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Gonzalez-Urquijo M, Fumagal González GA, Cárdenas Castro HM, Morales Guzman AA, Guzman Valladares AA, MacDonald DC, Moya Bencomo MD, Botello Arredondo I, Fabiani MA. Analysis of Aortic Arch Hemodynamics With Simulated Bird's Beak Effects. Vasc Endovascular Surg 2024; 58:595-601. [PMID: 38607697 DOI: 10.1177/15385744241247272] [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: 04/14/2024]
Abstract
OBJECTIVE The objective of this study was to investigate the flow effects in different degrees of thoracic aortic stent graft protrusion extension by creating bird beak effect simulations using accurate 3D geometry and a realistic, nonlinear, elastic biomechanical model using computer-aided software SolidWorks. METHODS Segmentation in 3D of an aortic arch from a computed tomography (CT) scan of a real-life patient was performed using SolidWorks. A parametric analysis of three models was performed: (A) Aortic arch with no stent, (B) 3 mm bird-beak configuration, and (C) 6.5 mm bird-beak configuration. Flow velocity, pressure, vorticity, wall shear stress (WSS), and time average WSS were assessed. RESULTS The flow velocity in Model A remained relatively constant and low in the area of the ostium of the brachiocephalic artery and doubled in the left subclavian artery. On the contrary, Models B and C showed a decrease in velocity of 52.3 % in the left subclavian artery. Furthermore, Model B showed a drop in velocity of 82.7% below the bird-beak area, whereas Model C showed a decline of 80.9% in this area. The pressure inside the supra-aortic branches was higher in Model B and C compared with Model A. In Model A, vorticity only appeared at the level of the descending aorta, with low to non-vorticity in the aortic arch. In contrast, Models B and C had an average vorticity of 241.4 Hz within the bird beak area. Regarding WSS, Model A, and Model B shared similar WSS in the peak systolic phase, in the aortic arch, and the bird beak area, whereas Model C had an increased WSS by 5 Pa on average at these zones. CONCLUSION In the present simulations' lower velocities, higher pressures, vortices, and WSS were observed around the bird beak zone, the aortic arch, and the supra-aortic vessels.
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Donik Ž, Li W, Nnate B, Pugar JA, Nguyen N, Milner R, Cerda E, Pocivavsek L, Kramberger J. A computational study of artery curvature and endograft oversize influence on seal zone behavior in endovascular aortic repair. Comput Biol Med 2024; 178:108745. [PMID: 38901185 DOI: 10.1016/j.compbiomed.2024.108745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 05/18/2024] [Accepted: 06/08/2024] [Indexed: 06/22/2024]
Abstract
Thoracic endovascular aortic repair (TEVAR) is a minimally invasive procedure involving the placement of an endograft inside the dissection or an aneurysm to direct blood flow and prevent rupture. A significant challenge in endovascular surgery is the geometrical mismatch between the endograft and the artery, which can lead to endoleak formation, a condition where blood leaks between the endograft and the vessel wall. This study uses computational modeling to investigate the effects of artery curvature and endograft oversizing, the selection of an endograft with a larger diameter than the artery, on endoleak creation. Finite element analysis is employed to simulate the deployment of endografts in arteries with varying curvature and diameter. Numerical simulations are conducted to assess the seal zone and to quantify the potential endoleak volume as a function of curvature and oversizing. A theoretical framework is developed to explain the mechanisms of endoleak formation along with proof-of-concept experiments. Two main mechanisms of endoleak creation are identified: local buckling due to diameter mismatch and global buckling due to centerline curvature mismatch. Local buckling, characterized by excess graft material buckling and wrinkle formation, increases with higher levels of oversizing, leading to a larger potential endoleak volume. Global buckling, where the endograft bends or deforms to conform to the centerline curvature of the artery, is observed to require a certain degree of oversizing to bridge the curvature mismatch. This study highlights the importance of considering both curvature and diameter mismatch in the design and clinical use of endografts. Understanding the mechanisms of endoleak formation can provide valuable insights for optimizing endograft design and surgical planning, leading to improved clinical outcomes in endovascular aortic procedures.
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Affiliation(s)
- Žiga Donik
- Faculty of Mechanical Engineering, University of Maribor, Smetanova ulica 17, 2000 Maribor, Slovenia.
| | - Willa Li
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, The University of Chicago, 5841 S Maryland Ave, MC 5028, Chicago, IL 60637, USA
| | - Blessing Nnate
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, The University of Chicago, 5841 S Maryland Ave, MC 5028, Chicago, IL 60637, USA
| | - Joseph A Pugar
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, The University of Chicago, 5841 S Maryland Ave, MC 5028, Chicago, IL 60637, USA
| | - Nhung Nguyen
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, The University of Chicago, 5841 S Maryland Ave, MC 5028, Chicago, IL 60637, USA
| | - Ross Milner
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, The University of Chicago, 5841 S Maryland Ave, MC 5028, Chicago, IL 60637, USA
| | - Enrique Cerda
- Departamento de Física, Facultad de Ciencia, Universidad de Santiago de Chile (USACH), Santiago Chile
| | - Luka Pocivavsek
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, The University of Chicago, 5841 S Maryland Ave, MC 5028, Chicago, IL 60637, USA.
| | - Janez Kramberger
- Faculty of Mechanical Engineering, University of Maribor, Smetanova ulica 17, 2000 Maribor, Slovenia
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Gonzalez-Urquijo M, Hosseinzadeh E, Aguirre-Soto A, Fabiani MA. Stereolithographic (SLA) 3D Printing for Preprocedural Planning in Endovascular Aortic Repair of a Thoracic Aneurysm. Vasc Endovascular Surg 2024; 58:343-349. [PMID: 37944002 DOI: 10.1177/15385744231215560] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
BACKGROUND When treating aortic aneurysm patients with complex anatomical features, preprocedural planning aided by 3D-printed models offers valuable insights for endovascular intervention. This study highlights the use of stereolithographic (SLA) 3D printing to fabricate a phantom of a challenging aortic arch aneurysm with a complex neck anatomy. CLINICAL CASE A 75-year-old female presented with a 58 mm descending thoracic aortic aneurysm (TAA) extending to the distal arch, involving the left subclavian artery (LSA) and the left common carotid artery (LCCA). The computed tomography (CT) scans underwent scrutiny by radiology and vascular teams. Nevertheless, the precise spatial relationships of the ostial origins proved to be challenging to ascertain. To address this, a patient-specific phantom of the aortic arch was fabricated utilizing an SLA printer and a biomedical resin. The thoracic endovascular aortic repair (TEVAR) procedure was simulated using fluoroscopy on the phantom to enhance procedural preparedness. Subsequently, the patient underwent a right carotid-left carotid bypass and a right carotid-left subclavian bypass. After a 24-hour interval, the patient underwent the TEVAR procedure, during which a 37 mm × 150 mm stent graft (CTAG, WL Gore and Associates, Flagstaff, AZ, USA) and a 40 mm × 200 mm stent graft (CTAG, WL Gore and Associates, Flagstaff, AZ, USA) were deployed, effectively covering the LSA and LCCA. Notably, the aneurysm exhibited complete sealing, with no indications of endoleaks or graft infoldings. At the 12-month follow-up, the patient remains in good health, with no evidence of endoleaks or any other surgery-related complication. CONCLUSION This report showcases the successful use of a 3D-printed endovascular phantom in guiding the decision-making process during the preparation for a TEVAR procedure. The simulation played a pivotal role in selecting the appropriate stent graft, ensuring an intervention protocol optimized based on the patient-specific anatomy.
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Affiliation(s)
| | - Elnaz Hosseinzadeh
- School of Engineering and Sciences, Tecnologico de Monterrey, Monterrey, Mexico
| | - Alan Aguirre-Soto
- School of Engineering and Sciences, Tecnologico de Monterrey, Monterrey, Mexico
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Shahbazian N, Romero DA, Forbes TL, Amon CH. Prediction of bird-beak configuration in thoracic endovascular aortic repair preoperatively using patient-specific finite element simulations. JVS Vasc Sci 2023; 4:100108. [PMID: 37519336 PMCID: PMC10372321 DOI: 10.1016/j.jvssci.2023.100108] [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: 12/16/2022] [Accepted: 04/03/2023] [Indexed: 08/01/2023] Open
Abstract
Objectives Formation of bird-beak configuration in thoracic endovascular aortic repair (TEVAR) has been shown to be correlated with the risk of complications such as type Ia endoleaks, stent graft migration, and collapse. The aim of this study was to use patient-specific computational simulations of TEVAR to predict the formation of bird-beak configuration preoperatively. Methods Patient-specific TEVAR computational simulations are developed using a retrospective cohort of patients treated for thoracic aortic aneurysm. The preoperative computed tomography images were segmented to develop three-dimensional geometry of the thoracic aorta. These geometries were used in finite element simulations of stent graft deployment during TEVAR. Simulated results were compared against the postoperative computed tomography images to assess the accuracy of simulations in predicting the proximal position of a deployed stent graft and presence of bird-beak. In cases with a bird-beak configuration, the length and angle of the bird-beak were measured and compared between the simulated and postoperative results. Results Twelve TEVAR patient cases were simulated. Computational simulations were able to accurately predict whether the proximal stent graft was fully apposed, proximal bare stents were protruded, or bird-beak configuration was present. In three cases with bird-beak configuration, simulations predicted the length and angle of the bird-beak with less than 10% and 24% error, respectively. Other factors such as a small aortic arch angle, small oversizing value, and landing zones close to the arch apex may have played a role in formation of bird-beak in these patients. Conclusions Computational simulations of TEVAR accurately predicted the proximal position of a deployed stent graft and the presence of bird-beak preoperatively. The computational models were able to predict the length and angle of bird-beak configurations with good accuracy. These simulations can provide insight into the surgical planning process with the goal of minimizing bird-beak occurrence.
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Affiliation(s)
- Negin Shahbazian
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, ON, Canada
| | - David A. Romero
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, ON, Canada
| | - Thomas L. Forbes
- Division of Vascular Surgery, Department of Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Cristina H. Amon
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, ON, Canada
- Department of Mechanical and Industrial Engineering, Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
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Identification of geometric and mechanical factors predictive of bird-beak configuration in thoracic endovascular aortic repair using computational models of stent graft deployment. JVS Vasc Sci 2022; 3:259-273. [PMID: 35938091 PMCID: PMC9352945 DOI: 10.1016/j.jvssci.2022.05.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/25/2022] [Indexed: 11/21/2022] Open
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Impact of target visceral vessel anatomical configuration on early complications following endovascular repair of thoracoabdominal aortic aneurysms. Ann Vasc Surg 2021; 81:60-69. [PMID: 34788702 DOI: 10.1016/j.avsg.2021.10.044] [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: 07/09/2021] [Revised: 10/10/2021] [Accepted: 10/11/2021] [Indexed: 11/20/2022]
Abstract
Impact of target visceral vessel anatomical configuration on early complicatins following endovascular repair of thoracoabdominal aortic aneurysms Objectives: Fenestrated and branched endovascular aortic repair (fEVAR-bEVAR) is a viable treatment option for thoracoabdominal aortic aneurysms but target visceral stent (TVS) endoleak and thrombosis remain a limiting factor. This study aims to evaluate TVS anatomy impact on one-year risk of thrombosis and endoleak. METHODS Patients treated with fEVAR-bEVAR for thoracoabdominal aneurysms between 2008-2020 in our centre were enrolled. We recorded comorbidities, operative details, one-month postoperative CT scan (anatomical reference), and TVS behaviour: thrombosis and endoleak at one-year follow-up. For each TVS, different points were identified using a centre-lumen-line: (A) TVS origin, (B) end of branch/fenestration, (C) visceral vessel entry, (D) end of TVS, (E) 1-cm distally. We analyzed TVS tortuosity ((centre-lumen-line/straight distance)-1, in %), image vector analysis of each segment in 2D (antero-posterior, left-right) and 3D (craneo-caudal displacement), and centre-lumen-line analysis (bending in ABC and CDE). Three independent observers performed a blind analysis, and anatomical differences between bEVAR/fEVAR, and cases with/without 1-year thrombosis and TVS endoleak, were compared using Kaplan-Meier curves (Log-Rank test), and T-Test/Wilcoxon signed-ranks test respectively. RESULTS 54 patients (72±713 years mean age; 182 TVS: 50 branches, 132 fenestrations) met the inclusion criteria. bEVAR cases had longer stents, with more caudal 3D angulation and greater ABC angulated segment. After excluding bEVAR cases (low case number), 97 fEVAR TVS were analyzed. Five thrombosis and seven endoleaks were observed. While anatomical configuration showed no association to thrombosis, it was related to endoleak: these cases presented more tortuous stents (5.97%±0.10, 21.40%±0,22, P=.011), with more angulated centre-lumen-line at ABC segment (5.69°±15.77°, 7.18°±7.77°, P=.012), and more upward-pointing stents in the origin of the stent (AB: 89.07°±24.46°, 109.09°±16.56°, P=.012; BC: 87.86°±21.10°, 113.11°±22.23°, P=.026). CONCLUSIONS Anatomical configuration of the TVS is associated with stent type I-III endoleak, but not thrombosis, at one-year following fEVAR. Cases with endoleak presented more tortuous stents, with a more angulated exit from the endograft and upward-pointing of the origin of the stent.
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7
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Cao L, Ge Y, He Y, Wang X, Rong D, Lu W, Liu X, Guo W. Association between aortic arch angulation and bird-beak configuration after thoracic aortic stent graft repair of type B aortic dissection. Interact Cardiovasc Thorac Surg 2021; 31:688-696. [PMID: 33025008 DOI: 10.1093/icvts/ivaa171] [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: 04/03/2020] [Revised: 07/06/2020] [Accepted: 07/15/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The goal of this study was to investigate factors favouring the bird-beak configuration after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection. METHODS We retrospectively analysed 76 patients with type B aortic dissection who underwent landing zone 1 and 2 TEVAR from December 2015 to January 2018. Preoperative aortic arch geometry (aortic arch length, maximal diameter and angulation), stent graft details and operative details were evaluated. A bird-beak configuration was defined as a ≥5-mm gap between the proximal end of the stent and the aortic wall of the lesser curvature. RESULTS Patients were stratified into those with (n = 46) and without (n = 30) a bird-beak configuration. The baseline demographics, dissection chronicity, clinical features and implanted devices were largely similar between the 2 groups. No significant difference was observed in the arch length or maximal arch diameter. However, the mean aortic arch angulation was greater in patients with than without a bird-beak configuration (61.4° vs 51.3°; P < 0.001). No influence of either the stent graft brand or the proximal stent graft type was observed. The multivariable analysis showed that the aortic arch angulation was an independent risk factor for a bird-beak configuration (odds ratio 1.15, 95% confidence interval 1.07-1.24; P < 0.001). A cut-off angle of 59.15° was predictive of a bird-beak configuration (sensitivity 59%; specificity 77%). CONCLUSIONS The preoperative aortic arch angulation was an independent predictor of a postoperative bird-beak configuration in patients with type B aortic dissection who underwent TEVAR that involved the aortic arch. An angle of >59.15° may imply a relatively hostile anatomy with a higher risk of a bird-beak configuration.
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Affiliation(s)
- Long Cao
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China.,Department of General Surgery, Chinese PLA No. 983 Hospital, Tianjin, China
| | - Yangyang Ge
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Yuan He
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Xinhao Wang
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Dan Rong
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Weihang Lu
- Department of General Surgery, The Sixth Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Xiaoping Liu
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Wei Guo
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
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8
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Frohlich MM, Suh GY, Bondesson J, Leineweber M, Lee JT, Dake MD, Cheng CP. Thoracic aortic geometry correlates with endograft bird-beaking severity. J Vasc Surg 2020; 72:1196-1205. [DOI: 10.1016/j.jvs.2019.11.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 11/22/2019] [Indexed: 10/25/2022]
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Marrocco-Trischitta MM, de Beaufort HW, Piffaretti G, Bonardelli S, Gargiulo M, Antonello M, van Herwaarden JA, Boveri S, Bellosta R, Trimarchi S, Castelli P, Gallitto E, Macchi E, Mazzeo G, Saviane G, Secchi F, Spampinato B, Xodo A. The Modified Arch Landing Areas Nomenclature predicts proximal endograft failure after thoracic endovascular aortic repair. Eur J Cardiothorac Surg 2020; 58:309-318. [DOI: 10.1093/ejcts/ezaa115] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 02/18/2020] [Accepted: 02/27/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
Our goal was to assess the value of the Modified Arch Landing Areas Nomenclature (MALAN) for thoracic endovascular aortic repair (TEVAR), in which each landing area (LA) is identified by a proximal landing zone and the type of arch (e.g. 0/I), as predictors of postoperative proximal endograft performance.
METHODS
A multicentre retrospective analysis was performed of patients treated with arch TEVAR (i.e. proximal landing zone 0–3) for various indications between 2007 and 2017. Patients were stratified by the MALAN classification into hostile LAs (i.e. 2/III and 3/III) and favourable LAs (i.e. 0/I–III, 1/I–III, 2/I–II and 3/I–II). Outcome criteria included composite proximal endograft failure (including type Ia endoleak, persistent false lumen perfusion at the level of the most proximal communication between the lumina in aortic dissections, endograft migration and retrograde dissection) and deaths from all causes. Competing risk analyses were performed.
RESULTS
A total of 359 patients (hostile LAs 133; favourable LAs 226) were identified. The median age was 71.0 (62.0–77.0); 78.3% were men. Proximal endograft failure occurred in 28/133 patients (21.1%) in the hostile LA group and in 12/226 (5.3%) in the favourable LA group. On multivariate analysis, hostile LAs were independently associated with proximal endograft failure (P < 0.0001). There was no other independent risk factor. Favourable LAs were associated with an increased mortality rate (P = 0.006), which could be attributed to the proximal LA subgroup (i.e. 0/I–III and 1/I–III) (P < 0.0001), in addition to age (P < 0.0001).
CONCLUSIONS
The MALAN classification identifies hostile proximal landing zones for TEVAR, namely 2/III and 3/III LAs, which are associated with dismal proximal endograft performance. The MALAN appears to be an intuitive and valuable tool to improve the preoperative decision-making process.
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Affiliation(s)
| | - Hector W de Beaufort
- Clinical Research Unit and Division of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Italy
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Gabriele Piffaretti
- Vascular Surgery, Department of Surgery and Morphological Sciences, Circolo University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
| | - Stefano Bonardelli
- Department of Vascular Surgery, A.O Spedali Civili di Brescia, University of Brescia, Brescia, Italy
| | - Mauro Gargiulo
- Vascular Surgery, DIMES, Policlinico Sant’Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - Michele Antonello
- Vascular and Endovascular Surgery Division, Padua University, School of Medicine, Padua, Italy
| | | | - Sara Boveri
- Scientific Directorate, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Raffaello Bellosta
- Vascular Surgery Unit, Cardiovascular Surgery Department, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Santi Trimarchi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical and Community Sciences, University of Milan, Milan, Italy
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Kudo T, Kuratani T, Shimamura K, Sawa Y. Determining the Optimal Proximal Landing Zone for TEVAR in the Aortic Arch: Comparing the Occurrence of the Bird-Beak Phenomenon in Zone 0 vs Zones 1 and 2. J Endovasc Ther 2020; 27:368-376. [DOI: 10.1177/1526602820914269] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To identify the optimal proximal landing zone for thoracic aortic endovascular repair (TEVAR) of aortic arch pathologies so as to avoid the bird-beak phenomenon that leads to type Ia endoleak. Materials and Methods: A retrospective single-center review was conducted of 164 patients (mean age 70.3±10.8 years, range 29–93; 127 men) who underwent repairs of the aortic arch using hybrid TEVAR from April 2008 to March 2017. The patients were divided into 2 groups according to the proximal landing zone: 43 zone 0 patients (26.2%) had total debranching TEVAR (n=18) or total endovascular aortic repair (n=25) while 121 patients (73.8%) had TEVAR landing in zones 1 (n=41) or 2 (n=80). Bird-beak configurations, endoleaks, and stent migrations were assessed on the postoperative and latest computed tomography angiography (CTA) scans. Overall survival and freedom from the bird-beak configuration, aorta-related death, and aortic events were estimated using the Kaplan-Meier method. Hazard ratios (HR) were calculated with the 95% confidence interval (CI). Results: All procedures were successful, without any 30-day mortality. There were 3 early complications (1.8%; all strokes) and 10 early endoleaks (6.1%; no type Ia). On the first postoperative CTA, 42 patients (25.6%) had a bird-beak configuration. The zone 0 patients had significantly fewer (p<0.001), shorter (p<0.004), and less angulated (p<0.001) bird-beak configurations than in zones 1–2. The mean follow-up period was 4.2 years (range 0.5–8.8). There were 18 late deaths (11.0%); only one was related to the aorta (rupture due to a type Ib endoleak in a zone 0 patient). The 5-year freedom from aorta-related death was not significantly different between groups (zone 0: 96.9% vs zones 1–2: 100%, p=0.080). On the latest CTA, 51 (31.0%) patients had a bird-beak configuration; of those, 22 (13.4%) showed >3-mm progression. The freedom from bird-beak configuration estimate was significantly higher in the zone 0 group (95.4%) vs zones 1–2 (57.8%; HR 0.10, 95% CI 0.02 to 0.31, p<0.001). There were 9 late endoleaks (4 type Ia; none in the zone 0 group). The rate of stent-graft migration was significantly lower in the zone 0 group (2.3% vs 14.1% in zones 1–2, p=0.035). Conclusion: Early and most late results in zone 0 TEVAR were equal to those in zones 1 and 2; however, there were no late type Ia endoleaks and fewer bird-beak configurations associated with zone 0 TEVAR, which suggests that zone 0 landing is advantageous for preventing these complications.
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Affiliation(s)
- Tomoaki Kudo
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Toru Kuratani
- Department of Minimally Invasive Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kazuo Shimamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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11
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Torsello GF, Argyriou A, Stavroulakis K, Bosiers MJ, Austermann M, Torsello GB. One-Year Results From the SURPASS Observational Registry of the CTAG Stent-Graft With the Active Control System. J Endovasc Ther 2020; 27:421-427. [PMID: 32193990 PMCID: PMC7288855 DOI: 10.1177/1526602820913007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Purpose: To report the outcomes from the observational SURPASS
registry, which was created to assess the performance of the Conformable TAG
(CTAG) stent-graft with the Active Control System (ACS) in patients undergoing
thoracic endovascular aortic repair (TEVAR) in a real-world setting.
Materials and Methods: The SURPASS registry
(ClinicalTrials.gov; identifier NCT03286400) was an
observational, prospective, single-arm, post-market, international study that
enrolled patients undergoing TEVAR using the CTAG with ACS for both acute and
chronic thoracic aortic disease between October 2017 and July 2018. The CTAG
with ACS features 2-stage deployment of the stent-graft and an optional
angulation mechanism that modifies only the proximal end of the stent-graft.
During the observation period, 127 patients (mean age 67.1±12.1 years, range
27–86; 92 men) were enrolled and treated for an array of aortic pathologies,
including chronic and acute lesions and 4 ruptured descending thoracic
aneurysms. The primary outcome of this study was technical success; secondary
outcomes were clinical success and major adverse events at 30 days and 12
months. The numbers of 2-stage device deployments and applications of the
angulation mechanism were recorded, along with the reasons for use.
Results: Technical success of the TEVAR was 97.6% owing to
unintentional partial coverage of supra-aortic branches in 3 cases (the vessels
were patent on imaging). The stent-graft was repositioned at its intermediate
diameter in 79 patients (62.2%), and the angulation feature was applied in 64
cases (50.4%), mainly to improve proximal wall apposition and orthogonality in
the aorta. The desired effect was achieved in 60 cases (93.8%). There was no
device compression, bird-beak configuration, fracture, or graft occlusion. The
30-day and 12-month clinical success rates were 97.6% and 92.9%, respectively.
There were 3 aorta-related deaths at 30 days and a further 3 at 12 months.
Fatalities were due to a retrograde type A dissection (0.8%), paraplegia, bowel
ischemia, sepsis in the setting of a mycotic aneurysm, aneurysm rupture post
aortoesophageal fistula, and multiorgan dysfunction syndrome. Three endoleaks (2
type Ia and 1 type III) required reintervention. Conclusion: In the
SURPASS registry, the use of the CTAG device with ACS showed promising outcomes
despite the challenging pathologies. The new delivery system enables a
controlled staged delivery with in situ adjustments during positioning,
facilitating the treatment of complex aortic disease.
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Affiliation(s)
- Giovanni Federico Torsello
- Department of Vascular Surgery, St Franziskus Hospital Münster, University of Münster, Germany.,Department of Diagnostic and Interventional Radiology and Nuclear Medicine, Charité Campus Virchow-Klinikum, Charité University Medicine Berlin, Germany
| | - Angeliki Argyriou
- Department of Vascular Surgery, St Franziskus Hospital Münster, University of Münster, Germany
| | | | - Michel J Bosiers
- Department of Vascular Surgery, St Franziskus Hospital Münster, University of Münster, Germany
| | - Martin Austermann
- Department of Vascular Surgery, St Franziskus Hospital Münster, University of Münster, Germany
| | - Giovanni B Torsello
- Department of Vascular Surgery, St Franziskus Hospital Münster, University of Münster, Germany
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12
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Affiliation(s)
- Mourad Boufi
- Department of Vascular Surgery, APHM, University Hospital Nord, Marseille, France.,Aix-Marseille Université, IFSTTAR, Marseille, France
| | - Giorgiana Alexandru
- Department of Vascular Surgery, APHM, University Hospital Nord, Marseille, France
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13
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Azizzadeh A, Desai N, Arko FR, Panneton JM, Thaveau F, Hayes P, Dagenais F, Lei L, Verzini F. Pivotal results for the Valiant Navion stent graft system in the Valiant EVO global clinical trial. J Vasc Surg 2019; 70:1399-1408.e1. [DOI: 10.1016/j.jvs.2019.01.067] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 01/22/2019] [Indexed: 10/26/2022]
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14
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Marrocco-Trischitta MM, Spampinato B, Mazzeo G, Mazzaccaro D, Milani V, Alaidroos M, Ambrogi F, Nano G. Impact of the Bird-Beak Configuration on Postoperative Outcome After Thoracic Endovascular Aortic Repair: A Meta-analysis. J Endovasc Ther 2019; 26:771-778. [DOI: 10.1177/1526602819865906] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Purpose: To investigate the association between the bird-beak configuration (BBC), a wedge-shaped gap between the undersurface of a thoracic endograft and the lesser curvature of the arch after thoracic endovascular aortic repair (TEVAR), and postoperative outcome after TEVAR. Methods: The study was performed according to the PRISMA guidelines. The PubMed, EMBASE, and Cochrane databases were searched to identify all case series reporting BBC after TEVAR between 2006 and April 2018. Data analysis was performed considering the difference in the risk of complications for presence vs absence of BBC. After screening 1633 articles, 21 studies were identified that matched the selection criteria; 12 of these reported detailed information to investigate the postoperative outcome using proportion meta-analysis with a random effects model. The pooled risk difference is reported with the 95% confidence interval (CI). Heterogeneity of the included studies was assessed with the I2 statistic (low 25%, medium 50%, high 75%). Results: Complications occurred within a range of 0 to 72 months in 14.7% (95% CI 7.4% to 27.3%) of patients with BBC and in 6.3% (95% CI 2.5% to 15.4%) of patients without BBC. A cumulative incidence could not be assessed. The summary risk difference was 11.1% (95% CI −0.1% to 22.3%, p=0.052). There was significant heterogeneity ( I2=85.6%). The Egger test did not show evidence of publication bias (p=0.975). When specifically considering type Ia endoleak and endograft migration, the risk difference between BBC and non-BBC patients was 8.2% (95% CI 0.3% to 16.1%, p=0.042; I2=69.0%). The specific risk difference for endograft collapse/infolding and thrombosis was 3.7% (95% CI −3.5% to 11.1%, p=0.308; I2=10.2%). Conclusion: At present the literature does not provide statistical evidence to establish an overall prognostic value of the BBC. Nevertheless, the BBC appears to be associated with a high risk of type Ia endoleak and endograft migration, which warrants specific and long-term surveillance. Clinically relevant values for BBC grading should be established to perhaps define indications for preemptive treatment based on the presence of BBC only.
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Affiliation(s)
- Massimiliano M. Marrocco-Trischitta
- Clinical Research Unit, Cardiovascular Department, IRCCS Policlinico San Donato, Milan, Italy
- Vascular Surgery Unit, Cardiovascular Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Benedetta Spampinato
- Vascular Surgery Unit, Cardiovascular Department, IRCCS Policlinico San Donato, Milan, Italy
- Residency Program in Vascular Surgery, University of Milan, Italy
| | - Girolomina Mazzeo
- Vascular Surgery Unit, Cardiovascular Department, IRCCS Policlinico San Donato, Milan, Italy
- Residency Program in Vascular Surgery, University of Milan, Italy
| | - Daniela Mazzaccaro
- Vascular Surgery Unit, Cardiovascular Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Valentina Milani
- Biostatistics Service, IRCCS Policlinico San Donato, Milan Italy
| | - Moad Alaidroos
- Vascular Surgery Unit, Policlinico San Marco, Zingonia, Italy
| | - Federico Ambrogi
- Biostatistics Service, IRCCS Policlinico San Donato, Milan Italy
- Laboratory of Medical Statistics, University of Milan, Italy
| | - Giovanni Nano
- Vascular Surgery Unit, Cardiovascular Department, IRCCS Policlinico San Donato, Milan, Italy
- Department of “Scienze Biomediche per la Salute,” University of Milan, Italy
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15
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The Modified Arch Landing Areas Nomenclature identifies hostile zones for endograft deployment: a confirmatory biomechanical study in patients treated by thoracic endovascular aortic repair†. Eur J Cardiothorac Surg 2018; 55:990-997. [DOI: 10.1093/ejcts/ezy409] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/22/2018] [Accepted: 10/23/2018] [Indexed: 12/20/2022] Open
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Mestres G, Blanco C, Martinez I, Noya JF, Inaraja-Pérez GC, Antonio Del Castro J, Salmeron LM, Malo N, Riambau V. Aortic Curvature Remodeling after Thoracic Endovascular Aortic Repair: Assessing Device Conformability, Using Image Vector Analysis. Ann Vasc Surg 2018; 56:216-223. [PMID: 30500645 DOI: 10.1016/j.avsg.2018.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 08/06/2018] [Accepted: 09/06/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Aortic arch curvature can be straightened by endograft placement. However, different measurement methods with dissimilar follow-up and endografts have been published. The aim of this study was to corroborate, for the first time, the pliability of the Conformable Gore TAG Thoracic Endoprosthesis (W.L. Gore and Associates, Flagstaff, AZ, USA) into the aortic arch, using different image vector analysis. MATERIAL AND METHODS We, retrospectively, analyzed patients primarily treated for thoracic aortic aneurysms and blunt traumatic aortic injuries by means of a Conformable Gore TAG Thoracic Endoprosthesis endograft proximally sealed into the aortic arch (zones Z1-Z3) in five different Spanish centers, between 2010 and 2017. The preoperative, one-month and six-month postoperative, computed tomography angiographies (CTAs) were obtained, creating accurate 3D center lumen line and external lumen line from the aortic valve to the renal arteries. Three different image analysis methods were used to compare modifications of the aortic curvature: first, segment analysis (angulations of the center lumen line when divided into seven precise segments, examining anterior-posterior, right-left, and cranial-caudal displacement), second, center lumen line analysis (bending of the center lumen line itself in seven definite points), and third, expected behavior (length of the endograft in the external lumen line). Two independent observers performed a blind analysis of all CTAs. Changes between preoperative and postoperative CTAs at one and six months are compared, and differences are viewed between cases sealed proximally (Z1-Z2) and distally (Z3) into the aortic arch. RESULTS We analyzed 37 cases. At 1- and 6-month follow-ups, minimal changes occurred first in segment analysis (only a slight decrease of -2.0° in the XY plane at 10 cm from the brachiocephalic trunk at six-month follow-up was seen, P = 0.027). Second, center lumen line analysis again only showed negligible aortic curvature straightening (+3.5° at 10 cm from the brachiocephalic trunk at one month, P = 0.006, disappearing at six-month follow-up). Finally, good device length predictability was shown (interclass correlation coefficients: 0.995 and 0.994 at one and six months, P > 0.001). No differences were seen between cases proximally sealed into the proximal and distal aortic arch. CONCLUSIONS Conformable Gore TAG Thoracic Endoprosthesis thoracic endograft showed a good pliability into the aortic arch and proximal thoracic aorta, with minimal changes in the aortic curvature after endograft placement in the short-term follow-up (up to six months). In addition, final endograft length into outer aortic curvature is highly predictable.
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Chen CK, Chou HP, Guo CY, Chang HT, Chang YY, Chen IM, Wu MH, Shih CC. Interobserver and intraobserver variability in measuring the tortuosity of the thoracic aorta on computed tomography. J Vasc Surg 2018; 68:1183-1192.e1. [PMID: 29705085 DOI: 10.1016/j.jvs.2018.01.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 01/22/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The variability in measuring the tortuosity of the thoracic aorta has not been previously studied. This study evaluated the interobserver and intraobserver variability of major methods used for measuring the tortuosity of the thoracic aorta in patients with aortic arch or descending thoracic aortic aneurysm. METHODS This retrospective study enrolled 66 patients with aortic arch or descending thoracic aortic aneurysm who had undergone thoracic endovascular aortic repair. Two radiologists used preoperative computed tomography images to measure the tortuosity of the thoracic aorta at multiple segments by using the fitting circle diameter, tortuosity index, and centerline angle methods; these measurements were repeated after an interval of >28 days. The variability of the methods was analyzed for interobserver and intraobserver reliability and agreement. The estimated intraclass correlation coefficient (ICC) was used to analyze the reliability. The Bland-Altman plot was used to analyze the interobserver and intraobserver agreement. The association between aortic characteristics, including calcification, luminal irregularity, shape, and diameter, and the variability of the measurements was also analyzed. RESULTS The interobserver ICC estimates for the tortuosity index at multiple aortic segments, centerline angle methods at the supra-aortic branch orifices, and fitting circle diameter on the greater and lesser curvature sides were 0.97 to 0.98, 0.39 to 0.75, and 0.82 to 0.84, respectively. The corresponding intraobserver ICC estimates were 0.98 to 1.00, 0.44 to 0.75, and 0.82 to 0.85, respectively. In the agreement analysis, the 95% limits of agreement for the tortuosity index, centerline angle, and fitting circle diameter were -5.5% to 5.6%, -10.9% to 10.9%, and -18.0% to 24.0%, respectively. The tortuosity index had the highest ICC estimate and narrowest 99.5% limits of agreement of the three methods. Aortic characteristics, including calcification, grade of atheroma, aneurysm shape, and diameter, were not associated with the variability of the tortuosity index method in the thoracic aorta. CONCLUSIONS The tortuosity index method has low interobserver and intraobserver variability in measuring the tortuosity of the thoracic aorta in patients with thoracic aortic aneurysm. The characteristics of the aorta and aneurysm are not associated with the interobserver or intraobserver variability of the tortuosity index.
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Affiliation(s)
- Chun-Ku Chen
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsiao-Ping Chou
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Radiology, Yonghe Cardinal Tien Hospital, New Taipei City, Taiwan
| | - Chao-Yu Guo
- Division of Biostatistics, Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Hsiao-Ting Chang
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ying-Yueh Chang
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - I-Ming Chen
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Mei-Han Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chun-Che Shih
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.
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Aortic Anatomy and Complications of the Proximal Sealing Zone after Endovascular Treatment of the Thoracic Aorta. Ann Vasc Surg 2018; 48:141-150. [DOI: 10.1016/j.avsg.2017.09.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 07/25/2017] [Accepted: 09/01/2017] [Indexed: 11/21/2022]
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Zhou M, Bai X, Ding Y, Wang Y, Lin C, Yan D, Shi Z, Fu W. Morphology and Outcomes of Total Endovascular Treatment of Type B Aortic Dissection with Aberrant Right Subclavian Artery. Eur J Vasc Endovasc Surg 2017; 54:722-728. [DOI: 10.1016/j.ejvs.2017.09.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 09/25/2017] [Indexed: 12/11/2022]
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20
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Early outcomes of the conformable stent graft for acute complicated and uncomplicated type B aortic dissection. J Vasc Surg 2017; 66:1644-1652. [DOI: 10.1016/j.jvs.2017.04.050] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 04/18/2017] [Indexed: 01/16/2023]
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21
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Bonci G, Steigner ML, Hanley M, Braun AR, Desjardins B, Gaba RC, Gage KL, Matsumura JS, Roselli EE, Sella DM, Strax R, Verma N, Weiss CR, Dill KE. ACR Appropriateness Criteria® Thoracic Aorta Interventional Planning and Follow-Up. J Am Coll Radiol 2017; 14:S570-S583. [DOI: 10.1016/j.jacr.2017.08.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 08/14/2017] [Indexed: 12/11/2022]
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22
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Kudo T, Kuratani T, Shimamura K, Sakamoto T, Kin K, Masada K, Shijo T, Torikai K, Maeda K, Sawa Y. Type 1a endoleak following Zone 1 and Zone 2 thoracic endovascular aortic repair: effect of bird-beak configuration†. Eur J Cardiothorac Surg 2017; 52:718-724. [DOI: 10.1093/ejcts/ezx254] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 04/30/2017] [Indexed: 11/12/2022] Open
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Boufi M, Guivier-Curien C, Loundou A, Deplano V, Boiron O, Chaumoitre K, Gariboldi V, Alimi Y. Morphological Analysis of Healthy Aortic Arch. Eur J Vasc Endovasc Surg 2017; 53:663-670. [DOI: 10.1016/j.ejvs.2017.02.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 02/20/2017] [Indexed: 11/30/2022]
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24
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Li Z, Lu Q, Feng R, Zhou J, Zhao Z, Bao J, Feng X, Feng J, Pei Y, Song C, Jing Z. Outcomes of Endovascular Repair of Ascending Aortic Dissection in Patients Unsuitable for Direct Surgical Repair. J Am Coll Cardiol 2016; 68:1944-1954. [DOI: 10.1016/j.jacc.2016.08.031] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 06/21/2016] [Accepted: 07/22/2016] [Indexed: 10/20/2022]
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Praveen Kumar G, Jafary-Zadeh M, Cui F. Deployment of a Bulk Metallic Glass-Based Self-Expandable Stent in a Patient-Specific Descending Aorta. ACS Biomater Sci Eng 2016; 2:1951-1958. [DOI: 10.1021/acsbiomaterials.6b00342] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Gideon Praveen Kumar
- Institute
of High Performance Computing, A*STAR, 1 Fusionopolis Way #16-16 Connexis, Singapore 138632
| | - Mehdi Jafary-Zadeh
- Institute
of High Performance Computing, A*STAR, 1 Fusionopolis Way #16-16 Connexis, Singapore 138632
| | - Fangsen Cui
- Institute
of High Performance Computing, A*STAR, 1 Fusionopolis Way #16-16 Connexis, Singapore 138632
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Mestres G, Garcia ME, Yugueros X, Urrea R, Tripodi P, Gomez F, Maeso J, Riambau V. Aortic Arch and Thoracic Aorta Curvature Remodeling after Thoracic Endovascular Aortic Repair. Ann Vasc Surg 2016; 38:233-241. [PMID: 27522975 DOI: 10.1016/j.avsg.2016.05.097] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 05/02/2016] [Accepted: 05/06/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The objective of this study was to analyze the original curvature of the aortic arch and thoracic aorta, and how it is modified after the placement of a thoracic endograft. METHODS We retrospectively analyzed all patients primarily treated for thoracic aortic aneurysms and blunt traumatic aortic injuries by means of an endograft sealed into the aortic arch (zones, Z1-Z3) in 2 different centers (Vascular Surgery Division, Hospital Clinic, UB; and Vascular and Endovascular Surgery Department, Hospital Vall d'Hebron, UAB; Barcelona, Spain), between 2010 and 2015. The last preoperative and early (1-month) postoperative computed tomography angiography (CTA) was obtained for all cases, and an accurate 3-dimensional (3D) center lumen line was created, from the aortic valve to the renal arteries. Angles in 2-dimensional (2D; XY-plane) and 3D (referred to cranial-caudal Z-axis) were analyzed in: the distal ascending aorta, aortic arch, and thoracic aorta (at 5, 10, 15, and 20 cm from the brachiocephalic trunk [BCT]) and celiac trunk (CT). Changes in preoperative-postoperative CTA were compared independently for both diseases. Thirty-six cases were included (20 aneurysms, 16 blunt traumatic injuries; mean age, 69.5 and 42.5 years). RESULTS After placement of an aortic endograft (sealed in Z1-Z2 in 30% of aneurysms and 75% of traumatic injuries; mean endograft length: 22.6 cm and 11.3 cm, respectively), a global left anterior displacement of the ascending aorta was observed (2D examination: -13.1° and -7.5°, P = 0.049 and 0.041, respectively). The 3D examination showed an average increase of the aortic angle at 5 and 10 cm from the BCT in the whole sample (+4.0°, +4.9° in reference to the vertical; P = 0.017, 0.001), softening the curvature of the proximal descending thoracic aorta. In addition, in traumatic injuries, a decrease in the aortic arch angle was observed (-3.5°, P = 0.030). CONCLUSIONS Placement of an endograft into the aortic arch and proximal thoracic aorta engenders a softening of the proximal descending thoracic aorta curvature, increasing its angle from the vertical. In blunt traumatic aortic injuries (with shorter and more proximally sealed endografts), an additional decrease of the aortic arch angle (3.5° more vertical), was observed.
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Affiliation(s)
- Gaspar Mestres
- Vascular Surgery Division, Cardiovascular Institute, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain.
| | - Marvin E Garcia
- Vascular and Endovascular Surgery Department, Vall d'Hebron Hospital, UAB, Barcelona, Spain
| | - Xavier Yugueros
- Vascular Surgery Division, Cardiovascular Institute, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Rodrigo Urrea
- Vascular Surgery Division, Cardiovascular Institute, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Paolo Tripodi
- Vascular Surgery Division, Cardiovascular Institute, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Fernando Gomez
- Angioradiology Department, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Jordi Maeso
- Vascular and Endovascular Surgery Department, Vall d'Hebron Hospital, UAB, Barcelona, Spain
| | - Vincent Riambau
- Vascular Surgery Division, Cardiovascular Institute, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
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Praveen Kumar G, Jafary-Zadeh M, Tavakoli R, Cui F. Feasibility of using bulk metallic glass for self-expandable stent applications. J Biomed Mater Res B Appl Biomater 2016; 105:1874-1882. [PMID: 27239801 DOI: 10.1002/jbm.b.33718] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 04/20/2016] [Accepted: 05/09/2016] [Indexed: 01/27/2023]
Abstract
Self-expandable stents are widely used to restore blood flow in a diseased artery segment by keeping the artery open after angioplasty. Despite the prevalent use of conventional crystalline metallic alloys, for example, nitinol, to construct self-expandable stents, new biomaterials such as bulk metallic glasses (BMGs) are being actively pursued to improve stent performance. Here, we conducted a series of analyses including finite element analysis and molecular dynamics simulations to investigate the feasibility of using a prototypical Zr-based BMG for self-expandable stent applications. We model stent crimping of several designs for different percutaneous applications. Our results indicate that BMG-based stents with diamond-shaped crowns suffer from severe localization of plastic deformation and abrupt failure during crimping. As a possible solution, we further illustrate that such abrupt failure could be avoided in BMG-based stents without diamond shape crowns. This work would open a new horizon for a quest toward exploiting superior mechanical and functional properties of metallic glasses to design future stents. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 1874-1882, 2017.
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Affiliation(s)
- Gideon Praveen Kumar
- Engineering Mechanics, Institute of High Performance Computing, A*STAR, Singapore, 138632
| | - Mehdi Jafary-Zadeh
- Engineering Mechanics, Institute of High Performance Computing, A*STAR, Singapore, 138632
| | - Rouhollah Tavakoli
- Department of Material Science and Engineering, Sharif University of Technology, Tehran, 113659466, Iran
| | - Fangsen Cui
- Engineering Mechanics, Institute of High Performance Computing, A*STAR, Singapore, 138632
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Bischoff MS, Müller-Eschner M, Meisenbacher K, Peters AS, Böckler D. Device Conformability and Morphological Assessment After TEVAR for Aortic Type B Dissection: A Single-Centre Experience with a Conformable Thoracic Stent-Graft Design. Med Sci Monit Basic Res 2015; 21:262-70. [PMID: 26718893 PMCID: PMC4725445 DOI: 10.12659/msmbr.897010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background The aim of this study was to analyze device conformability in TEVAR of acute and chronic (a/c) type B aortic dissections (TBAD) using the Gore Conformable Thoracic Aortic Stent-graft (CTAG). Material/Methods From January 1997 to February 2014, a total of 90 out of 405 patients in our center received TEVAR for TBAD. Since November 2009, 23 patients (16 men; median age: 62 years) were treated with the CTAG. Indications were complicated aTBAD in 15 (65%) and expanding cTBAD in 8 (35%) patients. Primary endpoints were the assessment of device conformability by measuring the distance (D) from the radiopaque gold band marker (GM) at the proximal CTAG end to the inner curvature (IC) of the arch on parasagittal multiplanar reformations of CT angiography, as well as the evaluation of aortic diameter changes following TEVAR. Median follow-up was 13.3 months (range: 2 days to 35 months). Results Primary and secondary success rates were 91.3% (21/23) and 95.6% (22/23), respectively. There was 1 type Ia endoleak, retrograde dissection or primary conversion was not observed. Median GM-IC-D was 0 mm (range: 0 mm to 10 mm). GM-IC-D was associated with zone 2 placement compared to zone 3 (P=0.036). There was no association between GM-IC-D formation and arch type. In aTBAD cases the true lumen significantly increased after TEVAR (P=0.017) and the false lumen underwent shrinkage (P=0.025). In cTBAD patients the false lumen decreased after TEVAR (P=0.036). Conclusions The CTAG shows favorable conformability and wall apposition in challenging arch pathologies such as TBAD.
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Affiliation(s)
- Moritz S Bischoff
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias Müller-Eschner
- Department of Radiodiagnostics and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Katrin Meisenbacher
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas S Peters
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Heidelberg, Germany
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Nauta FJH, Conti M, Kamman AV, van Bogerijen GHW, Tolenaar JL, Auricchio F, Figueroa CA, van Herwaarden JA, Moll FL, Trimarchi S. Biomechanical Changes After Thoracic Endovascular Aortic Repair in Type B Dissection. J Endovasc Ther 2015; 22:918-33. [DOI: 10.1177/1526602815608848] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Thoracic endovascular aortic repair (TEVAR) has evolved into an established treatment option for type B aortic dissection (TBAD) since it was first introduced 2 decades ago. Morbidity and mortality have decreased due to the minimally invasive character of TEVAR, with adequate stabilization of the dissection, restoration of true lumen perfusion, and subsequent positive aortic remodeling. However, several studies have reported severe setbacks of this technique. Indeed, little is known about the biomechanical behavior of implanted thoracic stent-grafts and the impact on the vascular system. This study sought to systematically review the performance and behavior of implanted thoracic stent-grafts and related biomechanical aortic changes in TBAD patients in order to update current knowledge and future perspectives.
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Affiliation(s)
- Foeke J. H. Nauta
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Italy
- Departments of Surgery and Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Michele Conti
- Department of Civil Engineering and Architecture, University of Pavia, Italy
| | - Arnoud V. Kamman
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Italy
- Departments of Surgery and Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
| | | | - Jip L. Tolenaar
- Department of General Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | - C. Alberto Figueroa
- Departments of Surgery and Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | | | - Frans L. Moll
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Santi Trimarchi
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Italy
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Kurimoto Y, Maruyama R, Ujihira K, Nishioka N, Hasegawa K, Iba Y, Hatta E, Yamada A, Nakanishi K. Thoracic Endovascular Aortic Repair for Challenging Aortic Arch Diseases Using Fenestrated Stent Grafts From Zone 0. Ann Thorac Surg 2015; 100:24-32; discussion 32-3. [DOI: 10.1016/j.athoracsur.2015.01.071] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 01/06/2015] [Accepted: 01/16/2015] [Indexed: 11/30/2022]
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Ito E, Kanaoka Y, Maeda K, Ohta H, Ishida A, Ohki T. Deployment Accuracy of the Conformable GORE(®) TAG(®) Thoracic Endoprosthesis in the Treatment of Zones 2 and 3 Aortic Arch Aneurysms Compared with the Previous TAG(®). Ann Vasc Dis 2015; 8:74-8. [PMID: 26131025 DOI: 10.3400/avd.oa.14-00141] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 02/19/2015] [Indexed: 11/13/2022] Open
Abstract
PURPOSES When placing stent grafts, deployment accuracy and birdbeaking due to inadequate conformability and device apposition along the inner curvature of the arch have been encountered. The new Conformable GORE® TAG® Thoracic Endoprosthesis (CTAG) is designed to have enhanced compression resistance and improved conformability in difficult anatomy. The present study compared the deployment accuracy and conformability of the CTAG Device with TAG Device. METHOD Deployment accuracy and birdbeaking was compared of CTAG Device and TAG Device implantation for initial treatment of thoracic aortic aneurysm conducted by our department between March 2010 and March 2012. Deployment accuracy was defined as the distance between the actual and intended device implantation locations measured from DSA images. RESULTS Deployment accuracy at the time of implantation (mean ± SD) was significantly better for the CTAG Device compared to the TAG Device (2.2 ± 1.7 mm vs. 4.4 ± 3.0 mm, P <0.05). Also, while birdbeaking was seen in 8 of 20 cases (40%) for the TAG Device, it was only seen in 1 of 12 cases (8%) for the CTAG Device. CONCLUSION The present study found enhanced deployment accuracy and conformability along the aortic arch using the CTAG Device compared to the previous-generation TAG Device.
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Affiliation(s)
- Eisaku Ito
- Vascular Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Yuji Kanaoka
- Vascular Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Koji Maeda
- Vascular Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Hiroki Ohta
- Vascular Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Atsushi Ishida
- Vascular Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Takao Ohki
- Vascular Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
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Tolenaar JL, de Vries JPPM. Commentary: New Low-Profile Zenith Alpha Stent-Graft for the Treatment of Thoracic Aortic Disease. J Endovasc Ther 2015; 22:160-2. [DOI: 10.1177/1526602815573247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kotelis D, Brenke C, Wörz S, Rengier F, Rohr K, Kauczor HU, Böckler D, von Tengg-Kobligk H. Aortic morphometry at endograft position as assessed by 3D image analysis affects risk of type I endoleak formation after TEVAR. Langenbecks Arch Surg 2015; 400:523-9. [PMID: 25702140 DOI: 10.1007/s00423-015-1291-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 02/12/2015] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this study was to identify morphologic factors affecting type I endoleak formation and bird-beak configuration after thoracic endovascular aortic repair (TEVAR). METHODS Computed tomography (CT) data of 57 patients (40 males; median age, 66 years) undergoing TEVAR for thoracic aortic aneurysm (34 TAA, 19 TAAA) or penetrating aortic ulcer (n = 4) between 2001 and 2010 were retrospectively reviewed. In 28 patients, the Gore TAG® stent-graft was used, followed by the Medtronic Valiant® in 16 cases, the Medtronic Talent® in 8, and the Cook Zenith® in 5 cases. Proximal landing zone (PLZ) was in zone 1 in 13, zone 2 in 13, zone 3 in 23, and zone 4 in 8 patients. In 14 patients (25%), the procedure was urgent or emergent. In each case, pre- and postoperative CT angiography was analyzed using a dedicated image processing workstation and complimentary in-house developed software based on a 3D cylindrical intensity model to calculate aortic arch angulation and conicity of the landing zones (LZ). RESULTS Primary type Ia endoleak rate was 12% (7/57) and subsequent re-intervention rate was 86% (6/7). Left subclavian artery (LSA) coverage (p = 0.036) and conicity of the PLZ (5.9 vs. 2.6 mm; p = 0.016) were significantly associated with an increased type Ia endoleak rate. Bird-beak configuration was observed in 16 patients (28%) and was associated with a smaller radius of the aortic arch curvature (42 vs. 65 mm; p = 0.049). Type Ia endoleak was not associated with a bird-beak configuration (p = 0.388). Primary type Ib endoleak rate was 7% (4/57) and subsequent re-intervention rate was 100%. Conicity of the distal LZ was associated with an increased type Ib endoleak rate (8.3 vs. 2.6 mm; p = 0.038). CONCLUSIONS CT-based 3D aortic morphometry helps to identify risk factors of type I endoleak formation and bird-beak configuration during TEVAR. These factors were LSA coverage and conicity within the landing zones for type I endoleak formation and steep aortic angulation for bird-beak configuration.
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Affiliation(s)
- Drosos Kotelis
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany,
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Joseph G, Chacko ST, Stephen E, Joseph E. Transseptal Ascending Aortic Access Facilitates Transcatheter Embolization of Proximal Type I Endoleak Associated With Bird-Beak Configuration of an Endograft in the Proximal Aortic Arch. J Endovasc Ther 2014; 21:805-11. [DOI: 10.1583/14-4876.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Guivier-Curien C, Boufi M, Deplano V, Boiron O, Loundou A, Alimi Y. Thoracic aorta morphometry and endograft deployment. Comput Methods Biomech Biomed Engin 2014; 17 Suppl 1:10-1. [PMID: 25074139 DOI: 10.1080/10255842.2014.931053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- C Guivier-Curien
- a Aix-Marseille Université, CNRS, ISM UMR 7287 , 13288 , Marseille , France
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