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Figueroa AV, Tanenbaum MT, Timaran CH, Oderich GS, Eagleton MJ, Schanzer A, Farber MA, Beck AW, Schneider DB, Gasper W, Sweet MP, Lee A, Cantor RS, Li X. Postdissection aortic aneurysm sac enlargement after fenestrated and branched endovascular aortic aneurysm repair. J Vasc Surg 2024:S0741-5214(24)01092-9. [PMID: 38909915 DOI: 10.1016/j.jvs.2024.04.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 04/29/2024] [Accepted: 04/29/2024] [Indexed: 06/25/2024]
Abstract
OBJECTIVES Aneurysm sac changes after fenestrated-branched endovascular aneurysm repair (FBEVAR) for postdissection thoracoabdominal aortic aneurysms (PD-TAAs) are poorly understood. Partial thrombosis of the false lumen and endoleaks may impair sac regression. To characterize sac changes after FBEVAR for PD-TAAs, this study examined midterm results and predictors for sac enlargement. METHODS FBEVARs performed for PD-TAAs in 10 physician-sponsored investigational device exemption studies from 2008 to 2023 were analyzed. The maximum aortic aneurysm diameter was compared between the 30-day computed tomography angiogram and follow-up imaging studies. Aneurysm sac enlargement was defined as an increase in diameter of ≥5 mm. Kaplan-Meier curves and Cox regression were used to evaluate sac enlargement and midterm FBEVAR outcomes. RESULTS Among 3296 FBEVARs, 290 patients (72.4% male; median age, 68.4 years) were treated for PD-TAAs. Most aneurysms treated were extent II (72%) and III (12%). Mean aneurysm diameter was 66.5 ± 11.2 mm. Mortality at 30 days was 1.4%. At a mean follow-up of 2.9 ± 1.9 years, at least one follow-up imaging study revealed sac enlargement in 43 patients (15%), sac regression in 115 patients (40%), and neither enlargement nor regression in 137 (47%); 5 (2%) demonstrated both expansion and regression during follow-up. Freedom from aneurysm sac enlargement was 93%, 82%, and 80% at 1, 3, and 5 years, respectively. Overall, endoleaks were detected in 27 patients (63%) with sac enlargement and 143 patients (58%) without enlargement (P = .54). Sac enlargement was significantly more frequent among older patients (mean age at the index procedure, 70.2 ± 8.9 years vs 66.5 ± 11 years; P = .04) and those with type II endoleaks at 1 year (74% vs 52%; P = .031). Cox regression revealed age >70 years at baseline (hazard ratio [HR], 2.146; 95% confidence interval [CI], 1.167-3.944; P = .010) and presence of type II endoleak at 1 year (HR, 2.25; 95% CI, 1.07-4.79; P = .032) were independent predictors of sac enlargement. Patient survival was 92%, 81%, and 68% at 1, 3, and 5 years, respectively. Cumulative target vessel instability was 7%, and aneurysm-related mortality was 2% at 5 years. At least 42% of patients required secondary interventions. Sac enlargement did not affect patient survival. CONCLUSIONS Aneurysm sac enlargement occurs in 15% of patients after FBEVAR for PD-TAAs. Elderly patients (>70 years at baseline) and those with type II endoleaks at 1 year may need closer monitoring and secondary interventions to prevent sac enlargement. Despite sac enlargement in some patients, aneurysm-related mortality at 5 years remains low and overall survival was not associated with sac enlargement.
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Affiliation(s)
- Andres V Figueroa
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Mira T Tanenbaum
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Carlos H Timaran
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
| | - Gustavo S Oderich
- Division of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andres Schanzer
- Division of Vascular and Endovascular Surgery, University of Massachusetts Memorial Hospital, Worcester, MA
| | - Mark A Farber
- Division of Vascular Surgery, University of North Carolina, Chapel Hill, NC
| | - Adam W Beck
- Division of Vascular and Endovascular Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Darren B Schneider
- Division of Vascular and Endovascular Surgery, University of Pennsylvania, Philadelphia, PA
| | - Warren Gasper
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA
| | - Matthew P Sweet
- Division of Vascular and Endovascular Surgery, University of Washington, Seattle, WA
| | - Anthony Lee
- Division of Vascular Surgery, Boca Raton Regional Hospital, Boca Raton, FL
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Frankort J, Mees B, Doukas P, Keszei A, Kontopodis N, Antoniou GA, Jacobs MJ, Gombert A. Systematic Review of the Effect of Cerebrospinal Fluid Drainage on Outcomes After Endovascular Descending Thoracic/Thoraco-Abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2023; 66:501-512. [PMID: 37182608 DOI: 10.1016/j.ejvs.2023.05.006] [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: 10/04/2022] [Revised: 04/07/2023] [Accepted: 05/05/2023] [Indexed: 05/16/2023]
Abstract
OBJECTIVE This study aimed to investigate whether prophylactic use of cerebrospinal fluid (CSF) drainage in endovascular descending thoracic aortic aneurysm (DTAA) and thoraco-abdominal aortic aneurysm (TAAA) repair contributes to a lower rate of post-operative spinal cord ischaemia (SCI). DATA SOURCES MEDLINE, Embase, and CINAHL. REVIEW METHODS A literature review was conducted in accordance with PRISMA guidelines (PROSPERO registration no. CRD42021245893). Risk of bias was assessed through the Newcastle-Ottawa scale (NOS), and the certainty of evidence was graded using the GRADE approach. A proportion meta-analysis was conducted to calculate the pooled rate and 95% confidence interval (CI) of both early and late onset SCI. Pooled outcome estimates were calculated using the odds ratio (OR) and associated 95% CI. The primary outcome was SCI, both early and lateonset. Secondary outcomes were complications of CSF drainage, length of hospital stay, and peri-operative (30 day or in hospital) mortality rates. RESULTS Twenty-eight observational, retrospective studies were included, reporting 4 814 patients (2 599 patients with and 2 215 without CSF drainage). The NOS showed a moderate risk of bias. The incidence of SCI was similar in patients with CSF drainage (0.05, 95% CI 0.03 ‒ 0.08) and without CSF drainage (0.05, 95% CI 0.00 ‒ 0.14). No significant decrease in SCI was found when using CSF drainage (OR 0.67, 95% CI 0.29 ‒ 1.55, p = .35). The incidence rate of CSF drainage related complication was 0.10 (95% CI 0.04 ‒ 0.19). The 30 day and in hospital mortality rate with CSF drainage was 0.08 (95% CI 0.05 ‒ 0.12). The 30 day and in hospital mortality rate without CSF drainage and comparison with late mortality and length of hospital stay could not be determined due to lack of data. The quality of evidence was considered very low. CONCLUSION Pre-operative CSF drainage placement was not related to a favourable outcome regarding SCI rate in endovascular TAAA and DTAA repair. Due to the low quality of evidence, no clear recommendation on pre-operative use of CSF drainage placement can be made.
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Affiliation(s)
- Jelle Frankort
- Department of Vascular Surgery, European Vascular Centre Aachen-Maastricht, RWTH Aachen, Aachen, Germany; Department of Vascular Surgery, European Vascular Centre Maastricht-Aachen, MUMC Maastricht, Maastricht, The Netherlands.
| | - Barend Mees
- Department of Vascular Surgery, European Vascular Centre Maastricht-Aachen, MUMC Maastricht, Maastricht, The Netherlands
| | - Panagiotis Doukas
- Department of Vascular Surgery, European Vascular Centre Aachen-Maastricht, RWTH Aachen, Aachen, Germany
| | - Andràs Keszei
- Centre for Translational & Clinical Research Aachen (CTC-A), University Hospital RWTH Aachen, Aachen, Germany
| | - Nikolaos Kontopodis
- Vascular Surgery Department, Medical School, University of Crete, Heraklion, Crete, Greece
| | - George A Antoniou
- Department of Vascular and Endovascular Surgery, Manchester University NHS Foundation Trust, Manchester, UK; Division of Cardiovascular Sciences, School of Medical Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Michael J Jacobs
- Department of Vascular Surgery, European Vascular Centre Aachen-Maastricht, RWTH Aachen, Aachen, Germany; Department of Vascular Surgery, European Vascular Centre Maastricht-Aachen, MUMC Maastricht, Maastricht, The Netherlands
| | - Alexander Gombert
- Department of Vascular Surgery, European Vascular Centre Aachen-Maastricht, RWTH Aachen, Aachen, Germany
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DiBartolomeo AD, Pyun AJ, Ding L, O'Donnell K, Paige JK, Magee GA, Weaver FA, Han SM. Comparative outcomes of physician-modified fenestrated-branched endovascular repair of post-dissection and degenerative complex abdominal or thoracoabdominal aortic aneurysms. J Vasc Surg 2023; 78:565-574.e2. [PMID: 37187413 DOI: 10.1016/j.jvs.2023.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/03/2023] [Accepted: 05/05/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE Fenestrated-branched endovascular repair has become a favorable treatment strategy for patients with complex abdominal aortic aneurysms (cAAAs) and thoracoabdominal aortic aneurysms (TAAAs) who are high risk for open repair. Compared with degenerative aneurysms, post-dissection aneurysms can pose additional challenges for endovascular repair. Literature on physician-modified fenestrated-branched endovascular aortic repair (PM-FBEVAR) for post-dissection aortic aneurysms is sparse. Therefore, the aim of this study is to compare the clinical outcomes of patients who underwent PM-FBEVAR for degenerative and post-dissection cAAAs or TAAAs. METHODS A single-center institutional database was retrospectively reviewed for patients that underwent PM-FBEVAR between 2015 and 2021. Infected aneurysms and pseudoaneurysms were excluded. Patient characteristics, intraoperative details, and clinical outcomes were compared between degenerative and post-dissection cAAAs or TAAAs. The primary outcome was 30-day mortality. The secondary outcomes included technical success, major complications, endoleak, target vessel instability, and reintervention. RESULTS Of the 183 patients who underwent PM-FBEVAR in the study, 32 had aortic dissections, and 151 had degenerative aneurysms. There was one 30-day death (3.1%) in the post-dissection group and eight 30-day deaths (5.3%) in the degenerative aneurysm group (P = .99). Technical success, fluoroscopy time, and contrast usage were similar between the post-dissection and degenerative groups. Reintervention during follow-up (28% vs 35%; P = .54) and major complications were not statistically significantly different between the two groups. Endoleak was the most common reason for reintervention, with the post-dissection group having a higher rate of type IC, II, and IIIA endoleaks (31% vs 3%; P < .0001; 59% vs 26%; P = .0002; and 16% vs 4%; P = .03). During the mean follow-up of 14 months, all-cause mortality was similar between the groups (12.5% vs 21.9%; P = .23). CONCLUSIONS PM-FBEVAR is a safe treatment for post-dissection cAAAs and TAAAs with high technical success. However, endoleaks requiring reintervention were more frequent in post-dissection patients. The impact of these reinterventions on long-term durability will be assessed with continued follow-up.
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Affiliation(s)
- Alexander D DiBartolomeo
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Alyssa J Pyun
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Li Ding
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Kathleen O'Donnell
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Jacquelyn K Paige
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Fred A Weaver
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Sukgu M Han
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA.
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Gallitto E, Faggioli G, Melissano G, Fargion A, Isernia G, Bertoglio L, Simonte G, Lenti M, Pratesi C, Chiesa R, Gargiulo M. Fenestrated and Branched Endografts for Post-Dissection Thoraco-Abdominal Aneurysms: Results of a National Multicentre Study and Literature Review. Eur J Vasc Endovasc Surg 2022; 64:630-638. [PMID: 35764243 DOI: 10.1016/j.ejvs.2022.06.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 05/27/2022] [Accepted: 06/19/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Fenestrated and branched endografting (F/B-EVAR) has been proposed as an endovascular solution for chronic post-dissection thoraco-abdominal aneurysms (PD-TAAAs). The aim of this study was to analyse the experience of four high volume centres nationwide and the current available literature. METHODS Data on patients undergoing F/B-EVAR in four Italian academic centres between 2008 and 2019 were collected, and those from patients with PD-TAAAs were analysed retrospectively. Peri-operative morbidity and mortality were assessed as early outcomes. Survival, freedom from re-intervention (FFR), target visceral vessel (TVV) patency, and aortic remodelling were assessed as follow up outcomes. A MEDLINE search was performed for studies published from 2008 to 2020 reporting on F/B-EVAR in PD-TAAAs. RESULTS Among 351 patients who underwent F/B-EVAR for TAAAs, 37 (11%) had PD-TAAAs (Crawford's extent I-III: 35% - 95%). Overall, 135 TVVs (from true lumen 120; false lumen seven; both true and false lumen eight) were accommodated by fenestrations (96% - 71%) and branches (39% - 29%). Technical success (TS) was achieved in 34 (92%) cases with three failures due to endoleaks (Ia: 1; Ic: 1; III: 1). There were no 30 day deaths. No cases of permanent spinal cord ischaemia (SCI) were recorded and six (16%) patients suffered from transient deficits. Renal function worsening (eGFR < 30% than baseline) and pulmonary complications were reported in two (5%) and four (11%) cases, respectively. From the Kaplan-Meier analysis, three year survival, FFR, and TVV patency were 81%, 66%, and 97%, respectively. Radiological imaging was available for 30 (81%) patients at 12 months with complete false lumen thrombosis in 26 (87%). Two hundred and fifty-six patients were reported in seven published papers with TS, 30 day mortality, and SCI ranging from 99% to 100%, 0 to 6%, and 0 to 16%, respectively. The mean follow up ranged from 12 to 26 months, with estimated two year survival between 81% and 90% and a re-intervention rate between 19% and 53%. CONCLUSION F/B-EVAR is effective to treat PD-TAAAs. A high re-intervention rate is necessary to complete the aneurysm exclusion and promote aortic remodelling successfully.
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Affiliation(s)
- Enrico Gallitto
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy.
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Germano Melissano
- Division of Vascular Surgery, Vita - Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Aaron Fargion
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Giacomo Isernia
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, Vita - Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gioele Simonte
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Massimo Lenti
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Carlo Pratesi
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, Vita - Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
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Thoracoabdominal Aortic Disease and Repair: JACC Focus Seminar, Part 3. J Am Coll Cardiol 2022; 80:845-856. [PMID: 35981828 DOI: 10.1016/j.jacc.2021.05.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/03/2021] [Accepted: 05/25/2021] [Indexed: 11/21/2022]
Abstract
Thoracoabdominal aortic disease is a rare but life-threatening condition that requires expert multidisciplinary collaborative management. Intervention is indicated in patients with symptomatic aneurysms or when an aneurysm reaches a certain threshold of diameter or rate of expansion. The strategies for spinal cord and end-organ protection have evolved over several decades, resulting in improved outcomes after repair. Open repair, although invasive, provides definitive and durable repair. Endovascular approaches are rapidly evolving, and the results with fenestrated and branched endografts are promising. Both open repair and endovascular repair require highly specialized expertise, and outcomes are best when repair is undertaken in an elective setting by a dedicated team. Patients with degenerative thoracoabdominal aortic aneurysms and chronic dissections should be followed up closely and referred for elective repair when indicated.
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de Marino PM, Ibraheem A, Tesinsky P, Jiries MA, Katsargyris A, Verhoeven EL. Fenestrated and branched stent grafts for the treatment of post-dissection thoracoabdominal aortic aneurysms. Semin Vasc Surg 2022; 35:312-319. [DOI: 10.1053/j.semvascsurg.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 11/11/2022]
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Fleischmann D, Afifi RO, Casanegra AI, Elefteriades JA, Gleason TG, Hanneman K, Roselli EE, Willemink MJ, Fischbein MP. Imaging and Surveillance of Chronic Aortic Dissection: A Scientific Statement From the American Heart Association. Circ Cardiovasc Imaging 2022; 15:e000075. [PMID: 35172599 DOI: 10.1161/hci.0000000000000075] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
All patients surviving an acute aortic dissection require continued lifelong surveillance of their diseased aorta. Late complications, driven predominantly by chronic false lumen degeneration and aneurysm formation, often require surgical, endovascular, or hybrid interventions to treat or prevent aortic rupture. Imaging plays a central role in the medical decision-making of patients with chronic aortic dissection. Accurate aortic diameter measurements and rigorous, systematic documentation of diameter changes over time with different imaging equipment and modalities pose a range of practical challenges in these complex patients. Currently, no guidelines or recommendations for imaging surveillance in patients with chronic aortic dissection exist. In this document, we present state-of-the-art imaging and measurement techniques for patients with chronic aortic dissection and clarify the need for standardized measurements and reporting for lifelong surveillance. We also examine the emerging role of imaging and computer simulations to predict aortic false lumen degeneration, remodeling, and biomechanical failure from morphological and hemodynamic features. These insights may improve risk stratification, individualize contemporary treatment options, and potentially aid in the conception of novel treatment strategies in the future.
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Verzini F, Gibello L, Varetto G, Frola E, Boero M, Porro L, Gattuso A, Peretti T, Rispoli P. Proportional meta-analysis of open surgery or fenestrated endograft repair for postdissection thoracoabdominal aneurysms. J Vasc Surg 2021; 74:1377-1385.e9. [PMID: 34019989 DOI: 10.1016/j.jvs.2021.04.053] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 04/16/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine outcomes of postdissection thoracoabdominal aneurysms by either open or endovascular repair with fenestrated or branched endografts. METHODS A systematic review was conducted for open or endovascular repair of postdissection thoracoabdominal aneurysms, between January 2009 and February 2020. A meta-analysis was performed for postoperative complications and both early and late mortality and reinterventions. RESULTS Fifteen noncomparative studies (eight endovascular repair and seven open repair) were suitable for meta-analysis. Overall, 1337 patients were included, 1068 in the open repair group (73% male; mean age 58 years) and 269 in the endovascular repair group (79% male; mean age 65 years). The 30-day mortality was 6% for open repair vs 3% for endovascular repair (P = .35), whereas the 30-day reintervention rate was 3% for open repair vs 1% for endovascular repair (P = .66). The only significant difference was reported for 30-day respiratory complication rate (30% open repair vs 2% endovascular repair; P < .01). The incidence of spinal cord ischemia was 9% for open repair vs 8% for endovascular repair (P = .95). The mean follow-up was 44 months: 48 months (range, 10-72 months) after open repair and 17 months (range, 12-25 months) after endovascular repair (P < .01). Late aortic reinterventions were more frequent after endovascular repair (11% vs 32%; P < .001). The late overall mortality rate was 19% for open repair vs 7% for endovascular repair (P = .08), whereas aortic-related mortality was 7% for open repair vs 3% for endovascular repair (P = .22). CONCLUSIONS In the absence of comparative studies, this meta-analysis showed that endovascular repair seems to be a viable alternative for patients unfit for open repair.
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Affiliation(s)
- Fabio Verzini
- Unit of Vascular Surgery, Department of Surgical Sciences, University of Turin, AOU Città della Salute e della Scienza, Turin, Italy.
| | - Lorenzo Gibello
- Unit of Vascular Surgery, Department of Surgical Sciences, University of Turin, AOU Città della Salute e della Scienza, Turin, Italy
| | - Gianfranco Varetto
- Unit of Vascular Surgery, Department of Surgical Sciences, University of Turin, AOU Città della Salute e della Scienza, Turin, Italy
| | - Edoardo Frola
- Unit of Vascular Surgery, Department of Surgical Sciences, University of Turin, AOU Città della Salute e della Scienza, Turin, Italy
| | - Michele Boero
- Unit of Vascular Surgery, Department of Surgical Sciences, University of Turin, AOU Città della Salute e della Scienza, Turin, Italy
| | - Luca Porro
- Unit of Vascular Surgery, Department of Surgical Sciences, University of Turin, AOU Città della Salute e della Scienza, Turin, Italy
| | - Andrea Gattuso
- Unit of Vascular Surgery, Department of Surgical Sciences, University of Turin, AOU Città della Salute e della Scienza, Turin, Italy
| | - Tania Peretti
- Unit of Vascular Surgery, Department of Surgical Sciences, University of Turin, AOU Città della Salute e della Scienza, Turin, Italy
| | - Pietro Rispoli
- Unit of Vascular Surgery, Department of Surgical Sciences, University of Turin, AOU Città della Salute e della Scienza, Turin, Italy
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Zeng Z, Zhao Y, Wu M, Bao X, Li T, Feng J, Feng R, Jing Z. Endovascular strategies for post-dissection aortic aneurysm (PDAA). J Cardiothorac Surg 2020; 15:287. [PMID: 33004048 PMCID: PMC7528487 DOI: 10.1186/s13019-020-01331-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 09/22/2020] [Indexed: 11/23/2022] Open
Abstract
Residual patent false lumen (FL) after type B aortic dissection (TBAD) repair is independently associated with poor long-term survival. Open surgery and endovascular repair result in good clinical outcomes in patients with AD. However, both treatments focus on proximal dissection but not distal dissection. About 13.4–62.5% of these patients present with different degrees of distal aneurysmal dilatation after primary repair. Although open surgery is the first-choice treatment for post-dissection aortic aneurysm (PDAA), there is a need for high technical demand since open surgery is associated with high mortality and morbidity. As a treatment strategy with minimal invasion, endovascular repair shows early benefits and low morbidity. For PDAA, the narrow true lumen (TL), rigid initial flap and branch arteries originating from FL have increased difficulties in operation. The aim of endovascular treatment is to promote FL thrombosis and aortic remodeling. Endovascular repair includes intervention from FL and TL sides. TL intervention techniques (parallel stent-graft, branched and fenestrated stent-graft among others) have been proven to be safe and effective in PDAA. Other FL intervention techniques that have been used in selected patients include FL embolization and candy-plug techniques. This article introduces available endovascular techniques and their outcomes for the treatment of PDAA.
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Affiliation(s)
- Zhaoxiang Zeng
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China
| | - Yuxi Zhao
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China
| | - Mingwei Wu
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China
| | - Xianhao Bao
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China
| | - Tao Li
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China
| | - Jiaxuan Feng
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China.
| | - Rui Feng
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China.
| | - Zaiping Jing
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China.
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10
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Edman NI, Bartek MA, Kang PC, Sweet MP. Anatomic Eligibility for Commercial Branched Endograft Repair of Thoracoabdominal Aortic Aneurysms. Ann Vasc Surg 2020; 70:481-490. [PMID: 32603844 DOI: 10.1016/j.avsg.2020.06.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/15/2020] [Accepted: 06/15/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND First-generation "off-the-shelf" branched endovascular stent grafts are in development for treatment of thoracoabdominal aortic aneurysms (TAAAs). Prior studies have assessed eligibility rates among highly selected cohorts of patients referred for endovascular treatment, and the broader applicability of these devices to all patients with TAAA is unknown. The aims of this study were to assess the overall suitability of the 3 commercial 4-branched devices with or without adjunct procedure(s) in an unselected cohort of patients with TAAA and to identify areas for improvement in the next generation of devices. METHODS A retrospective review of three-dimensional centerline reconstructions of contrast-enhanced computed tomography (CT) imaging was performed in consecutive patients with TAAA seen between 2013 and 2017. All patients with contrast-enhanced CT imaging were included, regardless of prior evaluation for suitability for endovascular repair. Eligibility for a device was assessed based on instructions for use (IFU) from the device manufacturer along with prespecified anatomic criteria. Adjunct procedures were defined as carotid-subclavian revascularization, target vessel endovascular intervention, and iliac conduit/revascularization. RESULTS Of 165 patients with TAAA, 122 had CT scans adequate for study inclusion. Eighteen patients (14.8%) were eligible for at least 1 device by IFU, and 41 (33.6%) could have been made eligible for at least 1 device by an adjunct procedure. Sixty-three (51.6%) were not eligible for any device within IFU even with adjunct procedures, including 31 of 32 patients with TAAA due to dissection. The most common reasons for ineligibility were perivisceral flow channel diameter <20 mm (n = 43) and an inadequate proximal seal zone (n = 29). Women were significantly less likely to be eligible for an off-the-shelf device (P = 0.03) and were more likely to require an iliac procedure to become eligible (P = 0.006). Almost none of the patients with dissection could receive a device even if adjunct procedures were used. CONCLUSIONS Over half of patients with TAAA could not be made eligible for an off-the-shelf device based on manufacturers' criteria, even with adjunct procedures. Women and patients with TAAA due to dissection had higher rates of ineligibility. These data demonstrate that custom fenestrated devices and low-profile devices are needed to expand eligibility for endovascular repair of TAAA.
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Affiliation(s)
- Natasha I Edman
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Matthew A Bartek
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - P Chulhi Kang
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Matthew P Sweet
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA.
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Verzini F, Ferrer C, Parlani G, Coscarella C, Giudice R, Frola E, Ruffino MA, Varetto G, Gibello L. Mid-Term Outcomes of Complex Endografting for Chronic Post-Dissection Thoracoabdominal Aortic Aneurysms. Cardiovasc Intervent Radiol 2020; 43:1440-1448. [PMID: 32556604 DOI: 10.1007/s00270-020-02555-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/04/2020] [Indexed: 12/30/2022]
Abstract
PURPOSE To report early and mid-term results of post-aortic dissection thoracoabdominal aneurysms (pD-TAAA) treated by complex endografting in three tertiary referral hospitals. MATERIALS AND METHODS A review of all patients with pD-TAAA unfit for open surgery treated with complex endovascular repair from 2012 to 2018 was performed. Simple thoracic endografts (TEVAR) were excluded. Staged procedures in case of extensive aortic coverage were always planned. RESULTS In total, 21 patients (16 males, mean age 63 ± 10 years) with pD-TAAA underwent aortic repair by fenestrated or branched thoracoabdominal endografts for visceral vessels. Mean TAAA diameter was 61 ± 6.2 mm. Spinal cord drainage was performed in all patients. A staged approach was used in 12 (57%) cases. Technical success was achieved in 18 (86%) patients. No in-hospital deaths occurred. Two patients experienced transient post-procedural spinal cord ischemia. At 30 days, six type II endoleaks (29%), two type Ic endoleak (9.5%) and one type IIIc endoleak (5%) were reported. At a mean follow-up of 23 ± 13 months, no late aortic-related deaths occurred. Three patients underwent reintervention for type Ic and IIIc endoleaks. No visceral vessel occlusion was observed. Estimated freedom from reintervention at 12 and 24 months was 85.7 ± 0.7%. In 13 cases, TAAA diameter decreased at least 5 mm, while increased > 5 mm in only one case. Complete false lumen thrombosis was achieved in 18 patients (86%). CONCLUSION Complex endografting for pD-TAAA showed favorable mid-term results. Staged and carefully planned endovascular procedures may represent a safe and effective therapeutic option in patients deemed at high risk of open repair.
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Affiliation(s)
- Fabio Verzini
- Unit of Vascular Surgery, Department of Surgical Sciences, AOU Città della Salute e della Scienza, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy.
| | - Ciro Ferrer
- Vascular and Endovascular Surgery Unit, S Giovanni-Addolorata Hospital, Rome, Italy
| | | | - Carlo Coscarella
- Vascular and Endovascular Surgery Unit, S Giovanni-Addolorata Hospital, Rome, Italy
| | - Rocco Giudice
- Vascular and Endovascular Surgery Unit, S Giovanni-Addolorata Hospital, Rome, Italy
| | - Edoardo Frola
- Unit of Vascular Surgery, Department of Surgical Sciences, AOU Città della Salute e della Scienza, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - Maria Antonella Ruffino
- Vascular Radiology, Department of Diagnostic Imaging and Radiotherapy, AOU Città della Salute e della Scienza, Turin, Italy
| | - Gianfranco Varetto
- Unit of Vascular Surgery, Department of Surgical Sciences, AOU Città della Salute e della Scienza, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - Lorenzo Gibello
- Unit of Vascular Surgery, Department of Surgical Sciences, AOU Città della Salute e della Scienza, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
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12
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He Y, Jia S, Sun G, Cao L, Wang X, Zhang H, Jia X, Ma X, Xiong J, Liu X, Guo W. Fenestrated/Branched Endovascular Repair for Postdissection Thoracoabdominal Aneurysms: A Systematic Review with Pooled Data Analysis. Vasc Endovascular Surg 2020; 54:510-518. [PMID: 32436464 DOI: 10.1177/1538574420927131] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Patients who have survived an acute aortic dissection remain at risk for postdissection thoracoabdominal aortic aneurysms (PD-TAAAs). Fenestrated/branched endovascular repair for PD-TAAA is increasingly used in some high-volume centers, but outcomes are still limited because of the additional challenges compared to atherosclerotic thoracoabdominal aneurysms. This study was performed to evaluate the literature on fenestrated/branched endovascular repair for PD-TAAAs. METHODS PubMed, Embase, and the Cochrane Database were searched for relevant studies published until September 2019. Outcome data were extracted to evaluate the technical success, 30-day mortality, later survival, major complications, endoleaks, target vessel patency, and reintervention. Studies were analyzed in a pooled proportion meta-analysis. RESULTS In total, 143 patients from 4 studies were identified for the pooled data analysis. The pooled technical success rate was 98% (95% CI: 86%-100%). After the treatment, the overall estimated 30-day mortality rate was 3% (95% CI: 1%-8%), early spinal cord ischemia rate was 10% (95% CI: 4%-21%), early renal injury rate was 5% (95% CI: 1%-19%), endoleak rate was 33% (95% CI: 22%-47%), reintervention rate at a median follow-up of 22.5 months was 34% (95% CI: 27%-42%), and all-cause mortality rate was 12% (95% CI: 6%-24%). CONCLUSIONS The use of fenestrated/branched stent grafts for the treatment of PD-TAAA appears generally feasible based on the limited literature, but endoleaks and reinterventions are frequent.
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Affiliation(s)
- Yuan He
- Department of Vascular Surgery, Chinese PLA General Hospital, Haidian District, Beijing, People's Republic of China
| | - Senhao Jia
- Department of Vascular Surgery, Chinese PLA General Hospital, Haidian District, Beijing, People's Republic of China
| | - Guoyi Sun
- Department of Vascular Surgery, Chinese PLA General Hospital, Haidian District, Beijing, People's Republic of China
| | - Long Cao
- Department of Vascular Surgery, Chinese PLA General Hospital, Haidian District, Beijing, People's Republic of China.,Department of General Surgery, Chinese PLA No. 983 Hospital, Hebei District, Tianjin, People's Republic of China
| | - Xinhao Wang
- Department of Vascular Surgery, Chinese PLA General Hospital, Haidian District, Beijing, People's Republic of China
| | - Hongpeng Zhang
- Department of Vascular Surgery, Chinese PLA General Hospital, Haidian District, Beijing, People's Republic of China
| | - Xin Jia
- Department of Vascular Surgery, Chinese PLA General Hospital, Haidian District, Beijing, People's Republic of China
| | - Xiaohui Ma
- Department of Vascular Surgery, Chinese PLA General Hospital, Haidian District, Beijing, People's Republic of China
| | - Jiang Xiong
- Department of Vascular Surgery, Chinese PLA General Hospital, Haidian District, Beijing, People's Republic of China
| | - Xiaoping Liu
- Department of Vascular Surgery, Chinese PLA General Hospital, Haidian District, Beijing, People's Republic of China
| | - Wei Guo
- Department of Vascular Surgery, Chinese PLA General Hospital, Haidian District, Beijing, People's Republic of China
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