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Santos-Venâncio M, Rocha-Neves J, Spath P, Oliveira-Pinto J. Complications and Technical Success on Upper Limb Vascular Access for Endovascular Repair of Complex Abdominal and Thoraco-abdominal Aortic Aneurysms: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2024; 109:433-443. [PMID: 39059630 DOI: 10.1016/j.avsg.2024.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 06/15/2024] [Accepted: 06/17/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Catheterization of target vessels (TV) represented by renal visceral vessels are the crucial aspect during fenestrated and branched endovascular repair. This study aims to assess the efficacy and complications associated with upper limb catheterization during complex aneurysm endovascular surgery repair. METHODS A systematic review was conducted after Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) guidelines, involving a search across PubMed, Cochrane CENTRAL, and Web of Science. Primary endpoint was represented by 30-day stroke. Secondary endpoints were target vessels' (TVs) technical success, 30-day mortality, and local access-related complications. Meta-analyses were performed using a random-effects model. RESULTS Sixteen observational studies encompassing 4,137 patients were included. The 30-day stroke incidence for upper limb access was 1.4% (95% CI 1.0-1.8%), which was slightly higher than lower limb, despite not statistically significant. Mortality varied between 0 and 6.8%, and local access-related complications occurred in 3.2% (95% CI 1.9-4.4%). Technical success in TV catheterization was 99.2% (95% CI 98.4-100.0%). CONCLUSIONS This systematic review and meta-analysis demonstrate the safety and efficacy of upper limb access for Fenestrated and Branched Endovascular Aortic Repair (f/b-EVAR), with low stroke risk, mortality rates, and minimal local complications. Despite the risk of bias, the findings suggest that upper limb access may be beneficial, especially in bailout situations when femoral access fails, offering valuable insights for clinical decision-making.
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Affiliation(s)
| | - João Rocha-Neves
- Department of Biomedicine - Unit of Anatomy, Faculdade de Medicina da Universidade do Porto, Porto, Portugal; RISE@Health, Porto, Portugal.
| | - Paolo Spath
- Department of Vascular Surgery, Hospital "Infermi" Rimini, AUSL Romagna, Rimini, Italy; Vascular Surgery, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy; Ludwig-Maximilians-Universitat Munchen, Vascular Surgery Marchionisteße Munchen, Bayern, Germany
| | - José Oliveira-Pinto
- RISE@Health, Porto, Portugal; Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
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Nana P, Spanos K, Panuccio G, Rohlffs F, Detter C, von Kodolitsch Y, Torrealba JI, Kölbel T. Branched and fenestrated endovascular aortic arch repair in patients with native proximal aortic landing zone. J Vasc Surg 2024; 80:621-629.e3. [PMID: 38580160 DOI: 10.1016/j.jvs.2024.03.444] [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: 01/11/2024] [Revised: 03/15/2024] [Accepted: 03/28/2024] [Indexed: 04/07/2024]
Abstract
OBJECTIVE Fenestrated and branched thoracic endovascular repair (f/bTEVAR) have been successfully applied in patients with diverse aortic arch pathologies. The aim of this study is to present the early and mid-term outcomes of patients with native proximal aortic landing (NPAL) managed with f/bTEVAR. METHODS A single-center retrospective analysis of patients with NPAL, managed with f/bTEVAR, between September 1, 2011, and June 30, 2022, was conducted. All patients were treated with custom-made devices (Cook Medical) with landing within Ishimaru zones 0 to 2. Primary outcomes were technical success, mortality, stroke, and retrograde type A dissection at 30 days. Follow-up outcomes were considered secondary. RESULTS A total of 126 patients were included (69.8% males; mean age, 70.8 ± 4.2 years; 18.3% urgent). The main indications (60.4%) for repair were aortic arch (29.4%) and thoracoabdominal aortic aneurysms (31.0%). Seventy-two patients (57.1%) were managed with fTEVAR. Proximal landing in zone 0 and 1 was chosen in 97.6%. Technical success was 94.4%, and 30-day mortality was 11.9%. Strokes were diagnosed in 13.5% of patients and major strokes were identified in 7.9% cases. Retrograde type A dissection rate was 3.9%. The multivariate analysis confirmed landing in Ishimaru zone 0 as an independently related factor for stroke (P = .005), whereas stroke (P < .001), pericardial effusion (P < .001), and acute kidney injury (P < .001) were independently related to 30-day mortality. Mean follow-up was 17.5 ± 9.3 months. The estimated survival rate and the freedom from reintervention rate were 72.6% (standard error, 4.4%) and 46.4% (standard error, 6.0%) at 24-month follow-up, respectively. CONCLUSIONS Stroke rate after endovascular arch repair was alarming among patients with NPAL. Proximal landing to zone 0 was related to higher risk of stroke. Reinterventions were common within the 24-month follow-up.
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Affiliation(s)
- Petroula Nana
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany.
| | - Konstantinos Spanos
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Christian Detter
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Yskert von Kodolitsch
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - José I Torrealba
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
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Potter HA, Ding L, Han SM, Fleischman F, Weaver FA, Magee GA. Spinal cord ischemia and reinterventions following thoracic endovascular repair for acute type B aortic dissections. J Vasc Surg 2024; 80:656-664. [PMID: 38723912 DOI: 10.1016/j.jvs.2024.03.458] [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: 11/27/2023] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 06/04/2024]
Abstract
OBJECTIVE The technical aspects of thoracic endovascular aortic repair (TEVAR) for acute type B aortic dissection (TBAD), specifically the location of proximal seal zone (PSZ) (need to cover the left subclavian artery [LSA]), distal seal zone (DSZ) (length of aortic coverage), benefit of LSA revascularization, and prophylactic lumbar drainage are still debated. Each of these issues has potential benefits but also has known risks. This study aims to identify factors associated with reintervention and spinal cord ischemia (SCI) following TEVAR for acute TBAD with a zone 3 entry tear. METHODS The Vascular Quality Initiative was queried for TEVARs performed for acute TBAD with zone 3 entry tear, zone 3 proximal zone of disease, treated with TEVAR extending between zone 2 and zone 5. The primary outcomes were SCI and related reintervention. Secondary outcomes were stroke, arm ischemia, and retrograde type A dissection (RTAD). The exposure variables were PSZ 2 vs 3, DSZ 4 vs 5, prophylactic lumbar drain, and LSA revascularization. Univariate analyses were conducted with χ2 analysis, and multivariable logistic regression was used to evaluate association with outcomes. RESULTS Of 583 patients who met inclusion criteria, 266 had PSZ 2 and 317 had PSZ 3. On univariate analysis, PSZ 2 was associated with a higher rate of reintervention, but PSZ2 was not significant on multivariable analysis after accounting for age, sex, race, smoking, PSZ, DSZ, prophylactic lumbar drain, and LSA patency. PSZ 2 was not associated with SCI, arm ischemia, or RTAD. PSZ 2 was associated with a trend towards a higher rate of stroke. DSZ 4 and DSZ 5 were performed in 161 and 422 TEVARs, respectively, and DSZ 5 was associated with a higher rate of SCI on univariate (3 [1.9%] vs 39 [9.2%]; P = .01) and multivariable (odds ratio, 7.384; 95% confidence interval, 2.193-24.867; P = .001) analyses. Prophylactic lumbar drain placement was not statistically significantly associated with SCI, but lack of postoperative LSA patency was associated with SCI (odds ratio, 2.966; 95% confidence interval, 1.016-8.656; P = .05). CONCLUSIONS This study found that PSZ 2 was not associated with lower reinterventions or higher rates of SCI but trended towards a higher rate of stroke than PSZ 3. Additionally, DSZ 5 was strongly associated with SCI when compared with DSZ 4, highlighting the importance of limiting aortic coverage to coverage of the proximal entry tear when possible.
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Affiliation(s)
- Helen A Potter
- Division of Vascular Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY.
| | - Li Ding
- Division of Biostatistics, Population and Public Health Sciences, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA
| | - Sukgu M Han
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA
| | - Fernando Fleischman
- Department of Cardiac Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA
| | - Fred A Weaver
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA
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Lemmens CC, Konings TJAJ, Dean A, Wanhainen A, Mani K, Gormley S, Khashram M, Mees BME, Schurink GWH. Branch Thrombus after Endovascular Treatment with Arch Branched Devices for Aortic Arch Pathologies. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00633-6. [PMID: 39053643 DOI: 10.1016/j.ejvs.2024.07.023] [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: 01/02/2024] [Revised: 06/17/2024] [Accepted: 07/18/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVE The aim of this study was to describe the occurrence of branch thrombosis following endovascular treatment of aortic arch pathology using an arch branched device (ABD) and to determine whether this is influenced by clinical and geometric parameters. METHODS In this retrospective observational study of patients treated with an ABD in three centres, the primary endpoint was thrombus formation within a branch during follow up. Secondary endpoints were technical success, serious adverse events (SAEs), early and late death, stroke, and re-interventions. Geometric measurements (tortuosity index and curvature) were determined on pre- and post-operative computed tomography angiograms. RESULTS Thirty nine patients were treated and 68 antegrade branches were analysed (innominate artery, n = 27; common carotid artery [CCA], n = 40; left subclavian artery [LSA], n = 1). Thrombus was identified within seven branches (10%) on surveillance imaging (innominate artery, n = 6; CCA, n = 1; LSA, n = 0; p = .021) and was associated with a wider distal bridging stent diameter (median 14.0 mm [13.3, 15.3] vs. 8.7 mm [IQR 5.9]; p = .026), a higher degree of reversed tapering (4.3 mm [3.8, 5.2] vs. 1.2 mm [0.3, 3.1]; p = .023), use of polyethylene terephthalate (Dacron) covered (vs. expanded polytetrafluoroethylene) bridging stents (23% vs. 2%; p = .011), and higher body mass index (BMI) (32.1 kg/m2 [28.7, 36.2] vs. 25.7 kg/m2 [23.8, 29.2]; p = .029), but not with pre-operative or post-operative tortuosity index or curvature or alterations. Regarding secondary outcomes, the technical success rate was 97%, SAEs occurred in 15 patients (38%), early and late death rates were 8% and 23%, respectively, and early and late stroke rates were 5% and 23%, respectively. CONCLUSION The risk of developing branch thrombosis after endovascular intervention with an ABD is considerable, especially of innominate artery branches, characterised by Dacron covered large diameter bridging stents, and in patients with a high BMI. Large prospective studies are required to analyse factors associated with branch thrombosis.
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Affiliation(s)
- Charlotte C Lemmens
- Department of Vascular Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands.
| | - Tom J A J Konings
- Department of Vascular Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Anastasia Dean
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden; Department of Surgical and Peri-operative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Sinead Gormley
- Department of Vascular and Endovascular Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Manar Khashram
- Department of Vascular and Endovascular Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Barend M E Mees
- Department of Vascular Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Geert Willem H Schurink
- Department of Vascular Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
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O'Donnell TFX, Dansey KD, Schermerhorn ML, Zettervall SL, DeMartino RR, Takayama H, Patel VI. National trends in utilization of surgeon-modified grafts for complex and thoracoabdominal aortic aneurysms. J Vasc Surg 2024; 79:1276-1284. [PMID: 38354829 DOI: 10.1016/j.jvs.2024.01.216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/16/2024]
Abstract
INTRODUCTION Custom-branched/fenestrated grafts are widely available in other countries, but in the United States, they are limited to a handful of centers, with the exception of a 3-vessel juxtarenal device (ZFEN). Consequently, many surgeons have turned to alternative strategies such as physician-modified endografts (PMEGs). We therefore sought to determine how widespread the use of these grafts is. METHODS We studied all complex endovascular repairs of complex and thoracoabdominal aortic aneurysms in the Vascular Quality Initiative from 2014 to 2022 to examine temporal trends. RESULTS A total of 5826 repairs were performed during the study period: 1895 ZFEN, 3241 PMEG, 595 parallel grafting, and 95 where parallel grafting was used in addition to ZFEN, with a mean of 2.7 ± 0.98 vessels incorporated. Over time, the number of PMEGs steadily increased, both overall and for juxtarenal aneurysms, whereas the number of ZFENs essentially leveled off by 2017 and has remained steady ever since. In the most recent complete year (2021), PMEGs outnumbered ZFENs by over 2:1 overall (567 to 256) and nearly twofold for juxtarenal repairs. In three-vessel cases involving juxtarenal aneurysms, PMEGs were used as frequently as ZFENs (43% vs 43%), whereas the proportion of juxtarenal aneurysms repaired using a four-vessel graft configuration increased from 20% in 2014 to 29% in 2021 (P < .001). The differences in PMEG use were more pronounced as surgeon volume increased. Surgeons in the lowest quartile of volume performed <2 complex repairs annually, evenly split between PMEGs and ZFENs. However, surgeons in the highest quartile of volume performed a median of 18 (interquartile range: 10-21) PMEGs/y, but only 1.6 (interquartile range: 0.8-3.4) ZFENs/y. The number of physician-sponsored investigational device exemption trials of PMEGs has expanded from 1 in 2012 to 8 currently enrolling. As those data are not included in the Vascular Quality Initiative, the true number of PMEGs is likely substantially higher. CONCLUSIONS PMEGs have become the dominant endovascular repair modality of complex abdominal and thoracoabdominal aortic aneurysms outside of investigational device exemptions. The field of endovascular aortic surgery and patients with complex aneurysms would benefit from broader publication of PMEG techniques, outcomes, and comparisons to custom-manufactured grafts.
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Affiliation(s)
- Thomas F X O'Donnell
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian/Columbia University Irving Medical Center/Columbia University Vagelos College of Physicians & Surgeons, New York, NY.
| | - Kirsten D Dansey
- Division of Vascular and Endovascular Surgery, University of Washington, Seattle, WA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, University of Washington, Seattle, WA
| | | | - Hiroo Takayama
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian/Columbia University Irving Medical Center/Columbia University Vagelos College of Physicians & Surgeons, New York, NY
| | - Virendra I Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian/Columbia University Irving Medical Center/Columbia University Vagelos College of Physicians & Surgeons, New York, NY
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Zuccon G, Wanhainen A, Lindström D, Tegler G, Grima MJ, Mani K. A SiMplified bARe-Wire Target Vessel (SMART) Technique for Fenestrated Endovascular Aortic Repair. J Endovasc Ther 2024; 31:381-389. [PMID: 36113080 DOI: 10.1177/15266028221121746] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
PURPOSE The aim of this study was to present a new technique for fenestrated endovascular aortic aneurysm repair (FEVAR) and to review its preliminary results. The SiMplified bARe-wire Target vessel (SMART) technique for FEVAR aims to simplify the procedure by avoiding guiding sheaths into visceral arteries during the main graft deployment. MATERIALS AND METHODS The SMART technique requires a 12 to 16Fr contralateral introducer, depending on number of fenestrations-compared with standard 18 to 22Fr for 3 to 4 FEVAR-to achieve target vessel catheterization and stenting during FEVAR by avoiding the use of parallel 6 to 7Fr guiding sheaths into each visceral vessel. Fenestrations are sequentially catheterized, assisted by a steerable sheath. A Rosen wire is maintained in each fenestration, with a single sheath parked in the final target vessel while releasing the fenestrated graft. Data on patients treated for pararenal or thoracoabdominal aortic aneurysms with FEVAR, adopting the SMART technique, were retrospectively reviewed. End points were technical success, intraprocedural variables, 90-day mortality, major adverse events (MAEs), and target vessel patency. RESULTS From May 2018 to December 2020, 57 consecutive patients were treated for pararenal or thoracoabdominal aortic aneurysms. Median total procedure time and total fluoroscopy time were 223 (196-271) minutes and 81 (71-94) minutes, respectively. Primary technical success was 96.4% (55/57). No misalignment occurred from graft deployment. The total number of fenestrations was 169, including 54 left and 53 right renal arteries, 43 superior mesenteric arteries and 18 celiac trunks (3.0±0.9 vessels/patient), with target vessel technical success of 98.2%. During the first 90 days, there were no deaths (0%). The MAEs included acute kidney injury (AKI) in 3 patients (5%) with no new dialysis onset, respiratory failure requiring prolonged ventilation in 2 patients (4%), myocardial ischemia in 1 patient (2%), but no lower limb ischemia, stroke, or spinal cord ischemia (SCI) occurred. After a mean follow-up of 14±10 months, there was 1 aortic-related death. Primary and assisted primary target vessel patency was 94.6%±1.8 and 97.0%±1.3% respectively. CONCLUSIONS The SMART technique proved to be a safe alternative to standard FEVARs, with excellent technical result and acceptable target vessel patency at mid-term, while reducing the risk for introducer-induced lower limb ischemia, related complications, and morbidity. CLINICAL IMPACT This study evalautes the outcome of fenestrated endovascular aortic repair (FEVAR) procedures at Uppsala university hospital using a simplified bare-wire Target vessel (SMART) technique. The SMART technique requires a smaller contralateral introducer compared to standard 18-22Fr for 3-4 FEVAR to achieve target vessel catetherization and stenting. Fifty-seven consecutive patients were treated for pararenal or thoracoabdominal aortic aneurysms. The SMART technique proved to be a safe alternative to standard FEVARs with excellent technical result and acceptable target vessel patency at mid-term, while reducing the risk for introducer-induced lower limb ischemia, related complications, and morbidity.
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Affiliation(s)
- Gianmarco Zuccon
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
- Faculty of Medicine and Surgery, University of Milan, Milan, Italy
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - David Lindström
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Gustaf Tegler
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Matthew Joe Grima
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
- Faculty of Medicine & Surgery, University of Malta, Msida, Malta
- Department of Surgery, Vascular Unit, Mater Dei Hospital, Msida, Malta
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
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Frese JP, Walter C, Carstens J, Bürger M, Greiner A, Assadian A, Kapahnke S, Falkensammer J. Technical Aspects and Outcome of Multi-Staged and Single-Staged Thoracoabdominal Fenestrated Endovascular Aortic Repair. J Endovasc Ther 2024:15266028241255533. [PMID: 38804508 DOI: 10.1177/15266028241255533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
PURPOSE In some cases of endovascular thoracoabdominal or juxtarenal aortic aneurysm repair, a thoracic endograft in combination with a fenestrated renovisceral device may be needed in order to create a sufficient proximal landing zone. This study aimed to evaluate the technical aspects and postoperative morbidity of a single- or 2-stage approach. METHODS Eighty-seven consecutive patients undergoing thoracic endovascular aortic repair (TEVAR) in combination with elective fenestrated repair (fenestrated endovascular aortic repair [FEVAR]; fenestrated Anaconda device) from 2015 to 2022 were included in this retrospective bicentric study. Underlying pathologies, aortic morphology, technical details, and postoperative morbidity were recorded. RESULTS Single-staged ("1S," n=61) and 2-staged ("2S," n=26) interventions were compared. Indications were thoracoabdominal aneurysms (TAAAs) (Crawford I-IV) (n=56, 64%) and juxtarenal aneurysms (n=31, 36%). In 2S, the proportion of TAAA was higher than in 1S (2S: 77%, 1S: 59%; p=0.001). In 2S, the covered length of the descending aorta was longer (1S: 128±60 mm, 2S: 202±64 mm; p=0.003). Temporary aneurysm sack perfusion (TASP) was established in 11 (18%) of 1S and 1 (4%) of 2S patients (p=0.079), as well as cerebrospinal fluid (CSF) drainage catheter in 48 (79%) of 1S and 19 (73%) of 2S. The rate of spinal cord ischemia (SCI) and the severity of SCI were not different in both groups, with a total of 3 cases of persisting paraplegia. The rate of access complications was higher in 2S (n=6, 23%) than in 1S (n=4, 7%; p=0.027). Postoperative 30 day morbidity did not significantly differ in both groups and neither did 30 day mortality (4.6% in 1S vs 3.8% in 2S; p=0.083). CONCLUSION The combination of TEVAR and FEVAR using a fenestrated endograft is feasible and safe. Aortic morphology does not change significantly after endovascular repair. A single-staged strategy is feasible with excellent results, especially in Crawford IV, Crawford V, or juxtarenal aneurysms. Two-staged repair is recommended in cases with long aortic coverage and a higher American Society of Anesthesiologists (ASA) class. Follow-up data are needed to evaluate the long-term stability of the TEVAR/FEVAR interconnection. CLINICAL IMPACT Our study has revealed the safety and efficacy of the combination of TEVAR and FEVAR in the treatment of TAAAs and juxtarenal aneurysms with compromised supravisceral landing zones. A single-staged concept is not necessary in all cases. Staged procedures may reduce postoperative morbidity in cases with long aortic coverage and higher ASA class.
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Affiliation(s)
- Jan Paul Frese
- Department of Vascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Corinna Walter
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
| | - Jan Carstens
- Department of Vascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Bürger
- Department of Vascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Greiner
- Department of Vascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Afshin Assadian
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
| | - Sebastian Kapahnke
- Department of Vascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Jürgen Falkensammer
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Vienna, Austria
- Department of Vascular Surgery, Konventhospital der Barmherzigen Brüder Linz, Linz, Austria
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Gibello L, Antonello M, Civilini E, Pellenc Q, Bellosta R, Carbonari L, Bonardelli S, Freyrie A, Riambau V, Varetto G, Verzini F. Multicentre experience of antegrade thoracic endovascular aortic repair for the treatment of thoracic aortic diseases. Eur J Cardiothorac Surg 2024; 65:ezae185. [PMID: 38733578 DOI: 10.1093/ejcts/ezae185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/09/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024] Open
Abstract
OBJECTIVES The goal of this multicentre retrospective cohort study was to evaluate technical success and early and late outcomes of thoracic endovascular repair (TEVAR) with grafts deployed upside down through antegrade access, to treat thoracic aortic diseases. METHODS Antegrade TEVAR operations performed between January 2010 and December 2021 were collected and analysed. Both elective and urgent procedures were included. Exclusion criteria were endografts deployed in previous or concomitant surgical or endovascular repairs. RESULTS Fourteen patients were enrolled; 13 were males (94%) with a mean age of 71 years (interquartile range 62; 78). Five patients underwent urgent procedures (2 ruptured aortas and 3 symptomatic patients). Indications for treatment were 8 (57%) aneurysms/pseudoaneurysms, 3 (21%) dissections and 3 (21%) penetrating aortic ulcers. Technical success was achieved in all procedures. Early mortality occurred in 4 (28%) cases, all urgent procedures. Median follow-up was 13 months (interquartile range 1; 44). Late deaths occurred in 2 (20%) patients, both operated on in elective settings. The first died at 19 months of aortic-related reintervention; the second died at 34 months of a non-aortic-related cause. Two patients (14%) underwent aortic-related reinterventions for late type I endoleak. The survival rate of those having the elective procedures was 100%, 84% and 67% at 12, 24 and 36 months, respectively. Freedom from reintervention was 92%, 56% and 56% at 12, 24 and 36 months, respectively. CONCLUSIONS Antegrade TEVAR can seldom be considered an alternative when traditional retrograde approach is not feasible. Despite good technical success and few access-site complications, this study demonstrates high rates of late type I endoleak and aortic-related reinterventions.
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Affiliation(s)
- Lorenzo Gibello
- Unit of Vascular Surgery, Department of Surgical Sciences, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Michele Antonello
- Section of Vascular and Endovascular Surgery, Department of Cardiac Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Efrem Civilini
- Humanitas University Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Quentin Pellenc
- Department of Thoracic and Vascular Surgery, Marfan Syndrome National Referral Center, Bichat University Hospital, APHP, Paris, France
- Vascular and Endovascular Surgery Division, La Cote HealthCare Group, Morges, VD, Switzerland
| | - Raffaello Bellosta
- Vascular and Endovascular Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | | | - Stefano Bonardelli
- Vascular Surgery, Department of Surgery, Spedali Civili University Teaching Hospital, University of Brescia School of Medicine, Brescia, Italy
| | - Antonio Freyrie
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Vincent Riambau
- Department of Vascular Surgery, Cardiovascular Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Gianfranco Varetto
- Unit of Vascular Surgery, Department of Surgical Sciences, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Fabio Verzini
- Unit of Vascular Surgery, Department of Surgical Sciences, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy
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9
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Mesnard T, Vacirca A, Baghbani-Oskouei A, Sulzer TAL, Savadi S, Kanamori LR, Tenorio ER, Mirza A, Saqib N, Mendes BC, Huang Y, Oderich GS. Prospective evaluation of upper extremity access and total transfemoral approach during fenestrated and branched endovascular repair. J Vasc Surg 2024; 79:1013-1023.e3. [PMID: 38141739 DOI: 10.1016/j.jvs.2023.12.033] [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: 10/09/2023] [Revised: 12/08/2023] [Accepted: 12/15/2023] [Indexed: 12/25/2023]
Abstract
OBJECTIVE Total transfemoral (TF) access has been increasingly used during fenestrated-branched endovascular aortic repair (FB-EVAR). However, it is unclear whether the potential decrease in the risk of cerebrovascular events is offset by increased procedural difficulties and other complications. The aim of this study was to compare outcomes of FB-EVAR using a TF vs upper extremity (UE) approach for target artery incorporation. METHODS We analyzed the clinical data of consecutive patients enrolled in a prospective, nonrandomized clinical trial in two centers to investigate the use of FB-EVAR for treatment of complex abdominal aortic aneurysms (CAAA) and thoracoabdominal aortic aneurysms (TAAA) between 2013 and 2022. Patients were classified into TF or UE access group with a subset analysis of patients treated using designs with directional branches. End points were technical success, procedural metrics, 30-day cerebrovascular events defined as stroke or transient ischemic attack, and any major adverse events (MAEs). RESULTS There were 541 patients (70% males; mean age, 74 ± 8 years) treated by FB-EVAR with 2107 renal-mesenteric TAs incorporated. TF was used in175 patients (32%) and UE in 366 patients (68%) including 146 (83%) TF and 314 (86%) UE access patients who had four or more TAs incorporated. The use of a TF approach increased from 8% between 2013 and 2017 to 31% between 2018 and 2020 and 96% between 2021 and 2022. Compared with UE access patients, TF access patients were more likely to have CAAAs (37% vs 24%; P = .002) as opposed to TAAAs. Technical success rate was 96% in both groups (P = .96). The use of the TF approach was associated with reduced fluoroscopy time and procedural time (each P < .05). The 30-day mortality rate was 0.6% for TF and 1.4% for UE (P = .67). There was no early cerebrovascular event in the TF group, but the incidence was 2.7% for UE patients (P = .035). The incidence of MAEs was also lower in the TF group (9% vs 18%; P = .006). Among 237 patients treated using devices with directional branches, there were no significant differences in outcomes except for a reduced procedural time for TF compared with UE access patients (P < .001). CONCLUSIONS TF access was associated with a decreased incidence of early cerebrovascular events and MAEs compared with UE access for target artery incorporation. Procedural time was decreased in TF access patients irrespective of the type of stent graft design.
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Affiliation(s)
- Thomas Mesnard
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Andrea Vacirca
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Aidin Baghbani-Oskouei
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Titia A L Sulzer
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Safa Savadi
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Lucas Ruiter Kanamori
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Emanuel R Tenorio
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Aleem Mirza
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Naveed Saqib
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Ying Huang
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Gustavo S Oderich
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX.
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10
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Goyal A, Fatima L, Mushtaq F, Tariq MD, Kamran A, Sohail AH, Chunawala Z, Sulaiman SA, Shrestha AB, Sheikh AB, Belur AD. Comparison between the outcomes of transfemoral access and transfemoral access with adjunct upper extremity access in patients undergoing endovascular aortic repair: A pilot systematic review and meta-analysis. Catheter Cardiovasc Interv 2024; 103:982-994. [PMID: 38584518 DOI: 10.1002/ccd.31048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/18/2024] [Accepted: 03/31/2024] [Indexed: 04/09/2024]
Abstract
Endovascular aortic repair is an emerging novel intervention for the management of abdominal aortic aneurysms. It is crucial to compare the effectiveness of different access sites, such as transfemoral access (TFA) and upper extremity access (UEA). An electronic literature search was conducted using PubMed, EMBASE, and Google Scholar databases. The primary endpoint was the incidence of stroke/transient ischemic attack (TIA), while the secondary endpoints included technical success, access-site complications, mortality, myocardial infarction (MI), spinal cord ischemia, among others. Forest plots were constructed for the pooled analysis of data using the random-effects model in Review Manager, version 5.4. Statistical significance was set at p < 0.05. Our findings in 9403 study participants (6228 in the TFA group and 3175 in the UEA group) indicate that TFA is associated with a lower risk of stroke/TIA [RR: 0.55; 95% CI: 0.40-0.75; p = 0.0002], MI [RR: 0.51; 95% CI: 0.38-0.69; p < 0.0001], spinal cord ischemia [RR: 0.41; 95% CI: 0.32-0.53, p < 0.00001], and shortens fluoroscopy time [SMD: -0.62; 95% CI: -1.00 to -0.24; p = 0.001]. Moreover, TFA required less contrast agent [SMD: -0.33; 95% CI: -0.61 to -0.06; p = 0.02], contributing to its appeal. However, no significant differences emerged in technical success [p = 0.23], 30-day mortality [p = 0.48], ICU stay duration [p = 0.09], or overall hospital stay length [p = 0.22]. Patients with TFA had a lower risk of stroke, MI, and spinal cord ischemia, shorter fluoroscopy time, and lower use of contrast agents. Future large-scale randomized controlled trials are warranted to confirm and strengthen these findings.
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Affiliation(s)
- Aman Goyal
- Department of Internal Medicine, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Laveeza Fatima
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore, Pakistan
| | - Fiza Mushtaq
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore, Pakistan
| | - Muhammad Daoud Tariq
- Department of Internal Medicine, Foundation University Medical College, Islamabad, Pakistan
| | - Aemen Kamran
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Amir Humza Sohail
- Department of Surgery, University of New Mexico Health Sciences, Albuquerque, New Mexico, USA
| | - Zainali Chunawala
- Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Samia Aziz Sulaiman
- Department of Internal Medicine, School of Medicine, University of Jordan, Amman, Jordan
| | | | - Abu Baker Sheikh
- Department of Internal Medicine, University of New Mexico Health Sciences, Albuquerque, New Mexico, USA
| | - Agastya D Belur
- Department of Cardiovascular Medicine, University of Louisville, Louisville, Kentucky, USA
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11
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Gable DR, Verhoeven E, Trimarchi S, Böckler D, Milner R, Dubenec S, Silveira P, Weaver F. Endovascular treatment for thoracic aortic disease from the Global Registry for Endovascular Aortic Treatment. J Vasc Surg 2024; 79:1044-1056.e1. [PMID: 38154605 DOI: 10.1016/j.jvs.2023.12.040] [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: 10/19/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVE Global Registry for Endovascular Aortic Treatment (GREAT) is an international prospective multicenter registry collecting real-world data on performance of W. L. Gore thoracic and abdominal aortic endografts. This analysis evaluated the long-term differences in patient survival and device performance in patients undergoing thoracic endovascular aortic repair (TEVAR) for any thoracic aortic pathology. METHODS From August 2010 to October 2016, 5014 patients were enrolled in GREAT. The population of interest was comprised of only patients treated for thoracic aortic pathologies. Through 5 years, primary outcomes were all-cause and aortic-related mortality, stroke, aortic rupture, endoleaks, migration, fracture, compression, paraplegia, and any reintervention through 5 years, grouped by pathology. Secondary outcomes were reintervention rate and freedom from serious device- and aortic-related events. RESULTS The 578 patients with thoracic aortic pathologies enrolled in GREAT and identified for this analysis were categorized by common pathologies: thoracic aneurysm (n = 239), thoracic dissection (n = 203), arch (n = 26), and other (n = 110). The mean age of this population was 66.1 ± 12.8 years, and 64.7% were male. Procedure survival was 99.7%. In the overall group, at index procedure to 30 days and 31 days to 5 years, Kaplan-Meier estimates of freedom from all-cause mortality were 99.6% and 66.4%, respectively, and for aortic-related mortality were 97.7% and 94.6%, respectively. Aortic rupture rate was 0.5% (n = 3) at 30 days and 1.4% (n = 8) through 5 years. Stroke and spinal cord ischemic events were 1.9% (n = 11) and 1.6% (n = 9) at 30 days and at 5 years were 3.6% (n = 20), 0.5% (n = 3), respectively. Reinterventions were required in 7.3% (n = 42) at 30 days and 12.4% (n = 69) through 5 years. The number of patients with endoleaks at 30 days was 2.1% (n = 12): n = 3 (1.1%) for each of types IA, 1B, and II; n = 2 (0.3%) for type III; and n = 4 (0.7%) for unspecified. Through 5 years, the percentage of patients was 8.3% (n = 40): n = 15 (3.1%) for type IA; n = 10 (2.1%) for type IB; n = 11 (2.3%) for type II; and n = 9 (1.9%) for unspecified. One patient (0.2%) had stent migration at 30 days (aneurysm group); none were reported through 5 years. There were no incidents of stent compression or fracture from index procedure through 5 years. CONCLUSIONS Data herein demonstrates durability and support for treatment of thoracic aortic disease with the GORE TAG conformable thoracic stent graft, including no incidents of stent compression/fracture and high freedom from aortic-related mortality. The planned analysis of follow-up to 10 years in GREAT will be beneficial.
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Affiliation(s)
- Dennis R Gable
- Department of Vascular Surgery, Baylor Scott & White, The Heart Hospital, Plano, TX.
| | - Eric Verhoeven
- General Hospital and Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Santi Trimarchi
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milan, Milan, Italy; Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Ross Milner
- The Division of Vascular Surgery and Endovascular Therapy, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Steven Dubenec
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Pierre Silveira
- Department of Vascular Service and Surgery, Universidade Federal de Santa Catarina, Florianopolis, Brazil
| | - Fred Weaver
- Division of Vascular Surgery, Department of Surgery, University of Southern California, Los Angeles, CA
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12
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Taneva GT, Pitoulias AG, Avranas K, Donas KP. Latest evidence on chimney endovascular repair of abdominal aortic aneurysms and the renal artery angulation pitfall. THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:119-123. [PMID: 38618696 DOI: 10.23736/s0021-9509.24.12936-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
This article summarizes the key findings in literature up to date on the endovascular treatment of complex abdominal aortic aneurysms (AAAs) employing the chimney technique. Additionally, an unexplored pitfall is described regarding the target vessel angulation. Although balloon-expandable covered stents present more favorable configuration in downward-oriented target vessels, transverse and upward-oriented target vessels may benefit from other endovascular techniques imploring careful case planning and further investigation on the topic.
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Affiliation(s)
- Gergana T Taneva
- Department of Vascular and Endovascular Surgery, Rhein Main Vascular Center, Asklepios Clinics Langen, Langen, Germany -
| | - Apostolos G Pitoulias
- Department of Vascular and Endovascular Surgery, Rhein Main Vascular Center, Asklepios Clinics Langen, Langen, Germany
| | - Konstantinos Avranas
- Department of Vascular and Endovascular Surgery, Rhein Main Vascular Center, Asklepios Clinics Langen, Langen, Germany
| | - Konstantinos P Donas
- Department of Vascular and Endovascular Surgery, Rhein Main Vascular Center, Asklepios Clinics Langen, Langen, Germany
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13
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Nooromid M, Creisher BA, Abai B. Treatment of Uncomplicated Type B Aortic Dissection: Optimal Medical Therapy vs TEVAR + Optimal Medical Therapy. Vasc Endovascular Surg 2024; 58:115-122. [PMID: 37365809 DOI: 10.1177/15385744231184671] [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: 06/28/2023]
Abstract
Optimal Medical Therapy (OMT) has been the accepted mode of treatment for uncomplicated Type B Aortic Dissection (uTBAD). There is growing evidence that despite the short-term benefits of OMT, patients suffer deleterious consequences in the long-term with OMT alone. Thoracic Endovascular Aortic Repair (TEVAR) along with OMT has emerged as an alternative option for patients with uTBAD. This study evaluates the available literature for TEVAR + OMT as an alternative to OMT for treatment of uTBAD. In addition, issues related to TEVAR as a treatment for uTBAD are discussed.
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Affiliation(s)
- Michael Nooromid
- Division of Vascular and Endovascular Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Brandon A Creisher
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Babak Abai
- Division of Vascular and Endovascular Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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14
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Ma Y, Siddiqui MS, Farhan SA, Albuquerque FC, Larson RA, Levy MM, Chery J, Newton DH. A meta-analysis on the effect of proximal landing zone location on stroke and mortality in thoracic endovascular aortic repair. J Vasc Surg 2023; 78:1559-1566.e5. [PMID: 37201762 DOI: 10.1016/j.jvs.2023.05.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/19/2023] [Accepted: 05/10/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) involving the aortic arch may increase the opportunity for stroke owing to disruption of cerebral circulation and embolization. In this study, a systematic meta-analysis was performed to examine the impact of proximal landing zone location on stroke and 30-day mortality after TEVAR. METHODS MEDLINE and Cochrane Library were searched for all original studies of TEVAR reporting outcomes of stroke or 30-day mortality for at least two adjacent proximal landing zones, based on the Ishimaru classification scheme. Forest plots were created using relative risks (RR) with 95% confidence intervals (CI). An I2 of <40% was regarded as minimal heterogeneity. A P value of <.05 was considered significant. RESULTS Of the 57 studies examined, a total of 22,244 patients (male 73.1%, aged 71.9 ± 11.5 years) were included in the meta-analysis, with 1693 undergoing TEVAR with proximal landing zone 0, 1931 with zone 1, 5839 with zone 2, and 3089 with zone 3 and beyond. The overall risk of clinically evident stroke was 2.7% for zones ≥3, 6.6% for zone 2, 7.7% for zone 1, and 14.2% for zone 0. More proximal landing zones were associated with higher risks of stroke compared with distal (zone 2 vs ≥3: RR, 2.14; 95% CI, 1.43-3.20; P = .0002; I2 = 56%; zone 1 vs 2: RR, 1.48; 95% CI, 1.20-1.82; P = .0002; I2 = 0%; zone 0 vs 1: RR, 1.85; 95% CI, 1.52-2.24; P < .00001; I2 = 0%). Mortality at 30 days was 2.9% for zones ≥3, 2.4% for zone 2, 3.7% for zone 1, and 9.3% for zone 0. Zone 0 was associated with higher mortality compared with zone 1 (RR, 2.30; 95% CI, 1.75-3.03; P < .00001; I2 = 0%). No significant differences were found in 30-day mortality between zones 1 and 2 (P = .13) and between zone 2 and zones ≥3 (P = .87). CONCLUSIONS The risk of stroke from TEVAR is lowest in zone 3 and beyond, increasing significantly as the landing zone is moved proximally. Furthermore, perioperative mortality is increased with zone 0 compared with zone 1. Therefore, risk of stent grafting in the proximal arch should be weighed against alternative surgical or nonoperative options. It is anticipated that the risk of stroke will improve with further development of stent graft technology and implantation technique.
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Affiliation(s)
- Yuchi Ma
- Division of Vascular Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Mishal S Siddiqui
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Syed A Farhan
- Division of Vascular Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Francisco C Albuquerque
- Division of Vascular Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Robert A Larson
- Division of Vascular Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Mark M Levy
- Division of Vascular Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Josue Chery
- Division of Cardiothoracic Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Daniel H Newton
- Division of Vascular Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA.
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15
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DiBartolomeo AD, Ding L, Weaver FA, Han SM, Magee GA. Risk of Stroke with Thoracic Endovascular Aortic Repair of the Aortic Arch. Ann Vasc Surg 2023; 97:37-48. [PMID: 37121336 DOI: 10.1016/j.avsg.2023.04.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) involving the aortic arch is increasingly being performed and novel endografts have been developed for this procedure, but the association of stroke and relative risk of procedural techniques remains unclear. This study evaluates the procedural risk factors for stroke and mortality with zone 0-2 TEVAR. METHODS The Society for Vascular Surgery Vascular Quality Initiative registry was queried for patients who underwent TEVAR with proximal landing in zone 0-2 from 2013 to 2022. Emergent and ruptured cases were excluded. Primary exposure variables included proximal seal zone (0-2) and branch vessel revascularization technique: open debranching/bypass, total endovascular incorporation, or combination (at least 1 branch open and 1 branch endovascular). The primary outcome was perioperative inhospital stroke and the secondary outcome was inhospital mortality. Univariable and multivariable regression analyses were performed. RESULTS In total, 4,355 cases were analyzed with 350 in zone 0 (8%), 513 in zone 1 (12%), and 3,492 in zone 2 (80%). For zone 0, 1, and 2, the stroke rates were 11.1%, 5.3% and 4.7% (P < 0.0001) and inhospital mortality rates were 6.9%, 5.3% and 3.5% (P = 0.002), respectively. Branch vessel revascularization technique was associated with stroke in zone 0 with a 3-fold higher stroke rate for total endovascular incorporation of branches compared to combination and open techniques (P = 0.002). On multivariable analysis, zone 0 was independently associated with a greater than 2-fold increased odds of stroke compared to zone 2 (95% CI 1.4-3.2, P = 0.0008). CONCLUSIONS Stroke rate was 2-3 times higher for zone 0 TEVAR compared to zones 1 and 2. Within zone 0, total endovascular branch incorporation was associated with a 3-fold higher stroke rate than open and combination techniques. Future device design modifications and novel endovascular strategies for stroke prevention are required to make total endovascular repair of the aortic arch an acceptable alternative to combination and open debranching/bypass techniques.
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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
| | - Li Ding
- Department of Population and Public Health Sciences, Keck School of Medicine, 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
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA.
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16
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Cao L, Zhang H, Ge Y, Guo W. Avoiding Stroke in Patients Undergoing Endovascular Aortic Arch Repair: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 82:265-277. [PMID: 37438011 DOI: 10.1016/j.jacc.2023.04.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/10/2023] [Accepted: 04/24/2023] [Indexed: 07/14/2023]
Abstract
As the bottleneck of endovascular aortic arch repair, early postoperative stroke remains a devastating complication in high-risk patients and a critical concern for the development of optimal endovascular techniques and devices. The incidence of early postoperative stroke varies widely among currently available endovascular techniques and devices, with reported rates ranging from 0.0% to 42.9%, and is significantly influenced by the severity of the patient's preexisting aortic atherosclerotic burden, air released from the endovascular device, and a variety of factors leading to cerebral perfusion insufficiency. Currently, preidentification of high-risk patients and careful perioperative management appear to play a critical role in reducing stroke incidence. Specific intraoperative prevention methods are still lacking, but embolic protection devices and carbon dioxide or high-volume saline flushing of endovascular devices appear promising. Detailed preoperative stroke risk stratification and screening for optimal endovascular techniques and devices for aortic arch treatment are unmet clinical needs.
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Affiliation(s)
- Long Cao
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China; Department of General Surgery, The 983rd Hospital of Joint Logistic Support Force of PLA, Tianjin, China
| | - Hongpeng Zhang
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Yangyang Ge
- 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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17
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Asciutto G, Lindström D. E-nside, a New Kid on the Aortic Block. Eur J Vasc Endovasc Surg 2023; 65:818. [PMID: 36878353 DOI: 10.1016/j.ejvs.2023.02.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 02/20/2023] [Accepted: 02/28/2023] [Indexed: 03/07/2023]
Affiliation(s)
- Giuseppe Asciutto
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - David Lindström
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
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18
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Liu Y, Fang K, Luo MY, Xiao ZH, Yang P, Lu C, Zhang Y, Wang HY, Xie Y, Xu ZY, Zhang HW, Shu C, Hu J. Single-Center Preliminary Experience with Gutter-Plugging Chimney Stent-Graft for Aortic Dissection. Cardiovasc Intervent Radiol 2023:10.1007/s00270-023-03444-8. [PMID: 37198293 DOI: 10.1007/s00270-023-03444-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 04/06/2023] [Indexed: 05/19/2023]
Abstract
PURPOSE To report the early 2-year results and experience of a novel gutter-plugging chimney stent-graft in a single center that participated in the clinical trial of Prospective Study for Aortic Arch Therapy with stENt-graft for Chimney technology. MATERIALS AND METHODS Patients diagnosed with aortic dissection were treated with the novel chimney stent-grafts named Longuette™ for the left subclavian artery revascularization. Primary study outcomes were the incidence of freedom from major adverse events within 30 days and success rate of the operation over 12 months. RESULTS A total of 34 patients were enrolled between September 2019 and December 2020. The immediate technical success rate (stent-grafts successfully deployed without fast-flow type Ia or type III endoleak intraoperatively) was 100%, and there were no conversions to open repair. Type Ia and type II endoleaks were noted in three patients (8.8%) and one patient (2.9%) at discharge, respectively. One patient (2.9%) with type Ia endoleak underwent coil embolization at 12 months because of false lumen dilation, and one (2.9%) case of type Ia endoleak resolved spontaneously at 24 months. One chimney stent (2.9%) was revealed with stenosis at discharge and occluded with thrombosis at 6 months postoperatively. During the 2-year follow-up, there was no death, rupture, stroke, paraplegia, left arm ischemia, retrograde dissection, stent-graft induced new entry, or stent migration. CONCLUSION The initial results of the Longuette™ stent-graft for revascularization of the left subclavian artery are encouraging with a high technical success rate. Further multicenter follow-up outcomes are required to assess the long-term durability. LEVEL OF EVIDENCE Level 4, Case Series.
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Affiliation(s)
- Yu Liu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Kun Fang
- National Center for Cardiovascular Diseases, Fuwai Hospital, CAMS & PUMC, Beijing, China
| | - Ming-Yao Luo
- National Center for Cardiovascular Diseases, Fuwai Hospital, CAMS & PUMC, Beijing, China
| | - Zheng-Hua Xiao
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Peng Yang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Chen Lu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Yu Zhang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Hai-Yue Wang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Yi Xie
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Zhen-Yuan Xu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Hong-Wei Zhang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Chang Shu
- National Center for Cardiovascular Diseases, Fuwai Hospital, CAMS & PUMC, Beijing, China.
| | - Jia Hu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China.
- Department of Cardiovascular SurgeryWest China Guang'an Hospital, Sichuan University, Guang'an, 638000, Sichuan, China.
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Noda K, Koga M, Toyoda K. Recognition of Strokes in the ICU: A Narrative Review. J Cardiovasc Dev Dis 2023; 10:182. [PMID: 37103061 PMCID: PMC10145112 DOI: 10.3390/jcdd10040182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 04/28/2023] Open
Abstract
Despite the remarkable progress in acute treatment for stroke, in-hospital stroke is still devastating. The mortality and neurological sequelae are worse in patients with in-hospital stroke than in those with community-onset stroke. The leading cause of this tragic situation is the delay in emergent treatment. To achieve better outcomes, early stroke recognition and immediate treatment are crucial. In general, in-hospital stroke is initially witnessed by non-neurologists, but it is sometimes challenging for non-neurologists to diagnose a patient's state as a stroke and respond quickly. Therefore, understanding the risk and characteristics of in-hospital stroke would be helpful for early recognition. First, we need to know "the epicenter of in-hospital stroke". Critically ill patients and patients who undergo surgery or procedures are admitted to the intensive care unit, and they are potentially at high risk for stroke. Moreover, since they are often sedated and intubated, evaluating their neurological status concisely is difficult. The limited evidence demonstrated that the intensive care unit is the most common place for in-hospital strokes. This paper presents a review of the literature and clarifies the causes and risks of stroke in the intensive care unit.
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Affiliation(s)
- Kotaro Noda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita 564-8565, Japan
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8519, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita 564-8565, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita 564-8565, Japan
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Patel PB, Marcaccio CL, Swerdlow NJ, O'Donnell TFX, Rastogi V, Marino R, Patel VI, Zettervall SL, Lindsay T, Schermerhorn ML. Thoracoabdominal aortic aneurysm life-altering events following endovascular aortic repair in the Vascular Quality Initiative. J Vasc Surg 2023:S0741-5214(23)01018-2. [PMID: 37044316 DOI: 10.1016/j.jvs.2023.03.499] [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: 01/02/2023] [Revised: 03/18/2023] [Accepted: 03/22/2023] [Indexed: 04/14/2023]
Abstract
OBJECTIVE Endovascular aortic aneurysm repair has lower rates of postoperative mortality and morbidity when compared with open repair. However, endovascular repair still carries the risk of postoperative dialysis, paralysis, and stroke. This study examined the rates of postoperative mortality and morbidity stratified by type of endovascular aortic aneurysm repair. METHODS All patients who underwent endovascular aortic aneurysm repair in the Vascular Quality Initiative registry from January 2011 - May 2022 were identified. Patients were stratified by repair type: infrarenal endovascular aortic repair (EVAR), complex EVAR, thoracic endovascular aortic repair (TEVAR), extent I-III thoracoabdominal aortic aneurysm (TAAA) repair, or aortic arch repair. The primary outcome was postoperative thoracoabdominal aortic aneurysm life-altering events (TALE) across the different treatment groups. TALE was defined as a composite outcome of postoperative mortality, dialysis, paralysis, and/or stroke. Mixed effect logistic regression modeling was used to identify procedural and anatomic factors that were independently associated with TALE. RESULTS A total of 52,592 EVARs, 3,768 complex EVARs, 3,899 TEVARs, 1,139 extent I-III TAAA repairs, and 479 arch repairs were identified. TALE was observed in 1.2% of EVARs, 4.8% of complex EVARs, 6.0% of TEVARs, 10% of extent I-III TAAA repairs, and 14% of arch repairs. More proximal landing zone was associated with higher odds of TALE after complex EVAR (OR 1.9 [1.2-3.1]; p=.008), TEVAR (OR 2.2 [1.4-3.5]; p=.001), and extent I-III TAAA repair (OR 2.7 [1.5-4.9]; p=.001). Aortic diameter >65mm was associated with higher odds of TALE after infrarenal EVAR (OR 1.8 [1.4-2.3]; p<.001), complex EVAR (OR 1.6 [1.1-2.3]; p=.010), TEVAR (OR 2.7 [2.0-3.8]; p<.001), and arch repair (OR 2.4; [1.3-4.4]; p=.007). The use of parallel grafting technique (chimney/snorkel/periscope) during extent I-III TAAA repair was also associated with higher odds of TALE (OR 1.8 [1.1-3.2]; p=.032). Preoperative chronic kidney disease was also associated with higher odd of TALE after infrarenal EVAR (OR 4.3 [3.0-5.7]; p<.001), complex EVAR (OR 5.2 [3.3-8.2]; p<.001), TEVAR (OR 4.5 [2.8-7.1]; p<.001), and extent I-III TAAA repair (OR 3.2 [1.6-6.7]; p=.001). CONCLUSION While TALE was originally described for thoracoabdominal aortic aneurysm repairs, TALE may occur after complex EVAR, TEVAR, and arch repairs as well. Therefore, TALE and its component parts should be used to evaluate the efficacy of all aortic repairs and for preoperative counseling. Additionally, surgeons should be aware of anatomic and procedural characteristics that are associated with higher odds of TALE. The anticipated need for such interventions during aortic repair should be factored into preoperative risk assessment of patients.
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Affiliation(s)
- Priya B Patel
- The Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Christina L Marcaccio
- The Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Nicholas J Swerdlow
- The Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Thomas F X O'Donnell
- The Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA; Division of Vascular Surgery and Endovascular Interventions, Columbia University Medical Center, New York, NY
| | - Vinamr Rastogi
- The Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Virendra I Patel
- Division of Vascular Surgery and Endovascular Interventions, Columbia University Medical Center, New York, NY
| | - Sara L Zettervall
- Division of Vascular Surgery, University of Washington Medicine, Seattle, WA
| | - Thomas Lindsay
- Department of Vascular Surgery, University of Toronto, Canada
| | - Marc L Schermerhorn
- The Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
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21
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Arterial access for endovascular treatment of lower extremity peripheral arterial disease: A choice that matters and a matter of choice. J Vasc Surg 2023; 77:877-878. [PMID: 36822766 DOI: 10.1016/j.jvs.2022.11.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 11/15/2022] [Indexed: 02/25/2023]
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22
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Chamseddin K, Timaran CH, Oderich GS, Tenorio ER, Farber MA, Parodi FE, Schneider DB, Schanzer A, Beck AW, Sweet MP, Zettervall SL, Mendes B, Eagleton MJ, Gasper WJ. Comparison of upper extremity and transfemoral access for fenestrated-branched endovascular aortic repair. J Vasc Surg 2023; 77:704-711. [PMID: 36257344 DOI: 10.1016/j.jvs.2022.10.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 10/07/2022] [Accepted: 10/09/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The use of upper extremity (UE) access is an accepted and often implemented approach for fenestrated/branched endovascular aortic aneurysm repair (F-BEVAR). The advent of steerable sheaths has enabled the performance of F-BEVAR using a total transfemoral (TF) approach without UE access, potentially decreasing the risks of cerebral embolic events. The purpose of the present study was to assess the outcomes of F-BEVAR using UE vs TF access. METHODS Prospectively collected data from nine physician-sponsored investigational device exemption studies at U.S. centers were analyzed using a standardized database. All patients were treated for complex abdominal aortic aneurysms (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs) using industry-manufactured fenestrated and branched stent grafts between 2005 and 2020. The outcomes were compared between patients who had undergone UE vs total TF access. The primary composite outcome was stroke or transient ischemia attack (TIA) and 30-day or in-patient mortality during the perioperative period. The secondary outcomes included technical success, local access-related complications, and perioperative mortality. RESULTS Among 1681 patients (71% men; mean age, 73.43 ± 7.8 years) who had undergone F-BEVAR, 502 had had CAAAs (30%), 535 had had extent IV TAAAs (32%), and 644 had had extent I to III TAAAs (38%). UE access was used for 1103 patients (67%). The right side was used for 395 patients (24%) and the left side for 705 patients (42%). UE access was preferentially used for TAAAs (74% vs 47%; P < .001). In contrast, TF access was used more frequently for CAAAs (53% vs 26%; P < .01). A total of 38 perioperative cerebrovascular events (2.5%), including 32 strokes (1.9%) and 6 TIAs (0.4%), had occurred. Perioperative cerebrovascular events had occurred more frequently with UE access than with TF access (2.8% vs 1.2%; P = .036). An individual component analysis of the primary composite outcome revealed a trend for more frequent strokes (2.3% vs 1.2%; P = .13) and TIAs (0.54% vs 0%; P = .10) in the UE access group. On multivariable analysis, total TF access was associated with a 60% reduction in the frequency of perioperative cerebrovascular events (odds ratio, 0.39; P = .029). No significant differences were observed between UE and TF access in the technical success rate (96.5% vs 96.8%; P = .72), perioperative mortality (2.9% vs 2.6%; P = .72), or local access-related complications (6.5% vs 5.5%; P = .43). CONCLUSIONS In the present large, multicenter, retrospective analysis of prospectively collected data, a total TF approach for F-BEVAR was associated with a lower rate of perioperative cerebrovascular events compared with UE access. Although the cerebrovascular event rate was low with UE access, the TF approach offered a lower risk of stroke and TIA. UE access will continue to play a role for appropriately selected patients requiring more complex repairs with anatomy not amenable to the TF approach.
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Affiliation(s)
- Khalil Chamseddin
- Division of Vascular and Endovascular Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Carlos H Timaran
- Division of Vascular and Endovascular Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, John P. and Kathrine G. McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Emanuel R Tenorio
- Division of Vascular and Endovascular Surgery, John P. and Kathrine G. McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Mark A Farber
- Division of Vascular and Endovascular Surgery, University of North Carolina, Chapel Hill, NC
| | - F Ezequiel Parodi
- Division of Vascular and Endovascular Surgery, University of North Carolina, Chapel Hill, NC
| | - Darren B Schneider
- Division of Vascular and Endovascular Surgery, University of Pennsylvania, Philadelphia, PA
| | - Andres Schanzer
- Division of Vascular and Endovascular Surgery, University of Massachusetts, Worcester, MA
| | - Adam W Beck
- Division of Vascular and Endovascular Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Matthew P Sweet
- Division of Vascular and Endovascular Surgery, University of Washington, Seattle, WA
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, University of Washington, Seattle, WA
| | - Bernardo Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Warren J Gasper
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
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Rogers RT, Lemmens CC, Tenorio ER, Schurink GWH, DeMartino RR, Oderich GS, Mees BME, Mendes BC. Fenestrated/branched endovascular aortic repair using unilateral femoral access in patients with iliac occlusive disease. J Vasc Surg 2023; 77:722-730. [PMID: 36372375 DOI: 10.1016/j.jvs.2022.10.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/01/2022] [Accepted: 10/30/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Fenestrated/branched endovascular aortic repair (F/BEVAR) in patients with occluded iliac arteries is challenging owing to limited access for branch vessel catheterization and increased risk for leg and spinal ischemic complications. The aim of this study was to analyze technical strategies and outcomes of F/BEVAR in patients with unilateral iliofemoral occlusive disease. METHODS We performed a retrospective review of all consecutive patients treated by F/BEVAR in two institutions (2003-2021). Patients with unilateral iliofemoral occlusive disease were included in the analysis. All patients had one patent iliac artery that was used for advancement of the fenestrated-branch component. Preloaded catheter/guidewire systems or steerable sheaths were used as adjuncts to facilitate catheterization. Primary endpoints were technical success, mortality, major adverse events (stroke, spinal cord injury, dialysis or decrease in the glomerular filtration rate of more than 50%, bowel ischemia, myocardial infarction, or respiratory failure), primary iliac patency, and freedom from reinterventions. RESULTS There were 959 patients treated with F/BEVAR. Of these, 15 patients (1.56%; mean age, 74 years; 80% male) had occluded iliac arteries and 1 patent iliofemoral access and were treated for a thoracoabdominal aortic aneurysm (n = 8) or juxtarenal abdominal aortic aneurysm (n = 7). Brachial access was used in 14 of the 15 patients and preloaded systems in 7 of the 15 patients (47%). The remaining 53% had staggered deployment of stent grafts. There were seven physician-modified endovascular grafts, seven custom-made devices, and one off-the-shelf device used. Thirteen patients (87%) had distal seal using aortouni-iliac stent grafts and two (13%) had distal seal in the infrarenal aorta. Concomitant femoral crossover bypass (FCB) was performed in two patients and six patients had a prior FCB. Technical success was 100%. There were no intraoperative complications or early lower extremity ischemic complications, and all FCB were preserved. There was one mortality (7%) within 30 days owing to retrograde type A dissection. Major adverse events occurred in 20% of patients. The median follow-up was 12 months (range, 0-85 months). Two patients (13%) required three reinterventions. One patient required proximal stent graft extension for an acute type B dissection (3 months) and another required iliac extension for type Ib endoleak of an aortouni-iliac graft (21 months) and thrombolysis of that extension (50 months). At last follow-up, all patients had primary graft patency except one with secondary graft patency without new claudication. One patient had a single renal artery stent occlusion at follow-up with no r-intervention. The overall survival rate was 60%, without aortic-related deaths. CONCLUSIONS Although challenging, F/BEVAR with unilateral femoral/brachial approach is feasible in patients with occluded iliac limbs, with an important rate of ischemic complications, but satisfactory outcomes.
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Affiliation(s)
- Richard T Rogers
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Charlotte C Lemmens
- Division of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Emanuel R Tenorio
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Geert Willem H Schurink
- Division of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Barend M E Mees
- Division of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.
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Li RD, Chia MC, Eskandari MK. Thoracic Endovascular Aortic Repair with Supra-Aortic Trunk Revascularization is Associated with Increased Risk of Periprocedural Ischemic Stroke. Ann Vasc Surg 2022; 87:205-212. [PMID: 35835381 PMCID: PMC9901212 DOI: 10.1016/j.avsg.2022.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/20/2022] [Accepted: 06/23/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Ischemic stroke is a devastating complication of thoracic endovascular aortic repair (TEVAR). This risk may be higher in more proximal aneurysms that require arch manipulation. The purpose of this study is to (1) describe 30-day stroke and death rates in patients undergoing TEVAR, (2) compare stroke rates in patients undergoing TEVAR for arch versus descending aneurysm pathology, and (3) identify predictive factors associated with stroke after TEVAR. METHODS The Vascular Quality Initiative registry was queried (2015-2021) for TEVAR procedures performed for degenerative aneurysms. Our primary outcomes were any stroke or death at 30 days. Patient-, procedure-, and hospital-level predictors of stroke were assessed using multivariable Poisson regression. RESULTS Among 3,072 patients with degenerative aneurysms (197 [6.4%] arch versus 2,875 [93.6%] descending) treated with elective TEVAR, the median age was 73 years (interquartile range 67-79) and 54.8% were male. Within the arch aneurysm group, there were 27.4% zone 0, 22.8% zone 1, and 49.8% zone 2 interventions. Overall 30-day stroke and death rates were 3.2% and 3.8%. The distribution of stroke events was bilateral (52.9%), left carotid (20.7%), left vertebrobasilar (11.5%), right carotid (9.2%), and right vertebrobasilar (5.7%). Although mortality was similar between groups, the rate of ischemic stroke was higher for patients undergoing TEVAR for arch aneurysm versus descending aneurysms (7.1% arch versus 2.9% descending, P = 0.001). Factors that were associated with ischemic stroke after TEVAR included age (>79 years, relative risk [RR] 1.79, 95% confidence interval [CI] 1.08-2.98 vs. <79 years), dependent functional status (RR 1.73, 95% CI 1.07-2.78), procedural time (RR 1.25, 95% CI 1.15-1.36), and endovascular intervention for supra-aortic trunk revascularization (RR 2.66, 95% CI 1.06-6.70 versus no intervention). CONCLUSIONS Ischemic stroke risk after TEVAR was increased for arch aneurysms compared to descending aneurysms. More proximal zone coverage and endovascular interventions on the supra-aortic trunks were associated with increasing risk for stroke. Adequate preparation for stroke prevention is necessary prior to TEVAR with supra-aortic trunk revascularization.
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Affiliation(s)
- Ruojia Debbie Li
- Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL
| | - Matthew C Chia
- Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL
| | - Mark K Eskandari
- Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.
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Patel RJ, Mathlouthi A, Al-Nouri O, Lane JS, Malas MB, Barleben AR. A Single Center Review of a Total Transfemoral Approach to Upper Extremity Access in Branched and Fenestrated Physician Modified Endografts. Ann Vasc Surg 2022; 86:117-126. [PMID: 35809740 PMCID: PMC10339283 DOI: 10.1016/j.avsg.2022.05.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 05/29/2022] [Accepted: 05/30/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Aortic aneurysms are normally treated by an endovascular approach. Due to the lack of devices and increasing experience, there is a growing number of complex aneurysms undergoing repair by physician modified endografts (PMEGs). Previously, our practice was to target visceral vessels exclusively through upper extremity access. We have since then shifted to an all transfemoral approach when possible. This study aims to show the operative benefits of transfemoral only approaches. METHODS Patients who underwent a PMEG at a tertiary center between 2015 and 2020 were included. Patients were stratified into 2 groups based on branched vessel approach-transfemoral only versus axillary or composite (axillary and femoral). Forty-one patients had a pararenal or type IV thoracoabdominal aortic aneurysm (TAAA) and 15 patients had more complex TAAA. Primary outcomes were operative time, radiation exposure, fluoroscopy time, contrast, and blood loss. Secondary outcomes were 30-day mortality and major adverse events. Linear regression models were used to evaluate the association between approach type and the main outcomes. RESULTS Fifty-six patients were included with 48% (n = 27) in the transfemoral group and 52% (n = 29) in the axillary/composite group. Baseline characteristics were similar between the groups. Intraoperative outcomes revealed significant increase in the average operative time (418 vs. 246 min, P < 0.001), in radiation exposure (2,755 vs. 1,740 mGy, P = 0.03), in fluoroscopy time (108 vs. 74 min, P = 0.01) and in blood loss (579 vs. 202 cc, P = 0.002) in the axillary/composite group compared to the transfemoral group. There was no significant difference in 30-day mortality or major adverse events including stroke. CONCLUSIONS This study shows a transfemoral approach to complex endovascular aortic aneurysm repair as opposed to axillary/composite approach has decreased operative time, radiation exposure, and fluoroscopy time and no significant differences in 30-day mortality or major adverse events. When treating complex aneurysms, improving efficiency is important to minimize morbidity to patients and operators.
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Affiliation(s)
- Rohini J Patel
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, CA
| | - Asma Mathlouthi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, CA
| | - Omar Al-Nouri
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, CA
| | - John S Lane
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, CA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, CA
| | - Andrew R Barleben
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, CA.
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Marques de Marino P, Hagen M, Katsargyris A, Botos B, Verhoeven EL. Outcomes of upper access with surgical exposure of the axillary artery in fenestrated and branched endovascular aneurysm repair. Eur J Vasc Endovasc Surg 2022; 64:332-338. [PMID: 35963515 DOI: 10.1016/j.ejvs.2022.07.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 06/16/2022] [Accepted: 07/22/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES This study aims to assess the safety of upper access with surgical exposure of the axillary artery in fenestrated and branched endovascular aneurysm repair (F/B-EVAR), evaluating neurologic and local complications as well as reinterventions associated with this technique. METHODS All patients undergoing a F/B-EVAR procedure with surgical exposure of the axillary artery between January 2010 and March 2020 were included in this retrospective single-centre study. Endpoints were neurological and access-related complications and reinterventions related to the upper extremity access. Complications related to the technique included stroke/transient ischaemic attack, wound infection, peripheral nerve injury and arterial complications. RESULTS 264 patients (192 male, mean age 70 ± 7 years) were included. Upper access was performed over the left axillary artery in 257 (97%) of the cases, and over the right axillary artery in the remaining seven cases. Six (2,2%) patients had early complications related to the arterial access: four with postoperative bleeding and two with acute arm ischaemia. Two patients with postoperative bleeding and both patients with ischaemic complications required reintervention. One of these patients with arm ischaemia died five weeks after the reintervention due to sepsis complications related to patch infection. Sixteen (6%) patients presented transient arm paraesthesia or sensory neurologic deficit postoperatively. The symptoms completely recovered in all cases with no residual deficits. Perioperative ischaemic stroke occurred in three (1%) patients (two minor, one major). No other access related complications were recorded during follow up in any of the patients with no cases of late stenosis/occlusion. CONCLUSIONS Upper access with surgical exposure of the axillary artery is a safe method for antegrade catheterization of fenestrations and branches in complex endovascular aneurysm repair.
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Affiliation(s)
- Pablo Marques de Marino
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
| | - Maike Hagen
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
| | - Athanasios Katsargyris
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
| | - Balazs Botos
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
| | - Eric L Verhoeven
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
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Benk J, Siepe M, Berger T, Beyersdorf F, Kondov S, Rylski B, Czerny M, Kreibich M. Early and mid-term outcomes of thoracic endovascular aortic repair to treat aortic rupture in patients with aneurysms, dissections and trauma. Interact Cardiovasc Thorac Surg 2022; 35:ivac042. [PMID: 35167665 PMCID: PMC9714596 DOI: 10.1093/icvts/ivac042] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/27/2022] [Accepted: 01/31/2022] [Indexed: 09/10/2023] Open
Abstract
OBJECTIVES The aim of this study was to analyse outcomes of thoracic endovascular aortic repair to treat aortic rupture. METHODS Patient and outcome characteristics of all emergent endovascular treatments for thoracic aortic rupture between January 2009 and December 2019 were analysed. RESULTS Thoracic aortic rupture occurred in patients with aortic aneurysms (n = 42, 49%), aortic dissection (n = 13, 16%) or after trauma (n = 30, 35%). Preoperative cerebrospinal fluid drainage was placed in 9 patients (11%) and 18 patients (21%) underwent perioperative supra-aortic transposition. The proximal landing zones were: zone 1 (n = 1, 1%), zone 2 (n = 23, 27%), zone 3 (n = 52, 61%) and zone 4 (n = 9, 11%). Temporary spinal cord injury occurred in 1 patient (1%), permanent spinal cord injury in 7 patients (8%). Two patients (2%) experienced a postoperative stroke. Seventeen patients (20%) expired in-hospital. Aortic dissection (odds ratio: 16.246, p = 0.001), aneurysm (odds ratio: 9.090, P = 0.003) and preoperative shock (odds ratio: 4.646, P < 0.001) were predictive for mortality. Eighteen patients (21%) required a stent-graft-related aortic reintervention for symptomatic supra-aortic malperfusion (n = 3, 4%), endoleaks (n = 6, 7%), a second aortic rupture (n = 4, 5%), retrograde type A aortic dissection (n = 2, 2%), aortic-oesophageal fistulation (n = 2, 2%) and stent-graft kinking (n = 1, 1%). CONCLUSIONS Thoracic endovascular aortic repair in patients with aortic rupture has become a valuable treatment modality to stabilize patients. However, a significant risk of postoperative morbidity and mortality remains, particularly in patients with aortic dissections, aneurysms or shock. Patients require thorough follow-up ideally in an aortic clinic with a staff having the entire spectrum of cardiovascular and thoracic surgical expertise.
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Affiliation(s)
- Julia Benk
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Tim Berger
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
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High risk of early and late cardiovascular events after endovascular aortic aneurysm repair. Ann Vasc Surg 2022; 86:320-327. [PMID: 35483617 DOI: 10.1016/j.avsg.2022.04.028] [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: 11/28/2021] [Revised: 02/27/2022] [Accepted: 04/17/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The objective of this population-based study was to analyze short- and long-term major adverse cardiovascular events (MACE) after endovascular repair of ruptured or non-ruptured thoracic (TAA) and abdominal aortic aneurysms (AAA). METHODS Nationwide retrospective registry study including all patients that underwent endovascular repair (thoracic endovascular aortic repair, TEVAR; abdominal endovascular aneurysm repair, EVAR) for non-ruptured/intact (iAAA/iTAA) or ruptured (rAAA/rTAA) abdominal or thoracic aneurysms between 2000 and 2018. The primary outcome was a composite of cardiovascular death, stroke, or myocardial infarction (MACE). RESULTS There were 8641 patients with TAA and AAA; 634 TEVAR procedures [iTAA 488; rTAA 146] and 8007 EVAR procedures [iAAA 7071; rAAA 936] were performed. MACE incidence at 90-day after TEVAR for iTAA was 10.2% and for rTAA 26.7% [HR 3.02, 95% CI 1.99-4.6]; MACE at 90-day after EVAR for iAAA was 3.7% and for rAAA 26.9 % [HR 8.5, 95% CI: 7.16-10.11]. There was a higher cumulative incidence of MACE at 90-day after TEVAR for iTAA compared to EVAR for iAAA [HR 2.82, 95% CI 2.09-3.82] but no difference between the procedures after ruptured aneurysm repair. The median follow-up time was 3.28 years [IQR 1.31-5.94]. There was no long-term difference in MACE between EVAR and TEVAR after ruptured [90d-5y: HR 1.14, 95% CI 0.76-1.71; 5y-10y: HR 0.78, 95% CI 0.31-1.96] or intact [90d-5y: HR 1.19, 95% CI 0.97-1.46; 5y-10y: HR 0.82, 95% CI 0.56-1.21] aneurysm repair. Female gender had higher long-term incidence of MACE after intact [HR 1.14, 95% CI 1.03-1.27] and ruptured [HR 1.36, 95% CI 1.12-1.65] endovascular aortic aneurysm treatment. After intact aneurysms repair; age [HR 1.05, 95% CI 1.04-1.05], history of angina pectoris [HR 1.19, 95% CI 1.08-1.32], heart failure [HR 1.90, 95% CI 1.69-2.13], and stroke [HR 1.33, 95% CI 1.15-1.53] were associated with MACE. CONCLUSIONS This nationwide cohort study demonstrated still a high risk of early and late cardiovascular events after endovascular aortic repair. Comprehensive strategies for postoperative cardiovascular disease prevention may here be needed.
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Hauck SR, Eilenberg W, Kupferthaler A, Kern M, Dachs TM, Wressnegger A, Neumayer C, Loewe C, Funovics MA. Use of a Steerable Sheath for Completely Femoral Access in Branched Endovascular Aortic Repair Compared to Upper Extremity Access. Cardiovasc Intervent Radiol 2022; 45:744-751. [PMID: 35391546 PMCID: PMC9117381 DOI: 10.1007/s00270-022-03064-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 01/22/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE To compare bridging stent graft (BSG) implantation in downward oriented branches in branched endovascular aortic repair (bEVAR), using a commercially available steerable sheath from an exclusively femoral access (TFA) with traditional upper extremity access (UEA). METHODS In a retrospective cohort study, 7 patients with 19 branches in the TFA cohort received BSG insertion using the Medtronic Heli FX steerable sheath from a femoral access, and 10 patients with 32 branches in the UEA cohort from a brachial approach. Technical success, total intervention time, fluoroscopy time, branch cannulation time, and complication rate were recorded. RESULTS Technical success was 19/19 branches in the TFA and 31/32 in the UEA cohort. The mean branch cannulation time was considerably shorter in the TFA group (17 vs. 29 min, p = 0.003), and total intervention time tended to be shorter (169 vs. 217 min, p = 0.176). CONCLUSION Using a commercially available steerable sheath allowed successful cannulation of all branches in this cohort and was associated with significantly shorter branch cannulation times. Potentially, this technique can lower the stroke and brachial puncture site complication risk as well as reduce total intervention time and radiation dose. LEVEL OF EVIDENCE 2b, retrospective cohort study.
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Affiliation(s)
- Sven R Hauck
- Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Wolf Eilenberg
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Alexander Kupferthaler
- Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
- Department of Diagnostic and Interventional Radiology, Ordensklinikum Linz, Linz, Austria
- Johannes Kepler University Linz, Medical Faculty, Linz, Austria
| | - Maximilian Kern
- Department of Radiology, Klinik Floridsdorf, Vienna, Austria
| | - Theresa-Marie Dachs
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Alexander Wressnegger
- Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Christoph Neumayer
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Christian Loewe
- Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Martin A Funovics
- Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria.
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Physician-modified endografts are associated with a survival benefit over parallel grafting in thoracoabdominal aneurysms. J Vasc Surg 2022; 76:318-325.e4. [PMID: 35276268 DOI: 10.1016/j.jvs.2022.02.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/16/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Physician-modified endografts (PMEG) and parallel grafting (PG) are important techniques for endovascular repair of complex aortic aneurysms using off-the-shelf devices. However, there is little data regarding the relative efficacy and outcomes of these techniques in thoracoabdominal extent aneurysms. This study sought to compare outcomes of PG and PMEG across different extents of thoracoabdominal aneurysms to which they can be employed. METHODS The SVS VQI TEVAR/Complex EVAR module was queried for all patients undergoing repair of an unruptured, thoracoabdominal aneurysm (TAAA, Extents I-IV) years 2012-2020; aneurysm types were defined by repair extent as determined by proximal and distal seal zones. Patients were differentiated based on whether they received repair with a physician-modified endograft (PMEG) or parallel grafting technique (PG). The primary outcomes for this study were overall survival and freedom from aneurysm/procedure-related mortality at 1-year determined via Kaplan-Meier analysis, with Cox hazard regression analysis conducted to examine the independent association of repair modality with primary outcomes. RESULTS 813 patients met inclusion criteria (TAAA I-III 362, TAAA IV 451; 426 PG, 387 PMEG). PMEG repairs were performed at centers with a nearly 2-3-fold higher annual volume of endovascular TAAA repairs. Type Ia endoleaks were reduced with PMEG repair, most significantly in TAAA IV (TAAA I-III: 2.2% PMEG vs. 10% PG, p = 0.2; TAAA IV: 1.2% PMEG vs. 21.6% PG, p <0.001). Thoracoabdominal repairs demonstrated improved survival at 1-year with PMEG devices, significant for TAAA I-III repairs (TAAA I-III: PMEG 85% vs. PG 74%, p = 0.01; TAAA IV: 84% PMEG vs. PG 78%, p = 0.08). Freedom from aneurysm/procedure-related mortality was also improved with PMEG repairs, remaining significant at 1-year in the case of TAAA IV (TAAA I-III: PMEG 94% vs. PG 86%, p = 0.06; TAAA IV: PMEG 94% vs. PG 88%, p = 0.02). PMEG demonstrated reductions in several measures of post-operative morbidity, including stroke/death, MACE, and post-operative complications. In multivariate analysis, repair modality was not associated with either primary outcome, rather, several perioperative complications conveyed the greatest hazard for both primary outcomes across repair extents. CONCLUSIONS Survival after endovascular TAAA repair is improved with the use of PMEG compared to PG. Several key factors of this study demonstrate the shortcomings of parallel grafting in complex aneurysm repair, namely high rates of critical endoleaks, the need for adjunctive access sites, and an increase in perioperative complications that influence longer-term outcomes.
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Kapahnke S, Bürger M, Torsello GF, Omran S, Hinterseher I, Greiner A, Frese JP. Cannulation of visceral vessels using a steerable sheathin fenestrated and branched aortic endografts. Ann Vasc Surg 2022; 85:305-313. [PMID: 35271960 DOI: 10.1016/j.avsg.2022.02.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/18/2022] [Accepted: 02/19/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION A critical step in the endovascular treatment of complex aortic aneurysm is the cannulation and stenting of renovisceral vessels, especially in cases with a complex anatomy or atherosclerotic lesions. This study aimed to demonstrate the results of renovisceral vessel cannulation using a steerable sheath in fenestrated or branched endovascular aortic procedures (FB-EVAR). METHODS Patients undergoing elective FB-EVAR for asymptomatic thoracoabdominal or juxtarenal aneurysm at a single tertiary referral center from 2016 to 2019 were included in this study. Underlying pathologies, renovisceral target vessels (TV), technical success (TS), freedom from reintervention (FFR), and TV patency were assessed. Target vessels were categorized as challenging or non-challenging TV. RESULTS Fifty-three patients (median age 73 (Q1, Q3 (68 - 80)); 43 male (81%)) who underwent elective FB-EVAR were included. Indications comprised thoracoabdominal aneurysms (Crawford I-IV) (n = 26; 49%), juxtarenal aneurysms (n = 23; 43.5%) and penetrating aortic ulcers (PAU) (n = 4; 7.5%). Two patients (4%) had prior open aortic surgery, and three patients (6%) had undergone a failed standard EVAR before. Of the 196 treated TV, 131 (67%) were categorized as challenging. Cannulation was successful in 194 of 196 vessels (99%). A total of three TV (1.5%) showed periprocedural complications. No significant difference was found in the rate of intraoperative complications between challenging versus non-challenging TV (p = 0.457). One patient died within 30 days of the procedure (1.9%). No stroke or intestinal ischemia occurred. After 12, 24, and 36 months, the survival rate was 87%, 87%, and 81%, respectively Primary patency after 12 months was 98.6%, and 97.9% of vessels remained FFR during follow-up. CONCLUSION Transfemoral, retrograde cannulation of renovisceral vessels using a steerable sheath is feasible and safe and provides good mid-term results, especially in cases with challenging renovisceral vessels. The potential complications of antegrade vascular access can be avoided.
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Affiliation(s)
- Sebastian Kapahnke
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Hindenburgdamm 30, 12203 Berlin, Germany.
| | - Matthias Bürger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Giovanni Federico Torsello
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Diagnostic and Interventional Radiology and Nuclear Medicine, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Safwan Omran
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Irene Hinterseher
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Hindenburgdamm 30, 12203 Berlin, Germany; Medizinische Hochschule Brandenburg Theodor Fontane - Campus Neuruppin, Vascular Surgery; Fehrbelliner Str. 38, 16816 Neuruppin, Germany
| | - Andreas Greiner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Jan Paul Frese
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Hindenburgdamm 30, 12203 Berlin, Germany
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Marcaccio CL, Zettervall SL, Wu WW, Schermerhorn ML, Wyers MC. Endovascular Snare Facilitates Difficult Transfemoral Target Vessel Cannulation During Fenestrated and Branched Endovascular Aortic Aneurysm Repair. Ann Vasc Surg 2021; 77:338-342. [PMID: 34464731 DOI: 10.1016/j.avsg.2021.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 04/17/2021] [Accepted: 05/01/2021] [Indexed: 10/20/2022]
Abstract
We developed a novel technique using an endovascular snare system to stabilize target vessel cannulation via transfemoral access during fenestrated and branched endovascular aortic aneurysm repair (FBEVAR) in patients with challenging target vessel anatomy. This technique uses a snare, an outer sheath, and an inner delivery sheath to facilitate target vessel cannulation and stenting during FBEVAR. With the outer sheath positioned in the lower end of the partially deployed aortic graft and the delivery sheath within, a large snare is advanced through the outer sheath and over the outside of the delivery sheath until it reaches the curved portion of the delivery sheath at the level of the target vessel. The snare is then tightened to provide stability and maintain proper curvature and alignment of the delivery sheath while the target vessel is selected and stented. Following successful passage, the snare is loosened and removed from the body via the outer sheath. This snare technique is a simple, effective, and inexpensive tool that can be used for difficult target vessel cannulation during FBEVAR.
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Affiliation(s)
- Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Division of Vascular Surgery, University of Washington, Seattle, WA
| | - Winona W Wu
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mark C Wyers
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Determination of Optimal and Safest Proximal Sealing Length During Thoracic Endovascular Aortic Repair. Eur J Vasc Endovasc Surg 2021; 62:423-430. [PMID: 34247901 DOI: 10.1016/j.ejvs.2021.05.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 04/26/2021] [Accepted: 05/08/2021] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To determine the optimal and safest proximal sealing length (PSL) during thoracic endovascular aortic repair (TEVAR), depending on anatomical aortic arch types and proximal landing zones (LZs). METHODS This was a single centre retrospective observational study of consecutive TEVAR patients (2008-2020). All aortic pathologies requiring Ishimaru landing zone (LZ) 0 - 3 were included; results were stratified by aortic arch type. The PSL was measured as the length of complete aortic wall to endograft apposition at the level of the proximal neck. The primary endpoint was proximal failure (type 1A endoleak, endograft migration, or re-intervention requiring proximal graft extension). Freedom from proximal failure was estimated with Kaplan-Meier curves. An "optimal" sealing length (PSL cutoff maximising sensitivity + specificity for proximal failure) and "safest length" (PSL cutoff determining ≥ 90% sensitivity) were identified using receiver operating characteristic curve analysis. RESULTS One hundred and forty patients received TEVAR; mean ± standard deviation PSL was 29 ± 9 mm. Freedom from proximal endograft failure at five years (median 31 months) was 82.4% (95% confidence interval [CI] 72 - 95); the shorter the PSL, the greater was the risk of failure (hazard ratio 0.90, 95% CI 0.84 - 0.97; p = .004). Overall optimal and safest PSL were 25 mm (sensitivity 78%, specificity 66%) and 30 mm (sensitivity 92%, specificity 30%), respectively. In type I arch, the optimal PSL was 22 mm (sensitivity 50%, specificity 87%). In type II, the optimal PSL was 25 mm (sensitivity 89%, specificity 59%) overall and 27 mm for type II/LZ 2 - 3 (sensitivity 31%, specificity 68%). For type III, the optimal PSL was 27 mm (sensitivity 80%, specificity 87%); the safest was 30 mm (sensitivity 100%, specificity 61%) In type III/LZ 2 - 3, the optimal PSL was 27 mm (sensitivity 31%, specificity 68%) and safest was 30 mm (sensitivity 100%, specificity 55%). CONCLUSION A 20 mm PSL may be acceptable only for type I arches. For types II/III, that represent the majority of cases, a 25 - 30 mm PSL may be required for a safe and durable TEVAR.
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Pyun AJ, Zhang LL, Magee GA, Ziegler KR, Rowe VL, Weaver FA, Caldera R, Han SM. Use of Inner Branches During Physician-Modified Endografting for Complex Abdominal and Thoracoabdominal Aortic Aneurysms. Ann Vasc Surg 2021; 76:244-253. [PMID: 34186181 DOI: 10.1016/j.avsg.2021.04.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 04/05/2021] [Accepted: 04/18/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms have been performed widely in an increasing number of centers, utilizing custom-manufactured or physician-modified stent grafts containing fenestrations and side-arm branches for visceral and renal artery incorporation. Alternatively, inner branch configurations may be useful in complex anatomy, where application of fenestrations or side-arm branches can be challenging. Our study aims to evaluate the incidence of target vessel instability when incorporated with inner branch configurations, and report clinical outcomes of patients who underwent fenestrated/branched endovascular aortic repairs (F-BEVAR) containing one or more inner branches. METHODS We reviewed patients who underwent F-BEVAR with at least one inner branch configuration for complex abdominal or thoracoabdominal aortic aneurysms at Keck Hospital of University of Southern California from 2014 to 2020. Endpoints were mortality, major adverse events (MAE), technical success, and target vessel instability. Target vessel instability was assessed using follow-up computed tomography (CT) and duplex imaging. RESULTS Out of the 175 patients who underwent F-BEVAR for complex abdominal and TAAA during the study period, 17 patients had at least one inner branch configuration. All were deemed high-risk for open repair with multiple cardiovascular and/or pulmonary comorbidities. Eight (47%) patients had extent I, II, III thoracoabdominal aortic aneurysms, and 10 (59%) had prior aortic repairs. A total of 68 target vessels were incorporated (mean = 4 vessels/patient, range=1~6), of which 40% were inner branch configurations, most commonly for renal arteries. Technical success was 94.1%. There was one perioperative mortality due to massive myocardial infarction, as well as one patient who needed temporary hemodialysis. No device-related mortalities were observed. At 30 days, primary inner branch patency was 100% with no target vessel instability or reintervention. At mean follow-up of 5.8 months, the overall survival was 94% with one patient who expired from unknown cause. Overall primary inner branch patency was 96.3%, due to occlusion of a long lumbar artery branch with no clinical sequelae. CONCLUSION Inner branch configurations can provide a safe alternative technique of branch incorporation during complex endovascular aortic repair.
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Affiliation(s)
- Alyssa J Pyun
- Comprehensive Aortic Center, Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Louis L Zhang
- Comprehensive Aortic Center, Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Gregory A Magee
- Comprehensive Aortic Center, Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Kenneth R Ziegler
- Comprehensive Aortic Center, Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Vincent L Rowe
- Comprehensive Aortic Center, Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Fred A Weaver
- Comprehensive Aortic Center, Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Raquel Caldera
- Comprehensive Aortic Center, Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Sukgu M Han
- Comprehensive Aortic Center, Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA.
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D'Oria M, Mani K, DeMartino R, Czerny M, Donas KP, Wanhainen A, Lepidi S. Narrative review on endovascular techniques for left subclavian artery revascularization during thoracic endovascular aortic repair and risk factors for postoperative stroke. Interact Cardiovasc Thorac Surg 2021; 32:764-772. [PMID: 33575743 DOI: 10.1093/icvts/ivaa342] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/04/2020] [Accepted: 12/06/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES The aim of this study was to present a narrative review on endovascular techniques (ET) for revascularization of the left subclavian artery (LSA) during zone 2 thoracic endovascular aortic repair (TEVAR) and on risk factors for postoperative stroke following TEVAR procedures. METHODS Non-systematic search of the literature from the PubMed, Ovid and Scopus databases to identify relevant English-language articles fully published in the period 1 January 2010-1 August 2020. RESULTS Current general agreement is that LSA revascularization should be always attempted in the elective setting. Under urgent circumstances, it can be delayed but might be considered during the same session on a case-by-case basis. Three ET are currently available: (i) chimney/snorkels (also known as parallel grafts), (ii) fenestrations or branches and (iii) proximal scallops. The main issue with ET is the potential for increased peri-operative stroke risk owing to increased manipulation within the aortic arch. Also, they are relatively novel and further assessment of their long-term durability is needed. Intra-operative embolism and loss of left vertebral artery perfusion are hypothesized as the main causes of stroke in patients undergoing TEVAR. CONCLUSIONS The overall risk of stroke seems higher without LSA revascularization during zone 2 TEVAR. As LSA revascularization might have a direct effect in preventing posterior stroke, it should be routinely performed in elective cases, while a case-by-case evaluation can be made under urgent circumstances. While ET can provide effective options for LSA revascularization during zone 2 TEVAR, they are novel and need further durability assessment. Stroke after TEVAR is a multifactorial pathological process and preventing TEVAR-related cerebral injury remains a significant unmet clinical need.
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Affiliation(s)
- Mario D'Oria
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden.,Division of Vascular and Endovascular Surgery, Cardiovascular Department, University of Trieste Medical School, Trieste, Italy.,Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic Rochester Campus, Rochester, MN, USA
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Randall DeMartino
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic Rochester Campus, Rochester, MN, USA
| | - Martin Czerny
- Division of Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Freiburg, Germany
| | - Konstantinos P Donas
- Department of Vascular Surgery, Asklepios Clinic Langen, Goethe-University of Frankfurt, Langen, Germany
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University of Trieste Medical School, Trieste, Italy
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Reyes Valdivia A, Chaudhuri A, Milner R, Pratesi G, Reijnen MM, Tinelli G, Schuurmann R, Barbante M, Babrowski TA, Pitoulias G, Tshomba Y, Gandarias C, Badawy A, de Vries JPP. Endovascular aortic repair with EndoAnchors demonstrate good mid-term outcomes in physician-initiated multicenter analysis-The PERU registry. Vascular 2021; 30:27-37. [PMID: 33568007 DOI: 10.1177/1708538121992596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES We aim to describe real-world outcomes from multicenter data about the efficacy of adjunct Heli-FX EndoAnchor usage in preventing or repairing failures during infrarenal endovascular aneurysm repair (EVAR), so-called EndoSutured-aneurysm-repair (ESAR). METHODS The current study has been assigned an identifier (NCT04100499) at the US National Library of Medicine (https://ClinicalTrials.gov). It is an observational retrospective study of prospectively collected data from seven vascular surgery departments between June 2010 and December 2019. Patients included in the ANCHOR registry were excluded from this analysis. The decision for the use of EndoAnchors was made by the treating surgeon or multidisciplinary aortic committee according to each center's practice. Follow-up imaging was scheduled according to each center's protocol, which necessarily included either abdominal ultrasound or radiography or computed tomographic scan imaging. The main outcomes analyzed were technical success, freedom from type Ia endoleaks (IaEL), all-cause and aneurysm-related mortality, and sac variation and trends evaluated for those with at least six months imaging follow-up. RESULTS Two hundred and seventy-five patients underwent ESAR in participating centers during the study period. After exclusions, 221 patients (184 males, 37 females, mean age 75 ± 8.3 years) were finally included for analysis. Median follow-up for the cohort was 27 (interquartile range 12-48) months. A median 6 (interquartile range 3) EndoAnchors were deployed at ESAR, 175 (79%) procedures were primary and 46 (21%) revision cases, 40 associated with type IaEL. Technical success at operation (initial), 30-day, and overall success were 89, 95.5, and 96.8%, respectively; the 30-day success was higher due to those with subsequent spontaneous proximal endoleak seal. At two years, freedom from type IaEL was 94% for the whole series; 96% and 86% for the primary and revision groups, respectively; whereas freedom from all-cause mortality, aneurysm-related mortality, and reintervention was 89%, 98%, and 87%, respectively. Sac evolution pre-ESAR was 66 ± 15.1 vs. post ESAR 61 ± 17.5 (p < 0.001) and for 180 patients with at least six-month follow-up, 92.2% of them being in a stable (51%) or regression (41%) situation. CONCLUSIONS This real-world registry demonstrates that adjunct EndoAnchor usage at EVAR achieves high rates of freedom from type IaEL at mid-term including in a high number of patients with hostile neck anatomy, with positive trends in sac-size evolution. Further data with longer follow-up may help to establish EndoAnchor usage as a routine adjunct to EVAR, especially in hostile necks.
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Affiliation(s)
- Andrés Reyes Valdivia
- Department of Vascular and Endovascular Surgery, Ramón y Cajal's University Hospital, Madrid, Spain
| | - Arindam Chaudhuri
- Bedfordshire - Milton Keynes Vascular Centre, Bedfordshire Hospitals Foundation Trust, Bedford, UK
| | - Ross Milner
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Giovanni Pratesi
- Vascular Surgery Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Michel Mpj Reijnen
- Department of Surgery, Rijnstate, Arnhem and the Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Giovanni Tinelli
- Unit of Vascular Surgery, Fondazione Policlinico Universitario Gemelli IRCCS - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Richte Schuurmann
- Department of Vascular Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands, and Department of Surgery, Division of Vascular Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Matteo Barbante
- Vascular Surgery Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Trissa A Babrowski
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Georgios Pitoulias
- Faculty of Medicine, 2nd Department of Surgery, Division of Vascular Surgery, Thessaloniki General Hospital, Aristotle University of Thessaloniki, "G. Gennimatas," Greece
| | - Yamume Tshomba
- Unit of Vascular Surgery, Fondazione Policlinico Universitario Gemelli IRCCS - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Claudio Gandarias
- Department of Vascular and Endovascular Surgery, Ramón y Cajal's University Hospital, Madrid, Spain
| | - Ayman Badawy
- Bedfordshire - Milton Keynes Vascular Centre, Bedfordshire Hospitals Foundation Trust, Bedford, UK
| | - Jean-Paul Pm de Vries
- Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, the Netherlands.,Department of Surgery, Division of Vascular Surgery, University Medical Centre Groningen, Groningen, The Netherlands
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Branzan D, Geisler A, Steiner S, Lautenschlaeger T, Doss M, Matschuck M, Scheinert D, Schmidt A. Stroke rate after thoracic endovascular aortic repair using de-airing of stentgrafts with high-volume of saline solution. VASA 2021; 50:186-192. [PMID: 33559507 DOI: 10.1024/0301-1526/a000937] [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] [Indexed: 11/19/2022]
Abstract
Background: Our aim was to determine the rate of ischemic stroke following thoracic endovascular aortic repair (TEVAR) after reducing gas volume released during stentgraft deployment by de-airing of thoracic stentgrafts with high-volume of 0.9% heparinized saline solution. Patients and methods: A single center retrospective analysis of all consecutive patients undergoing TEVAR from 2014 to 2019 was performed. All thoracic stentgrafts were flushed with 120 ml 0.9% heparinized saline solution before implantation, according to our institutional protocol. Endpoints were in-hospital rates of ischemic stroke and spinal cord ischemia (SCI), and all-cause mortality. Results: One hundred and fifty-four patients (mean age: 66.8 ± 13.6 years, 64.9% males) were treated with TEVAR during the study period. Indications for treatment were thoracic aortic aneurysms (n = 75, 48.7%), acute type B aortic dissections (n = 46, 29.9%), aortic arch aneurysms and penetrating aortic ulcers (n = 28, 18.2%), and blunt traumatic aortic injuries (n = 5, 3.2%). Timing of procedure was urgent in 75 patients (48.7%). Proximal landing zone were zone 0-1-2 (n = 75, 48.7%), zone 3 (n = 66, 42.9%) and zone 4 (n = 13, 8.4%). Supra-aortic vessels were revascularized with custom-made fenestrated stentgrafts in 9 patients (5.8%), using chimney technique in 4 patients (2.6%), and with debranching procedures in 19 patients (12.3%). Left subclavian artery was covered without revascularization in 46 patients (29.9%). In-hospital stroke occurred in two patients (1.3%) and SCI in another two patients (1.3%). In-hospital mortality rate was 0.6%. No further in-hospital events were noted. Conclusions: De-airing of stentgrafts with high-volume of 0.9% heparinized saline solution seems to be safe and can be used as an adjunct to keep occurrence of neurological events after TEVAR as low as possible.
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Affiliation(s)
- Daniela Branzan
- Department of Vascular Surgery, University Hospital Leipzig, Germany
| | - Antonia Geisler
- Department of Vascular Surgery, University Hospital Leipzig, Germany
| | - Sabine Steiner
- Department of Interventional Angiology, University Hospital Leipzig, Germany
| | | | - Markus Doss
- Department of Vascular Surgery, University Hospital Leipzig, Germany
| | - Manuela Matschuck
- Department of Interventional Angiology, University Hospital Leipzig, Germany
| | - Dierk Scheinert
- Department of Interventional Angiology, University Hospital Leipzig, Germany
| | - Andrej Schmidt
- Department of Interventional Angiology, University Hospital Leipzig, Germany
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Mpody C, Cui J, Awad H, Bhandary S, Essandoh M, Harter RL, Tobias JD, Nafiu OO. Primary Stroke and Failure-to-Rescue Following Thoracic Endovascular Aortic Aneurysm Repair. J Cardiothorac Vasc Anesth 2020; 35:2338-2344. [PMID: 33358740 DOI: 10.1053/j.jvca.2020.11.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/10/2020] [Accepted: 11/27/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To characterize the impact, on failure to rescue, of cerebrovascular accident as a first postoperative complication after thoracic endovascular aortic aneurysm repair (TEVAR). DESIGN A retrospective cohort study using of National Surgical Quality Improvement Program Participants User File. SETTING United States hospitals taking part in the National Surgical Quality Improvement Program. PARTICIPANTS Patients >18 years, who underwent TEVAR for nonruptured thoracic aortic aneurysm between 2005 and 2018, and developed one or more major postoperative complications within 30 days after surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Out of 3,937 patients who underwent TEVAR for nonruptured thoracic aneurysm, 1,256 (31.9%) developed major postoperative complications (stroke incidence: 11.4% [143/1256]). In adults <65 years old, the occurrence of stroke as the primary complication, relative to the occurrence of other complications, was associated with ten times greater risk of failure to rescue (29.4% v 4.6%; odds ratio [OR]: 10.10; 95% confidence interval [CI] 2.45-41.56; p < 0.001). The effect size was relatively lower when stroke occurred but was not the primary complication (20.0% v 4.6%; OR: 7.55; 95% CI 1.37-41.71; p = 0.020). In patients ≥65 years, the occurrence of stroke as the primary complication did not carry the similar prognostic value. CONCLUSION Younger patients who developed stroke were up to ten times more likely to die, relative to patients who developed other major complications. Survival was substantially reduced when stroke was the primary complication. The authors' findings imply that to maximize the survival of patients undergoing TEVAR, efforts may be needed to predict and prevent stroke occurrence as a primary postoperative morbidity event.
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Affiliation(s)
- Christian Mpody
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Jerry Cui
- Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH
| | - Hamdy Awad
- Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH
| | - Sujatha Bhandary
- Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH
| | - Michael Essandoh
- Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH
| | - Ronald L Harter
- Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Olubukola O Nafiu
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH.
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Eilenberg W, Kölbel T, Rohlffs F, Oderich G, Eleshra A, Tsilimparis N, Debus S, Panuccio G. Comparison of transfemoral versus upper extremity access to antegrade branches in branched endovascular aortic repair. J Vasc Surg 2020; 73:1498-1503. [PMID: 33248122 DOI: 10.1016/j.jvs.2020.11.020] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 11/18/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We studied the outcomes of transfemoral access (TFA) vs upper extremity access (UEA) for branched endovascular aortic repair (BEVAR). METHODS From January 2016 to October 2019, 152 consecutive patients underwent BEVAR under general anesthesia at a single institution. In 2018, an alternative approach to the antegrade branches using TFA compared with conventional UEA was introduced. The cohort was divided into TFA and UEA groups according to the access approach. The end points were technical success, adverse events (including perioperative stroke/transient ischemic attack), access complications, operation time, and radiation exposure. RESULTS The TFA group included 60 patients (63% male; median age, 71 years; interquartile range [IQR], 65-76 years). The UEA group included 92 patients (67% male; median age, 73 years; IQR, 66-78 years). The number of target vessels (TVs) was similar in both groups (median, 4.0 TVs per procedure; range, 1-7 TVs for both). Technical success was greater in the TFA group (60 of 60 patients; 209 of 209 TVs) than in the UEA group (87 of 92 patients; 334 of 346 TVs; P < .01). The fluoroscopy time (median, 69 minutes; IQR, 48-87 minutes; vs 88 minutes; IQR, 65-104 minutes; P = .39) and contrast agent volume (median, 141 mL; IQR, 123-165 mL; vs median, 130 mL; IQR, 101-157 mL; P = .34) were similar in both groups. The radiation exposure (221 Gy × cm2; IQR, 138-406 Gy × cm2; vs median, 255 Gy × cm2; IQR, 148-425 Gy × cm2; P = .05) was lower and the operation time (median, 300 minutes; IQR, 240-356 minutes; vs median, 364 minutes; IQR, 290-475 minutes; P = .01) was shorter in the TFA group. Brachial access complications (0 of 60 vs 3 of 92 patients) and perioperative strokes/transient ischemic attacks (0 of 60 vs 8 of 92 patients) only occurred in the UEA group (P = .018). CONCLUSIONS The use of TFA to catheterize antegrade branches was associated with a lower rate of complications in the present study and has become our preferred approach for BEVAR.
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Affiliation(s)
- Wolf Eilenberg
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Gustavo Oderich
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Ahmed Eleshra
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Nikolaos Tsilimparis
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Sebastian Debus
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
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Perioperative Outcomes of Carotid–Subclavian Bypass or Transposition versus Endovascular Techniques for Left Subclavian Artery Revascularization during Nontraumatic Zone 2 Thoracic Endovascular Aortic Repair in the Vascular Quality Initiative. Ann Vasc Surg 2020; 69:17-26. [DOI: 10.1016/j.avsg.2020.05.062] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/19/2020] [Accepted: 05/20/2020] [Indexed: 12/31/2022]
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Journal of Vascular Surgery – November 2020 Audiovisual Summary. J Vasc Surg 2020. [PMCID: PMC7576144 DOI: 10.1016/j.jvs.2020.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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