shandong University, China
| | - Han Song
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, No. 107, West Wenhua Road, Jinan 250012, Shandong, China; Institute of Thoracoscopy in Cardiac Surgery, Shandong University, China
| | - Duoliang Wei
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, No. 107, West Wenhua Road, Jinan 250012, Shandong, China; Institute of Thoracoscopy in Cardiac Surgery, Shandong University, China
| | - Bowen Li
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, No. 107, West Wenhua Road, Jinan 250012, Shandong, China; Institute of Thoracoscopy in Cardiac Surgery, Shandong University, China
| | - Kai Xu
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, No. 107, West Wenhua Road, Jinan 250012, Shandong, China; Institute of Thoracoscopy in Cardiac Surgery, Shandong University, China
| | - Zengshan Ma
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, No. 107, West Wenhua Road, Jinan 250012, Shandong, China; Institute of Thoracoscopy in Cardiac Surgery, Shandong University, China
| | - Xin Zhao
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, No. 107, West Wenhua Road, Jinan 250012, Shandong, China; Institute of Thoracoscopy in Cardiac Surgery, Shandong University, China.
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Tallarita T, Rogers RT, Bower TC, Stone W, Farres H, Money SR, Colglazier JJ. Characterization and surgical management of aberrant subclavian arteries. J Vasc Surg 2023; 77:1006-1015. [PMID: 36565775 DOI: 10.1016/j.jvs.2022.12.018] [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: 10/12/2022] [Revised: 12/14/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Aberrant subclavian arteries (aSCAs), with or without aortic pathology, are uncommon. The purpose of the present study was to review our experience with the surgical management of aSCA. METHODS We performed a retrospective review of patients who had undergone surgery for an aSCA between 1996 and 2020. Symptomatic and asymptomatic patients were included. The primary end points were ≤30-day and late mortality. The secondary end points were ≤30-day complications, graft patency, and reinterventions. RESULTS A total of 46 symptomatic and 3 asymptomatic patients with aSCA had undergone surgery (31 females [62%]; median age, 45 years). An aberrant right subclavian artery was present in 38 (78%) and an aberrant left subclavian artery in 11 patients (22%). Of the 49 patients, 41 (84%) had had a Kommerell diverticulum (KD) and 11 (22%) had had a concomitant distal arch or proximal descending thoracic aortic aneurysm. Symptoms included dysphagia (56%), dyspnea (27%), odynophagia (20%), and upper extremity exertional fatigue (16%). Five patients (10%) had required emergency surgery. The aSCA had been treated by transposition in 32, a carotid to subclavian bypass in 11, and an ascending aorta to subclavian bypass in 6. The KD was treated by resection and oversewing in 19 patients (39%). Fifteen patients (31%) had required distal arch or proximal descending thoracic aortic replacement for concomitant aortic disease and/or KD treatment. Thoracic endovascular aortic repair was used to exclude the KD in six patients (12%). Seven patients (14%) had undergone only bypass or transposition. The 30-day complications included one death from pulseless electrical activity arrest secondary to massive pulmonary embolism. The 30-day major complications (14%) included acute respiratory failure in three, early mortality in one, stroke in one, non-ST-elevation myocardial infarction in one, and temporary dialysis in one patient. The other complications included chylothorax/lymphocele (n = 5; 10%), acute kidney injury (n = 2; 4%), pneumonia (n = 2; 4%), wound infection (n = 2; 4%), atrial fibrillation (n = 2; 4%), Horner syndrome (n = 2; 4%), lower extremity acute limb ischemia (n = 1; 2%), and left recurrent laryngeal nerve injury (n = 1; 2%). At a median follow-up of 53 months (range, 1-230 months), 40 patients (82%) had had complete symptom relief and 9 (18%) had experienced improvement. Six patients had died at a median of 157 months; the deaths were not procedure or aortic related. The primary patency was 98%. Reintervention at ≤30 days had been required for two patients (4%) for ligation of lymphatic vessels and bilateral lower extremity fasciotomy after proximal descending thoracic aorta replacement. One patient had required late explantation of an infected and occluded carotid to subclavian bypass graft, which was treated by cryopreserved allograft replacement. CONCLUSIONS Surgical treatment of the aSCA can be accomplished with low major morbidity and mortality with excellent primary patency and symptom relief.
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Affiliation(s)
- Tiziano Tallarita
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Richard T Rogers
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.
| | - Thomas C Bower
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - William Stone
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Phoenix, AZ
| | - Houssam Farres
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL
| | - Samuel R Money
- Division of Vascular Surgery, Ochsner Health Center, New Orleans, LA
| | - Jill J Colglazier
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
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Zhang Y, Xie X, Yuan Y, Hu C, Wang E, Zhao Y, Lin P, Li Z, Mo F, Fu W, Wang L. Comparison of techniques for left subclavian artery preservation during thoracic endovascular aortic repair: A systematic review and single-arm meta-analysis of both endovascular and surgical revascularization. Front Cardiovasc Med 2022; 9:991937. [PMID: 36186963 PMCID: PMC9520576 DOI: 10.3389/fcvm.2022.991937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundCurrently, the optimal technique to revascularize the left subclavian artery (LSA) during thoracic endovascular aortic repair (TEVAR) remains controversial. Our study seeks to characterize early and late clinical results and to assess the advantages and disadvantages of endovascular vs. surgical strategies for the preservation of LSA.MethodsPubMed, Embase and Cochrane Library searches were conducted under the PRISMA (Preferred Reporting Items for Systematic review and Meta-Analyses) standards. Only literature published after January 1994 was included. Studies reporting on endovascular revascularization (ER), surgical revascularization (SR) for LSA preservation were included. 30-day mortality and morbidity rates, restenosis rates, and rates of early and late reintervention are measured as outcomes.ResultsA total of 28 studies involving 2,759 patients were reviewed. All articles were retrospective in design. Single-arm analysis found no significant statistical differences in ER vs. SR in terms of 30-day mortality and perioperative complication rates. The mean follow-up time for the ER cohort was 12.9 months and for the SR cohort was 26.6 months, respectively. Subgroup analysis revealed a higher risk of perioperative stroke (4.2%) and endoleaks (14.2%) with the chimney technique compared to the fenestrated and single-branched stent approaches. Analysis of the double-arm studies did not yield statistically significant results.ConclusionBoth ER and SR are safe and feasible in the preservation of LSA while achieving an adequate proximal landing zone. Among ER strategies, the chimney technique may presents a greater risk of neurological complications and endoleaks, while the single-branched stent grafts demonstrate the lowest complication rate, and the fenestration method for revascularization lies in an intermediate position. Given that the data quality of the included studies were relatively not satisfactory, more randomized controlled trials (RCTs) are needed to provide convincing evidence for optimal approaches to LSA revascularization in the future.
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Affiliation(s)
- Yuchong Zhang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Xiamen, China
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Vascular Surgery Institute of Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Fudan Zhangjiang Institute, Shanghai, China
| | - Xinsheng Xie
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Xiamen, China
| | - Ye Yuan
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Xiamen, China
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Vascular Surgery Institute of Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Fudan Zhangjiang Institute, Shanghai, China
| | - Chengkai Hu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Xiamen, China
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Vascular Surgery Institute of Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Fudan Zhangjiang Institute, Shanghai, China
| | - Enci Wang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Xiamen, China
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Vascular Surgery Institute of Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Fudan Zhangjiang Institute, Shanghai, China
| | - Yufei Zhao
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Xiamen, China
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Vascular Surgery Institute of Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Fudan Zhangjiang Institute, Shanghai, China
| | - Peng Lin
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Xiamen, China
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Vascular Surgery Institute of Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Fudan Zhangjiang Institute, Shanghai, China
| | - Zheyun Li
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Xiamen, China
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Vascular Surgery Institute of Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Fudan Zhangjiang Institute, Shanghai, China
| | - Fandi Mo
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Xiamen, China
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Vascular Surgery Institute of Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Fudan Zhangjiang Institute, Shanghai, China
| | - Weiguo Fu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Xiamen, China
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Vascular Surgery Institute of Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Fudan Zhangjiang Institute, Shanghai, China
- *Correspondence: Weiguo Fu,
| | - Lixin Wang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Xiamen, China
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Vascular Surgery Institute of Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Fudan Zhangjiang Institute, Shanghai, China
- Lixin Wang,
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Grigorian A, Lewis M, Wlodarczyk JR, Chien CY, Park T, Demetriades D. Left subclavian artery coverage during endovascular repair of thoracic aorta injury in trauma and non-trauma patients. Eur J Trauma Emerg Surg 2022; 48:4425-4429. [PMID: 35713681 DOI: 10.1007/s00068-022-02027-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/28/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE In thoracic endovascular aortic repair (TEVAR), the left subclavian artery (LSA) is often occluded. Although most patients tolerate this, some develop ischemic symptoms to the brain or left upper extremity (LUE). A revascularization procedure may be associated with significant complications. The purpose of this review was to assess the incidence of LSA occlusion, resulting ischemic symptoms, and complications related to revascularization operations in trauma patients compared to non-trauma patients. METHODS Studies from 2010 to 2020 were fully reviewed if they discussed incidence of LSA coverage, LUE ischemia, carotid-subclavian bypass, or complications associated with carotid-subclavian bypass. RESULTS Seventeen articles were included in this analysis. A total of 167 patients were identified as trauma cases. Incidence of LSA occlusion in trauma was 91/167 (54%) compared to 281/1446 (19%) in the population exclusive of trauma (p < 0.001). Following LSA occlusion, the rate of LUE claudication/ischemia was 21/56 (38%) for trauma, compared to 12/193 (6%) in non-trauma cases (p < 0.001). The overall complication rate after carotid-subclavian rescue bypass was 29.2% (33/112), with phrenic nerve palsy (24%), recurrent laryngeal nerve palsy (5%), and pseudoaneurysm (1.7%) being the most common. CONCLUSION LSA coverage following TEVAR is common and associated with significant complications, often requiring operative management. The incidence of ischemic complications after occlusion of the LSA is significantly higher in the trauma population. Revascularization procedures to correct the occlusion have a high rate of complications.
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Affiliation(s)
- Areg Grigorian
- Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA.
| | - Meghan Lewis
- Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA
| | - Jordan R Wlodarczyk
- Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA
| | - Chih Ying Chien
- Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA
| | - Timothy Park
- Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA
| | - Demetrios Demetriades
- Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA
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Squiers JJ, DiMaio JM, Schaffer JM, Baxter RD, Gable CE, Shinn KV, Harrington K, Moore DO, Shutze WP, Brinkman WT, Gable DR. Surgical Debranching versus Branched Endografting in Zone 2 Thoracic Endovascular Aortic Repair. J Vasc Surg 2022; 75:1829-1836.e3. [PMID: 34998942 DOI: 10.1016/j.jvs.2021.12.068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 12/19/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Left subclavian artery (LSA) revascularization is recommended in patients undergoing elective thoracic endovascular aortic repair (TEVAR) with proximal zone 2 landing requiring coverage of the LSA. The gold-standard remains surgical LSA revascularization, but recently the feasibility of branched endografts has been demonstrated. We compared the perioperative and mid-term outcomes of these approaches. METHODS A retrospective review of consecutive patients undergoing TEVAR with proximal zone 2 landing at a single center from 2014-2020 was performed. Patients were divided into cohorts for comparison: those undergoing surgical revascularization (SR-TEVAR group) and those undergoing thoracic branched endografting with an investigational device (TBE group). Patients who did not receive LSA revascularization were excluded. Perioperative outcomes including procedural success, death, stroke, limb ischemia, and length of stay were compared. Kaplan-Meier survival curves were compared with the log-rank test. The cumulative incidences of device-related endoleak (type I and III) and device-related reintervention, accounting for death as a competing hazard, were compared with the Fine-Gray test. RESULTS A total of 55 patients were included: 31 (56%) SR-TEVAR and 24 (44%) TBE. Preoperative demographics and comorbidities were similar between the groups. Procedural success was 100% in both cohorts, and there were no periprocedural strokes or left upper extremity ischemic events. One operative/30-day mortality (TBE 4.2% vs SR-TEVAR 3.2%, p=0.99) occurred in each cohort. Total operative time (minutes, TBE 203 ± 79 vs SR-TEVAR 250 ± 79 p=0.03) and total length of stay (days, TBE 5.2 ± 3.6 vs SR-TEVAR 9.9 ± 7.2, p=0.004) were both significantly shorter in the TBE group. There was no difference in mid-term survival (log-rank p=0.50), nor the cumulative incidence of device-related endoleak (Fine-Gray p=0.51) or reintervention (Fine-Gray p=0.72). There have been no occlusions of the TBE graft nor surgical bypass/transpositions after a mean follow-up for 28 ± 16 and 34 ± 24 months, respectively. CONCLUSIONS Thoracic branched endografting can be performed with similar procedural success and comparable safety profile to TEVAR with surgical revascularization, while reducing total length of stay, in patients requiring proximal zone 2 coverage. Mid-term outcomes of each approach are also similar. Prospective, randomized comparisons of these techniques are warranted.
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Affiliation(s)
- John J Squiers
- Baylor Scott & White Research Institute, Baylor Scott & White Heart Hospital Plano; Plano, TX.
| | - J Michael DiMaio
- Department of Cardiothoracic Surgery, Baylor Scott & White Heart Hospital Plano; Plano, TX
| | - Justin M Schaffer
- Department of Cardiothoracic Surgery, Baylor Scott & White Heart Hospital Plano; Plano, TX
| | - Ronald D Baxter
- Department of Surgery, Baylor University Medical Center; Dallas, TX
| | - Cara E Gable
- Department of Biomedical Sciences, Texas A&M University; College Station, TX
| | - Kathryn V Shinn
- Baylor Scott & White Research Institute, Baylor Scott & White Heart Hospital Plano; Plano, TX
| | - Katherine Harrington
- Department of Cardiothoracic Surgery, Baylor Scott & White Heart Hospital Plano; Plano, TX
| | - David O Moore
- Department of Cardiothoracic Surgery, Baylor Scott & White Heart Hospital Plano; Plano, TX
| | - William P Shutze
- Department of Vascular Surgery, Baylor Scott & White Heart Hospital Plano; Plano, TX
| | - William T Brinkman
- Department of Cardiothoracic Surgery, Baylor Scott & White Heart Hospital Plano; Plano, TX
| | - Dennis R Gable
- Department of Vascular Surgery, Baylor Scott & White Heart Hospital Plano; Plano, TX
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9
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Mandigers TJ, de Beaufort HW, Smeenk HG, Vos JA, Heijmen RH. Long-term patency of surgical left subclavian artery revascularization. J Vasc Surg 2022; 75:1977-1984.e1. [DOI: 10.1016/j.jvs.2021.12.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/24/2021] [Indexed: 11/25/2022]
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10
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Carotid-Vertebral or Carotid-Subclavian Transpositions in Supra-Aortic Steno-Occlusive Diseases When Endovascular Therapy Is Unfeasible or Unsuccessful. Int Surg 2021. [DOI: 10.9738/intsurg-d-17-00097.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background and purpose
Despite advances in endovascular therapies, some patients experience vertebral artery stenosis or subclavian artery occlusion and may not benefit from less-invasive angioplasty/stenting. This study described 4 cases in which carotid-vertebral transposition (CVT) or carotid-subclavian transposition (CST) was adapted when endovascular treatment was unfeasible or unsuccessful.
Presentation
Case 1: A 65-year-old woman presented with severe stenosis of the right vertebral artery ostium, dysplastic left vertebral artery, and aneurysmal dilatation of proximal right subclavian artery and brachiocephalic trunk. Case 2: A 23-year-woman had severe stenosis at the first portion of left vertebral artery caused by Takayasu's arteritis. Because endovascular intervention was unfeasible, CVTs were performed in cases 1 and 2. Case 3: A 73-year-old man presented with total occlusion of the proximal right subclavian artery and severe stenosis of the right internal carotid artery. Case 4: A 58-year-old man experienced complete occlusion of the left subclavian artery and severe stenosis of the left common carotid artery. Duplex ultrasonography showed reverse flow in the vertebral artery in keeping with vertebral steal syndrome. Endovascular treatment was unsuccessful because the wire did not cross the occlusion of the subclavian artery. CSTs were performed with concurrent ipsilateral carotid endarterectomy in cases 3 and 4.
Conclusion
The present case series demonstrated that CST and CVT were effective treatment modalities for subclavian or vertebral artery lesions. Although endovascular stenting and angioplasty have been advocated as first-line management, CST and CVT should be considered as the remedy when endovascular intervention is unsuccessful or unfeasible.
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11
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Xinping M, Peng X, Jinxing C, Zhiwei W, Jun X. Cervical Debranching Through Suprasternal Fossa Access During Hybrid Aortic Arch Endovascular Repair. Eur J Vasc Endovasc Surg 2021; 62:1002-1003. [PMID: 34563450 DOI: 10.1016/j.ejvs.2021.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 07/29/2021] [Accepted: 08/14/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Min Xinping
- Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xu Peng
- Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Chang Jinxing
- Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Wang Zhiwei
- Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xia Jun
- Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, Wuhan, China.
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12
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Qiao Z, Chen S, Guo R, Zhong Y, Ge Y, Li C, Liu Y, Zhu J, Sun L. Comparison of Open Repair vs. the One-Stage Hybrid Extra-Anatomic Technique for Distal Aortic Arch Disease Treatment: Mid-term Outcomes With a Risk-Adjusted Analysis. Front Cardiovasc Med 2021; 8:725902. [PMID: 34504880 PMCID: PMC8421766 DOI: 10.3389/fcvm.2021.725902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/02/2021] [Indexed: 11/16/2022] Open
Abstract
Objective: This study aims to compare the short- and mid-term outcomes of the stented elephant trunk (SET) procedure combined with supra-arch branch reconstruction and one-stage hybrid arch repair combined thoracic endovascular aortic repair (TEVAR) with extra-anatomic bypass in the management of distal arch disease. Methods: From January 2009 to January 2019, 97 patients underwent one-stage hybrid arch repair combined with TEVAR with extra-anatomic bypass (HAR group), and 206 patients underwent the SET procedure with supra-arch branch reconstruction (SET group). We used inverse-probability-of treatment weighting (IPTW) to adjust baseline differences. Results: Before IPTW adjustment, there was no significant difference in operative mortality between the two groups (5.2 vs. 1.0%, P = 0.064). The incidences of stroke, spinal cord injury (SCI), acute kidney injury (AKI), and endoleak also showed no significant differences (4.1 vs. 0.5%, P = 0.066; 2.1 vs. 1.5%, P = 1.000; 0 vs. 1.0%, P = 0.831; 6.2 vs. 1.9%, P = 0.113, respectively). After IPTW adjustment, the incidences of stroke, SCI, and AKI showed no significant differences between the two groups (1.8 vs. 1.1%, P = 0.138; 0.8 vs. 1.6%, P = 0.448; and 0 vs. 0.7%, P = 0.148, respectively). However, the HAR group tended to have higher operative mortality and incidence of endoleak than the SET group (12.4 vs. 1.3%, P = 0.01; 9.9 vs. 1.8%, P = 0.031, respectively). In the multivariate analysis, open repair decreased the risks of endoleak (odds ratio [OR], 0.171, 95% CI, 0.060–0.401; P < 0.001) and operative mortality (OR, 0.093, 95% CI, 0.027–0.238; P < 0.001). The overall survival and event-free survival of the HAR group were significantly lower than those of the SET group (P < 0.001). Conclusion: One-stage hybrid arch repair combined TEVAR with extra-anatomic bypass and the SET procedure with supra-arch branch reconstruction both provided good postoperative treatment outcomes for distal arch disease. However, hybrid arch repair increased the risks of endoleak and operative mortality. The SET procedure provided better mid-term survival than hybrid arch repair without increasing operative mortality. Carefully selecting the indications for the procedure, while receiving close long-term follow-up, may improve the survival rate of patients undergoing hybrid arch repair.
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Affiliation(s)
- Zhiyu Qiao
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Suwei Chen
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Rutao Guo
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Yongliang Zhong
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Yipeng Ge
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Chengnan Li
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Yongmin Liu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Junming Zhu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Lizhong Sun
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
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13
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Awad H, Raza A, Saklayen S, Bhandary S, Kelani H, Powers C, Bourekas E, Stine I, Milner R, Valentine E, Essandoh M. Combined Stroke and Spinal Cord Ischemia in Hybrid Type I Aortic Arch Debranching and TEVAR and the Dual Role of the Left Subclavian Artery. J Cardiothorac Vasc Anesth 2021; 36:3687-3700. [PMID: 34538558 DOI: 10.1053/j.jvca.2021.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Hamdy Awad
- Department of Anesthesiology at the Wexner Medical Center at the Ohio State University, Columbus, OH.
| | - Arwa Raza
- Ohio State University College of Medicine, Columbus, OH
| | - Samiya Saklayen
- Department of Anesthesiology at the Wexner Medical Center at the Ohio State University, Columbus, OH
| | - Sujatha Bhandary
- Department of Anesthesiology at Emory University School of Medicine, Atlanta, GA
| | - Hesham Kelani
- Department of Anesthesiology at the Wexner Medical Center at the Ohio State University, Columbus, OH
| | - Ciaran Powers
- Department of Neurosurgery at the Wexner Medical Center at the Ohio State University, Columbus, OH
| | - Eric Bourekas
- Department of Radiology at Wexner Medical Center at the Ohio State University, Columbus, OH
| | - Ian Stine
- Department of Surgery at the University of Chicago, Chicago, IL
| | - Ross Milner
- Department of Surgery at the University of Chicago, Chicago, IL
| | - Elizabeth Valentine
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Michael Essandoh
- Department of Anesthesiology at the Wexner Medical Center at the Ohio State University, Columbus, OH
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14
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Aru RG, Tyagi SC, Minion DJ, Orr NT, Bounds MC. Carotid-Carotid Transposition for Zone 1 Thoracic Endovascular Aortic Repair. Ann Vasc Surg 2021; 76:325-329. [PMID: 33951527 DOI: 10.1016/j.avsg.2021.04.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/05/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Carotid-carotid bypass is the standard technique for cervical aortic arch debranching to maintain left common carotid artery perfusion with zone I thoracic endovascular aortic repair (TEVAR), while left-to-right carotid-carotid transposition (CCT) has been described as an autologous alternative. We report on our center's experience with CCT in the setting of zone I TEVAR. This is the only published series of this technique. METHODS All patients who underwent CCT, defined by CPT code 35509, between 2017 and 2020 were identified at our tertiary care center. Patient demographics, indications for CCT, complications specific to CCT, operative details, post-operative course, and outcomes were retrospectively reviewed. RESULTS A total of 13 patients underwent CCT prior to zone 1 TEVAR. The indications for intervention were thoracic or thoracoabdominal aortic aneurysms and dissections secondary to hypertension (n = 10), Marfan syndrome (n = 2), and Turner syndrome with aneurysmal degeneration of previous coarctation repair (n = 1). There was a high incidence of preexisting hypertension (92%), malnutrition (69%), and smoking (61%) in this cohort. Operative intervention was performed on both an elective (n = 7, 54%) and an urgent (n = 6, 46%) basis. Complications directly related to CCT included transient unilateral recurrent laryngeal nerve deficit (n = 1, 7.7%). There were no cerebrovascular events, surgical site infections, or procedure-related mortalities. All transpositions with follow-up imaging were patent without stenosis or thrombosis (average 7.2 months, n = 10). There were no late complications related to CCT. CONCLUSIONS CCT is a safe and autologous alternative to carotid-carotid bypass for left common carotid artery revascularization with zone I TEVAR.
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Affiliation(s)
- Roberto G Aru
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY.
| | - Sam C Tyagi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY
| | - David J Minion
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY
| | - Nathan T Orr
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY
| | - Michael C Bounds
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY
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15
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Gordeev ML, Uspenskiĭ VE, Rubinchik VE, Kotin AN, Skripnik AI, Zverev DA. [Removal of ascending aortic dissection and residual blood flow after transcatheter isolation of descending aortic dissection]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:65-71. [PMID: 33825730 DOI: 10.33529/angio2021111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Presented herein is a clinical case report concerning successful simultaneous surgical treatment of a female patient with a complication after transcatheter treatment for chronic dissection of the descending portion of the thoracic aorta. The woman was subjected to elective transcatheter isolation of chronic dissection of the descending thoracic aorta using a stent graft with complete coverage of the zone of the origin of the left subclavian artery. Repeat control imaging studies several months after the intervention revealed residual blood flow through the false channel, directed retrogradely from the distal edge of the stent graft to the left subclavian artery. Besides, the patient was also found to have local dissection of the distal part of the ascending aorta (zone 0). An operative intervention was performed: sternotomy, prosthetic repair of the ascending portion of the aorta and part of the aortic arch, as well as transposition of the left subclavian artery to the left common carotid artery. The control imaging studies confirmed radical removal of the false aneurysm of the ascending aorta and the presence of total thrombosis of the false channel at the level of the stent graft.
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Affiliation(s)
- M L Gordeev
- Scientific Research Laboratory of Surgery for Cardiac Defects and Ischaemic Heart Disease, National Medical Research Centre named after V.A. Almazov under the RF Ministry of Public Health, Saint Petersburg, Russia
| | - V E Uspenskiĭ
- Scientific Research Laboratory of Surgery for Cardiac Defects and Ischaemic Heart Disease, National Medical Research Centre named after V.A. Almazov under the RF Ministry of Public Health, Saint Petersburg, Russia
| | - V E Rubinchik
- Scientific Research Laboratory of Surgery for Cardiac Defects and Ischaemic Heart Disease, National Medical Research Centre named after V.A. Almazov under the RF Ministry of Public Health, Saint Petersburg, Russia
| | - A N Kotin
- Scientific Research Laboratory of Surgery for Cardiac Defects and Ischaemic Heart Disease, National Medical Research Centre named after V.A. Almazov under the RF Ministry of Public Health, Saint Petersburg, Russia
| | - A Iu Skripnik
- Scientific Research Laboratory of Surgery for Cardiac Defects and Ischaemic Heart Disease, National Medical Research Centre named after V.A. Almazov under the RF Ministry of Public Health, Saint Petersburg, Russia
| | - D A Zverev
- Scientific Research Laboratory of Surgery for Cardiac Defects and Ischaemic Heart Disease, National Medical Research Centre named after V.A. Almazov under the RF Ministry of Public Health, Saint Petersburg, Russia
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16
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D'Oria M, Mani K, DeMartino R, Czerny M, Donas KP, Wanhainen A, Lepidi S. Narrative review on endovascular techniques for left subclavian artery revascularization during thoracic endovascular aortic repair and risk factors for postoperative stroke. Interact Cardiovasc Thorac Surg 2021; 32:764-772. [PMID: 33575743 DOI: 10.1093/icvts/ivaa342] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/04/2020] [Accepted: 12/06/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES The aim of this study was to present a narrative review on endovascular techniques (ET) for revascularization of the left subclavian artery (LSA) during zone 2 thoracic endovascular aortic repair (TEVAR) and on risk factors for postoperative stroke following TEVAR procedures. METHODS Non-systematic search of the literature from the PubMed, Ovid and Scopus databases to identify relevant English-language articles fully published in the period 1 January 2010-1 August 2020. RESULTS Current general agreement is that LSA revascularization should be always attempted in the elective setting. Under urgent circumstances, it can be delayed but might be considered during the same session on a case-by-case basis. Three ET are currently available: (i) chimney/snorkels (also known as parallel grafts), (ii) fenestrations or branches and (iii) proximal scallops. The main issue with ET is the potential for increased peri-operative stroke risk owing to increased manipulation within the aortic arch. Also, they are relatively novel and further assessment of their long-term durability is needed. Intra-operative embolism and loss of left vertebral artery perfusion are hypothesized as the main causes of stroke in patients undergoing TEVAR. CONCLUSIONS The overall risk of stroke seems higher without LSA revascularization during zone 2 TEVAR. As LSA revascularization might have a direct effect in preventing posterior stroke, it should be routinely performed in elective cases, while a case-by-case evaluation can be made under urgent circumstances. While ET can provide effective options for LSA revascularization during zone 2 TEVAR, they are novel and need further durability assessment. Stroke after TEVAR is a multifactorial pathological process and preventing TEVAR-related cerebral injury remains a significant unmet clinical need.
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Affiliation(s)
- Mario D'Oria
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden.,Division of Vascular and Endovascular Surgery, Cardiovascular Department, University of Trieste Medical School, Trieste, Italy.,Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic Rochester Campus, Rochester, MN, USA
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Randall DeMartino
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic Rochester Campus, Rochester, MN, USA
| | - Martin Czerny
- Division of Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Freiburg, Germany
| | - Konstantinos P Donas
- Department of Vascular Surgery, Asklepios Clinic Langen, Goethe-University of Frankfurt, Langen, Germany
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University of Trieste Medical School, Trieste, Italy
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17
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Zhu J, Ma C, Dai X, Wang Z, Fan H, Feng Z, Luo Y, Zhang Y, Hu F. Outcomes of single physician-modified fenestrated stent grafts for endovascular repair of thoracic aortic lesions involving the distal aortic arch. Interact Cardiovasc Thorac Surg 2020; 32:560-565. [PMID: 33319231 DOI: 10.1093/icvts/ivaa295] [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: 08/02/2020] [Revised: 09/09/2020] [Accepted: 10/04/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Our goal was to evaluate the outcomes of fenestrated thoracic endovascular aortic repair of thoracic aortic lesions involving the distal aortic arch using single physician-modified stent grafts. METHODS This single-centre, retrospective study included 58 consecutive patients (mean age, 57 ± 14 years; 11 women) who underwent fenestrated thoracic endovascular aortic repair for thoracic aortic pathologies involving the distal aortic arch using single physician-modified stent grafts between November 2015 and December 2018. Indications included complicated acute type B dissection or intramural haematoma with an unfavourable proximal landing zone (n = 49), type Ia endoleak subsequent to thoracic endovascular aortic repair due to acute type B dissection (n = 1) and distal arch degenerative aneurysms <15 mm from the left subclavian artery (n = 8). RESULTS The technical success rate was 94.8%. The 30-day mortality was 1.7%, and the perioperative ischaemic stroke rate was 1.7%. The incidence of perioperative complications was 10.3%. At a mean follow-up of 26.3 months (range, 7-44), all target vessels were patent. All-cause mortality was 5.2%. Estimated 1-, 2- and 3-year survival was 98.3 ± 1.7%, 96.4 ± 2.5% and 93.2 ± 3.9%, respectively. CONCLUSION The single fenestrated stent graft technique is feasible and effective for endovascular repair of thoracic aortic pathologies involving the distal aortic arch.
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Affiliation(s)
- Jiechang Zhu
- Department of Vascular Surgery, General Hospital of Tianjin Medical University, Tianjin, China
| | - Chao Ma
- Department of Vascular Surgery, General Hospital of Tianjin Medical University, Tianjin, China
| | - Xiangchen Dai
- Department of Vascular Surgery, General Hospital of Tianjin Medical University, Tianjin, China
| | - Zheng Wang
- Department of Vascular Surgery, General Hospital of Tianjin Medical University, Tianjin, China
| | - Hailun Fan
- Department of Vascular Surgery, General Hospital of Tianjin Medical University, Tianjin, China
| | - Zhou Feng
- Department of Vascular Surgery, General Hospital of Tianjin Medical University, Tianjin, China
| | - Yudong Luo
- Department of Vascular Surgery, General Hospital of Tianjin Medical University, Tianjin, China
| | - Yiwei Zhang
- Department of Vascular Surgery, General Hospital of Tianjin Medical University, Tianjin, China
| | - Fanguo Hu
- Department of Vascular Surgery, General Hospital of Tianjin Medical University, Tianjin, China
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18
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Perioperative Outcomes of Carotid–Subclavian Bypass or Transposition versus Endovascular Techniques for Left Subclavian Artery Revascularization during Nontraumatic Zone 2 Thoracic Endovascular Aortic Repair in the Vascular Quality Initiative. Ann Vasc Surg 2020; 69:17-26. [DOI: 10.1016/j.avsg.2020.05.062] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/19/2020] [Accepted: 05/20/2020] [Indexed: 12/31/2022]
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19
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Carotid to subclavian bypass and Amplatzer vascular plug subclavian endovascular occlusion before thoracic open or endovascular repair. J Vasc Surg 2020; 71:1480-1488.e1. [DOI: 10.1016/j.jvs.2019.08.237] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 08/15/2019] [Indexed: 11/17/2022]
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20
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Bianco V, Sultan I, Kilic A, Aranda-Michel E, Cuddy RJ, Srivastava A, Navid F, Gleason TG. Concomitant left subclavian artery revascularization with carotid-subclavian transposition during zone 2 thoracic endovascular aortic repair. J Thorac Cardiovasc Surg 2020; 159:1222-1227. [DOI: 10.1016/j.jtcvs.2019.03.060] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 03/02/2019] [Accepted: 03/26/2019] [Indexed: 12/18/2022]
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21
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Protack CD, Smith A, Moennich LA, Hardy D, Lyden SP, Farivar BS. Midterm outcomes of subclavian artery revascularization in the setting of thoracic endovascular aortic repair. J Vasc Surg 2020; 72:1222-1228. [PMID: 32093914 DOI: 10.1016/j.jvs.2019.11.049] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/20/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The outcomes of subclavian artery revascularization (SAR) have been examined extensively in the setting of atherosclerotic occlusive disease but have been poorly characterized in the setting of thoracic endovascular aortic repair (TEVAR). As trials for branched thoracic endovascular stent grafts materialize, the outcomes of the subclavian artery branched prosthesis will need to be compared with TEVAR with SAR by carotid-subclavian bypass or subclavian transposition. METHODS A database of 1516 patients undergoing TEVAR from 2000 to 2015 was queried. Of those undergoing TEVAR, 19% (282 patients) also underwent SAR. Patient demographics, TEVAR indication, 30-day morbidity and mortality, and midterm patency and survival were analyzed. RESULTS During the study period, 282 patients underwent 288 SARs in the setting of TEVAR. A total of 269 (93%) carotid-subclavian bypasses and 19 (7%) subclavian artery transpositions were performed; 76% of the SARs occurred before TEVAR, 14% occurred concurrently with TEVAR, and 10% occurred after TEVAR. The most common indications for TEVAR was aortic aneurysm (56%), chronic aortic dissection with aneurysmal degeneration (23%), and aortic dissections (13%). The 30-day ipsilateral stroke rate was 3.5%. Eight patients (2.8%) underwent an unplanned return to the operating room (2.1% for hematoma evacuation and 0.7% for management of chyle leak). Six patients (2.1%) sustained a nerve injury. The mean follow-up was 4.2 years. All-cause 30-day mortality was 4.6%. The overall survival rates at 1 year, 5 years, and 10 years were 82%, 60%, and 42%, respectively. The median survival was 7.2 years. Four patients were found to have a failure in primary patency during follow-up. All four patients had undergone a carotid-subclavian bypass. The 1-, 2-, and 5-year primary patency rates were 99.5%, 98.9%, and 98.0%, respectively, for carotid-subclavian bypass and 100% for carotid-subclavian transposition. CONCLUSIONS During our 16-year study, we found SAR in the setting of TEVAR to be associated with low morbidity, durable long-term patency, and infrequent need for reintervention.
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Affiliation(s)
| | - Andrew Smith
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - David Hardy
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Sean P Lyden
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Behzad S Farivar
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio.
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Konstantinou N, Debus ES, Vermeulen CF, Wipper S, Diener H, Larena-Avellaneda A, Kölbel T, Tsilimparis N. Cervical Debranching in the Endovascular Era: A Single Centre Experience. Eur J Vasc Endovasc Surg 2019; 58:34-40. [DOI: 10.1016/j.ejvs.2018.12.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 12/09/2018] [Indexed: 11/26/2022]
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23
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Choo SJ. Commentary: Different routes, same destination? J Thorac Cardiovasc Surg 2019; 159:1231-1232. [PMID: 31235352 DOI: 10.1016/j.jtcvs.2019.05.011] [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: 05/08/2019] [Accepted: 05/10/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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24
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Chen X, Wang J, Premaratne S, Zhao J, Zhang WW. Meta-analysis of the outcomes of revascularization after intentional coverage of the left subclavian artery for thoracic endovascular aortic repair. J Vasc Surg 2019; 70:1330-1340. [PMID: 31176636 DOI: 10.1016/j.jvs.2019.03.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 03/07/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Coverage of the left subclavian artery (LSA) is often required to achieve complete proximal sealing during thoracic endovascular aortic repair. However, whether LSA revascularization should be performed remains controversial. METHODS MEDLINE, Embase, and Cochrane databases were systematically searched to identify all the relevant studies. A random-effects model was applied to pool the effect measures. Dichotomous data were presented using an odds ratio (OR). RESULTS There were 32 studies included for qualitative analysis and 31 studies for quantitative analysis. We found that patients who underwent LSA revascularization had a significantly decreased risk of spinal cord ischemia (OR, 0.62; 95% confidence interval [CI], 0.41-0.92; P = .02; I2 = 0%), cerebrovascular accident (OR, 0.63; 95% CI, 0.42-0.95; P = .03; I2 = 22%), and left upper extremity ischemia (OR, 0.18; 95% CI, 0.09-0.36; P < .00001; I2 = 0%). However, no significant differences were found in the risk of paraplegia (OR, 0.91; 95% CI, 0.55-1.51; P = .71; I2 = 0%) and 30-day mortality (OR, 0.89; 95% CI, 0.59-1.36; P = .60; I2 = 21%) between the groups of patients with and without LSA revascularization. CONCLUSIONS Revascularization of the LSA is associated with decreased risks of cerebrovascular accident, spinal cord ischemia, and left upper limb ischemia in thoracic endovascular aortic repair with LSA coverage at the cost of higher local complications, such as possible vocal cord paresis.
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Affiliation(s)
- Xiyang Chen
- Department of Vascular Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Jiarong Wang
- Department of Vascular Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Shyamal Premaratne
- Hunter Holmes McGuire Veterans Administration Medical Center, Richmond, Va
| | - Jichun Zhao
- Department of Vascular Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Wayne W Zhang
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Washington and Puget Sound VA Health Care System, Seattle, Wash.
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25
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Midterm results of laser generated in situ fenestration of the left subclavian artery during thoracic endovascular aneurysm repair. J Vasc Surg 2019; 69:1664-1669. [DOI: 10.1016/j.jvs.2018.09.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 09/30/2018] [Indexed: 11/18/2022]
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26
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Outcomes After Thoracic Endovascular Aortic Repair With Overstenting of the Left Subclavian Artery. Ann Thorac Surg 2019; 107:1372-1379. [DOI: 10.1016/j.athoracsur.2018.10.051] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 09/25/2018] [Accepted: 10/16/2018] [Indexed: 11/17/2022]
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27
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Asano S, Hayashida N, Shibata Y, Koizumi S, Ito T, Ikeuchi H, Hasegawa H, Abe S, Kabasawa M, Hirose N, Ohba M, Hirano M, Matsuo K, Murayama H. A Case of Thoracic Endovascular Aortic Repair Using Carotid Access with Axillary-Carotid Bypass for Descending Aortic Aneurysm in a Patient with Aortoiliac Occlusive Disease. Ann Vasc Dis 2019; 12:105-108. [PMID: 30931072 PMCID: PMC6434357 DOI: 10.3400/avd.cr.18-00143] [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 authors report a 71-year-old male with descending thoracic aortic aneurysm and multiple risk factors (aortoiliac occlusive disease, obesity, ascending aorta dilatation, and history of left ventriculoperitoneal shunt for hydrocephalus) who was treated with thoracic endovascular aortic repair (TEVAR) via left common carotid artery (LCCA) access and left axillary–carotid artery (Ax–CA) bypass; this approach shortened the LCCA clamp time during the procedure. The patient was discharged without any complications. TEVAR via LCCA access with left Ax–CA bypass is a useful and safe procedure for patients in whom conventional femoral artery access is not feasible.
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Affiliation(s)
- Soichi Asano
- Department of Cardiovascular Surgery, Chiba Cerebral and Cardiovascular Center, Ichihara, Chiba, Japan
| | - Naoki Hayashida
- Department of Cardiovascular Surgery, Chiba Cerebral and Cardiovascular Center, Ichihara, Chiba, Japan
| | - Yusuke Shibata
- Department of Cardiovascular Surgery, Chiba Cerebral and Cardiovascular Center, Ichihara, Chiba, Japan
| | - Shintaro Koizumi
- Department of Cardiovascular Surgery, Chiba Cerebral and Cardiovascular Center, Ichihara, Chiba, Japan
| | - Takahiro Ito
- Department of Cardiovascular Surgery, Chiba Cerebral and Cardiovascular Center, Ichihara, Chiba, Japan
| | - Hiroki Ikeuchi
- Department of Cardiovascular Surgery, Chiba Cerebral and Cardiovascular Center, Ichihara, Chiba, Japan
| | - Hideomi Hasegawa
- Department of Cardiovascular Surgery, Chiba Cerebral and Cardiovascular Center, Ichihara, Chiba, Japan
| | - Shinichiro Abe
- Department of Cardiovascular Surgery, Chiba Cerebral and Cardiovascular Center, Ichihara, Chiba, Japan
| | - Masashi Kabasawa
- Department of Cardiovascular Surgery, Chiba Cerebral and Cardiovascular Center, Ichihara, Chiba, Japan
| | - Nobuyuki Hirose
- Department of Surgery II, Kochi Medical School, Nankoku, Kochi, Japan
| | - Masanao Ohba
- Department of Cardiovascular Surgery, Kawaguchi Municipal Medical Center, Kawaguchi, Saitama, Japan
| | - Masao Hirano
- Department of Cardiovascular Surgery, National Hospital Organization Chiba Medical Center, Ichihara, Chiba, Japan
| | - Kozo Matsuo
- Department of Cardiovascular Surgery, Chiba Cerebral and Cardiovascular Center, Ichihara, Chiba, Japan
| | - Hirokazu Murayama
- Department of Cardiovascular Surgery, Chiba Cerebral and Cardiovascular Center, Ichihara, Chiba, Japan
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Galyfos GC, Kakisis I, Maltezos C, Geroulakos G. Open versus endovascular treatment of subclavian artery atherosclerotic disease. J Vasc Surg 2019; 69:269-279.e7. [DOI: 10.1016/j.jvs.2018.07.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 07/26/2018] [Indexed: 12/19/2022]
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29
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Voigt SL, Bishawi M, Ranney D, Yerokun B, McCann RL, Hughes GC. Outcomes of carotid-subclavian bypass performed in the setting of thoracic endovascular aortic repair. J Vasc Surg 2018; 69:701-709. [PMID: 30528402 DOI: 10.1016/j.jvs.2018.07.022] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 07/09/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Subclavian artery revascularization is frequently performed in the setting of thoracic endovascular aortic repair (TEVAR). However, there is little information on the short- and long-term outcomes of patients undergoing carotid to subclavian artery bypass in this clinical setting. As such, this study sought to define the early and late outcomes associated with this procedure. METHODS Patients undergoing carotid-subclavian bypass in conjunction with TEVAR between June 2005 and September 2016 were retrospectively identified from a prospectively maintained, single-center aortic surgery database. The 30-day outcomes specific to the carotid-subclavian bypass procedure were analyzed, including cervical plexus nerve injury, bleeding complications, and local vascular complications. All preoperative and postoperative chest radiographs were carefully analyzed to assess for hemidiaphragm elevation indicative of phrenic nerve palsy. Long-term outcomes included primary graft patency and anastomotic complications. RESULTS Of 579 consecutive patients undergoing TEVAR during this time interval, 112 patients (19%) underwent concomitant carotid-subclavian bypass. The cohort was 38% female (n = 43), with a mean age of 65 ± 14 years. The majority of conduits were 8-mm polytetrafluoroethylene grafts (n = 107 [95.5%]), with a minority being reversed saphenous vein (n = 4 [3.6%]) or Dacron (n = 1 [0.9%]) grafts. The bypass procedure was done concurrently at the time of TEVAR in 91% (n = 102) of cases. The short-term complication rate attributed specifically to the carotid-subclavian bypass was 29% (n = 33). These complications included phrenic nerve palsy in 25% (n = 27), recurrent laryngeal nerve palsy in 5% (n = 6), axillary nerve palsy in 2% (n = 2), and neck hematoma requiring re-exploration in 1% (n = 1) of patients. The 30-day in-hospital all-cause mortality rate was 5% (n = 6), and the rate of permanent paraparesis or paraplegia was 0.9% (n = 1). Of the operative survivors (n = 106), follow-up imaging of the bypass graft was available in 87% (n = 92) of patients. Actuarial primary graft patency was 97% at 5 years. There were three patients (3%) with bypass graft occlusions, two of which were clinically silent and detected on follow-up imaging. The third was detected because of symptoms of subclavian steal and required repeated revascularization. Two patients (2%) developed a late anastomotic pseudoaneurysm requiring either endovascular (n = 1) or surgical (n = 1) intervention. CONCLUSIONS Carotid-subclavian bypass for revascularization of the subclavian artery performed in the setting of TEVAR is durable, although the true complication rate is likely higher than is generally reported in the literature because of a not insignificant rate of phrenic nerve palsy. These data should serve well as "gold standard" comparison data for emerging branch graft devices.
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Affiliation(s)
- Soraya L Voigt
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Muath Bishawi
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - David Ranney
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Babatunde Yerokun
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Richard L McCann
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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30
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Piffaretti G, Pratesi G, Gelpi G, Galli M, Criado FJ, Antonello M, Fontana F, Piacentino F, Macchi E, Tozzi M, Castelli P, Barbante M, Ippoliti A, Romagnoni C, Antona C, Paggi A, Xodo A, Grego F. Comparison of Two Different Techniques for Isolated Left Subclavian Artery Revascularization During Thoracic Endovascular Aortic Repair in Zone 2. J Endovasc Ther 2018; 25:740-749. [DOI: 10.1177/1526602818802581] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Purpose: To analyze the results of isolated left subclavian artery (LSA) revascularization during thoracic endovascular aortic repair (TEVAR) using carotid-subclavian bypass (CSbp) or chimney grafts (CGs). Methods: A retrospective multicenter, observational study identified 73 patients (mean age 68±13 years, range 22–87; 56 men) with acute or chronic thoracic aortic lesions who underwent TEVAR with isolated LSA revascularization using either CSbp (n=42) or CGs (n=31) from January 2010 and February 2017. Primary endpoints were TEVAR-related mortality, postoperative stroke, freedom from type Ia endoleak, and LSA patency. Results: Primary technical success was achieved in all cases. Early TEVAR-related mortality was 4.2% (CSbp 2% vs CG 6%, p=0.571). Two (3%) patients had major ischemic strokes (one in each group). Mean follow-up was 24±21 months (range 1–72; median 15). Estimated freedom from TEVAR-related mortality was 93%±3% (95% CI 84.3% to 97.0%) at 12 and 36 months, with no significant difference between CSbp and CG (p=0.258). Aortic reintervention did not differ between the groups (CSbp 5% vs CG 6%, p=0.356); nor did freedom from type Ia endoleak (CSbp 98% vs CG 87%, p=0.134). Gutter-related endoleaks occurred in 4 (13%) CG patients, but none of the patients experienced sac enlargement or the need for reintervention and none died. Primary patency of the LSA was 100% for the entire group during the observation period. Conclusion: In our experience, LSA revascularization proved most satisfactory and equally effective with both the CSbp and CG techniques, without discernible differences at midterm follow-up.
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Affiliation(s)
- Gabriele Piffaretti
- Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, Circolo University Hospital, Varese, Italy
| | - Giovanni Pratesi
- Vascular Surgery, Department of Surgery, Policlinico Tor Vergata, Rome, Italy
| | - Guido Gelpi
- Cardiac Surgery, Department of Cardiovascular Surgery, Sacco Hospital, Milan, Italy
| | - Mario Galli
- Interventional Cardiology, Department of Medicine, Sant’Anna Hospital, Como, Italy
| | - Frank J. Criado
- Division of Vascular Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Michele Antonello
- Vascular Surgery, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua School of Medicine, Padua University Hospital, Padua, Italy
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31
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van der Weijde E, Saouti N, Vos JA, Tromp SC, Heijmen RH. Surgical left subclavian artery revascularization for thoracic aortic stent grafting: a single-centre experience in 101 patients†. Interact Cardiovasc Thorac Surg 2018; 27:284-289. [DOI: 10.1093/icvts/ivy059] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 02/04/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Emma van der Weijde
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Nabil Saouti
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Jan Albert Vos
- Department of Interventional Radiology, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Selma C Tromp
- Department of Clinical Neurophysiology, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Robin H Heijmen
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, Netherlands
- Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, Netherlands
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32
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Landau JH, Dubois LA, Chu MWA. Hybrid Arch Frozen Elephant Trunk for Persistent Endoleak After Thoracic Endovascular Aortic Repair. Ann Thorac Surg 2017; 104:e227-e229. [PMID: 28838513 DOI: 10.1016/j.athoracsur.2017.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 03/06/2017] [Accepted: 05/02/2017] [Indexed: 11/18/2022]
Abstract
Aneurysms of the distal aortic arch and proximal descending thoracic aorta remain challenging to treat. Whereas thoracic endovascular aortic repair (TEVAR) with arch debranching has provided a more minimally invasive option for patients with such aneurysms, recurrent type Ia endoleaks can be difficult or impossible to treat with further endovascular intervention. We report the successful use of a hybrid arch and frozen elephant trunk graft for the treatment of a patient with a recurrent type Ia endoleak after TEVAR and arch debranching.
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Affiliation(s)
- John H Landau
- Division of Vascular, Western University, London, Ontario, Canada
| | - Luc A Dubois
- Division of Vascular, Western University, London, Ontario, Canada
| | - Michael W A Chu
- Division of Cardiac Surgery, Western University, London, Ontario, Canada.
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van der Weijde E, Bakker OJ, Tielliu IFJ, Zeebregts CJ, Heijmen RH. Results From a Nationwide Registry on Scalloped Thoracic Stent-Grafts for Short Landing Zones. J Endovasc Ther 2016; 24:97-106. [DOI: 10.1177/1526602816674942] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To report the perioperative results and short-term follow-up of patients treated with scalloped thoracic stent-grafts. Methods: A multicenter registry in the Netherlands captured data on 30 patients (mean age 68 years; 17 men) with thoracic aortic pathology and a short (<20 mm) proximal or distal landing zone who received a custom-made scalloped stent-graft between January 2013 and February 2016. Patients were treated for saccular (n=13) aneurysms, fusiform (n=9) aneurysms, pseudoaneurysms (n=4), or chronic type B dissections (n=4). The scallop was used to preserve flow in the left subclavian artery (LSA) (n=17), left common carotid artery (n=5), innominate artery (n=1), and celiac trunk (n=7). In 7 (23%) patients, the scallop also included the adjacent artery. Results: Technical success was achieved in 28 (93%) patients. In 1 patient, a minor type Ia endoleak was observed intraoperatively, which was no longer visible on computed tomography angiography at 3 months. In another patient, the LSA was unintentionally obstructed due to migration of the stent-graft on deployment. Concomitant carotid-carotid or carotid-subclavian bypass was performed in 4 patients. There was no retrograde type A dissection or conversion to open surgery. In-hospital mortality was 3%, and the perioperative ischemic stroke rate was 3%. At a mean follow-up of 9.7 months (range <1 to 31), 29 of 30 target vessels were patent. Conclusion: The scalloped stent-graft appears to be a safe and relatively simple alternative for the treatment of thoracic aortic lesions with short landing zones. Larger patient series and long-term follow-up are required to confirm these early results.
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Affiliation(s)
- Emma van der Weijde
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Olaf J. Bakker
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
- Department of Vascular & Endovascular Surgery, University Medical Centre Utrecht, the Netherlands
| | - Ignace F. J. Tielliu
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, the Netherlands
| | - Clark J. Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, the Netherlands
| | - Robin H. Heijmen
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
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Canaud L, Ziza V, Ozdemir BA, Berthet JP, Marty-Ané CH, Alric P. Outcomes of Left Subclavian Artery Transposition for Hybrid Aortic Arch Debranching. Ann Vasc Surg 2016; 40:94-97. [PMID: 27671454 DOI: 10.1016/j.avsg.2016.06.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 06/11/2016] [Accepted: 06/19/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of this study was to evaluate outcomes of left subclavian artery (LSA) revascularization for hybrid aortic arch debranching. METHODS Between 1998 and 2015, 68 patients (41 men; mean age, 67 ± 16 years) underwent thoracic endovascular aortic repair (TEVAR) with LSA coverage, 19.2% (n = 13) were never revascularized, and the remaining patients underwent LSA revascularization (n = 55; 80.8%). Revascularization was achieved by LSA-carotid transposition via a medial approach in 81.8% (n = 45) and a lateral approach in 18.2% (n = 10). The indication for TEVAR was aneurysmal disease in 30.9% (n = 17), dissection in 29% (n = 16; acute, n = 5), traumatic aortic injury in 21.8% (n = 12), pseudoaneurysm in 10.9% (n = 6), aortobronchial fistula in 5.5% (n = 3), and penetrating atherosclerotic ulcer in 1.9% (n = 1). Elective cases accounted for 52.7% (n = 29). Follow-up computed tomography scans were performed at 1 week, 3 and 6 months, and annually thereafter. RESULTS LSA revascularization was achieved in all the cases. Thirty-day mortality rate was 12.7%. Thirty-day mortality related to LSA revascularization was 0%. No patient suffered a stroke. Vocal cord paralysis was detected in 7.2% of patients (n = 4). Hematoma requiring surgical drainage was observed in 3.6% of patients (n = 2). Lymph leak requiring revision surgery was observed in 1.8% of patients (n = 1). Phrenic nerve palsy was not observed. The local complication rate was significantly higher (P = 0.03) in patients with LSA transposition via a lateral approach (20%; n = 2) when compared to patients with LSA revascularization via a medial approach (11.1%; n = 5). After a mean follow-up of 31.5 months (range, 2-171 months), the patency of the LSA revascularization was maintained in all patients. CONCLUSIONS During TEVAR, when LSA coverage is required, LSA revascularization is a durable procedure associated with a low morbidity rate. LSA transposition via a medial approach would appear to be associated with significantly fewer complications.
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Affiliation(s)
- Ludovic Canaud
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.
| | - Vincent Ziza
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Baris Ata Ozdemir
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Jean-Philippe Berthet
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Charles-Henri Marty-Ané
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Pierre Alric
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
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Hajibandeh S, Hajibandeh S, Antoniou SA, Torella F, Antoniou GA. Meta-analysis of Left Subclavian Artery Coverage With and Without Revascularization in Thoracic Endovascular Aortic Repair. J Endovasc Ther 2016; 23:634-41. [DOI: 10.1177/1526602816651417] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To examine the role of left subclavian artery (LSA) revascularization in thoracic endovascular aortic repair (TEVAR) with LSA coverage. Methods: A systematic search was conducted to identify all studies providing comparative outcomes with or without LSA revascularization for LSA occlusion during TEVAR. The search included MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of Controlled Trials, the World Health Organization International Clinical Trials Registry, ClinicalTrials.gov , ISRCTN Register, and bibliographic reference lists. The primary outcome parameters were perioperative stroke, spinal cord ischemia (SCI), and mortality. Combined overall effect sizes were calculated using fixed effect or random effects models; results are reported as the odds ratio (OR) and 95% confidence interval (CI). Results: Five observational studies reporting a total of 1161 patients were identified; 444 patients underwent LSA revascularization and the remaining 717 patients did not. LSA revascularization was associated with a similar risk of stroke (OR 0.70, 95% CI 0.43 to 1.14, p=0.15), SCI (OR 0.56, 95% CI 0.28 to 1.10, p=0.09), and mortality (OR 0.87, 95% CI 0.55 to 1.39, p=0.56) compared with no LSA revascularization. Conclusion: LSA revascularization was not found to significantly reduce neurologic complications or mortality in patients undergoing TEVAR with coverage of the LSA origin. Randomized clinical trials are required to elucidate the role of routine or selective LSA revascularization in these cases.
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Affiliation(s)
- Shahin Hajibandeh
- Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
| | - Shahab Hajibandeh
- Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
| | - Stavros A. Antoniou
- Department of General Surgery, University Hospital of Heraklion, University of Crete, Heraklion, Greece
| | - Francesco Torella
- Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
| | - George A. Antoniou
- Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Manchester, UK
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Matalanis G, Perera NK, Galvin SD. Total aortic repair: the new paradigm in the treatment of acute type A aortic dissection. Ann Cardiothorac Surg 2016; 5:216-21. [PMID: 27386409 DOI: 10.21037/acs.2016.05.02] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The surgical management of acute type A aortic dissection (ATAAD) is in a period of rapid evolution. Understanding the complex physiology and anatomy of both acute and chronic dissection has been enhanced by the ready availability of state of the art imaging techniques. Technical advances in the intraoperative monitoring of organ perfusion, together with adjuncts to limit organ injury and increasing sophistication in open and endovascular surgery have led to a major reduction in both perioperative morbidity and mortality. In many centers, there has been a transition in mindset and surgical approach away from a purely central aortic operation focusing on the ascending aorta and a 'live to fight another day' philosophy. The current more global perspective recognizes the importance of aortic valve function, malperfusion, false lumen (FL) patency and the potential for future complex aneurysm development. The time is now right to transition into the next phase of sophistication in the management of ATAAD with the aim of achieving not only a safe acute operation, but to either entirely prevent chronic complications or to greatly simplify their management by the creation of an anatomical situation that facilitates future endovascular intervention in place of complex re-do surgery. We present our view on the evolution of surgery for ATAAD leading to our current technique of Branch First Arch replacement and Total Aortic Repair, which not only provides a safe immediate operation, but also offers the hope of a simplified future management if not a total cure for the pathology.
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Affiliation(s)
- George Matalanis
- 1 Department of Cardiac Surgery, The Austin Hospital, Heidelberg, Australia ; 2 Department of Cardiothoracic Surgery, Wellington Regional Hospital, Wellington, New Zealand
| | - Nisal K Perera
- 1 Department of Cardiac Surgery, The Austin Hospital, Heidelberg, Australia ; 2 Department of Cardiothoracic Surgery, Wellington Regional Hospital, Wellington, New Zealand
| | - Sean D Galvin
- 1 Department of Cardiac Surgery, The Austin Hospital, Heidelberg, Australia ; 2 Department of Cardiothoracic Surgery, Wellington Regional Hospital, Wellington, New Zealand
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Bosiers MJ, Donas KP, Mangialardi N, Torsello G, Riambau V, Criado FJ, Veith FJ, Ronchey S, Fazzini S, Lachat M. European Multicenter Registry for the Performance of the Chimney/Snorkel Technique in the Treatment of Aortic Arch Pathologic Conditions. Ann Thorac Surg 2016; 101:2224-30. [DOI: 10.1016/j.athoracsur.2015.10.112] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 10/13/2015] [Accepted: 10/27/2015] [Indexed: 11/26/2022]
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Van Der Weijde E, Bakker OJ, Heijmen RH. A custom-made scalloped stentgraft to preserve left subclavian artery flow in descending thoracic aortic disease with a short neck. Expert Rev Med Devices 2016; 13:487-96. [PMID: 27018248 DOI: 10.1586/17434440.2016.1171710] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
In thoracic stentgrafting, a short proximal landing zone may necessitate intentional occlusion of the left subclavian artery, which may lead to brain, spinal cord, and left arm malperfusion. A scalloped stentgraft is designed for adequate proximal sealing and preserving the left subclavian artery flow. We performed a systematic review, describe the required pre-operative planning and details of the perioperative technique used and report our own experience. In literature, only 29 patients were reported so far using a proximal scalloped stentgraft. Results show a high technical success rate and low complication rate. These results are comparable to the results from our own institution. From these first small series the scalloped thoracic endovascular aortic repair appears to be a safe and relatively simple solution for thoracic aortic disease involving the left subclavian artery.
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Affiliation(s)
- Emma Van Der Weijde
- a Department of Cardiothoracic Surgery , St. Antonius Hospital , Nieuwegein , The Netherlands
| | - Olaf J Bakker
- a Department of Cardiothoracic Surgery , St. Antonius Hospital , Nieuwegein , The Netherlands.,b Department of Vascular & Endovascular Surgery , University Medical Center Utrecht , Utrecht , The Netherlands
| | - Robin H Heijmen
- a Department of Cardiothoracic Surgery , St. Antonius Hospital , Nieuwegein , The Netherlands
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Sonesson B, Dias N, Resch T, Kristmundsson T, Holst J. Laser Generated In situ Fenestrations in Dacron Stent Grafts. Eur J Vasc Endovasc Surg 2016; 51:499-503. [PMID: 26739804 DOI: 10.1016/j.ejvs.2015.11.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 11/26/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE/BACKGROUND To evaluate if the creation of laser generated in situ fenestrations in polyester/Dacron stent grafts causes embolization. METHODS In seven pigs, Dacron stent grafts were implanted from the infrarenal aorta to the right iliac artery. Prior to placing the stent graft, a carotid artery protection filter, with a pore size of 70-200 μm, was placed in the proximal left common iliac artery. An excimer laser catheter was then advanced antegradely through the stent graft and positioned at the level of origin of the left iliac artery. A fenestration was then created with the laser probe. The carotid filter was retrieved and inspected macroscopically with magnifying glasses, for emboli and clot. RESULTS Seven pigs with a median weight of 90 kg (range 78-98 kg) were tested. The median operating time was 170 minutes. All laser fenestrations were successfully completed. No emboli or clot could be detected in the protection filters. CONCLUSION Creation of laser generated, in situ fenestrations do not produce macroscopically visible emboli/clot. This might indicate safe usage of laser created fenestrations for endovascular arch repair and left subclavian artery revascularization.
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Affiliation(s)
- B Sonesson
- Vascular Center Malmö-Lund, Skåne University Hospital, 205 03 Malmö, Sweden.
| | - N Dias
- Vascular Center Malmö-Lund, Skåne University Hospital, 205 03 Malmö, Sweden
| | - T Resch
- Vascular Center Malmö-Lund, Skåne University Hospital, 205 03 Malmö, Sweden
| | - T Kristmundsson
- Vascular Center Malmö-Lund, Skåne University Hospital, 205 03 Malmö, Sweden
| | - J Holst
- Vascular Center Malmö-Lund, Skåne University Hospital, 205 03 Malmö, Sweden
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Salman R, Hornsby J, Wright LJ, Elsaid T, Timmons G, Mudawi A, Bhattacharya V. Treatment of subclavian artery stenosis: A case series. Int J Surg Case Rep 2015; 19:69-74. [PMID: 26722712 PMCID: PMC4756098 DOI: 10.1016/j.ijscr.2015.12.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 12/11/2015] [Accepted: 12/12/2015] [Indexed: 11/24/2022] Open
Abstract
Case presentation of a patient treated with subclavian artery stenting. Case presentation of a patient treated with transposition of the left subclavian artery onto the left common carotid artery. Case presentation of a patient treated with carotid- subclavian artery bypass with a PTFE graft. Case presentation of a patient treated with carotid to axillary bypass. Discussion and literature review of methods and indications of treatment of subclavian artery occlusive disease.
Introduction In this case series, different modalities of treatment for patients with ischaemic symptoms of subclavian stenosis are described, including the different operative strategies that can be adopted in more challenging cases. This is the first case series describing these four management options. Presentation Case 1: A seventy-one year-old female presented with acute on chronic ischaemia of her left arm following a fall and developed dry gangrene of her left thumb. This was initially managed with a heparin infusion followed by stenting of the subclavian artery which relieved her symptoms. Case 2: A fifty-nine year-old male presented with chronic ischemia of the left arm secondary to an occlusion of the left subclavian artery. This was managed by transposition of the left subclavian artery onto the left common carotid artery. Case 3: A sixty-four year-old female presented with left subclavian steal syndrome secondary to subclavian artery stenosis. She underwent carotid subclavian artery bypass. Case 4: A fifty-six year-old female presented with acute left upper limb ischaemia secondary to acutely thrombosed subclavian artery on a CT-angiography. She underwent a carotid to axillary bypass. Discussion and conclusion This case series demonstrates the treatment options available to vascular surgeons when managing symptomatic subclavian artery disease. Symptomatic subclavian artery occlusive disease should be treated with endovascular stenting and angioplasty as first line management. If it is not successful then open surgery should be considered. Bypassing the carotid to the subclavian or to the axillary artery are both good treatment modalities.
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Affiliation(s)
- Reem Salman
- Queen Elizabeth Hospital, Queen Elizabeth Avenue, Gateshead NE9 6SX, UK.
| | - Jane Hornsby
- Queen Elizabeth Hospital, Queen Elizabeth Avenue, Gateshead NE9 6SX, UK.
| | - Lucie J Wright
- Queen Elizabeth Hospital, Queen Elizabeth Avenue, Gateshead NE9 6SX, UK.
| | - Tarek Elsaid
- Queen Elizabeth Hospital, Queen Elizabeth Avenue, Gateshead NE9 6SX, UK.
| | - Grace Timmons
- Queen Elizabeth Hospital, Queen Elizabeth Avenue, Gateshead NE9 6SX, UK.
| | - Ahmed Mudawi
- Queen Elizabeth Hospital, Queen Elizabeth Avenue, Gateshead NE9 6SX, UK.
| | - Vish Bhattacharya
- Queen Elizabeth Hospital, Queen Elizabeth Avenue, Gateshead NE9 6SX, UK.
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Outcomes of Thoracic Endovascular Aortic Repair and Subclavian Revascularization Techniques. J Am Coll Surg 2015; 221:93-100. [PMID: 25872688 DOI: 10.1016/j.jamcollsurg.2015.02.028] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Revised: 02/14/2015] [Accepted: 02/16/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Practice guidelines for management of the left subclavian artery (LSA) during thoracic endovascular aortic repair (TEVAR) are based on low-quality evidence, and there is limited literature that addresses optimal revascularization techniques. The purpose of this study was to compare outcomes of LSA coverage during TEVAR and revascularization techniques. STUDY DESIGN We performed a single-center retrospective cohort study from 2001 to 2013. Patients were categorized by LSA revascularization and by revascularization technique, carotid-subclavian bypass (CSB), or subclavian-carotid transposition (SCT). Thirty-day and mid-term stroke, spinal cord ischemia, vocal cord paralysis, upper extremity ischemia, primary patency of revascularization, and mortality were compared. RESULTS Eighty patients underwent TEVAR with LSA coverage, 25% (n = 20) were unrevascularized and the remaining patients underwent CSB (n = 22 [27.5%]) or SCT (n = 38 [47.5%]). Mean follow-up time was 24.9 months. Comparisons between unrevascularized and revascularized patients were significant for a higher rate of 30-day stroke (25% vs 2%; p = 0.003) and upper extremity ischemia (15% vs 0%; p = 0.014). However, there was no difference in 30-day or mid-term rates of spinal cord ischemia, vocal cord paralysis, or mortality. There were no statistically significant differences in 30-day or midterm outcomes for CSB vs SCT. Primary patency of revascularizations was 100%. Survival analysis comparing unrevascularized vs revascularized LSA was statistically significant for freedom from stroke and upper extremity ischemia (p = 0.02 and p = 0.003, respectively). After adjustment for advanced age, urgency, and coronary artery disease, LSA revascularization was associated with lower rates of perioperative adverse events (odds ratio = 0.23; p = 0.034). CONCLUSIONS During TEVAR, LSA coverage without revascularization is associated with an increased risk of stroke and upper extremity ischemia. When LSA coverage is required during TEVAR, CSB and SCT are equally acceptable options.
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Epelboym I, Gawlas I, Lee JA, Schrope B, Chabot JA, Allendorf JD. Limitations of ACS-NSQIP in reporting complications for patients undergoing pancreatectomy: underscoring the need for a pancreas-specific module. World J Surg 2015; 38:1461-7. [PMID: 24407939 DOI: 10.1007/s00268-013-2439-1] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Large centralized databases are used with increasing frequency for reporting hospital-specific and nationwide trends and outcomes after various surgical procedures in order to improve quality of surgical care. American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) is a risk-adjusted, case-weighted complication tracking initiative that reports 30-day outcomes from more than 400 academic and community institutions in the US. However, the accuracy of event reporting specific to pancreatic surgery has never been examined in depth. METHODS We retrospectively reviewed medical records of patients, the information on whose postoperative course was originally reported through ACS-NSQIP between 2006 and 2010. Preoperative characteristics, operative data, and postoperative events were recorded after review of electronic medical records including physician and nursing notes, operative room records and anesthesiologist reports. Fidelity of reported clinical events was assessed. Accuracy, sensitivity, and specificity were calculated for each variable of interest. RESULTS Two hundred and forty-nine pancreatectomies were reviewed, including 145 (58.2 %) Whipple procedures, 19 (7.6 %) total pancreatectomies, 65 (26.1 %) distal pancreatectomies, and 15 (6.0 %) central or partial resections. Median age was 65.7, males comprised 41.5 % of the group, and 74.3 % of patients were Caucasian. The overall rate of complications reported by NSQIP was 44.0 %, compared with 45.0 % in our review, however discordance was observed in 27.3 % of the time, including 34 cases of reporting a complication where there was not one, and 34 cases of missed complication. The most frequently reported event was postoperative bleeding requiring transfusion, however this was also the event most commonly misclassified. Additionally, three procedures unrelated to the index operation were recorded as reoperation events. While a pancreas-specific module does not yet exist, ACS-NSQIP reports a 7.6 % rate of organ-space surgical site infections; when compared with our institutional rate of Grades B and C postoperative fistula (10.4 %), we observed discordance 4.4 % of the time. Delayed gastric emptying, a common post-pancreatectomy morbidity, was not captured at all. Additionally, there were significant inaccuracies in reporting urinary tract infections, postoperative pneumonia, wound complications, and postoperative sepsis, with discordance rates of 4.4, 3.2, 3.6, and 6.8 %, respectively. CONCLUSIONS ACS-NSQIP data are an important and valuable tool for evaluating quality of surgical care, however pancreatectomy-specific postoperative events are often misclassified, underscoring the need for a hepatopancreatobiliary-specific module to better capture key outcomes in this complex and unique patient population.
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Affiliation(s)
- Irene Epelboym
- Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY, USA
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Fujikawa T, Yamamoto S, Sekine Y, Oshima S, Kasai R, Sasaguri S. Beveled reversed elephant trunk procedure for complex aortic aneurysm. Asian Cardiovasc Thorac Ann 2014; 24:272-5. [DOI: 10.1177/0218492314558635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The reversed elephant trunk procedure uses an inverted graft for distal aortic replacement before aortic arch replacement in patients with mega aorta, to reduce the risk in the second stage. However, the conventional technique restricts the maximum diameter of the inverted graft to the aortic graft diameter. We employed a beveled reversed elephant trunk procedure to overcome the discrepancy between graft diameters in a 54-year-old woman with a severely twisted ascending aortic graft and enlarging chronic dissection of the aortic arch and descending thoracic aorta. The patient was discharged with a satisfactory repair and no neurologic deficit.
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Affiliation(s)
- Takuya Fujikawa
- Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Kanagawa, Japan
| | - Shin Yamamoto
- Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Kanagawa, Japan
| | - Yuji Sekine
- Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Kanagawa, Japan
| | - Susumu Oshima
- Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Kanagawa, Japan
| | - Reo Kasai
- Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Kanagawa, Japan
| | - Shiro Sasaguri
- Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Kanagawa, Japan
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Parikh JA, Beane JD, Kilbane EM, Milgrom DP, Pitt HA. Is American College of Surgeons NSQIP organ space infection a surrogate for pancreatic fistula? J Am Coll Surg 2014; 219:1111-6. [PMID: 25442065 DOI: 10.1016/j.jamcollsurg.2014.08.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 08/14/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND In the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), pancreatic fistula has not been monitored, although organ space infection (OSI) data are collected. Therefore, the purpose of this analysis was to determine the relationship between ACS NSQIP organ space infection and pancreatic fistulas. STUDY DESIGN From 2007 to 2011, 976 pancreatic resection patients were monitored via ACS NSQIP at our institution. From this database, 250 patients were randomly chosen for further analysis. Four patients were excluded because they underwent total pancreatectomy. Data on OSI were gathered prospectively. Data on pancreatic fistulas and other intra-abdominal complications were determined retrospectively. RESULTS Organ space infections (OSIs) were documented in 22 patients (8.9%). Grades B (n = 26) and C (n = 5) pancreatic fistulas occurred in 31 patients (12.4%); grade A fistulas were observed in 38 patients (15.2%). Bile leaks and gastrointestinal (GI) anastomotic leaks each developed in 5 (2.0%) patients. Only 17 of 31 grade B and C pancreatic fistulas (55%), and none of 38 grade A fistulas were classified as OSIs in ACS NSQIP. In addition, only 2 of 5 bile leaks (40%) and 2 of 5 GI anastomotic leaks (40%) were OSIs. Moreover, 3 OSIs were due to bacterial peritonitis, a chyle leak, and an ischemic bowel. CONCLUSIONS This analysis suggests that the sensitivity (55%) and specificity (45%) of organ space infection (OSI) in ACS NSQIP are too low for OSI to be a surrogate for grade B and C pancreatic fistulas. We concluded that procedure-specific variables will be required for ACS NSQIP to improve outcomes after pancreatectomy.
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Affiliation(s)
- Janak Atul Parikh
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Joal D Beane
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | | | - Daniel P Milgrom
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Henry A Pitt
- Department of Surgery, Temple University School of Medicine, Philadelphia, PA.
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Contemporary comparison of supra-aortic trunk surgical reconstructions for occlusive disease. J Vasc Surg 2014; 59:1577-82, 1582.e1-2. [DOI: 10.1016/j.jvs.2013.12.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 12/06/2013] [Accepted: 12/07/2013] [Indexed: 11/15/2022]
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Midterm Outcomes of Carotid-to-Carotid Bypass for Hybrid Treatment of Aortic Arch Disease. Ann Vasc Surg 2014; 28:860-5. [DOI: 10.1016/j.avsg.2013.10.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 10/11/2013] [Accepted: 10/24/2013] [Indexed: 11/18/2022]
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Wojciechowski J, Znaniecki L, Bury K, Rogowski J. Thoracic endovascular aortic repair with left subclavian artery coverage without prophylactic revascularisation-early and midterm results. Langenbecks Arch Surg 2014; 399:619-27. [PMID: 24770837 PMCID: PMC4050290 DOI: 10.1007/s00423-014-1186-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Accepted: 03/23/2014] [Indexed: 12/02/2022]
Abstract
Background The management of the left subclavian artery when coverage is necessary during thoracic aorta endografting remains a matter of debate. Materials and methods A retrospective analysis of a single-centre experience with thoracic endovascular aorta repair (TEVAR) was performed. Between April 2004 and October 2012, 125 cases of TEVAR were performed. The analysis focused on patients who required coverage of the left subclavian artery (LSA). We analysed mortality and morbidity with special attention to the rates of cerebrovascular accidents (CVAs) and spinal cord ischaemia (SCI) in the early and midterm. Results Of the 125 patients, 53 (42 %, group A) required an intentional coverage of the LSA to obtain an adequate proximal seal for the endograft; the remaining patients constituted group B. None of the patients in group A had protective LSA revascularisation prior to TEVAR. The primary technical success rate was 79.2 vs. 90.3 % (group A vs. group B, p = 0.08), and the primary clinical success rate was 77.4 vs. 82 % (group A vs. group B, p = 0.53). The 30-day mortality rate was 11.3 vs. 11.1 % (group A vs. group B, p = 0.97). The 30-day morbidity was 7.5 vs. 13.9 % (group A vs. group B, p = 0.4). CVA occurred in 1.9 % of group A patients, compared to 1.4 % of patients from group B (p = 0.82). The SCI incidence rate was 0 vs. 1.4 % (p = 0.39). The mean follow-up of group A was 24.1 months (range 2–64.6 months, SD = 19). Additionally, the 1-year estimated survival was 85.5 %, and the 3-year estimated survival was 78 %. There were no midterm CVAs; one event of SCI occurred in the seventh post-operative month in group A. Conclusion Our analysis, although retrospective and based on one institution experience, shows a realistic population of TEVAR patients. We prove that TEVAR with coverage of LSA origin can be accomplished with minimal neurological morbidity in this patient population. The study shows that LSA revascularisation is not mandatory before endograft deployment, especially in emergency settings. We also prove that although zone 2 TEVAR extends the proximal landing zone, it does not prevent type IA endoleaks from appearing. A multicentre randomised control trial with higher number of patients is necessary for proper, robust conclusion to be established.
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Affiliation(s)
- J. Wojciechowski
- Department of Cardiac and Vascular Surgery, Medical University of Gdansk, ul. Debinki 7, 80-211 Gdansk, Poland
| | - L. Znaniecki
- Department of Cardiac and Vascular Surgery, Medical University of Gdansk, ul. Debinki 7, 80-211 Gdansk, Poland
| | - K. Bury
- Department of Cardiac and Vascular Surgery, Medical University of Gdansk, ul. Debinki 7, 80-211 Gdansk, Poland
| | - J. Rogowski
- Department of Cardiac and Vascular Surgery, Medical University of Gdansk, ul. Debinki 7, 80-211 Gdansk, Poland
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Saouti N, Hindori V, Morshuis WJ, Heijmen RH. Left subclavian artery revascularization as part of thoracic stent grafting†. Eur J Cardiothorac Surg 2014; 47:120-5; discussion 125. [DOI: 10.1093/ejcts/ezu130] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Transaortic stent grafting of a Kommerell diverticulum arising from a right-sided aortic arch. Ann Vasc Surg 2013; 28:1037.e15-9. [PMID: 24333523 DOI: 10.1016/j.avsg.2013.08.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 07/13/2013] [Accepted: 08/13/2013] [Indexed: 11/21/2022]
Abstract
In this article, we report the case of a 68-year-old woman who presented with shortness of breath. Respiratory function tests showed a slightly obstructive physiology. Computed tomography (CT) results revealed an aberrant left subclavian artery and a Kommerell diverticulum arising from a right-sided aortic arch that was compressing the trachea and the surrounding tissues. A median sternotomy was performed with the patient under circulatory arrest with moderate hypothermia, and a transaortic stent graft was inserted to exclude the Kommerell diverticulum. The aberrant left subclavian artery was ligated and an axillo-axillar bypass was constructed. Postoperative CT showed complete exclusion of the Kommerell diverticulum without an endoleak. The patient's breathing difficulty was resolved, and she was discharged uneventfully. This procedure should be considered as an alternative strategy for exclusion of Kommerell diverticulum.
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Wilson JE, Galiñanes EL, Hu P, Dombrovskiy VY, Vogel TR. Routine revascularization is unnecessary in the majority of patients requiring zone II coverage during thoracic endovascular aortic repair: A longitudinal outcomes study using United States Medicare population data. Vascular 2013; 22:239-45. [DOI: 10.1177/1708538113502649] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective We aimed to evaluate outcomes of thoracic endovascular aortic repair (TEVAR) with left subclavian artery (LSA) coverage without bypass (TEVAR + SUB) to TEVAR with coverage of the LSA with a bypass at the time of the initial procedure or later at a separate procedure (TEVAR + SUB + BYPASS). Methods The Centers for Medicare & Medicaid Services inpatient claims for 2006–2007 were queried using Current Procedural Terminology codes for TEVAR, TEVAR + SUB, TEVAR + SUB + BYPASS or later as a separate procedure. Results A total of 2676 patients underwent TEVAR; 869 (32.5%) underwent TEVAR + SUB and 49 (5.6%) TEVAR + SUB + BYPASS. At the time of the initial procedure, TEVAR + SUB + BYPASS was associated with a higher incidence of stroke compared to TEVAR + SUB (12.8% vs. 3.8 %; p = 0.0033). Among TEVAR + SUB, only 1.93% (50 patients) had a subsequent bypass performed during a one-year follow-up. Overall rates of morbidity ( p = 0.004) and mortality ( p = 0.011) trended towards significance in favor of TEVAR + SUB. Conclusions TEVAR + SUB were associated with lower rates of mortality and complications. Only a small percentage of TEVAR + SUB required a bypass at one year after procedure. Our data suggest that routine LSA bypass during TEVAR is unnecessary and associated with increase morbidity and mortality.
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Affiliation(s)
- Jonathan E Wilson
- Division of Vascular Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Edgar L Galiñanes
- Division of Vascular Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Parker Hu
- Division of Vascular Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Viktor Y Dombrovskiy
- Department of Surgery, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Todd R Vogel
- Division of Vascular Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, MO, USA
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