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Ferrer C, Gallitto E, Borghese O, Lodato M, Cappiello A, Cao P, Gargiulo M, Giudice R. Long-term results of fenestrated and branched endovascular aneurysm repair for complex abdominal and thoracoabdominal aortic aneurysms in young and fit patients. J Vasc Surg 2024; 80:1639-1649. [PMID: 39084495 DOI: 10.1016/j.jvs.2024.07.090] [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: 06/10/2024] [Revised: 07/19/2024] [Accepted: 07/23/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Endovascular repair of complex abdominal aortic aneurysms (CAAAa) and thoracoabdominal aortic aneurysms (TAAAs) with fenestrated and branched devices (F/BEVAR) represents the first-line treatment in old or unfit patients. Currently, the widespread diffusion of these techniques has led to a progressive increase of complex endovascular procedures also in younger and fitter patients, but the related results have been only minimally reported, without long-term data. We investigated the long-term results of F/BEVAR for CAAA and TAAA repair in young and fit patients. METHODS All consecutive patients, aged ≤70 years, who underwent F/BEVAR for CAAA and TAAA over the last 13 years at two tertiary institutions were included in the study. All subjects presented a low to intermediate risk according to the Society for Vascular Surgery clinical comorbidity grading system. The primary end points were technical and clinical success and late overall and aortic-related survival. Major complications and specific target vessel-related outcomes were investigated as secondary end points. RESULTS A total of 183 patients (155 males [84.7%]; mean age, 64.5 ± 5.7 years; range, 33-70 years) underwent F/BEVAR during the study period, for a total of 167 degenerative (91.3%) and 16 postdissection (8.7%) aneurysms, including 44 (24%) juxtarenal, 33 (18%) pararenal, and 106 (58%) TAAAs. Technical and clinical success were achieved in 176 patients (96.2%) and 171 patients (93.4%), respectively. Four patients (2.2%) died perioperatively, of which two (1.1%) operated in emergency. Postoperatively, five patients (2.7%) presented permanent grade 3 spinal cord injury and three (1.6%) renal failure needing permanent dialysis. The mean follow-up was 65.7 ± 39.6 months (range, 1-158 months). The estimated overall and aortic-related survival at 12, 60, and 120 months was 94.0%, 85.1%, 72.2%, and 97.8%, 97.8%, 96.2%, respectively, and reintervention and branch instability-free survival at the same time points were 84.4%, 71.8%, 71.8%, and 93.2%, 86.3%, 72.2%, respectively. An aneurysm growth of >5 mm was detected in six patients (3.3%), and a sac shrinkage of >5 mm was achieved in 118 cases (64.5%). The Cox regression analysis demonstrated the need for unplanned procedure as the only risk factor for overall mortality (odds ratio, 3.331; 95% confidence interval, 1.397-7.940; P < .01]. CONCLUSIONS F/BEVAR in young and fit patients led to low perioperative mortality and major morbidity rates and a favorable overall survival rate in the long-term, making this technique particularly appealing in such a subgroup of patients. The availability of long-term data derived from the results of young patients, may additionally provide helpful information to redefine the indications for treatment and allow future targeted device and technique improvements.
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Affiliation(s)
- Ciro Ferrer
- Vascular Surgery Unit, San Giovanni-Addolorata Hospital, Rome, Italy.
| | - Enrico Gallitto
- Vascular Surgery Unit, University of Bologna and IRCCS Sant'Orsola, Bologna, Italy
| | - Ottavia Borghese
- Vascular Surgery Unit, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Marcello Lodato
- Vascular Surgery Unit, University of Bologna and IRCCS Sant'Orsola, Bologna, Italy
| | - Antonio Cappiello
- Vascular Surgery Unit, University of Bologna and IRCCS Sant'Orsola, Bologna, Italy
| | | | - Mauro Gargiulo
- Vascular Surgery Unit, University of Bologna and IRCCS Sant'Orsola, Bologna, Italy
| | - Rocco Giudice
- Vascular Surgery Unit, San Giovanni-Addolorata Hospital, Rome, Italy
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Sun CB, Han XQ, Wang H, Zhang YX, Wang MC, Liu YN. Effect of two surgical approaches on the lung function and prognosis of patients with combined esophagogastric cancer. World J Gastrointest Surg 2023; 15:1986-1994. [PMID: 37901732 PMCID: PMC10600760 DOI: 10.4240/wjgs.v15.i9.1986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/04/2023] [Accepted: 07/31/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Adenocarcinoma of the esophagogastric junction has a center of origin within 5 cm of the esophagogastric junction. Surgical resection remains the main treatment. A transthoracic approach is recommended for Siewert I adenocarcinoma of the esophagogastric junction and a transabdominal approach is recommended for Siewert III adenocarcinoma of the esophagogastric junction. However, there is a need to determine the optimal surgical approach for Siewert II adenocarcinoma of the esophagogastric junction to improve lung function and the prognosis of patients. AIM To investigate and compare the surgical effects, postoperative changes in pulmonary function, and prognoses of two approaches to treating combined esophagogastric cancer. METHODS One hundred and thirty-eight patients with combined esophagogastric cancer treated by general and thoracic surgeries in our hospital were selected. They were divided into group A comprising 70 patients (transabdominal approach) and group B comprising 68 patients (transthoracic approach) based on the surgical approach. The indexes related to surgical trauma, number of removed lymph nodes, indexes of lung function before and after surgery, survival rate, and survival duration of the two groups were compared 3 years after surgery. RESULTS The duration of surgery, length of hospital stay, and postoperative drainage duration of the patients in group A were shorter than those of the patients in group B, and the volume of blood loss caused by surgery was lower for group A than for group B (P < 0.05). At the one-month postoperative review, the first second, maximum ventilation volume, forceful lung volume, and lung volume values were higher for group A than for group B (P < 0.05). Preoperatively, the QLQ-OES18 scale scores of the patients in group A were higher than those in group B on re-evaluation at 3 mo postoperatively (P < 0.05). The surgical complication rate of the patients in group A was 10.00%, which was lower than that of patients in group B, which was 23.53% (P < 0.05). CONCLUSION Transabdominal and transthoracic surgical approaches are comparable in treating combined esophagogastric cancer; however, the former results in lesser surgical trauma, milder changes in pulmonary function, and fewer complications.
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Affiliation(s)
- Chong-Bing Sun
- Department of General Surgery, Weifang People's Hospital, Weifang 261041, Shandong Province, China
| | - Xiao-Qing Han
- Department of Spinal Surgery, Weifang People's Hospital, Weifang 261041, Shandong Province, China
| | - Hao Wang
- Department of General Surgery, Weifang People's Hospital, Weifang 261041, Shandong Province, China
| | - Yi-Xuan Zhang
- Department of Medical, Weifang People's Hospital, Weifang 261041, Shandong Province, China
| | - Meng-Chun Wang
- Department of General Surgery, Weifang People's Hospital, Weifang 261041, Shandong Province, China
| | - Yong-Ning Liu
- Department of General Surgery, Weifang People's Hospital, Weifang 261041, Shandong Province, China
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Hossack M, Simpson G, Shaw P, Fisher R, Torella F, Brennan J, Smout J. Open Retroperitoneal Repair for Complex Abdominal Aortic Aneurysms. AORTA (STAMFORD, CONN.) 2022; 10:114-121. [PMID: 36318932 PMCID: PMC9626034 DOI: 10.1055/s-0042-1748959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Background
Open surgical repair (OSR) of complex abdominal aortic aneurysms (CAAAs) can be challenging. We frequently utilize the retroperitoneal (RP) approach for such cases. We audited our outcomes with the aim of establishing the utility and safety of this approach.
Methods
Retrospective analysis was performed of all patients undergoing OSR of an unruptured CAAA via a RP approach in our center over a 7-year period. Data on repairs via a transperitoneal (TP) approach were collected to provide context. Demographic, operative, radiological, and biochemical data were collected. The primary outcome measure was 30-day/inpatient mortality. Secondary outcomes included the need for reoperation, incidence of postoperative chest infection, acute kidney injury (AKI) and length of stay (LOS). All patients received aortic clamping above at least one main renal artery.
Results
One hundred and three patients underwent OSR of an unruptured CAAA; 55 via a RP approach, 48 TP. The RP group demonstrated a more advanced pattern of disease with a larger median maximum diameter (65 vs. 61 mm,
p
= 0.013) and a more proximal extent. Consequently, the rate of supravisceral clamping was higher in RP repair (66 vs. 15%,
p
< 0.001). Despite this there were no differences in the observed early mortality (9.1 vs. 10%, NS); incidence of reoperation (10.9 vs. 12.5%, NS), chest infection (32.7 vs. 25%, NS), and AKI (52.7 vs. 45.8%, NS); or median LOS (10 vs. 12 days, NS) following RP and TP repair.
Conclusion
OSR of CAAAs carries significant 30-day mortality. In patients unsuitable for fenestrated endovascular aortic repair or those desiring a durable long-term solution, OSR can be performed through the RP or TP approach. This study has demonstrated that in our unit RP repair facilitates treatment of more advanced AAA utilizing complex proximal clamp zones with similar perioperative morbidity and mortality compared with TP cases utilizing more distal clamping.
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Affiliation(s)
- Martin Hossack
- Liverpool Vascular and Endovascular Service, Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom,Liverpool Centre for Cardiovascular Sciences, University of Liverpool, Liverpool, United Kingdom,Address for correspondence Martin Hossack, MBChB, BSc Liverpool Vascular and Endovascular ServiceLink 8C, Royal Liverpool University Hospital, Prescot Street, Liverpool, United Kingdom L7 8XP
| | - Gregory Simpson
- Liverpool Vascular and Endovascular Service, Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom
| | - Penelope Shaw
- Liverpool Vascular and Endovascular Service, Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom
| | - Robert Fisher
- Liverpool Vascular and Endovascular Service, Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom
| | - Francesco Torella
- Liverpool Vascular and Endovascular Service, Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom,Liverpool Centre for Cardiovascular Sciences, University of Liverpool, Liverpool, United Kingdom
| | - John Brennan
- Liverpool Vascular and Endovascular Service, Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom
| | - Jonathan Smout
- Liverpool Vascular and Endovascular Service, Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom
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Rastogi V, Kim NH, Marcaccio CL, Patel PB, Varkevisser RRB, de Bruin JL, Verhagen HJM, Schermerhorn ML. Retroperitoneal versus Transperitoneal Approach for Open Repair of Complex Abdominal Aortic Aneurysms. Eur J Vasc Endovasc Surg 2022; 64:23-31. [PMID: 35605910 PMCID: PMC9420765 DOI: 10.1016/j.ejvs.2022.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 05/03/2022] [Accepted: 05/14/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Several studies have demonstrated advantages of the retroperitoneal approach (RP) over the transperitoneal approach (TP) for infrarenal abdominal aortic aneurysm (AAA) repair. A retrospective analysis was performed comparing the outcomes of a TP vs. RP surgical approach for open complex AAA (cAAA) repair and evaluated their relative use over time. METHODS Patients undergoing open repair for intact cAAA (juxtarenal, suprarenal, or type IV thoraco-abdominal aortic aneurysms) between 2011 and 2019 were identified in the National Surgical Quality Improvement Program. The primary outcome was peri-operative death. Secondary outcomes included peri-operative complications and approach use over time. Multivariable adjustment was performed by creating propensity scores and using inverse probability weighted logistic regression. RESULTS Among 1 195 patients identified, 729 (61%) underwent cAAA repair via a TP approach and 466 (39%) via an RP approach. Compared with a TP approach, RP patients more frequently had a supracoeliac clamp position (32% vs. 20%, p < .001) and concomitant renal revascularisation (30% vs. 18%, p < .001). After adjustment, an RP approach was associated with lower odds of peri-operative death (4.0% vs. 7.2%; odds ratio [OR] 0.54; 95% confidence interval [CI] 0.32 - 0.91; p = .022). Furthermore, an RP approach was associated with lower odds of any major complication (24% vs. 30%; OR 0.73; 95% CI 0.56 - 0.94), cardiac complications (4.9% vs. 8.2%; OR 0.60; 95% CI 0.37 - 0.96), wound complications (2.1% vs. 6.0%; OR 0.34; 95% CI 0.17 - 0.64), and post-operative sepsis (0.8% vs. 2.4%; OR 0.37; 95% CI 0.12 - 0.99). The proportion of repairs using an RP approach decreased between 2011 - 2015 and 2016 - 2019 (42% vs. 35%, p = .020), particularly for suprarenal and type IV thoraco-abdominal aneurysms (49% vs. 37%, p = .023). CONCLUSION In open cAAA repair, the RP approach may be associated with lower peri-operative mortality and morbidity rates compared with the TP approach. However, it was found that the relative use of the RP approach is decreasing over time, even in suprarenal/type IV thoraco-abdominal aneurysms, and repairs using a supracoeliac clamp. Increased use of the RP approach, when appropriate, may lead to improved outcomes following open cAAA repair.
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Affiliation(s)
- Vinamr Rastogi
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA; Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Nicole H Kim
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Christina L Marcaccio
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Priya B Patel
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Rens R B Varkevisser
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA.
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Lateral approach for abdominal aortic aneurysm repair and avoiding opening of peritoneal sac for total retroperitoneal approach. J Vasc Surg 2021; 74:1430. [PMID: 34598760 DOI: 10.1016/j.jvs.2021.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/17/2021] [Indexed: 11/21/2022]
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Deery SE, Schermerhorn ML. Reply. J Vasc Surg 2021; 73:1475. [PMID: 33766253 DOI: 10.1016/j.jvs.2020.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 12/02/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Sarah E Deery
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins Hospital, Baltimore, Md
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
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