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Račytė A, Arzola LH, Wanhainen A, Asciutto G, Kuzniar M, Mani K. Left subclavian artery bridging stent fracture after in-situ laser fenestration during emergent thoracic endovascular aortic repair. J Vasc Surg Cases Innov Tech 2024; 10:101550. [PMID: 39069993 PMCID: PMC11277743 DOI: 10.1016/j.jvscit.2024.101550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/23/2024] [Indexed: 07/30/2024] Open
Abstract
In-situ laser fenestration (ISLF) has been described as a viable option for urgent thoracic aortic aneurysm cases involving supra-aortic vessels. There are, however, limited data on its durability. Here, we present a case of a 70-year-old man with a symptomatic 13-cm thoracic aortic aneurysm extending proximally to the origin of the left subclavian artery (LSA). Emergent thoracic endovascular aortic repair with chimney stenting of the left common carotid artery and ISLF for the LSA was successfully performed. During the follow-up, a compression of the bridging stent to the LSA progressed to a stent fracture needing realignment. Despite ISLF's reported technical success, this case highlights the risk of bridging stent complications, emphasizing the need for a close follow-up.
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Affiliation(s)
- Austėja Račytė
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Luis H. Arzola
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Giuseppe Asciutto
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Marek Kuzniar
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
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Chou EL, Lu E, Dake MD, Fischbein MP, Bavaria JE, Oderich G, Makaroun MS, Charlton-Ouw KM, Naslund T, Suckow BD, Matsumura JS, Patel HJ, Azizzadeh A. Initial Outcomes of the Gore TAG Thoracic Branch Endoprosthesis for Endovascular Repair of Blunt Thoracic Aortic Injury. Ann Vasc Surg 2024; 104:147-155. [PMID: 38492730 DOI: 10.1016/j.avsg.2023.12.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 03/18/2024]
Abstract
BACKGROUND Endovascular repair of blunt thoracic aortic injury (BTAI) has dramatically reduced the morbidity and mortality of intervention. Injuries requiring zone 2 coverage of the aorta traditionally require left subclavian artery (LSA) sacrifice or open revascularization. Furthermore, these injuries are associated with an increased risk of in-hospital mortality and long-term morbidity. Here we report 1-year outcomes of total endovascular repair of BTAI with the GORE® TAG® Thoracic Branch Endoprosthesis for LSA preservation. METHODS Across 34 investigative sites, 9 patients with BTAI requiring LSA coverage were enrolled in a nonrandomized, prospective study of a single-branched aortic endograft. The thoracic branch endoprosthesis device allows for graft placement proximal to the LSA and incorporates a single side branch for LSA perfusion. RESULTS This initial cohort included 8 male and 1 female patient with a median age of 43 (22, 76) and 12 months of follow-up. Five total years of follow-up are planned. All participants had grade 3 BTAI. All procedures took place between 2018 and 2019. The median injury severity score was 2 (0, 66). The median procedure time was 109 min (78, 162). All aortic injuries were repaired under general anesthesia and with heparinization. A spinal drain was used in one patient. Post-deployment balloon angioplasty was conducted in one case at the distal landing zone. There was one asymptomatic LSA branch occlusion 6 months after repair. It was attributed to the purposeful proximal deployment of the branch stent to accommodate an early vertebral takeoff. The occlusion did not require revascularization. There were no strokes, mortalities, or aortic adverse events (migration, endoleak, native aortic expansion, dissection, or thrombosis) through 12 months of follow-up. CONCLUSIONS Initial cohort outcomes suggest that endovascular repair of zone 2 BTAI is feasible and has favorable outcomes using the thoracic branch device with LSA preservation. Additional cases and longer-term follow-up are required for a definitive assessment of the device's safety and durability in traumatic aortic injuries.
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Affiliation(s)
- Elizabeth L Chou
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Eileen Lu
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Michael D Dake
- Department of Medical Imaging, University of Arizona Health System, Tucson, AZ
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University Hospitals, Palo Alto, CA
| | - Joseph E Bavaria
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PE
| | | | - Michel S Makaroun
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PE
| | - Kristofer M Charlton-Ouw
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX
| | - Thomas Naslund
- Department of Vascular Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Bjoern D Suckow
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Jon S Matsumura
- Division of Vascular Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI
| | - Ali Azizzadeh
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
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Pinheiro Ribeiro Alves A, da Costa Cettolin Q, Dos Santos Domingues G, Dos Santos HÁG, Sampaio RC, Aquino MDA. Results of the in situ fenestration technique for preservation of the Left subclavian artery in the endovascular repair of acute aortic syndromes in a reference center. Vascular 2024; 32:490-498. [PMID: 36750245 DOI: 10.1177/17085381231155959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The in situ fenestration (ISF) technique consists of maintaining the patency of the aortic branch after the endoprosthesis is already in place as a viable, effective, and fast-performing alternative to revascularize the aortic arch arteries. OBJECTIVE To report the experience with a series of cases of endovascular treatment of Acute Aortic Syndromes involving the aortic arch, using the ISF technique in a specialized center. METHODS We analyzed data collected from patients treated with ISF during TEVAR for Acute Aortic Syndromes involving the aortic arch from June 2020 to January 2022, assessing perioperative outcomes, including immediate and late success rates, complications, morbidity and mortality, and short and medium term aortic branch patency. RESULTS Of the 11 patients eligible for the ISF procedure, 9 were successful, with a technical success rate of 81%. No patient had a type 1A endoleak related to fenestration. There was complete thrombosis of the false lumen in the thoracic aorta in 77% cases. No death was related to the fenestration technique. CONCLUSION ISF as feasible and with a high rate of technical success and good results in the short and medium term. Prospective studies with long-term clinical follow-up are still needed to fully assess the durability of these unreinforced fenestrations.
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Affiliation(s)
- André Pinheiro Ribeiro Alves
- Departamento de Hemodinâmica, Hospital Geral Roberto Santos, Serviço de Angiorradiologia e Cirurgia Endovascular, Salvador, Brazil
| | - Queise da Costa Cettolin
- Departamento de Hemodinâmica, Hospital Geral Roberto Santos, Serviço de Angiorradiologia e Cirurgia Endovascular, Salvador, Brazil
| | - Gustavo Dos Santos Domingues
- Departamento de Hemodinâmica, Hospital Geral Roberto Santos, Serviço de Angiorradiologia e Cirurgia Endovascular, Salvador, Brazil
| | | | - Renata Caires Sampaio
- Departamento de Hemodinâmica, Hospital Geral Roberto Santos, Serviço de Angiorradiologia e Cirurgia Endovascular, Salvador, Brazil
| | - Mauricio de Amorim Aquino
- Departamento de Hemodinâmica, Hospital Geral Roberto Santos, Serviço de Angiorradiologia e Cirurgia Endovascular, Salvador, Brazil
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Antonello M, Spertino A, Rodinò G, Tarantini G. Emergent In Situ Fenestration in the Ascending Aorta for the Endovascular Repair of a Large Pseudoaneurysm: A Technical Note. J Endovasc Ther 2024; 31:366-370. [PMID: 36214426 DOI: 10.1177/15266028221125587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE The purpose of this article is to describe an emergent in situ fenestration (ISF) technique in the ascending aorta for the endovascular repair of a large pseudoaneurysm using a trans-septal needle device through direct right common carotid artery access, in a patient with left ventricular assist device (LVAD). TECHNIQUE We performed, in a multidisciplinary team-work approach, an emergent ISF to correct the displacement of a physician-modified thoracic endograft released in the ascending aorta to correct a large anastomotic pseudoaneurysm in a patient who underwent ascending aorta replacement and subsequent LVAD implantation. We used a trans-septal needle device inserted through a direct access to the right carotid artery and performed an ISF to restore the patency of the outflow ostium of the LVAD. Window was then completed and stabilized with a nitinol balloon expandable covered stent graft obtaining an effective exclusion of the anastomotic aortic aneurism and the regular patency of the LVAD outflow graft with no signs of leaks. CONCLUSIONS Multidisciplinary teamwork approach can be crucial in challenging procedures where an alternative approach may lead to problem solving. The ISF technique may be a valid option to adopt in emergency cases in which no other technical solutions are suitable. CLINICAL IMPACT The endovascular approach has become more and more frequent for the treatment of vascular pathologies, getting increasingly refined and complex. Thereby the chance of incurring intraprocedural troubles has grown and bailout strategies should always be present. In situ fenestration is a technique to be aware of and that could help you recover from difficult situations. We report a possible rescue maneuver that can be applied also in arduous anatomies such as the ascending aorta. Moreover, we would like to highlight the importance of a multidisciplinary working environment that can enrich our everyday practice accomplishing effective and unexpected solutions.
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Affiliation(s)
- Michele Antonello
- Vascular and Endovascular Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Andrea Spertino
- Vascular and Endovascular Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giulio Rodinò
- Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giuseppe Tarantini
- Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, 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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Zhao L, Liu J, Cai X, Yang W, Wang J. Image fusion guidance for left subclavian artery in situ fenestration during thoracic endovascular repair. J Cardiothorac Surg 2024; 19:104. [PMID: 38388911 PMCID: PMC10885385 DOI: 10.1186/s13019-024-02561-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 01/30/2024] [Indexed: 02/24/2024] Open
Abstract
OBJECTIVES To evaluate the feasibility and clinical benefit of utilizing image fusion for thoracic endovascular repair (TEVAR) with in situ fenestration (ISF-TEVAR). MATERIALS AND METHODS Between January 2020 and December 2020, we prospectively collected 18 consecutive cases with complex thoracic aortic lesions who underwent image fusion guided ISF-TEVAR. As a control group, 18 patients were collected from historical medical records from June 2019 to December 2019. The fusion group involved the use of 3D fusion of CTA and fluoroscopic images for real-time 3D guidance, and the control group involved the use of only regular fluoroscopic images for guidance. The total contrast medium volume, hand-injected contrast medium volume, overall operative time, radiation dose and fluoroscopy time were compared between the two groups. Accuracy was measured based on preoperative CTA and intraoperative digital subtraction angiography. RESULTS 3D fusion imaging guidance was successfully implemented in all patients in the fusion group. Hand-injected contrast medium volume and overall operative time were significantly lower in the fusion group than in the control group (p = .028 and p = .011). Compared with the control group, the fusion group showed a significant reduction in time and radiation dose-area product (DAP) for fluoroscopy (p = .004 and p = .010). No significant differences in total radiation dose (DAP) or total contrast medium volume were observed (p = .079 and p = .443). Full accuracy was achieved in 8 cases (44%), with a mean deviation of 2.61 mm ± 3.1 (range 0.0-8.4 mm). CONCLUSIONS 3D image fusion for ISF-TEVAR was associated with a significant reduction in hand-injected contrast medium, time and radiation exposure for fluoroscopy and overall operative time. The image fusion guidance showed potential clinical benefits towards improved treatment safety and accuracy for complex thoracic endovascular interventions.
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Affiliation(s)
- Liang Zhao
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, P. R. China
| | - Jidong Liu
- Department of Cardiovascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, P. R. China
| | - Xiaoshu Cai
- Advanced Therapies, Siemens Healthineers Ltd, Shanghai, China
| | - Wengang Yang
- Department of Cardiovascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, P. R. China
| | - Ji Wang
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, P. R. China.
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DiLosa K, Pozolo C, Heafner T, Humphries M, Kwong M, Maximus S. Early experience with the Gore TAG thoracic branch endoprosthesis for treatment of acute aortic pathology. J Vasc Surg Cases Innov Tech 2024; 10:101363. [PMID: 38130369 PMCID: PMC10731599 DOI: 10.1016/j.jvscit.2023.101363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 10/21/2023] [Indexed: 12/23/2023] Open
Abstract
The Gore TAG thoracic branch endoprosthesis (TBE) is the first Food and Drug Administration-approved device for zone 2 thoracic endovascular aortic repair, allowing for graft placement proximal to the left subclavian artery origin and maintaining vessel patency through a side branch. We describe our experience with the Gore TBE device in 20 patients for acute indications, including blunt thoracic aortic injuries, complicated dissections, and ruptured aneurysms. Technical success, with exclusion of pathology and left subclavian patency, was 100% without major complications within 30 days. Our early Gore TBE device experience demonstrates safe use in acute aortic pathology without an increased risk of complications.
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Affiliation(s)
- Kathryn DiLosa
- Division of Vascular Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA
| | - Cara Pozolo
- Division of Vascular Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA
| | - Thomas Heafner
- Division of Vascular Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA
| | - Misty Humphries
- Division of Vascular Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA
| | - Mimmie Kwong
- Division of Vascular Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA
| | - Steven Maximus
- Division of Vascular Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA
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Piffaretti G, Franchin M, Gnesutta A, Gatta T, Piacentino F, Rivolta N, Lomazzi C, Bissacco D, Fontana F, Trimarchi S. Anatomic Feasibility of In-Situ Fenestration for Isolate Left Subclavian Artery Preservation during Thoracic Endovascular Aortic Repair Using an Adjustable Needle Puncturing System. J Clin Med 2023; 13:162. [PMID: 38202169 PMCID: PMC10779778 DOI: 10.3390/jcm13010162] [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: 10/24/2023] [Revised: 12/14/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
OBJECTIVES To evaluate the feasibility of thoracic endovascular aortic repair (TEVAR) using the Ankura™ device (Lifetech Scientific, Shenzhen, China) with left subclavian artery (LSA) in-situ fenestration (ISF) using an adjustable puncture device system. METHODS It is a single center, retrospective, financially unsupported cohort study of TEVAR performed from 16 February 2007 to 10 January 2023. Inclusion criteria were isolate LSA revascularization for elective or urgent/emergent "zone 2" TEVAR, and the availability of the preoperative computed tomography angiography. RESULTS Post-hoc analysis identified 52 TEVARs. There were 39 (75.0%) males, and 13 (25.0%) females: median age was 74.5 years (IQR, 65.5-78). Index TEVAR was performed for atherosclerotic aneurysm in 27 (51.9%) cases, dissection-related diseases in 18 (34.6%), penetrating aortic ulcer in 5 (9.6%), and blunt traumatic aortic injury in 2 (3.8%). Access-vessel feasibility rate of TEVAR using the Ankura™ device would have been 98.1% (51/52). Considering the morphology of the aortic arch, ISF TEVAR feasibility would have been 61.5% (32/52). Binary logistic regression analysis identified LSA angulation (OR: 1.1, 95%CI: 1.03-1.14, p = 0.003) to be associated with ISF feasibility using this endograft and a self-centering adjustable needle-based puncture device. CONCLUSIONS Potential feasibility of TEVAR using the Ankura™ endograft with ISF using a self-centering adjustable needle system was 61.5%. Left subclavian artery angulation seems to be the most important and limiting anatomical constraint.
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Affiliation(s)
- Gabriele Piffaretti
- Vascular Surgery—Department of Medicine and Surgery, University of Insubria School of Medicine, 21100 Varese, Italy; (M.F.); (N.R.)
- ASST Settelaghi University Teaching Hospital, 21100 Varese, Italy
| | - Marco Franchin
- Vascular Surgery—Department of Medicine and Surgery, University of Insubria School of Medicine, 21100 Varese, Italy; (M.F.); (N.R.)
- ASST Settelaghi University Teaching Hospital, 21100 Varese, Italy
| | - Aroa Gnesutta
- ASST Settelaghi University Teaching Hospital, 21100 Varese, Italy
| | - Tonia Gatta
- ASST Settelaghi University Teaching Hospital, 21100 Varese, Italy
| | - Filippo Piacentino
- ASST Settelaghi University Teaching Hospital, 21100 Varese, Italy
- Interventional Radiology—Department of Medicine and Surgery, University of Insubria School of Medicine, ASST Settelaghi University Teaching Hospital, 21100 Varese, Italy
| | - Nicola Rivolta
- Vascular Surgery—Department of Medicine and Surgery, University of Insubria School of Medicine, 21100 Varese, Italy; (M.F.); (N.R.)
- ASST Settelaghi University Teaching Hospital, 21100 Varese, Italy
| | - Chiara Lomazzi
- Vascular Surgery, Cardio Thoracic Vascular Department, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy (S.T.)
| | - Daniele Bissacco
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Federico Fontana
- ASST Settelaghi University Teaching Hospital, 21100 Varese, Italy
| | - Santi Trimarchi
- Vascular Surgery, Cardio Thoracic Vascular Department, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy (S.T.)
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
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Zhou Z, Zhou M, Ding Y, Li X, Wang Y, Xie T, Shi Z. Endovascular treatment of type B aortic dissection in patients with end-stage renal disease. Vascular 2023; 31:1043-1050. [PMID: 35791091 DOI: 10.1177/17085381221112550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study aimed to evaluate the postoperative and intermediate outcomes of thoracic endovascular aortic repair (TEVAR) in patients with end-stage renal disease (ESRD). METHODS We retrospectively reviewed patients with type B aortic dissection (TBAD) undergoing TEVAR at our single center from January 2010 to December 2020. Patients with pre-existing ESRD were enrolled as the study group. One hundred consecutive patients from September 2013 to March 2015 without ESRD were included as the control group. The primary and secondary outcomes were adverse events and survival, respectively. Kaplan-Meier curves of survival and freedom from adverse events were calculated and analyzed using the log-rank univariate test. Multivariable analysis was used to isolate the effects of ESRD. RESULTS A total of 39 patients with ESRD and TBAD underwent TEVAR during the study period. The median follow-up time of patients with and without ESRD was 45 and 46 months, respectively. There was significant difference between the survival at 4 years of patients with and without ESRD (72.8% vs 94.9%; p = 0.011). Meanwhile, the incidence of adverse events was significantly higher in patients with ESRD (p = 0.026). Multivariable logistic regression analysis showed that ESRD (OR, 2.46; p = 0.049) and peripheral artery disease (OR, 4.11; p = 0.002) were the predictors of adverse events. CONCLUSIONS The rates of adverse events and survival expectancy were poor in patients with ESRD and TBAD.
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Affiliation(s)
- Zhenyu Zhou
- Department of Vascular Surgery, Zhongshan Hospital, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Min Zhou
- Department of Vascular Surgery, Zhongshan Hospital, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Yong Ding
- Department of Vascular Surgery, Zhongshan Hospital, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Xu Li
- Department of Vascular Surgery, Zhongshan Hospital, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Yonggang Wang
- Department of Vascular Surgery, Zhongshan Hospital, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Tianchen Xie
- Department of Vascular Surgery, Zhongshan Hospital, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Zhenyu Shi
- Department of Vascular Surgery, Zhongshan Hospital, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
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Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
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11
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Peterss S, Stana J, Rantner B, Buech J, Radner C, Konstantinou N, Hagl C, Pichlmaier M, Tsilimparis N. Expert opinion: How to treat type IA endoleakage. Asian Cardiovasc Thorac Ann 2023; 31:604-614. [PMID: 36740844 DOI: 10.1177/02184923231154742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Type Ia endoleaks due to failed sealing or loss of landing zone and the adequate management thereof remain crucial for long-term therapeutic success following TEVAR. This expert opinion summarizes our institutional experience with endovascular, open surgical, and hybrid techniques in the context of recent scientific publications. The rapid turnover of technical innovations, but most importantly outcome data demonstrate the requirement for increasingly patient-tailored treatment strategies and the need for specialized aortic centers. The latter should offer a complete range of treatment options, an adequate perioperative management, and the highest level of multidisciplinary expertise.
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Affiliation(s)
- Sven Peterss
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Jan Stana
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany
- Department of Vascular and Endovascular Surgery, LMU University Hospital, Munich, Germany
| | - Barbara Rantner
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany
- Department of Vascular and Endovascular Surgery, LMU University Hospital, Munich, Germany
| | - Joscha Buech
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner site Munich Heart Alliance, Munich, Germany
| | - Caroline Radner
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner site Munich Heart Alliance, Munich, Germany
| | - Nikolaos Konstantinou
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany
- Department of Vascular and Endovascular Surgery, LMU University Hospital, Munich, Germany
| | - Christian Hagl
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner site Munich Heart Alliance, Munich, Germany
| | - Maximilian Pichlmaier
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Nikolaos Tsilimparis
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany
- Department of Vascular and Endovascular Surgery, LMU University Hospital, Munich, Germany
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12
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Li RD, Soult MC. Advanced Endovascular Treatment of Complex Aortic Pathology. Surg Clin North Am 2023; 103:e1-e11. [PMID: 37839825 DOI: 10.1016/j.suc.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
Endovascular aortic aneurysm repair and thoracic endovascular aortic repair have been shown to reduce blood loss, operative time, length of hospital stay, mortality, and morbidity compared with open surgical repair for abdominal aortic aneurysms and thoracic aortic aneurysms. However, there are anatomical constraints that limit the application of the endovascular approach in 30% to 40% of patients, including those with short necks, excessive angulation, or aneurysms with the involvement of aortic side branches such as supra-aortic trunks, arch aneurysms, visceral arteries, or internal iliac arteries.
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Affiliation(s)
- Ruojia Debbie Li
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University, Stritch School of Medicine, Maywood, IL, USA. https://twitter.com/RDebbieLi
| | - Michael C Soult
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University, Stritch School of Medicine, Maywood, IL, USA.
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13
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McKinley H, El Sayed H, Panneton J. Laser Fenestration in TEVAR - Perspectives and Future Directions. Ann Vasc Surg 2023:S0890-5096(23)00317-5. [PMID: 37328097 DOI: 10.1016/j.avsg.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/23/2023] [Accepted: 06/06/2023] [Indexed: 06/18/2023]
Abstract
Endovascular aortic repair has been increasingly utilized to treat a multitude of thoracic aortic pathologies. When placement of a thoracic endograft necessitates coverage of one or more of the great vessels, in situ laser fenestration is a safe and effective option for supra-aortic trunk revascularization. Certain anatomic factors may render laser fenestration more technically challenging, particularly depending on aortic arch type and branch vessel characteristics. Short-term and mid-term outcomes have shown promising results for mortality, stroke, and complication rates. Future developments may extend the utility of this approach and allow it to be applied to a more widespread set of patients with challenging anatomy.
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Affiliation(s)
- Hilary McKinley
- Division of Vascular Surgery, Eastern Virginia Medical School, P.O. Box 1980, Norfolk, Virginia 23501
| | - Hosam El Sayed
- Division of Vascular Surgery, Eastern Virginia Medical School, P.O. Box 1980, Norfolk, Virginia 23501
| | - Jean Panneton
- Division of Vascular Surgery, Eastern Virginia Medical School, P.O. Box 1980, Norfolk, Virginia 23501.
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14
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Le Houérou T, Álvarez-Marcos F, Gaudin A, Bosse C, Costanzo A, Vallée A, Haulon S, Fabre D. Midterm Outcomes of Antegrade In Situ Laser Fenestration of Polyester Endografts for Urgent Treatment of Aortic Pathologies Involving the Visceral and Renal Arteries. Eur J Vasc Endovasc Surg 2023; 65:720-727. [PMID: 36731765 DOI: 10.1016/j.ejvs.2023.01.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 11/20/2022] [Accepted: 01/24/2023] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Aortic endografting and antegrade in situ laser fenestration of visceral arteries (LFEVAR) may be considered as an alternative to open surgery for the emergency repair of complex abdominal aortic aneurysms (AAA) in fragile patients. The aim of this article was to evaluate the midterm results of LFEVAR performed with polyester endografts. METHODS From August 2015 to December 2020, all consecutive LFEVAR performed for non-deferrable treatment of complex AAA were analysed. Polyester endografts were deployed and subsequently fenestrated using an atherectomy laser probe; the fenestrations were enlarged using cutting and semicompliant balloons before implantation of balloon expandable bridging stents into the target vessels. Prospectively collected midterm survival, patency, and re-intervention rates were analysed. RESULTS Forty four procedures were performed for 11 type 1a endoleaks, five thoraco-abdominal aneurysms, 20 pararenal aneurysms, four segmental renal artery (RA) preservations, three anastomotic aneurysms, and one aortic dissection. One hundred and eight laser fenestrations were performed (26 for the superior mesenteric artery [SMA], 13 for the coeliac trunk, 33 and 31 for the right and left RA, respectively). The median ischaemia duration was 7, 48, 48, and 45 minutes, respectively. The technical success rate was 97%, with no open surgical conversions. The 30 day mortality was 4.5% (n = 2). No spinal cord ischaemia events were observed nor early stent related complications. Kaplan-Meier overall survival at two years was 73%, the aortic related re-intervention free survival was 70%, and the stent related re-intervention free survival was 90.6%. Four target vessel thromboses were detected, of which three were rescued. Three type IIIc endoleaks, one RA false aneurysm, and one SMA stenosis, required re-intervention during a median follow up of 24.7 months. CONCLUSION Antegrade LFEVAR is feasible, safe, and provides satisfactory early and midterm outcomes for non-deferrable treatment of aortic pathologies involving the visceral segment. Long term data are mandatory to confirm the usefulness of this promising off label technique.
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Affiliation(s)
- Thomas Le Houérou
- Department of Cardiovascular Surgery, Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Francisco Álvarez-Marcos
- Vascular Surgery Department, Hospital Universitario Central de Asturias (HUCA), Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Asturias, Spain
| | - Antoine Gaudin
- Department of Cardiovascular Surgery, Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Côme Bosse
- Department of Cardiovascular Surgery, Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Alessandro Costanzo
- Department of Cardiovascular Surgery, Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Aurélien Vallée
- Department of Cardiovascular Surgery, Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Stéphan Haulon
- Department of Cardiovascular Surgery, Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Dominique Fabre
- Department of Cardiovascular Surgery, Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France.
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15
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Tish S, Chase JA, Scoville C, Vogel TR, Cheung S, Bath J. A Systematic Review of Contemporary Outcomes from Aortic Arch In Situ Laser Fenestration During Thoracic Endovascular Aortic Repair. Ann Vasc Surg 2023; 91:266-274. [PMID: 36642166 DOI: 10.1016/j.avsg.2023.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/21/2022] [Accepted: 01/05/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND In situ laser fenestrated endovascular aortic repair (L-FEVAR) is a novel and creative solution for complex aortic pathologies in the urgent and emergency setting. Outcomes of this technique, however, are poorly reported. We sought to evaluate the efficacy, safety, and outcomes of L-FEVAR in aortic arch pathologies. METHODS A systematic literature review and analysis were conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses and Cochrane guidelines. A search was conducted using Google, PubMed, and Scopus to identify studies evaluating L-FEVAR. Two independent reviewers determined study inclusion. Case reports and series including < 10 patients were excluded. Reviewers also assessed the methodological quality and extracted data regarding outcomes. A meta-analysis of endoleak event rates was conducted using a fixed-effect model due to small sample size. RESULTS Eight studies met inclusion criteria between 2013 and 2021. Most studies were retrospective (87.5%) with median follow-up duration of 12.5 months (range 10-42). There were 440 patients included (range 15-148), mostly men (64%). Mean age was 61 years (range 53-68). Included patients were all symptomatic with L-FEVAR being technically successful in 93.3% of cases. The main indication for aortic arch intervention was aortic dissection. Single fenestrations occurred most frequently (68%), followed by triple (22%) then double fenestrations (9%). Meta-analysis of 8 studies (n = 440) demonstrated an endoleak event rate of 0.06 (95% confidence interval 0.04-0.09, P < 0.001) with no observed statistically significant heterogeneity of effects (Q = 7.91, P = 0.34). The median operative time was 162 min (range 53-252) with median length of stay of 10 days (range 7-17). Primary branch patency was 96.6%. Secondary patency rate was 97%. Pooled complication rates such as endoleak occurred in 4.8%, stroke in 2.0%, spinal cord ischemia in 0.2%, retrograde dissection in 0.9%, and 30-day death in 2.0%. Access complications occurred in 0.4%. Antiplatelet regimen was poorly reported in the study cohort. CONCLUSIONS In situ laser fenestration is a feasible, safe, and effective approach to treat aortic arch disease in patients who are unsuitable for open or custom-made endovascular means. High technical success and excellent short-term branch patency can be achieved. These single-institution series exhibit promising short-term outcomes. In a similar paradigm to investigational device exemptions studies for custom-made and physician modified endografts, these preliminary data make a persuasive argument for larger long-term multi-institutional prospective study of this promising technique.
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Affiliation(s)
- Shahed Tish
- Department of Surgery, University of Missouri, Columbia, MO
| | - Jo-Ana Chase
- University of Missouri School of Nursing, Columbia, MO
| | - Caryn Scoville
- Health Sciences Library, University of Missouri, Columbia, MO
| | - Todd R Vogel
- Division of Vascular Surgery, University of Missouri, Columbia, MO
| | - Steven Cheung
- Division of Vascular Surgery, University of Missouri, Columbia, MO
| | - Jonathan Bath
- Division of Vascular Surgery, University of Missouri, Columbia, MO.
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16
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Houérou TL, Nana P, Pernot M, Guihaire J, Gaudin A, Lerisson E, Costanzo A, Fabre D, Haulon S. Systematic Review on In Situ Laser Fenestrated Repair for the Endovascular Management of Aortic Arch Pathologies. J Clin Med 2023; 12:jcm12072496. [PMID: 37048580 PMCID: PMC10095564 DOI: 10.3390/jcm12072496] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/12/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023] Open
Abstract
Background: In situ laser-fenestrated thoracic aortic endovascular repair (FTEVAR) has emerged as a valuable alternative for aortic arch management. This review assessed the early and follow-up outcomes of in situ laser-FTEVAR in aortic arch pathologies. Methods: The PRISMA statement was followed. The English literature was searched, via Ovid, until 15 October 2022. Observational studies, published after 2000, reporting on early and follow-up outcomes for the in situ laser-FTEVAR were eligible. The Newcastle–Ottawa Scale was used to assess the risk of bias. Primary outcomes were the technical success, stroke, and mortality at 30-days, and the secondary were the mortality and reintervention during follow-up. Results: Six retrospective studies from 591 and 247 patients were included. Fifty-nine (23.9%) patients were managed for aortic arch aneurysms and 146 (59.1%) for dissections; 22.6% of them for type A. Technical success was at 98% (range 90–100%). Eight patients died (3.2%) and 11 cases presented any type of stroke (4.5%) during the 30-day follow-up. The mean follow-up was 15 months (1–40 months). Ten deaths were reported (4.2%); one was aortic-related (10%). Thirteen re-interventions (6.0%) were performed. Conclusions: In situ laser-FTEVAR for aortic arch repair may be performed with high technical success and low 30-day and midterm follow-up mortality, stroke, and re-intervention rates when applied in well selected patients and performed by experienced teams.
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17
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Lounes Y, Belarbi A, Hireche K, Chassin-Trubert L, Ozdemir BA, Akodad M, Alric P, Canaud L. Physician-Modified Stent Graft for Blunt Thoracic Aortic Injuries: Do the Benefits Worth the Trouble? Ann Vasc Surg 2023; 90:100-108. [PMID: 36270548 DOI: 10.1016/j.avsg.2022.09.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 09/18/2022] [Accepted: 09/21/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Obtaining a suitable proximal landing zone in blunt thoracic aortic injuries (BTAI) often necessitates coverage of the left subclavian artery (LSA). This study aimed to evaluate the outcomes of physician-modified endovascular grafts (PMEGs) in this indication. METHODS We performed a retrospective analysis of a prospective registry including all patients who had undergone a thoracic endovascular aortic repair (TEVAR) for BTAI from October 2008 to October 2020. Starting in 2015, patients requiring coverage of the LSA were either treated using a physician-modified proximal scalloped or single-fenestrated stent graft. After an early postoperative computed tomography scan, follow-up was performed at 3 months, 6-months, and yearly. RESULTS Among 58 patients treated with TEVAR for BTAI, 23 (39.6%) patients required a zone 2 landing zone of which 10 (17.2%) patients were treated with PMEGs. The median age was 48 [31-64.5] years, and 78.2% (n = 18) patients were male. The median Injury Severity Score was 38 [27-55.5]. Coverage of the LSA was performed in 25.8% (n = 15) of the total population in which 5 patients had an LSA transposition. The median modification time was 18 [14-27] minutes. Technical success of PMEGs was 90.0% overall and 100% for fenestrated stent grafts. No stroke, paraplegia, or retrograde dissection was observed. The primary patency of the LSA in the PMEGs group was 90 % at 1 year and 28.8 % in the LSA coverage group (P < 0.01). CONCLUSIONS The use of PMEGs is feasible and effective in the management of BTAI with a short proximal landing zone. Further evaluation of long-term outcomes and durability are awaited.
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Affiliation(s)
- Youcef Lounes
- Department of Vascular and Thoracic Surgery, University of Montpellier, CHU Montpellier, Montpellier, France; PhyMedExp, Univ Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France.
| | - Amin Belarbi
- Department of Vascular and Thoracic Surgery, University of Montpellier, CHU Montpellier, Montpellier, France
| | - Kheira Hireche
- Department of Vascular and Thoracic Surgery, University of Montpellier, CHU Montpellier, Montpellier, France
| | - Lucien Chassin-Trubert
- Department of Vascular and Thoracic Surgery, University of Montpellier, CHU Montpellier, Montpellier, France
| | - Baris Ata Ozdemir
- Department of Vascular and Thoracic Surgery, University of Montpellier, CHU Montpellier, Montpellier, France; Department of Cardiology, University of Montpellier, CHU Montpellier, Montpellier, France; University of Bristol, Bristol, UK
| | - Mariama Akodad
- PhyMedExp, Univ Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France; Department of Cardiology, University of Montpellier, CHU Montpellier, Montpellier, France
| | - Pierre Alric
- Department of Vascular and Thoracic Surgery, University of Montpellier, CHU Montpellier, Montpellier, France; PhyMedExp, Univ Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France
| | - Ludovic Canaud
- Department of Vascular and Thoracic Surgery, University of Montpellier, CHU Montpellier, Montpellier, France; PhyMedExp, Univ Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France
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18
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Wilderman M, Dudiy Y, Simonian G. Novel Approach to treating a COVID-19 positive patient with a Complex Arch and Descending Aneurysm and Dissection in whom open surgery is prohibitive. J Vasc Surg Cases Innov Tech 2023; 9:101130. [PMID: 36845641 PMCID: PMC9941075 DOI: 10.1016/j.jvscit.2023.101130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/29/2022] [Accepted: 01/31/2023] [Indexed: 02/24/2023] Open
Abstract
Ascending aortic and arch aneurysms are a challenging group of pathologies for surgeons. These typically require a complex open repair, including hypothermic circulatory arrest and carry a high peri-operative risk. Outcomes are best when performed in centers with significant experience and expertise. Many patients, because of co-morbidities, are at a prohibitive risk for these open surgeries. Thoracic endovascular aortic repair (TEVAR) has become the preferred treatment of most acute descending thoracic aortic pathologies.[1] However, these require strict anatomic criteria to be successful and are usually confined to the distal arch and descending thoracic aorta. There are no commercially available endovascular devices in the United States to treat this patient population with ascending or proximal arch aneurysms or dissections, especially in an urgent or emergent setting, whose anatomy does not meet criteria for standard TEVAR. We present a novel endovascular approach, including a cerebral protection strategy, to treat a complex arch aneurysm and dissection in a patient who was not a candidate for an open repair.
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Affiliation(s)
- Michael Wilderman
- Hackensack University Medical Center, Hackensack, NJ 07601,Corresponding author: Michael Wilderman 236 Hudson Ave, Tenafly NJ 07670 2158166570
| | - Yuriy Dudiy
- Hackensack University Medical Center, Hackensack, NJ 07601
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19
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Liang NL, Dake MD, Fischbein MP, Bavaria JE, Desai ND, Oderich GS, Singh MJ, Fillinger M, Suckow BD, Matsumura JS, Patel HJ, Makaroun MS. Midterm Outcomes of Endovascular Repair of Aortic Arch Aneurysms with the Gore Thoracic Branch Endoprosthesis. Eur J Vasc Endovasc Surg 2022; 64:639-645. [PMID: 35970335 DOI: 10.1016/j.ejvs.2022.08.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 07/17/2022] [Accepted: 08/05/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Aortic aneurysms involving aortic arch vessels are anatomically unsuitable for standard thoracic endovascular repair (TEVAR) without cervical debranching of the arch vessels. Three year outcomes of a single branched thoracic endograft following previous publication of peri-operative and one year outcomes are reported. METHODS This was a multicentre feasibility trial of the GORE TAG Thoracic Branch Endoprosthesis (TBE), a thoracic endovascular graft incorporating a single retrograde branch for aortic arch vessel perfusion. The first study arm enrolled patients with an intact descending thoracic aortic aneurysm extending to the distal arch with left subclavian artery (LSA) incorporation (zone 2). The second arm enrolled patients with arch aneurysms requiring incorporation of the left carotid or innominate artery (zone 0/1) and extra-anatomic surgical revascularisation of the remaining aortic arch vessels. Outcomes at three years are reported. RESULTS The cohort comprised 40 patients (31 zone 2, nine zone 0/1). The majority were male (52%). Mean follow up was 1 408 ± 552 days in the zone 2 and 1 187 ± 766 days in the zone 0/1 cohort. During three year follow up there was no device migration, fracture, or aortic rupture in either arm. In the zone 2 arm, freedom from re-intervention was 97% at one and three years but there were two side branch occlusions. Two patients had aneurysm enlargement > 5 mm without documented endoleak or re-intervention. Freedom from death at one and three years was 90% and 84%. In the zone 0/1 arm there were no re-interventions, loss of branch patency, or aneurysm enlargement at three years. Cerebrovascular events occurred in three patients during follow up: two unrelated to the device or procedure, and one of unknown relationship. Two patients in this arm died during the follow up period, both unrelated to the procedure or the aneurysm. CONCLUSION Initial three year results of the TBE device for endovascular repair of arch aneurysms show favourable patency and durability with low rates of graft related complications.
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Affiliation(s)
- Nathan L Liang
- Division of Vascular Surgery, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA.
| | - Michael D Dake
- Department of Medical Imaging, University of Arizona Health System, Tucson, AZ, USA
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University Hospitals, Palo Alto, CA, USA
| | - Joseph E Bavaria
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Nimesh D Desai
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Centre at Houston, McGovern Medical School, Houston, TX, USA
| | - Michael J Singh
- Division of Vascular Surgery, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
| | - Mark Fillinger
- Section of Vascular of Surgery, Dartmouth-Hitchcock Medical Centre, Lebanon, NH, USA
| | - Bjoern D Suckow
- Section of Vascular of Surgery, Dartmouth-Hitchcock Medical Centre, Lebanon, NH, USA
| | - Jon S Matsumura
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison WI, USA
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Centre, Ann Arbor, MI, USA
| | - Michel S Makaroun
- Division of Vascular Surgery, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
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20
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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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21
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Scurto L, Peluso N, Pascucci F, Sica S, De Nigris F, Filipponi M, Minelli F, Donati T, Tinelli G, Tshomba Y. Type 1A Endoleak after TEVAR in the Aortic Arch: A Review of the Literature. J Pers Med 2022; 12:jpm12081279. [PMID: 36013228 PMCID: PMC9410239 DOI: 10.3390/jpm12081279] [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: 07/01/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 12/02/2022] Open
Abstract
Aortic arch repair is a challenging intervention. Open surgical repair is still considered the gold standard, but in high-risk patients, it is not always a reasonable option, making endovascular approaches an enticing, when not the only available, alternative for treatment. The strategies more commonly adopted are surgical supra-aortic trunk (SAT) rerouting followed by deployment of a standard thoracic endoprosthesis, chimney techniques, custom-made scalloped, fenestrated, and branched devices, and in situ or physician-modified fenestrations. If we excluded techniques involving SAT rerouting where the arch anatomy is surgically modified in order to make deployment in the aortic arch of a standard thoracic endoprosthesis possible, in the other techniques, one or more SATs are incorporated in the thoracic endoprosthesis. In these cases, no matter what solution is adopted, because of the morphology of the aorta at this level, achieving an ideal sealing is extremely difficult, and endovascular treatments of the arch are burdened by an increased risk of type IA endoleaks. PubMed, EMBASE, and Cochrane Library were searched. We identified 1277 records. After reading titles, abstracts, and full texts, we excluded 1231 records. Exclusion criteria were low-quality evidence, abstracts, case reports, conference presentations, reviews, editorials, and expert opinions. A total of 48 studies were included, for a total of 3114 patients. A type IA endoleak occurred in 248 patients (7.7%) with a mean incidence of 18.8% in chimney procedures, 4.8% and 3%, respectively, in fenestrated and branched devices, and 2.2% in in situ fenestration. We excluded from our analysis scalloped technology that is used when the target vessel originates from a healthy landing zone and represents a different anatomical setting. Type IA endoleaks are a concern with all types of endovascular aortic arch repair, and they can compromise the outcomes of the procedure. The rate of type IA endoleaks appears to be significantly higher in chimney procedures. In order to maximize sealing, whenever possible, endovascular repair of the arch should be achieved with custom-made fenestrated devices. However, chimney configurations are still a valuable solution particularly in the emergency setting, although in such a procedure, to guarantee accurate postoperative management and follow-up, an imaging protocol could be useful.
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Affiliation(s)
- Lucia Scurto
- Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli I.R.C.C.S., Università Cattolica del Sacro Cuore, 00168 Roma, Italy
- Correspondence:
| | - Nicolò Peluso
- Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli I.R.C.C.S., Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Federico Pascucci
- Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli I.R.C.C.S., Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Simona Sica
- Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli I.R.C.C.S., Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Francesca De Nigris
- Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli I.R.C.C.S., 00168 Roma, Italy
| | | | - Fabrizio Minelli
- Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli I.R.C.C.S., Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Tommaso Donati
- Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli I.R.C.C.S., 00168 Roma, Italy
| | - Giovanni Tinelli
- Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli I.R.C.C.S., Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Yamume Tshomba
- Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli I.R.C.C.S., Università Cattolica del Sacro Cuore, 00168 Roma, Italy
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22
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Waterford SD, Ghoreishi M, Toursavadkohi S, Taylor BS. The 10 Commandments of Aortic Arch Endovascular Repair. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:266-272. [PMID: 35997683 DOI: 10.1177/15569845221116864] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Stephen D Waterford
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center Hamot, Erie, PA, USA
| | - Mehrdad Ghoreishi
- Division of Cardiac Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shahab Toursavadkohi
- Division of Vascular Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bradley S Taylor
- Division of Cardiac Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
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23
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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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24
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Physician-Modified TEVAR versus Hybrid Repair of the Proximal Descending Thoracic Aorta. J Clin Med 2022; 11:jcm11123455. [PMID: 35743525 PMCID: PMC9225072 DOI: 10.3390/jcm11123455] [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: 05/06/2022] [Revised: 06/09/2022] [Accepted: 06/14/2022] [Indexed: 11/17/2022] Open
Abstract
There are different surgical options for the treatment of proximal lesions of the descending thoracic aorta. The aim of this study was to compare the outcome of physician-modified TEVAR (pmTEVAR) vs. hybrid repair of the thoracic aorta in terms of TEVAR with carotid-subclavian bypass (hdTEVAR). This was a single-centre, retrospective comparative study of all patients who underwent pmTEVAR and hybrid repair of the proximal descending aorta from January 2018 to June 2021. Primary outcomes were technical success, 30-day mortality, perioperative stroke, 30-day reinterventions and supraaortic access related complications. Secondary outcomes were patient survival, late complications, late reinterventions, and bypass/bridging stent patency. A total of 181 patients underwent TEVAR within the period of 42 months. In our study, only patients with proximal landing in zone 2 (n = 39) were included. A total of 5 of 15 pmTEVAR and 8 of 24 hybrid repair operations (33% vs. 33%, respectively) were performed due to aneurysms. Among the rest of the patients, 10 of 15 pmTEVAR and 16 of 24 hybrid operations (67% vs. 67%) were performed due to aortic dissection. Technical success was achieved in 100% of the patients. No significant difference in terms of postoperative complications could be detected in the early and midterm follow up period. The 30-day mortality was 12.5% in the hybrid repair group (n = 3) vs. 6.66% (n = 1) in the pmTEVAR group (p = 0.498). These patients underwent the operation in an emergency setting. No patient died after an elective operation. The causes of early mortality were major stroke (n = 2), haemorrhagic shock (n = 1) in the hybrid group and progredient spinal cord ischemia with tetraplegia and acute respiratory insufficiency (n = 1) in the pmTEVAR group. In conclusion, both therapies are robust techniques, with comparable patency rate and perioperative complications. pmTEVAR appears to be advantageous in terms of operation time and tendency to lower mortality rates.
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25
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Li Y, Li Z, Feng J, Feng R, Zhou J, Jing Z. A Novel Solution for Distal Dilation of Chronic Dissection After Repair Involving Visceral Branches: The Road Block Strategy. Front Cardiovasc Med 2022; 9:821260. [PMID: 35355962 PMCID: PMC8959700 DOI: 10.3389/fcvm.2022.821260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/31/2022] [Indexed: 12/02/2022] Open
Abstract
Aim Notwithstanding that unprecedented endovascular progress has been achieved in recent years, it remains unclear what is the best strategy to preserve the blood perfusion of abdominal visceral arteries and promote positive aortic remodeling in patients with distal dilatation of chronic aortic dissection in abdominal visceral part (CADAV) after aortic repair. The present study developed a Road Block Strategy (RBS) to solve this conundrum. Methods and Results This prospective single-center clinical study included patients suffering from symptomatic distal dilatation of CADAV after aortic repair treated with RBS from January 2015 to December 2019 and followed up regularly for at least 2 years. Stent grafts were implanted first to cover distal tears and expand the true lumen. Device embolization was performed to induce proximal and distal segmental false lumen thrombosis (FLT) apart from the level of the ostia of vital branches. Successful RBS was performed in 13 patients. Significant differences were found in maximum true lumen diameter (p < 0.05), blood flow area in false lumen (FL) (p < 0.001), and the ratio of blood lumen to FL area (p < 0.05) between the pre-procedure and the latest follow-up results. No aortic rupture, vital branches occlusion, thoracic and abdominal pain, or death occurred during hospitalization and follow-up. Conclusions Our findings suggest that RBS is feasible in treating distal dilatation of chronic aortic dissection after prior proximal repair, inducing false lumen thrombosis, preventing deterioration of aortic dissection, and maintaining the patency of abdominal visceral arteries.
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Affiliation(s)
- Yiming Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
- Endovascular Diagnosis and Treatment Center for Aortic Diseases, Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Zhenjiang Li
- Department of Vascular Surgery, The First Affiliated Hospital of the Medical School of Zhejiang University, Hangzhou, China
| | - Jiaxuan Feng
- Endovascular Diagnosis and Treatment Center for Aortic Diseases, Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Rui Feng
- Department of Vascular Surgery, Shanghai General Hospital, Affiliated to Shanghai Jiaotong University, Shanghai, China
| | - Jian Zhou
- Endovascular Diagnosis and Treatment Center for Aortic Diseases, Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, China
- *Correspondence: Zaiping Jing
| | - Zaiping Jing
- Endovascular Diagnosis and Treatment Center for Aortic Diseases, Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, China
- Jian Zhou
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D’Onofrio A, Caraffa R, Cibin G, Antonello M, Gerosa G. Total Endovascular Aortic Arch Repair: From Dream to Reality. Medicina (B Aires) 2022; 58:medicina58030372. [PMID: 35334549 PMCID: PMC8948628 DOI: 10.3390/medicina58030372] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 11/16/2022] Open
Abstract
The gold-standard therapy for the treatment of aortic arch pathologies is conventional open surgery. Recently, total endovascular aortic arch replacement with branched stent-grafts has been introduced into clinical practice with the aim of reducing invasiveness especially in selected high-risk patients. The aim of this review is to describe the two most commonly used branched devices for endovascular arch stent-grafting: Nexus (Endospan, Herzlia, Israle) and RelayBranch (Terumo Aortic, Glasgow, United Kingdom). Nexus is a CE-certified off-the-shelf, single branch, double stent graft system. It consists of two different components: a main module for the aortic arch and the descending aorta with a side-branch for the brachiocephalic artery (BCA), and a curved module for the ascending aorta that lands into the sino-tubular junction and connects to the main module through a side-facing self-protecting sleeve. Nexus may be used in urgent-emergency cases and also in patients with only one suitable supra-aortic target vessel but, on the other hand, it makes cerebral blood flow dependent on one source vessel only. The RelayBranch Thoracic Stent-Graft System is a custom made, double branched endograft with a wide window on its superior portion to accommodate two inner tunnels for BCA and left common carotid artery connection; bilateral cervical accesses are generally used to advance guidewires for catheterization of the inner tunnels in a retrograde fashion. RelayBranch can be customized on every patient’s specific anatomy and provides a double blood source for the brain, but it cannot be used in urgent-emergency conditions. Therefore, in order to optimize outcomes, the choice of the most appropriate device should be made considering pros and cons of each system and patient’s anatomy by an experienced aortic team. In conclusion, total endovascular aortic arch exclusion is a promising reality in selected high-risk patients.
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Affiliation(s)
- Augusto D’Onofrio
- Division of Cardiac Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy; (R.C.); (G.C.); (G.G.)
- Correspondence: ; Tel.: +39-0498212410
| | - Raphael Caraffa
- Division of Cardiac Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy; (R.C.); (G.C.); (G.G.)
| | - Giorgia Cibin
- Division of Cardiac Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy; (R.C.); (G.C.); (G.G.)
| | - Michele Antonello
- Division of Vascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy;
| | - Gino Gerosa
- Division of Cardiac Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy; (R.C.); (G.C.); (G.G.)
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Ghanem M, Meyer F, Halloul Z. Covering/Overstenting of the left subclavian artery (LSA) in thoracic endovascular repair (TEVAR) to treat various thoracic/thoracoabdominal aortic lesions: Is revascularization of the left arm a must?
(A retrospective cohort study with 12 years of experience to describe the real-world situation of daily clinical practice and the literature review). POLISH JOURNAL OF SURGERY 2022. [DOI: 10.5604/01.3001.0015.7090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Pathologies of the descending thoracic aorta inwardly extended towards the aortic arch actually shorten the proximal landing zone for aortic prosthesis. This, in turn, worsens the feasibility of the aorta for endovascular therapeutic options of those pathologies.
Objective: This work considers the blockage of the left subclavian artery (LSA) through endovascular treatment of the pathologies of the descending aorta as a main work question, which is based on the hypothesis that there is no necessity for primary standard revascularization of the LSA in TEVAR with LSA covering. The researchers have 12 years of experience in treatment of different thoracic aortic lesions. Their experience will also be reviewed in this paper.
Design: Retrospective unicenter cohort study in consecutive patients order to describe the real-world situation of daily clinical practice
Material: All the patients who had undergone endovascular, hybrid, or open operative therapy of variant pathologies of descending aorta were included in this study.
Methods: Various parameters were investigated, including therapeutic procedures such as i) pure endovascular vs. hybrid; ii) year of therapy; iii) symptomatic vs. asymptomatic status of the patients; iv) variant epidemiological factors (age, sex, risk factors, mortality, and follow up); v) overstenting/blocking of the LSA; vi) complications of applied therapies; vii) further operations/interventions to treat such complications; viii) radiologic aortic measurements (such as lumen extensions, false lumen measurements, distance to the supra-aortic and visceral vessels); and ix) multiple other pathological features. Different statistical parameters were also examined. Survival was analysed by the Kaplan–Meier assessment in the group of whole patients vs. the group of over-stented patients. Here the analysis of variance is performed for the independent parameters for the revascularized patients—not the revascularized patients—who had undergone LSA coverage. For statistical approval, U-test was used. The p-value < 0.05 was considered significantly different. The literature review was achieved by a search in PubMed, Google scholar, Research Gate, ScienceDirect, and Cochrane library by using the following terms endovascular, TEVAR, revascularization, stroke, and left-subclavian-artery ischemia. The literature is classified accordingly in relation to the main topic. In fact, the literature undergoes further analysis if it goes with or against our hypothesis.
Results: Overall, 112 patients were enrolled in the study. There was no significant difference comparing the not-revascularized vs. the revascularized group of patients, considering the consequences on cerebrovascular blood circulation (in particular, n=1 case [4.8 %] vs. no case [0 %]; p=1) or the spinal cord ischemia (n=2 [9.5 %] vs. n=1 [7.1 %]; p=1). As the main result, there was no case of manifest left arm ischemia and deaths (mortality, 0). Survival was in both groups as follows: 22 [95% CI, 14.154–29.904] months vs. 43 [95% CI, 33.655–51.921] months with no significant statistical difference (p>0.05) . The only statistically significant risk factor found was renal insufficiency (p, 0.028), but this too is considered a trend by the urgency of revascularization. Postoperatively, pneumonia showed a trend of higher frequency (p=0.058) in the revascularized cases (n=0 in the not-revascularized vs. n=3 [21.4 %] in the revascularized cases). There was no significant difference in the occurance of postoperative neurovascular complications (such as cerebrovascular accidents, spinal cord ischemia, or left arm ischemia) by comparing the groups of not-revascularized and revascularized patients.
Conclusion: The revascularization of the overstented LSA due to TEVAR should be limited to certain indications, including i) the inadequate intracerebral circle of Willis; ii) the predominantly perfused left vertebral artery with inadequate blood perfusion via the right vertebral artery (e.g., by stenosis), iii) anatomic variance such as the left vertebral artery originating directly from the aortic arch (and must be blocked by TEVAR); iv) the need of an adequate left internal thoracic artery for coronary-artery-bypass grafting (CABG); v) the need of patent LSA for the dialysis shunt of the left arm. However, there is no appropriate evidence as yet based on sufficient study results achieved in trials with an advanced design (such as [double-]blind, multicenter randomized study) that appears to be urgently required.
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Affiliation(s)
- Mohammad Ghanem
- Division of Vascular Surgery; Department of General, Abdominal, Vascular and Transplant Surgery; Otto-von-Guericke University with University Hospital; Magdeburg, Germany
| | - Frank Meyer
- Dept. of General, Abdominal and Vascular Surgery, University Hospital at Magdeburg, Magdeburg (Germany)
| | - Zuhir Halloul
- Division of Vascular Surgery; Department of General, Abdominal, Vascular and Transplant Surgery; Otto-von-Guericke University with University Hospital; Magdeburg, Germany
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Atkins MD, Lumsden AB. Parallel grafts and physician modified endografts for endovascular repair of the aortic arch. Ann Cardiothorac Surg 2022; 11:16-25. [PMID: 35211381 PMCID: PMC8807419 DOI: 10.21037/acs-2021-taes-171] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 10/27/2021] [Indexed: 10/31/2023]
Abstract
Aortic arch aneurysms are a challenging clinical problem especially in high-risk patients. Open aortic arch replacement, even in the best of centers, carries significant risk of stroke or death in this high-risk population. Many high-risk patients are deemed inoperable and not offered repair. Branched and fenestrated thoracic endografts are currently undergoing clinical trials in the United States but are not yet commercially available. Many elderly and frail patients have significant brachiocephalic occlusive disease or anatomy excluding them for consideration for such clinical trials. These patients also present with acute aortic syndromes requiring urgent or emergent repair and are unable to participate in clinical trials due to the time required to have such devices available. Alternative endovascular therapies, including parallel stent grafts (including Chimneys, Snorkels and Periscopes) and physician modified thoracic endografts, have been used to treat such high-risk patients combined with commercially available thoracic endovascular aneurysm repair (TEVAR) devices. This paper aims to review the techniques and current reported outcomes from parallel stent grafts and physician modified devices used to treat high risk patients undergoing repair for aortic arch pathologies.
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Affiliation(s)
- Marvin D Atkins
- Houston Methodist Hospital and Houston Methodist DeBakey Cardiovascular Surgery Associates, Houston, TX, USA
| | - Alan B Lumsden
- Houston Methodist Hospital and Houston Methodist DeBakey Cardiovascular Surgery Associates, Houston, TX, USA
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Ohki T, Maeda K, Baba T, Kaneko K, Shukuzawa K, Hara M, Omori M, Ozawa H. Early Clinical Outcomes of Retrograde In-Situ Branched Stent Grafting for Complex Aortic Arch Aneurysms. J Vasc Surg 2021; 75:803-811.e2. [PMID: 34742885 DOI: 10.1016/j.jvs.2021.10.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/13/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To evaluate the early outcomes of retrograde in-situ branched stent grafting (RIBS) using the gutter balloon technique for complex aortic arch aneurysms (CAAs). METHODS The RIBS technique is an in-situ needle fenestration procedure during thoracic endovascular aortic repair (TEVAR) with the reconstruction of cervical branches. The Double-RIBS (D-RIBS) for the reconstruction of the left common carotid artery and the brachiocephalic artery using the gutter balloon technique was performed in 30 high-risk patients. We describe the early clinical results of the D-RIBS technique for CAAs. Primary endpoints were technical success and 30-day mortality. Secondary endpoints were postoperative complications, rates of endoleaks, overall survival, aneurysm-related death, and re-interventions. RESULTS The mean age was 77.1±6.6 years and the mean maximum minor-axis aneurysmal diameter was 65.9±8.9 mm. Twenty six patients underwent D-RIBS for elective arch aortic aneurysm and four patients were for reintervention after Zone 2 TEVAR failure. Stent graft puncture was performed 60 times from the common carotid arteries and technical success was achieved in all cases (100%). Postoperative complications included cerebral infarction in 2 patients (6.7%), recurrent nerve palsy in one patient (3.3%). The 30-day mortality was 0%. During the median follow-up period of 14 months (6-56), overall survival at 12 months was 92.3% without any aneurysm-related death. Type 1b and type 2 endoleaks were observed in one each and no reintervention was encountered. CONCLUSION Early clinical outcomes of the D-RIBS for high-risk patients with CAAs are acceptable. The gutter balloon method enables safe and reliable fenestration. Further studies and dedicated devices are warranted.
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Affiliation(s)
- Takao Ohki
- Division of Vascular Surgery, Department of Surgery, the Jikei University School of Medicine, Tokyo, Japan.
| | - Koji Maeda
- Division of Vacular Surgery, International University of Health and Welfare, Narita, Japan
| | - Takeshi Baba
- Division of Vascular Surgery, Department of Surgery, the Jikei University School of Medicine, Tokyo, Japan
| | - Kenjirou Kaneko
- Department of Surgery, Shinyurigaoka General Hospital, Kawasaki, Japan
| | - Kota Shukuzawa
- Division of Vascular Surgery, Department of Surgery, the Jikei University School of Medicine, Tokyo, Japan
| | - Masayuki Hara
- Division of Vascular Surgery, Department of Surgery, the Jikei University School of Medicine, Tokyo, Japan
| | - Makiko Omori
- Division of Vascular Surgery, Department of Surgery, the Jikei University School of Medicine, Tokyo, Japan
| | - Hirotsugu Ozawa
- Division of Vascular Surgery, Department of Surgery, the Jikei University School of Medicine, Tokyo, Japan
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Bao X, Zhao Y, Li T, Wu M, Zeng Z, Gao M, Xu D, Feng J, Feng R. Chimney Graft Technique Combined With Embolization for Treating Ruptured Aortic Arch Lesions. Front Cardiovasc Med 2021; 8:711283. [PMID: 34671650 PMCID: PMC8520930 DOI: 10.3389/fcvm.2021.711283] [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: 06/15/2021] [Accepted: 09/03/2021] [Indexed: 11/13/2022] Open
Abstract
Background: This study aimed to share the experience in applying the chimney graft technique combined with embolization for treating aortic arch rupture under emergency conditions and evaluating early-term results in these patients. Methods: This study retrospectively included patients with ruptured aortic arch lesions who received the chimney graft technique combined with embolization between March 2016 and March 2021. The primary endpoint was a technical success, deemed as successful stent graft deployment to the planned location, patency of the target branch vessel, and absence of significant type I endoleak. The secondary endpoint was clinical success defined with the size of false lumen in follow-up remaining unchanged or decreasing over time, 30-day mortality, complication, and primary patency of chimney graft. Results: This study included 12 patients (age, 61 ± 12 years; male, 83%). Five patients (42%) received single chimney, one patient (8%) received double chimney, and six patients (50%) received triple chimney. Intraoperative type I endoleak occurred in six patients (50%) who underwent endovascular embolization in the primary operation. Post-operative type I endoleak, evaluated by computed tomography angiography examination following the primary operation, occurred in seven patients (58%), including one patient who received endovascular embolization two times. All patients with post-operative type I endoleak were successfully re-treated using coil and Onyx glue within 1 week, and the median length of stay was 22 ± 11 days (range: 7-44 days). Overall technical success was 100%. Eleven patients had completed their follow-up (median, 12 months, range: 1-34 months), and one patient was out of contact. The 30-day mortality was 9% (1/11, post-operative death of a patient with cerebral hemorrhage). No major complications and no chimney compression, migration, occlusion, or stenosis were recorded during follow-up. Seven patients (58%) have ≥6 months of clinical follow-up time with appropriate imaging. In four (57%) of these patients, diameter stabilization was detected, whereas three (43%) experienced significant reduction (≥5 mm). Conclusion: The patients in this study had satisfactory early-term outcomes. The chimney graft technique combined with coil and Onyx glue embolization may be a safe and effective treatment for ruptured aortic arch lesions under emergency conditions.
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Affiliation(s)
- Xianhao Bao
- Department of Vascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuxi Zhao
- Department of Vascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tao Li
- Department of Cardiovascular Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Mingwei Wu
- Department of Vascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhaoxiang Zeng
- Department of Vascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Minxin Gao
- Department of Vascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ding Xu
- Department of Vascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiaxuan Feng
- Department of Vascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rui Feng
- Department of Vascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Stana J, Peterß S, Prendes CF, Stavroulakis K, Rantner B, Pichlmaier M, Tsilimparis N. [Ascending Aorta and Aortic Arch - Endovascular Therapy Today and in the Future]. Zentralbl Chir 2021; 146:479-485. [PMID: 34666362 DOI: 10.1055/a-1644-1759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Pathologies in the region of the aortic arch may occur in isolation, but adjacent segments of the thoracic aorta - the ascending or descending aorta - are much more commonly affected. The first surgical procedures to treat the aortic arch were performed nearly six decades ago. Despite numerous improvements and innovations in the 20th and early 21st centuries, these procedures are still associated with relevant operative mortality and neurological complication rates. Endovascular techniques and modern hybrid procedures are increasingly expanding the therapeutic spectrum in the aortic arch, although the open surgical approach is currently still the gold standard. Endovascular treatment of aortic aneurysm was first performed in the early 1990s in the infrarenal abdominal aorta. It was not long before the first attempts at endovascular therapy were made for the treatment of the aortic arch. In 1996, Inoue et al. reported the use of the first commonly used endoprosthesis to treat aneurysms in the aortic arch. Continuous improvements and refinements in implantation techniques and also implanted material have resulted in endovascular therapy now being an increasingly important option compared to open surgical procedures in the descending thoracic and abdominal aorta and has partially replaced them as the gold standard. This review article aims to provide an overview of the prerequisites, results, but also limitations of endovascular surgery of the aortic arch.
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Affiliation(s)
- Jan Stana
- Abteilung für Gefäßchirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
| | - Sven Peterß
- Abteilung für Gefäßchirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
| | | | | | - Barbara Rantner
- Abteilung für Gefäßchirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
| | - Maximilian Pichlmaier
- Herzchirurgische Klinik und Poliklinik, Klinikum der Ludwig-Maximilians-Universität München, Standort Großhadern, München, Deutschland
| | - Nikolaos Tsilimparis
- Abteilung für Gefäßchirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
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Prendes CF, Lindström D, Mani K, Tegler G, Wanhainen A. A systematic review of experimental and clinical studies reporting on in situ laser fenestration of aortic endografts. J Vasc Surg 2021; 75:740-752.e1. [PMID: 34634422 DOI: 10.1016/j.jvs.2021.09.031] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 09/12/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To summarize available in-situ laser fenestration (ISLF) literature, including experimental studies with their subsequent recommendations regarding optimal fenestration technique and fabric; as well as the short and mid-term results of clinical studies. METHODS A systematic review of English articles was performed in MEDLINE, the Cochrane Database and EMBASE, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines by two researchers. The search period was without starting date until the 31st August 2020, and search terms included were in situ, laser, fenestration, and endograft. Quality assessment of the studies was performed using the Newcastle-Ottawa scale by two other independent researchers. RESULTS A total of 19 clinical studies were included, with a total of 428 patients (390 supra-aortic trunk ISLF, 38 visceral vessel ISLF). The technical success was 96.9% and 95.6% supra-aortic and visceral vessel ISLF, respectively. Most studies have less than 12-month follow-up, and the longest available follow-up (in one study) was 5-years for left-subclavian fenestration and 17-months for visceral vessel ISLF. Overall, the quality of the evaluated clinical studies was low. Six experimental studies were included, with the highest level of evidence suggesting fenestration of multifilament polyethylene terephthalate grafts, followed by dilation with either a 6- or 8-mm non-compliant balloon. CONCLUSION Experimental studies favour the use of multifilament polyethylene terephthalate , followed by dilation with non-compliant balloons as the most durable "in-vitro" technique for ISLF. Short-term outcomes for arch and visceral vessel revascularization are promising, with low rates of in-hospital mortality, stroke, and end-organ ischemia. Nonetheless, the long-term durability of ISLF is yet to be determined and they should be limited to selected symptomatic or urgent cases.
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Affiliation(s)
| | - David Lindström
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Kevin Mani
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Gustaf Tegler
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Anders Wanhainen
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
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Tsilimparis N, Prendes CF, Rouhani G, Adam D, Dias N, Stana J, Rohlffs F, Mani K, Wanhainen A, Kölbel T. Pre-Loaded Fenestrated Thoracic Endografts for Distal Aortic Arch Pathologies: Multicentre Retrospective Analysis of Short and Mid Term Outcomes. Eur J Vasc Endovasc Surg 2021; 62:887-895. [PMID: 34629278 DOI: 10.1016/j.ejvs.2021.08.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 07/24/2021] [Accepted: 08/14/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To determine short and midterm outcomes of a pre-loaded fenestrated thoracic endograft (f-TEVAR) for exclusion of distal aortic arch pathologies. METHODS This was a multicentre, retrospective study including consecutive patients from six experienced European vascular centres undergoing f-TEVAR for distal arch pathologies. Primary endpoints included peri-operative mortality and peri-operative stroke and/or spinal cord ischaemia rates. Secondary outcomes were technical success and mid to late events, including death and re-interventions. Statistical analysis was performed with SPSS 26. Mid to late term events were calculated using Kaplan-Meier survival analysis. RESULTS One hundred and eight patients were included (mean age 68 ± 11 years, 70% men). A total of 38% (n = 42) had a prior history of aortic dissection, and 24% (n = 26) prior aortic surgery. The mean aneurysm diameter was 59 ± 12 mm and the most frequent indication for treatment was post-dissection aneurysms (n = 42, 39%). Technical success was 99% (n = 107) despite intra-operative wire entanglement occurring in 29% (n = 31). The 30 day mortality rate was 3.7% (n = 4), with a 5.6% major stroke incidence (n = 6) and 3.7% (n = 4) spinal cord ischaemia rate. Three cases of retrograde dissection occurred (two of which were fatal), all in post-type B dissecting aneurysm patients without prior aortic surgery (three of 19, 15.8%). Median follow up was 12 months (range, 1 - 26). Endoleaks were documented during follow up, with 3.5% type Ia (4/104) and 2.9% type Ib (3/104) as a result of persistent false lumen perfusion. The one, two, and three year survivals and freedom from re-intervention rates were 93.2% and 92.1%, 89.1% and 86.3%, and 84.4% and 73%, respectively. CONCLUSION This multicentre study shows that treatment of the distal aortic arch by f-TEVAR is feasible, with promising 30 day mortality, stroke, and spinal cord ischaemia rates.
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Affiliation(s)
- Nikolaos Tsilimparis
- Department of Vascular Surgery, Ludwig Maximilians University Hospital, Munich, Germany.
| | - Carlota F Prendes
- Department of Vascular Surgery, Ludwig Maximilians University Hospital, Munich, Germany
| | - Guido Rouhani
- Section of Vascular Surgery, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Donald Adam
- Department of Vascular and Endovascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Nuno Dias
- Department of Vascular Surgery, Malmö Vascular Centre, Sweden
| | - Jan Stana
- Department of Vascular Surgery, Ludwig Maximilians University Hospital, Munich, Germany
| | - Fiona Rohlffs
- German Aortic Centre Hamburg, Department of Vascular Medicine, Hamburg, Germany
| | - Kevin Mani
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Sweden
| | - Anders Wanhainen
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Sweden; Department of Surgical and Peri-operative Sciences, Umeå University, Sweden
| | - Tilo Kölbel
- German Aortic Centre Hamburg, Department of Vascular Medicine, Hamburg, Germany
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Schenning RC, Al-Hakim R. Aortic Dissection: Branched, Fenestrated, and Parallel Aortic Stent Grafts in the Ascending Aorta and Arch. Tech Vasc Interv Radiol 2021; 24:100754. [PMID: 34602271 DOI: 10.1016/j.tvir.2021.100754] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Open surgical repair of dissections and post-dissection degenerative aneurysms involving the ascending thoracic aorta and aortic arch, whether in the acute or post-repair state, is associated with high rates of morbidity and mortality. Recent advancements in minimally invasive endovascular techniques have expanded the role of thoracic endovascular aortic repair (TEVAR) for dissections and dissection-related arch pathologies. Image-guided endovascular techniques, such as in situ fenestrated grafts, chimney and/or periscope grafts, along with newly developed commercially available branched aortic devices, have allowed for an increasing number of high-risk operative candidates to undergo definitive repair of aortic arch pathology who otherwise would have been destined for non-operative management. This paper reviews the data, pre-procedural planning, and technical considerations for complex TEVAR techniques for ascending and aortic arch dissections and dissection-related aneurysms.
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Affiliation(s)
- Ryan C Schenning
- Charles T. Dotter Department of Interventional Radiology, Oregon Health & Science University, Portland, OR.
| | - Ramsey Al-Hakim
- Charles T. Dotter Department of Interventional Radiology, Oregon Health & Science University, Portland, OR
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Brown JA, Arnaoutakis GJ, Szeto WY, Serna-Gallegos D, Sultan I. Endovascular repair of the aortic arch: State of the art. J Card Surg 2021; 36:4292-4300. [PMID: 34405439 DOI: 10.1111/jocs.15920] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 08/08/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Open total arch replacement remains the gold standard treatment for aneurysms and dissections involving the aortic arch. However, high-risk surgical candidates may benefit from endovascular techniques to reduce the risk of perioperative mortality and morbidity, especially neurologic complications. Numerous endografts are available for investigational use in the aortic arch as part of investigational device exemption (IDE) programs. Some devices are fenestrated or scalloped, while others are branched, ranging from single branch to triple branch stent-grafts. Furthermore, chimney techniques and in situ fenestration may be utilized in bailout or emergent situations. RESULTS Initial results describing outcomes of complete endovascular repair of the aortic arch are encouraging, with current data estimating that technical success ranges from 84.2% to 100%. Moreover, operative mortality may be as high as 13.2%, while neurologic complications also remain common, with stroke rates being as high as 20% and spinal cord ischemia being as high as 3.1%. However, more data are necessary to determine the comparative treatment effect of endovascular stent-grafting of the aortic arch, compared with conventional open and hybrid repairs. Longitudinal follow-up is also lacking, which will determine the long-term durability of endografts in the aortic arch. Nevertheless, endovascular repair represents an important opportunity for improving outcomes in patients with complex and potentially devastating pathologies of the aortic arch.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - George J Arnaoutakis
- Division of Cardiovascular Surgery, University of Florida, Gainesville, Florida, USA
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Derek Serna-Gallegos
- UPMC Center for Thoracic Aortic Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,UPMC Center for Thoracic Aortic Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Song J, Qian J, Duan Q, Dong A, Kong M. The effect of in situ laser fenestration for total endovascular arch repair in redo aortic dissection. Vascular 2021; 30:1044-1050. [PMID: 34402656 DOI: 10.1177/17085381211041474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Treatment of aortic arch pathologies in redo cases is technically challenging. In this study, we assessed early and mid-term outcomes of total endovascular arch repair combined with a new method of in situ laser fenestration. METHODS Between January 2018 and March 2019, five patients with a history of cardiovascular surgery underwent in situ laser fenestration procedures using the "squid capture technique" for aortic arch pathologies with dissection. All patients were followed up regularly and imaging examinations were performed. The technical success, procedural complications, as well as the early and mid-term mortality and morbidity rates were evaluated. RESULTS All patients survived the operation and fenestration was technically successful in all of the patients. There was no in-hospital mortality. No patients developed major complications, such as peri-operative strokes, transient ischemic attacks, or spinal cord ischemia. The 11-22 months follow-up (mean, 17 months) was completed by all patients. No endoleaks were discovered; false lumen thromboses and subsequent positive remodeling of the aorta were demonstrated and all in situ laser-fenestrated arteries were patent. CONCLUSIONS In situ laser fenestration combined with "squid capture technique" was shown to may be an effective and safe option for reconstruction of aortic arch during thoracic endovascular aortic repair. In situ laser fenestration combined with "squid capture technology" was shown to be an effective treatment option for patients with prior history of cardiovascular surgery and who are at high risk for redo open operations.
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Affiliation(s)
- Jiangwei Song
- Department of Cardiovascular Surgery, Second Affiliated Hospital, 89681Zhejiang University, Hangzhou, People's Republic of China
| | - Jianfang Qian
- Department of Cardiovascular Surgery, Second Affiliated Hospital, 89681Zhejiang University, Hangzhou, People's Republic of China
| | - Qunjun Duan
- Department of Cardiovascular Surgery, Second Affiliated Hospital, 89681Zhejiang University, Hangzhou, People's Republic of China
| | - Aiqiang Dong
- Department of Cardiovascular Surgery, Second Affiliated Hospital, 89681Zhejiang University, Hangzhou, People's Republic of China
| | - Minjian Kong
- Department of Cardiovascular Surgery, Second Affiliated Hospital, 89681Zhejiang University, Hangzhou, People's Republic of China
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Experimental Analysis of In Situ Fenestration of Endovascular Stent-Grafts: Comparison between Needle and Laser Puncture. Ann Vasc Surg 2021; 77:280-287. [PMID: 34411679 DOI: 10.1016/j.avsg.2021.05.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 05/15/2021] [Accepted: 05/19/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND To evaluate the quality of in vitro fenestrations during in situ fenestration (ISF) and investigate the differences between needle and laser puncture in current stent-grafts. METHODS An in vitro study evaluated the damage created by needle ISF on stent-graft fabrics versus laser ISF. Fenestrations were made in 5 different commercially available stent-grafts, including polyester stent-grafts (Relay, Valiant and Hercules) and expanded polytetrafluoroethylene (ePTFE) stent-grafts (TAG and Ankura). Each stent-graft received fenestration by needle and laser separately, followed by gradual dilation (4 mm, 6 mm, 8 mm, and 10 mm sequentially) of noncompliant balloons. Quantitative and qualitative evaluations including fenestration diameter, area, shape and margins were conducted using light microscopy and scanning electron microscope. RESULTS The primary fenestrations created by needle were slit-like with visible cut-off fibers in polyester stent-grafts and were almost circular with clear margins in ePTFE stent-grafts; those created by laser were squared or elliptical with ragged edges and burned fibers in all the stent-grafts. Fabric debris and toxic particles due to burning of the material were generated during laser-assisted fenestration. The Primary holes in polyester stent-grafts (Relay, Valiant and Hercules) by needle showed smaller area (0.05 mm2 vs. 0.22 mm2, 0.52 mm2 vs. 0.70 mm2 and 0.28 mm2 vs. 0.46 mm2; P < 0.01) and worse shape (0.93 vs. 2.46, 1.17 vs. 2.33 and 0.93 vs. 2.47; P < 0.01) than those by laser, while larger area (0.67 vs.0.43, 0.59 vs.0.45; P < 0.05), better shape (3.93 vs. 2.53, 3.90 vs. 2.93; P < 0.05) and better margin (3.83 vs. 2.47, 3.83 vs. 2.53; P < 0.05) in ePTFE stent-grafts (TAG and Ankrura). After gradual balloon dilation, the final holes showed no evident difference in maximal length, fenestration area, scores of shape and margin between the 2 ways of fenestration (P > 0.05). Ankura stent-graft showed the largest holes with best quality than the others. CONCLUSIONS The primary fenestrations were different between needle and laser puncture, laser induced fabric debris and toxic particles release should be cautiously considered. The final fenestrations were similar after gradual balloon dilation.
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Bashir M, Bailey D, Jones WD, White RD, Williams IM. The fate of the left subclavian artery in TEVAR for aortic arch pathology. J Card Surg 2021; 36:3547-3553. [PMID: 34309881 DOI: 10.1111/jocs.15831] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 07/10/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIM OF STUDY The origin of the vertebral artery (VA) from the left subclavian (LSA) is variable and must be considered when proximal ligation or embolization is performed post thoracic endovascular aortic repair (TEVAR) and extra-anatomical bypass (EAB). A retrospective study was conducted to understand the patency of the LSA and VAs after TEVAR and the relationship of the EAB to the LSA. METHODS Fifty-six patients underwent TEVAR where the LSA origin was occluded. A comparison was performed between the length of the proximal LSA from the arch of the aorta to the origin of the VA. Patient outcomes included posterior or anterior circulation cerebrovascular accident, spinal cord ischemia (SCI), and symptoms and signs of left arm ischemia (LAI). Thirty one underwent EAB with 8 undergoing occlusion of the LSA proximal to the origin of the left VA. A further 25 underwent TEVAR with no EAB performed. The mean (standard deviation) of origin of the VA from the origin at the arch was 37.0 (12.9) mm compared to 34.0 (13.7) mm in those where no bypass was performed (p 0.45). Four patients underwent intraluminal plug occlusion and four had external ligation of the proximal LSA in those undergoing EAB. CONCLUSIONS Careful evaluation of the LSA is needed when planning TEVAR as occlusion techniques may be dependent on a minimum length of the VA from the aortic arch. The mean length of the VA from the aorta has high heterogeneity which may dictate the optimum occlusion method for LSA.
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Affiliation(s)
- Mohamad Bashir
- Department of Vascular Surgery, University Hospital of Wales, Heath Park, Cardiff, UK
| | - Damian Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - William D Jones
- Department of Vascular Surgery, University Hospital of Wales, Heath Park, Cardiff, UK
| | - Richard D White
- Department of Vascular Surgery, University Hospital of Wales, Heath Park, Cardiff, UK
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Heath Park, Cardiff, UK
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Modern Management of Type B Aortic Dissections. CURRENT SURGERY REPORTS 2021. [DOI: 10.1007/s40137-021-00299-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Mesar T, Alie-Cusson FS, Rathore A, Dexter DJ, Stokes GK, Panneton JM. A more proximal landing zone is preferred for thoracic endovascular repair of acute type B aortic dissections. J Vasc Surg 2021; 75:38-46. [PMID: 34197944 DOI: 10.1016/j.jvs.2021.06.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 06/21/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Thoracic endovascular aortic repair (TEVAR) has become first line therapy for complicated acute type B aortic dissection (aTBAD). However, the strategy for optimal proximal landing zone remains to be determined. We compared early outcomes and late aortic-related adverse events in patients undergoing TEVAR for complicated aTBAD with endograft deployment in proximal landing zone 2 versus 3. METHODS We performed a retrospective chart review of adult patients undergoing TEVAR for complicated aTBAD within 6 weeks of diagnosis from 1/2008 to 12/2018. We excluded patients with connective tissue disorders and prior type A repair. Patients were divided into landing zone 2 TEVAR (Z2T) and zone 3 TEVAR (Z3T) groups. Z2 patients were divided between left subclavian artery (LSA) revascularization (Z2R) versus LSA coverage without revascularization (Z2C). Groups were compared for need for aortic re-intervention within 36 months of initial admission and freedom from aortic related adverse events and mortality (AREM), defined as need for aortic re-intervention, aortic-related death or rupture. RESULTS Eighty-three patients underwent TEVAR for complicated aTBAD within a mean of 4.1±7.8 days. 89.5% of patients had less than 2 cm of healthy proximal descending thoracic aorta. Landing zone was Z3T in 35 patients and 48 underwent Z2T: 10 Z2C and 38 Z2R. There were no differences between Z2T and Z3T in time from diagnosis to TEVAR, demographics, comorbidities and diameter aortic measurements. 30-day survival was 87.8%: 89.5% for Z2R, 88.6% for Z3 and 80.0 % for Z2C (p=0.610). Post-operative spinal cord ischemia rate was 3.7%: 2.7 % for Z2R, 0% for Z3T and 20.0% for Z2C (p=0.012). Post-operative thoracic aortic rupture was 2.2% in Z2 and 0 in Z3. Need for aortic re-intervention at 36 months post-TEVAR was lower for Z2T (10.4%) vs. Z3T (31.4%), p=0.025. Freedom from AREM at 36 months was higher in Z2T vs. Z3T - 87.5% vs. 68.6%, p= 0.048. Freedom from proximal re-intervention was higher in Z2T (95.8%) compared to Z3T (80.0%), p=0.019. Z3T deployment was predictive for AREM (OR:3.648,95%CI:1.161-11.465,p=0.027) and need for proximal re-intervention (OR: 5.542,95%CI:1.062-28.927,p=0.042). CONCLUSION Most patients with aTBAD have less than 2 cm of proximal healthy descending thoracic aorta. In patients treated for complicated aTBAD, zone 2 TEVAR is associated with a lower need for aortic re-intervention and aortic-related adverse events than zone 3 TEVAR. Patients may benefit from a more aggressive proximal landing zone with similar perioperative morbidity when zone 2 TEVAR is done with LSA revascularization.
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Affiliation(s)
- Tomaz Mesar
- Eastern Virginia Medical School, Division of Vascular Surgery, Norfolk, VA, USA.
| | - Fanny S Alie-Cusson
- Eastern Virginia Medical School, Division of Vascular Surgery, Norfolk, VA, USA
| | - Animesh Rathore
- Eastern Virginia Medical School, Division of Vascular Surgery, Norfolk, VA, USA
| | - David J Dexter
- Eastern Virginia Medical School, Division of Vascular Surgery, Norfolk, VA, USA
| | - Gordon K Stokes
- Eastern Virginia Medical School, Division of Vascular Surgery, Norfolk, VA, USA
| | - Jean M Panneton
- Eastern Virginia Medical School, Division of Vascular Surgery, Norfolk, VA, USA
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Evans E, Veeraswamy R, Zeigler S, Wooster M. Laser in situ Fenestration in Thoracic Endovascular Aortic Repair: A Single-Center Analysis. Ann Vasc Surg 2021; 76:159-167. [PMID: 34153488 DOI: 10.1016/j.avsg.2021.05.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/13/2021] [Accepted: 05/16/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Laser in situ fenestration (LISF) is an expanding technique for arch vessel revascularization in thoracic endovascular aortic repair (TEVAR). We present a single center's early and midterm outcomes using adjunctive LISF with TEVAR for treatment of various arch pathologies. METHODS 24 patients underwent TEVAR with LISF (2017-2020). Patients were evaluated by an Aortic Team consisting of cardiothoracic and vascular surgeons and were deemed unfit for open surgical repair. Informed consent emphasized the procedure's off-label nature. Thoracic stent-grafts were sized by preoperative Computed Tomography Angiogram and intraoperative Intravascular Ultrasound, with oversizing determined by pathology. Extra-anatomic debranching was performed in staged or concurrent fashion based on urgency of repair and access site options for branch fenestration. A 2.3 mm Spectranetics laser was used, with access site determined at surgeon discretion. Covered balloon expandable stent-grafts were deployed with 0-10% oversizing. RESULTS In 24 patients, a total of 30 fenestrations were created (LSA N = 19, LCCA N = 3, Innominate N = 7, RSA N = 1) with 1 (N = 18) or 2 (N = 6) fenestrations/patient. Indications included aneurysm (8), chronic dissection with aneurysmal degeneration (8), acute dissection (4), intramural hematoma (2), and pseudoaneurysm (2). 13 cases were elective, and 11 were emergent. Technical success was 100%. 12 patients underwent concurrent (N = 8) or staged (N = 4) extra-anatomic bypass. The major complication rate was 21%, including stroke (N = 3) and 30-day mortality (N = 2). The overall complication rate was 58%. Over a mean follow up of 261 days (15-864 days), 7 patients (32%) have required reinterventions. CONCLUSIONS LISF for branch revascularization in TEVAR is technically feasible for treating various aortic arch pathologies, demonstrating practicality in both elective and emergent settings. With a morbidity and mortality profile that is favorable compared to that of open repair, LISF with TEVAR is a promising potential option for patients with complex arch pathology and prohibitive open surgical risk.
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Affiliation(s)
- Elizabeth Evans
- Medical University of South Carolina, Ashley River Tower, Charleston, SC
| | | | - Sanford Zeigler
- Medical University of South Carolina, Ashley River Tower, Charleston, SC
| | - Mathew Wooster
- Medical University of South Carolina, Ashley River Tower, Charleston, SC.
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Endovascular Treatment of Post Type A Chronic Aortic Arch Dissection With a Branched Endograft: Early Results From a Retrospective International Multicenter Study. Ann Surg 2021; 273:997-1003. [PMID: 30973389 DOI: 10.1097/sla.0000000000003310] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate the outcome of endovascular aortic arch repair for chronic dissection with a custom-made branched endograft. BACKGROUND Acute type A aortic dissections are often treated with prosthetic replacement of the ascending aorta. During follow-up, repair of an aneurysmal evolution of the false lumen distal to the ascending prosthesis can be a challenge both for the surgeon and the patient. METHODS We conducted a multicenter, retrospective study of consecutive patients from 14 vascular units treated with a custom-made, inner-branched device (Cook Medical, Bloomington, IN) for chronic aortic arch dissection. Rates of in-hospital mortality and stroke, technical success, early and late complications, reinterventions, and mortality during follow-up were evaluated. RESULTS Seventy consecutive patients were treated between 2011 and 2018. All patients were considered unfit for conventional surgery. In-hospital combined mortality and stroke rate was 4% (n = 3), including 1 minor stroke, 1 major stroke causing death, and 1 death following multiorgan failure. Technical success rate was 94.3%. Twelve (17.1%) patients required early reinterventions: 8 for vascular access complication, 2 for endoleak correction, and 2 for pericardial effusion drainage. Median follow-up was 301 (138-642) days. During follow-up, 20 (29%) patients underwent secondary interventions: 9 endoleak corrections, 1 open repair for prosthetic kink, and 10 distal extensions of the graft to the thoracic or thoracoabdominal aorta. Eight patients (11%) died during follow-up because of nonaortic-related cause in 7 cases. CONCLUSIONS Endovascular treatment of aortic arch chronic dissections with a branched endograft is associated with low mortality and stroke rates but has a high reintervention rate. Further follow-up is required to confirm the benefits of this novel approach.
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Leoce BM, Bernik JT, Voigt B, Dardik H, Bernik TR. Ortner syndrome secondary to saccular thoracic aneurysm. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2021; 7:371-373. [PMID: 34278060 PMCID: PMC8261533 DOI: 10.1016/j.jvscit.2021.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 05/07/2021] [Indexed: 11/25/2022]
Abstract
Mechanical stretching of the left laryngeal nerve secondary to an enlarged left atrium was first described by Dr Norbert Ortner in 1987. An extensive literature search revealed only 76 reported cases of Ortner syndrome, with the more recent reports describing other causes of the syndrome such as pulmonary hypertension, aortic dissection, and a thoracic aneurysm. We recently encountered this rare pathologic entity in an elderly man who had presented with severe hoarseness, presumed to be due to one of the aforementioned vascular anomalies. In the present report, we have highlighted the pathology and hybrid repair of this challenging entity.
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Affiliation(s)
- Brian M Leoce
- Department of Vascular Surgery, Englewood Hospital and Medical Center, Englewood, NJ
| | - Jack T Bernik
- Department of Vascular Surgery, Englewood Hospital and Medical Center, Englewood, NJ
| | - Brett Voigt
- Department of Vascular Surgery, Englewood Hospital and Medical Center, Englewood, NJ
| | - Herbert Dardik
- Department of Vascular Surgery, Englewood Hospital and Medical Center, Englewood, NJ
| | - Thomas R Bernik
- Department of Vascular Surgery, Englewood Hospital and Medical Center, Englewood, NJ
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Post-operative Recurrent Ascending Aortic Pseudoaneurysm with Aorto-cutaneous Fistula- Endovascular management with an In-situ Stent-Graft Fenestration for the Innominate Artery. Ann Vasc Surg 2021; 75:534.e5-534.e9. [PMID: 33951525 DOI: 10.1016/j.avsg.2021.04.012] [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: 07/16/2020] [Revised: 02/22/2021] [Accepted: 04/04/2021] [Indexed: 11/21/2022]
Abstract
Ascending aortic pseudoaneurysm is a known complication of previous cardiac surgery that needs surgical or endovascular intervention. The presence of arch branches complicates the later approach necessitating additional procedures, either hybrid surgical or endovascular modification of the grafts. We describe a patient who developed an ascending aortic pseudoaneurysm after mitral valve replacement, which recurred after surgical patch closure with the formation of a cutaneous fistula. This high-risk patient was managed by an endovascular approach with in-situ fenestration for the innominate artery by a simple technique.
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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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Mulorz J, Knapsis A, Ertas N, Schelzig H, Wagenhäuser MU. Gimme' the Loop: Modifications to the Squid-Capture Technique for Laser-Fenestrated Thoracic Endografting. J Endovasc Ther 2021; 28:524-529. [PMID: 33855878 PMCID: PMC8276338 DOI: 10.1177/15266028211007475] [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] [Indexed: 11/16/2022]
Abstract
PURPOSE Laser-fenestrated thoracic endovascular aortic repair (LfTEVAR) in the aortic arch with covering of the left subclavian artery (LSA) orifice is challenging. To optimize fenestration, the so-called squid-capture technique has been introduced. We present here a modification to the technique that may help improve time-efficiency and safety. TECHNIQUE: During the originally proposed squid-capture maneuver, the stent-graft is deployed in a preset snare wire loop, which is used to pull the stent graft toward the penetration device during in-situ fenestration. In preparation, the guidewire needs to be passed through the loop inside the aortic arch, which can be difficult and may predispose for embolic events. We propose here the creation of a "guidewire-through-snare-loop" configuration outside the body, which can then be reliably transferred into the aortic arch. The modified technique was successfully applied in a patient undergoing LfTEVAR for penetrating aortic ulcers. CONCLUSION The proposed modification may help facilitate the squid-capture technique for LfTEVAR while saving time and resources. Given that LfTEVAR is becoming more frequently used, it is important to ensure technical success and safety of the procedure.
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Affiliation(s)
- Joscha Mulorz
- Department of Vascular and Endovascular Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Artis Knapsis
- Department of Vascular and Endovascular Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Neslihan Ertas
- Department of Vascular and Endovascular Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Hubert Schelzig
- Department of Vascular and Endovascular Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Markus Udo Wagenhäuser
- Department of Vascular and Endovascular Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
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Chang H, Wang Y, Liu B, Wang W, Li Y. Endovascular Repair for Acute Type B Aortic Dissection With Unfavorable Proximal Landing Zone. Ann Thorac Surg 2021; 113:545-553. [PMID: 33819473 DOI: 10.1016/j.athoracsur.2021.02.092] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 02/06/2021] [Accepted: 02/22/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The study aimed to compare the safety and effectiveness between fenestrated technique with or without chimney stent and single-branched stent graft for isolated left subclavian artery revascularization during endovascular repair of acute type B aortic dissection with unfavorable proximal landing zone. METHODS From January 2016 to December 2019, 65 acute type B aortic dissection patients with unfavorable proximal landing zone were treated with either the fenestrated technique (n = 34, group A) or single-branched stent graft (n = 31, group B). Type I endoleak, retrograde type A dissection, stroke, left subclavian artery patency, 30-day mortality, and aortic remodeling were systematically recorded and retrospectively analyzed. RESULTS Technical success rates for groups A and group B were 94.12% and 100%, respectively. Left subclavian artery primary patency was achieved for all enrolled patients. The incidence of type I endoleak, retrograde type A dissection, stroke, and 30-day mortality was 5.9%, 5.9%, 2.9%, and 2.9% in group A, respectively, but none were encountered in group B. Left subclavian artery occlusion was observed in 3 patients in group A and 2 patients in group B during a mean follow-up of 16.18 ± 2.08 months and 15.19 ± 2.68 months, respectively. After the procedure, significant aortic remodeling was detected in both groups during follow-up. CONCLUSIONS Both techniques are feasible and safe for isolated left subclavian artery revascularization during endovascular repair for acute type B aortic dissection. Apart from the associated perioperative risks of complications and mortality for the fenestrated technique, both procedures contributed to favorable aortic remodeling.
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Affiliation(s)
- Haiyang Chang
- Department of Intervention Medicine, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, China; Interventional Oncology Institute of Shandong University, Jinan, Shandong Province, China
| | - Yongzheng Wang
- Department of Intervention Medicine, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, China; Interventional Oncology Institute of Shandong University, Jinan, Shandong Province, China
| | - Bin Liu
- Department of Intervention Medicine, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, China; Interventional Oncology Institute of Shandong University, Jinan, Shandong Province, China
| | - Wujie Wang
- Department of Intervention Medicine, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, China; Interventional Oncology Institute of Shandong University, Jinan, Shandong Province, China
| | - Yuliang Li
- Department of Intervention Medicine, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, China; Interventional Oncology Institute of Shandong University, Jinan, Shandong Province, China.
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Li Y, He C, Chen X, Yao J, Zhang T, Zhang H. Endovascular In Situ Fenestration Technique of Aortic Arch Pathology: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2021; 76:472-480. [PMID: 33508460 DOI: 10.1016/j.avsg.2020.12.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 11/29/2020] [Accepted: 12/13/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the safety, applicability and outcomes of the endovascular in situ fenestration (ISF) technique for patients with aortic arch pathologies by performing a systematic review. METHODS We conducted a systematic search using the PubMed, Embase, and Cochrane databases to identify English language articles between January 2004 and March 2019 on the management of aortic arch pathologies using an in situ fenestration technique. Two independent observers selected studies for inclusion in the study, assessed the methodological quality of the included studies, and extracted the data. The studies included all investigated the clinical outcomes and postprocedural complications of using ISF techniques. RESULTS Seven studies reported on a total of 117 aortic arch pathologies patients. Including 52 dissection patients, 47 aneurysm patients, 18 intramural hematomas and penetrating ulcers patients. Needle fenestration and laser fenestration were performed in 62 and 45 patients respectively, and the rest 10 patients received radiofrequency fenestration. The follow-up period ranged from 1 to 55 months. The pooled technical success rates were 94% (95% confidence interval [CI]: 79-98%). The stroke rate was 6% (95% CI: 3-13%). The 30-day MAE was 11% (95% CI: 6-18%). CONCLUSION The results of the study showed that using the in-situ fenestration technique for treating patients with aortic arch pathologies produced encouraging mid-outcomes. Long-term outcomes remain undefined.
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Affiliation(s)
- Yue Li
- Department of Cardio-Vascular Surgery, Air Force Medical Center of People's Liberation Army, Beijing, 100142, China
| | - Changshun He
- Department of Vascular Surgery, Peking University People's Hospital, Beijing, People's Republic of China
| | - Xia Chen
- Department of Cardio-Vascular Surgery, Air Force Medical Center of People's Liberation Army, Beijing, 100142, China
| | - Jing Yao
- Department of Cardio-Vascular Surgery, Air Force Medical Center of People's Liberation Army, Beijing, 100142, China
| | - Tao Zhang
- Department of Vascular Surgery, Peking University People's Hospital, Beijing, People's Republic of China.
| | - Hongchao Zhang
- Department of Cardio-Vascular Surgery, Air Force Medical Center of People's Liberation Army, Beijing, 100142, China.
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Lin J, Rodriguez LE, Nutley M, Jun L, Mao Y, Parikh N, Alie-Cusson F, Zhang Z, Wang L, Panneton JM, Guidoin R. Optimal In Situ Fenestration Technique With Laser Perforation and Balloon Dilation for Aortic Stent-Grafts. J Endovasc Ther 2021; 28:300-308. [PMID: 33399011 DOI: 10.1177/1526602820981980] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE To evaluate the response of various stent-grafts after laser fenestration and dilation with noncompliant balloons to determine the optimal therapeutic combination for this treatment technique. MATERIALS AND METHODS Five aortic stent-grafts were evaluated ex vivo: the Bolton RelayPlus, Jotec E-vita Thoracic 3G, Medtronic Valiant, Cook Zenith Alpha, and Vascutek Anaconda. Small holes were created using an excimer laser with the grafts submerged in saline. Five rows of 5 fenestrations were created, 4 holes in each row were dilated once with a 6-, 8-, 10-, or 12-mm-diameter noncompliant balloon to the specified nominal pressure (one hole served as the control). The saline solution from each stent-graft was collected and qualitatively analyzed for debris. The fenestrations were evaluated under light and scanning electron microscopes. The maximum diameter and area for each fenestration were measured. The direction and length of tears were assessed. RESULTS The fenestration was feasible and reproducible in all the stent-grafts. The mean area of fenestration ranged from 7.63±1.63 to 14.75±0.73 mm2 when using balloons of 6- and 8-mm diameter, respectively. The 10- and 12-mm-diameter balloons caused a significant increase in area, variability, and tearing. The Anaconda graft tended to tear in the weft direction, while the other devices tore in the warp direction when using the 10- and 12-mm-diameter balloons. Dilation of the RelayPlus and Anaconda grafts with 6- and 8-mm-diameter balloons provided minimal tearing and precise fenestrations. Melted fiber remnants were observed after filtration of the saline solution for all devices. CONCLUSION Laser fenestration and dilation with noncompliant balloons is a relatively simple and reproducible option for revascularization in urgent, complex aortic endovascular repairs. In our model, large balloons (ie, >10 mm) increased the destruction and tearing of the fabric. The maximum dilation recommended is 6 to 8 mm to avoid significant tears. Development of stent-grafts or novel fabrics designed explicitly for fenestration is needed to reduce potential complications.
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Affiliation(s)
- Jing Lin
- Key Laboratory of Textile Science & Technology of Ministry of Education, College of Textiles, Donghua University, Shanghai, China
| | - Limael E Rodriguez
- Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Mark Nutley
- Division of Vascular Surgery and Department of Diagnostic Imaging, University of Calgary, Peter Lougheed Centre, Calgary, Alberta, Canada
| | - Lu Jun
- Key Laboratory of Textile Science & Technology of Ministry of Education, College of Textiles, Donghua University, Shanghai, China
| | - Ying Mao
- Key Laboratory of Textile Science & Technology of Ministry of Education, College of Textiles, Donghua University, Shanghai, China.,Department of Surgery, Faculty of Medicine, Université Laval and Centre de Recherche du CHU, Québec, Canada
| | - Niraj Parikh
- Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Fanny Alie-Cusson
- Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Ze Zhang
- Department of Surgery, Faculty of Medicine, Université Laval and Centre de Recherche du CHU, Québec, Canada
| | - Lu Wang
- Key Laboratory of Textile Science & Technology of Ministry of Education, College of Textiles, Donghua University, Shanghai, China
| | - Jean M Panneton
- Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Robert Guidoin
- Department of Surgery, Faculty of Medicine, Université Laval and Centre de Recherche du CHU, Québec, Canada
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Reevaluating the Need for Routine Coverage of the Left Subclavian Artery in Thoracic Blunt Aortic Injury. Ann Vasc Surg 2020; 73:22-26. [PMID: 33388410 DOI: 10.1016/j.avsg.2020.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 11/27/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) is the treatment of choice for thoracic blunt aortic injury (TBAI). A 20 mm proximal seal zone is recommended based on aneurysmal disease literature which often results in coverage of the left subclavian artery (LSA). The aim of this study was to analyze our experience with TEVAR for TBAI and evaluate whether 20 mm is required to achieve successful remodeling. METHODS This is a single-center, retrospective study of all consecutive patients who received a TEVAR for treatment of moderate and severe TBAI between April 2014 and November 2018. Three-dimensional software reconstruction was used for computed tomography (CT) scan centerline measurements. Outcomes included technical success, need for reinterventions, and immediate and long-term aortic-related complications. RESULTS Sixty-one patients underwent TEVAR for TBAI during the study period. Twenty-eight (46%) patients underwent LSA coverage with an average distance from the LSA to the injury of 6.4 mm (0-15.1 mm). Of the 33 (54%) patients who did not undergo coverage of the LSA, 22 patients (66%) had less than 20 mm of proximal seal zone. The mean distance from the LSA to injury in this group was 16.6 mm (7.9-29.5 mm). None of the patients with LSA coverage developed ischemic symptoms, and an average decrease in left arm systolic blood pressure of 24.8 mm Hg (0-62 mm Hg) was noted versus the right arm. There was no aortic-related mortality in either group. Follow-up CT scans revealed excellent remodeling. CONCLUSIONS Immediate outcomes of TEVAR for TBAI with LSA coverage are well tolerated; however, the long-term sequela of LSA coverage is unknown. Exclusion of the injury and excellent remodeling appear to occur with less than 20 mm of proximal seal, and perhaps more attention should be made to preservation of the LSA.
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