1
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Zhou Q, Ye M, Wei Y, Wu J, Shen Y, Zheng T, Shao G. The endovascular aortic repair for patients with traumatic thoracic aortic blunt injury: A single-center experience. VASCULAR INVESTIGATION AND THERAPY 2022. [DOI: 10.4103/2589-9686.348222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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2
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Teixeira PGR, Woo K, Beck AW, Scali ST, Weaver FA. Association of left subclavian artery coverage without revascularization and spinal cord ischemia in patients undergoing thoracic endovascular aortic repair: A Vascular Quality Initiative® analysis. Vascular 2017; 25:587-597. [DOI: 10.1177/1708538116681910] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives Investigate the impact of left subclavian artery coverage without revascularization on spinal cord ischemia development in patients undergoing thoracic endovascular aortic repair. Methods The Vascular Quality Initiative thoracic endovascular aortic repair module (April 2011–July 2014) was analyzed. Patients undergoing left subclavian artery coverage were divided into two groups according to revascularization status. The association between left subclavian artery revascularization with the primary outcome of spinal cord ischemia and the secondary outcome of stroke was assessed with multivariable analysis adjusting for between-group baseline differences. Results The left subclavian artery was covered in 508 (24.6%) of the 2063 thoracic endovascular aortic repairs performed. Among patients with left subclavian artery coverage, 58.9% underwent revascularization. Spinal cord ischemia incidence was 12.1% in the group without revascularization compared to 8.5% in the group undergoing left subclavian artery revascularization (odds ratio (95%CI): 1.48(0.82–2.68), P = 0.189). Multivariable analysis adjustment identified an independent association between left subclavian artery coverage without revascularization and the incidence of spinal cord ischemia (adjusted odds ratio (95%CI): 2.29(1.03–5.14), P = 0.043). Although the incidence of stroke was also higher for the group with a covered and nonrevascularized left subclavian artery (12.1% versus 8.5%), this difference was not statistically significant after multivariable analysis (adjusted odds ratio (95%CI): 1.55(0.74–3.26), P = 0.244). Conclusion For patients undergoing left subclavian artery coverage during thoracic endovascular aortic repair, the addition of a revascularization procedure was associated with a significantly lower incidence of spinal cord ischemia.
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Affiliation(s)
- Pedro GR Teixeira
- Department of Surgery and Perioperative Care, University of Texas at Austin, Austin, USA
| | - Karen Woo
- Division of Vascular Surgery, University of California, Los Angeles, Los Angeles, USA
| | | | | | - Fred A Weaver
- Division of Vascular Surgery and Endovascular Therapy, University of Southern California, Los Angeles, USA
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3
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Factors Related to Late False Lumen Enlargement after Thoracic Stent-Graft Placement for Type B Aortic Dissection. J Vasc Interv Radiol 2017; 28:44-49. [DOI: 10.1016/j.jvir.2016.09.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 08/31/2016] [Accepted: 09/14/2016] [Indexed: 11/19/2022] Open
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4
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Khalil KH, Palma JH, Simonato M, Dias RR, Jatene F. When Aortic Stenting Alone Does Not Solve It: Mass Effect of Thoracic Aneurysms. Ann Vasc Surg 2016; 39:284.e11-284.e13. [PMID: 27521829 DOI: 10.1016/j.avsg.2016.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 03/15/2016] [Accepted: 04/18/2016] [Indexed: 10/21/2022]
Abstract
Thoracic aneurysms can potentially cause substantial compression of adjacent structures, creating substantial symptoms. We present a case of a 56-year-old woman with fatigue and dyspnea for 6 months. We discuss her initial endovascular treatment, which was insufficient to improve symptoms, and further surgical intervention was needed to solve the issue.
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Affiliation(s)
- Kalil Hussein Khalil
- Instituto do Coração, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Jose Honorio Palma
- Instituto do Coração, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
| | | | - Ricardo Ribeiro Dias
- Instituto do Coração, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Fabio Jatene
- Instituto do Coração, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Mangialardi N, Costa P, Serrao E, Cavazzini C, Bergeron P. Aortic Arch Aneurysm and Patent Left Internal Mammary Artery: Technique of Transposition of Supra-aortic Vessels and Embolization of the Subclavian Artery. Vascular 2016; 13:298-300. [PMID: 16288705 DOI: 10.1258/rsmvasc.13.5.298] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Endovascular treatment of aortic arch aneurysms poses unique problems because of vascularization of the carotid arteries. Transposition of supra-aortic vessels is becoming an established and accepted strategy for expanding the applicability of stent graft repair. left subclavian artery (LSA) is not usually transposed because its overstenting does not produce relevant complications. Nevertheless, some selected cases need high-pressure revascularization of the LSA, such as in the presence of a patent left internal mammary artery. We present a technique of revascularization of supra-aortic vessels and “balloon protected” embolization of the origin of the LSA.
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Nauta FJH, Trimarchi S, Kamman AV, Moll FL, van Herwaarden JA, Patel HJ, Figueroa CA, Eagle KA, Froehlich JB. Update in the management of type B aortic dissection. Vasc Med 2016; 21:251-63. [DOI: 10.1177/1358863x16642318] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Stanford type B aortic dissection (TBAD) is a life-threatening aortic disease. The initial management goal is to prevent aortic rupture, propagation of the dissection, and symptoms by reducing the heart rate and blood pressure. Uncomplicated TBAD patients require prompt medical management to prevent aortic dilatation or rupture during subsequent follow-up. Complicated TBAD patients require immediate invasive management to prevent death or injury caused by rupture or malperfusion. Recent developments in diagnosis and management have reduced mortality related to TBAD considerably. In particular, the introduction of thoracic stent-grafts has shifted the management from surgical to endovascular repair, contributing to a fourfold increase in early survival in complicated TBAD. Furthermore, endovascular repair is now considered in some uncomplicated TBAD patients in addition to optimal medical therapy. For more challenging aortic dissection patients with involvement of the aortic arch, hybrid approaches, combining open and endovascular repair, have had promising results. Regardless of the chosen management strategy, strict antihypertensive control should be administered to all TBAD patients in addition to close imaging surveillance. Future developments in stent-graft design, medical therapy, surgical and hybrid techniques, imaging, and genetic screening may improve the outcomes of TBAD patients even further. We present a comprehensive review of the recommended management strategy based on current evidence in the literature.
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Affiliation(s)
- Foeke JH Nauta
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA
| | - Santi Trimarchi
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy
| | - Arnoud V Kamman
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy
| | - Frans L Moll
- Vascular Surgery Department, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joost A van Herwaarden
- Vascular Surgery Department, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - C Alberto Figueroa
- Departments of Biomedical Engineering and Surgery, University of Michigan, USA
| | - Kim A Eagle
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA
| | - James B Froehlich
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA
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Nauta FJH, Conti M, Kamman AV, van Bogerijen GHW, Tolenaar JL, Auricchio F, Figueroa CA, van Herwaarden JA, Moll FL, Trimarchi S. Biomechanical Changes After Thoracic Endovascular Aortic Repair in Type B Dissection. J Endovasc Ther 2015; 22:918-33. [DOI: 10.1177/1526602815608848] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Thoracic endovascular aortic repair (TEVAR) has evolved into an established treatment option for type B aortic dissection (TBAD) since it was first introduced 2 decades ago. Morbidity and mortality have decreased due to the minimally invasive character of TEVAR, with adequate stabilization of the dissection, restoration of true lumen perfusion, and subsequent positive aortic remodeling. However, several studies have reported severe setbacks of this technique. Indeed, little is known about the biomechanical behavior of implanted thoracic stent-grafts and the impact on the vascular system. This study sought to systematically review the performance and behavior of implanted thoracic stent-grafts and related biomechanical aortic changes in TBAD patients in order to update current knowledge and future perspectives.
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Affiliation(s)
- Foeke J. H. Nauta
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Italy
- Departments of Surgery and Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Michele Conti
- Department of Civil Engineering and Architecture, University of Pavia, Italy
| | - Arnoud V. Kamman
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Italy
- Departments of Surgery and Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
| | | | - Jip L. Tolenaar
- Department of General Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | - C. Alberto Figueroa
- Departments of Surgery and Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | | | - Frans L. Moll
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Santi Trimarchi
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Italy
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8
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Khan S, Caputo FJ, Trani J, Carpenter JP, Lombardi JV. Secondary Interventions after Endovascular Repair of Aortic Dissections. Ann Vasc Surg 2015; 29:1160-6. [DOI: 10.1016/j.avsg.2015.02.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 02/25/2015] [Accepted: 02/27/2015] [Indexed: 11/17/2022]
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9
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Wilson JE, Galiñanes EL, Hu P, Dombrovskiy VY, Vogel TR. Routine revascularization is unnecessary in the majority of patients requiring zone II coverage during thoracic endovascular aortic repair: A longitudinal outcomes study using United States Medicare population data. Vascular 2013; 22:239-45. [DOI: 10.1177/1708538113502649] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective We aimed to evaluate outcomes of thoracic endovascular aortic repair (TEVAR) with left subclavian artery (LSA) coverage without bypass (TEVAR + SUB) to TEVAR with coverage of the LSA with a bypass at the time of the initial procedure or later at a separate procedure (TEVAR + SUB + BYPASS). Methods The Centers for Medicare & Medicaid Services inpatient claims for 2006–2007 were queried using Current Procedural Terminology codes for TEVAR, TEVAR + SUB, TEVAR + SUB + BYPASS or later as a separate procedure. Results A total of 2676 patients underwent TEVAR; 869 (32.5%) underwent TEVAR + SUB and 49 (5.6%) TEVAR + SUB + BYPASS. At the time of the initial procedure, TEVAR + SUB + BYPASS was associated with a higher incidence of stroke compared to TEVAR + SUB (12.8% vs. 3.8 %; p = 0.0033). Among TEVAR + SUB, only 1.93% (50 patients) had a subsequent bypass performed during a one-year follow-up. Overall rates of morbidity ( p = 0.004) and mortality ( p = 0.011) trended towards significance in favor of TEVAR + SUB. Conclusions TEVAR + SUB were associated with lower rates of mortality and complications. Only a small percentage of TEVAR + SUB required a bypass at one year after procedure. Our data suggest that routine LSA bypass during TEVAR is unnecessary and associated with increase morbidity and mortality.
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Affiliation(s)
- Jonathan E Wilson
- Division of Vascular Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Edgar L Galiñanes
- Division of Vascular Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Parker Hu
- Division of Vascular Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Viktor Y Dombrovskiy
- Department of Surgery, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Todd R Vogel
- Division of Vascular Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, MO, USA
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10
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JONES MR, REID JH. Thoracic vascular imaging: thoracic aortic disease and pulmonary embolism. IMAGING 2013. [DOI: 10.1259/imaging.20100064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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11
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Wong CS, Healy D, Canning C, Coffey JC, Boyle JR, Walsh SR. A systematic review of spinal cord injury and cerebrospinal fluid drainage after thoracic aortic endografting. J Vasc Surg 2012; 56:1438-47. [PMID: 22884456 DOI: 10.1016/j.jvs.2012.05.075] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 05/08/2012] [Accepted: 05/16/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND The use of thoracic endovascular aneurysm repair (TEVAR) is increasing. Similar to open repair, TEVAR carries a risk of spinal cord ischemia (SCI). We undertook a systematic review to determine whether preoperative cerebrospinal fluid (CSF) drainage reduces SCI. METHODS PubMed, the Cochrane Library, and conference abstracts were searched using the keywords thoracic endovascular aortic repair, cerebrospinal fluid, spinal cord ischaemia, TEVAR, and aneurysm. Studies reporting SCI rates and CSF drain rates for TEVAR patients were eligible for inclusion. SCI rates across studies were pooled using random-effects modeling. Study quality was evaluated using the Downs and Black score. RESULTS Study quality was generally poor to moderate (median Downs and Black score, 9). The systematic review identified 46 eligible studies comprising 4936 patients; overall, SCI affected 3.89% (95% confidence interval, 2.95.05%-4.95%). Series reporting routine prophylactic drain placement or no prophylactic drain placement reported pooled SCI rates of 3.2% and 3.47%, respectively. The pooled SCI rate from 24 series stating that prophylactic drainage was used selectively was 5.6%. CONCLUSIONS Spinal chord injury is uncommon after TEVAR. The role of prophylactic CSF drainage is difficult to establish from the available literature. High-quality studies are required to determine the role of prophylactic CSF drainage in TEVAR.
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Affiliation(s)
- Chee S Wong
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
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12
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Abstract
Endovascular stent grafts have become a viable treatment for aortic thoracic and abdominal aneurysms in both elective and emergent situations. Computed tomographic (CT) angiography is the primary tool for determining eligibility for this procedure. This article discuses the preprocedural evaluation of an endovascular stent candidate. Evaluation begins with identification of the aneurysm pathology and its relationship to treatment efficacy. The radiologist must evaluate the aneurysm geometry for compatibility with stent hardware. Aneurysm features that suggest a contraindication must be recognized. Procedures that involve a combination of endovascular stenting and surgical revascularization are discussed so that the reader understands the limits of stent eligibility. Vascular access for stent placement must also be evaluated for the ability to accommodate stent delivery. The radiologist also must be familiar with CT imaging protocols and alternative methods of imaging that can evaluate stent feasibility. The utility of three-dimensional processing is discussed.
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Affiliation(s)
- Gregory Kicska
- Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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13
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Riambau V, Zipfel B, Coppi G, Czerny M, Tealdi DG, Ferro C, Chiesa R, Sassi C, Rousseau H, Berti S. Final operative and midterm results of the European experience in the RELAY Endovascular Registry for Thoracic Disease (RESTORE) study. J Vasc Surg 2011; 53:565-73. [DOI: 10.1016/j.jvs.2010.09.050] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 09/14/2010] [Accepted: 09/15/2010] [Indexed: 11/28/2022]
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14
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Rehman SM, Vecht JA, Perera R, Jalil R, Saso S, Kidher E, Chukwuemeka A, Cheshire NJ, Hamady MS, Darzi A, Gibbs RG, Anderson JR, Athanasiou T. How to manage the left subclavian artery during endovascular stenting for thoracic aortic dissection? An assessment of the evidence. Ann Vasc Surg 2011; 24:956-65. [PMID: 20832002 DOI: 10.1016/j.avsg.2010.05.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Revised: 03/26/2010] [Accepted: 05/16/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Despite the publication of recent guidelines for management of the left subclavian artery (LSA) during endovascular stenting procedures of the thoracic aorta, specific management for those presenting with dissection remains unclear. This systematic review attempts to address this issue. METHODS Systematic assessment of the published data on thoracic aorta dissection was performed identifying 46 studies, which incorporated 1,275 patients. Primary outcomes included the prevalence of left arm ischemia, stroke, spinal cord ischemia, endoleak, stent migration, and mortality. Outcomes were compared between patients with and without LSA coverage and revascularization incorporating factors such as the number of stents used, length of aorta covered, urgency of intervention, and type of dissection (acute or chronic). Statistical pooling techniques, χ(2) tests, and Fisher's exact testing were used for group comparisons. RESULTS As compared with other outcomes, LSA coverage without revascularization in the presence of aortic dissection is much more likely to be complicated by left arm ischemia (prevalence increased from 0.0% to 4.0% [p = 0.021]), stroke (prevalence increased from 1.4% to 9.0% [p = 0.009]), and endoleak (prevalence increased from 4.0% to 29.3% [p = 0.001]). However, revascularization was not shown to reverse these effects. Longer aortic coverage (≥ 150 mm) was associated with an increased prevalence of spinal cord ischemia (from 1.3% to 12.5% [p = 0.011]) and mortality (from 1.3% to 15.6% [p = 0.003]). CONCLUSION In patients undergoing endovascular stenting for thoracic aortic dissection, in cases where LSA coverage is necessary, revascularization should be considered before the procedure to avoid complications such as left arm ischemia, stroke, and endoleak, and where feasible, an appropriate preoperative assessment should be carried out.
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Affiliation(s)
- Syed M Rehman
- Department of Cardiothoracic Surgery, St. Mary's Hospital, Imperial College Healthcare Trust, London, United Kingdom
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15
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Mustafa ST, Sadat U, Majeed MU, Wong CM, Michaels J, Thomas SM. Endovascular repair of nonruptured thoracic aortic aneurysms: systematic review. Vascular 2010; 18:28-33. [PMID: 20122357 DOI: 10.2310/6670.2010.00003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Thoracic aortic aneurysms represent a major health problem. Untreated thoracic aortic aneurysms may rupture, which has a dismal outcome. The standard treatment for thoracic aneurysms is open surgical repair, but it is associated with high mortality and morbidity. Endovascular repair provides a less invasive and safer alternative. A systematic review was performed of all published literature on the above subject. Our primary objective was to measure 30-day mortality for nonruptured thoracic aortic aneurysms. Studies describing other pathologies, such as aortic dissection, mycotic aneurysms, penetrating ulcers, traumatic transactions, and pseudoaneurysms, and studies from which independent data for thoracic aortic aneurysm could not be separately extracted were excluded. Case series describing less than 10 patients and all case series describing ruptures or concealed ruptures were excluded as well. Twenty-six case series and one comparative study were identified. This formed a cohort of 1,038 patients. Technical success was possible in more than 97% of patients. The 30-day mortality was calculated to be 5.1% even though the group under study was mostly those who were refused surgery by a surgeon or had a higher surgical risk. The incidence of paraplegia and stroke was 3.1% and 4.7%, respectively. Early endoleak was seen in 16.7% of patients, whereas 11.7% of patients developed late endoleak, but most did not require any additional procedure. The rate of reintervention was 14.9%. The 12-month mortality rate was 14.2%. Endovascular repair shows encouraging short-term results. It is associated with significantly less mortality and morbidity, but long-term results need to be further investigated.
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Affiliation(s)
- Syed T Mustafa
- Academic Vascular Department, Sheffield University, Sheffield, United Kingdom.
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16
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Rizvi AZ, Murad MH, Fairman RM, Erwin PJ, Montori VM. The effect of left subclavian artery coverage on morbidity and mortality in patients undergoing endovascular thoracic aortic interventions: A systematic review and meta-analysis. J Vasc Surg 2009; 50:1159-69. [DOI: 10.1016/j.jvs.2009.09.002] [Citation(s) in RCA: 189] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2009] [Revised: 09/01/2009] [Accepted: 09/01/2009] [Indexed: 11/26/2022]
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Hybrid treatment of isolated aortic arch aneurysms. Radiol Med 2009; 114:1130-40. [DOI: 10.1007/s11547-009-0443-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2008] [Accepted: 01/07/2009] [Indexed: 11/30/2022]
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Baumert B, Körner M, Sadeghi-Azandaryani M, Rummeny C, Reiser M, Linsenmaier U. MDCT zur Diagnostik nichttraumatischer vaskulärer Notfälle. Radiologe 2009; 49:481-91. [DOI: 10.1007/s00117-008-1808-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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19
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Ting AC, Cheng SW, Ho P, Chan YC, Poon JT, Cheung GC. Endovascular Repair for Thoracic Aortic Pathologies—Early and Midterm Results. Asian J Surg 2009; 32:39-46. [DOI: 10.1016/s1015-9584(09)60007-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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20
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Abstract
Aortic dissection is an uncommon but potentially fatal disease with catastrophic complications. A high level of suspicion is required for successful diagnosis as presenting symptoms are so variable that dissection may be overlooked in up to 39% of cases. It most commonly presents in the elderly population with a history of chronic hypertension. Rapid intervention is necessary as delay leads to higher mortality. Despite advances in diagnostic and therapeutic techniques, morbidity and mortality remains high. Advances in diagnostic imaging have raised the awareness of variants of aortic dissection, including intramural hemorrhage and penetrating aortic ulcer. This distinction is important as the clinical course of these variants differs from that of classical aortic dissection, and thus treatment may also differ. Understanding of these variants has also led to the recognition of markers that may help predict progression to classical aortic dissection and thus warrant closer vigilance in selected patient populations. The recognition that rapid diagnosis is required for management of aortic dissection has led to the investigation of serum tests as diagnostic aids. Serum smooth muscle myosin heavy chain, d-dimer, and serum soluble elastin fragments are promising tests that may help raise suspicion for the diagnosis of acute aortic dissection. The high mortality associated with surgical therapy has led to investigation of alternative approaches. Endovascular therapy has emerged as a viable option in patients with type B dissection who are too unstable for surgery. However, long-term follow up is required to validate this procedure.
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Affiliation(s)
- Pawan D. Patel
- Department of Cardiology, Chicago Medical School, North Chicago VA Medical Centre-133B, 3001 Green Bay Road, North Chicago, IL-60064
| | - Rohit R. Arora
- Department of Cardiology, Chicago Medical School, North Chicago VA Medical Centre-133B, 3001 Green Bay Road, North Chicago, IL-60064,
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Chang CP, Liu JC, Liou YM, Chang SS, Chen JY. The Role of False Lumen Size in Prediction of In-Hospital Complications After Acute Type B Aortic Dissection. J Am Coll Cardiol 2008; 52:1170-6. [PMID: 18804746 DOI: 10.1016/j.jacc.2008.06.034] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2008] [Revised: 06/23/2008] [Accepted: 06/24/2008] [Indexed: 12/01/2022]
Affiliation(s)
- Chih-Ping Chang
- Division of Cardiology, Department of Medicine, China Medical University Hospital, Taichung, Taiwan
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22
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Noor N, Sadat U, Hayes PD, Thompson MM, Boyle JR. Management of the Left Subclavian Artery During Endovascular Repair of the Thoracic Aorta. J Endovasc Ther 2008; 15:168-76. [DOI: 10.1583/08-2406.1] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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23
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Svensson LG, Kouchoukos NT, Miller DC, Bavaria JE, Coselli JS, Curi MA, Eggebrecht H, Elefteriades JA, Erbel R, Gleason TG, Lytle BW, Mitchell RS, Nienaber CA, Roselli EE, Safi HJ, Shemin RJ, Sicard GA, Sundt TM, Szeto WY, Wheatley GH. Expert Consensus Document on the Treatment of Descending Thoracic Aortic Disease Using Endovascular Stent-Grafts⁎⁎Expert Consensus Document on the Treatment of Descending Thoracic Aortic Disease Using Endovascular Stent-Grafts has been supported by Unrestricted Educational Grants from Cook, Inc and Medtronic, Inc. Ann Thorac Surg 2008; 85:S1-41. [PMID: 18083364 DOI: 10.1016/j.athoracsur.2007.10.099] [Citation(s) in RCA: 550] [Impact Index Per Article: 34.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2007] [Revised: 10/17/2007] [Accepted: 10/18/2007] [Indexed: 01/15/2023]
Affiliation(s)
- Lars G Svensson
- Center for Aortic Surgery and Marfan Syndrome Clinic, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio 44195, USA.
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Endangered Cerebral Blood Supply After Closure of Left Subclavian Artery: Postmortem and Clinical Imaging Studies. Ann Thorac Surg 2008; 85:120-5. [DOI: 10.1016/j.athoracsur.2007.08.035] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2007] [Revised: 08/14/2007] [Accepted: 08/14/2007] [Indexed: 11/20/2022]
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25
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Neurologic complications associated with endovascular repair of thoracic aortic pathology: Incidence and risk factors. A study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) Registry. J Vasc Surg 2007; 46:1103-1110; discussion 1110-1. [DOI: 10.1016/j.jvs.2007.08.020] [Citation(s) in RCA: 470] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2007] [Revised: 08/10/2007] [Accepted: 08/10/2007] [Indexed: 11/22/2022]
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Sandroussi C, Waltham M, Hughes CF, May J, Harris JP, Stephen MS, White GH. ENDOVASCULAR GRAFTING OF THE THORACIC AORTA, AN EVOLVING THERAPY: TEN-YEAR EXPERIENCE IN A SINGLE CENTRE. ANZ J Surg 2007; 77:974-80. [DOI: 10.1111/j.1445-2197.2007.04293.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Buhr C, Eggebrecht H, Erbel R. Percutaneous occlusion of posttraumatic aortic arch pseudoaneurysm by catheter-based delivery of thrombin. Catheter Cardiovasc Interv 2007; 70:713-7. [DOI: 10.1002/ccd.21192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Alpagut U, Ugurlucan M, Dayioglu E. Endovascular Treatment of Thoracic Aortic Pathologies in Patients with Aortoiliac Occlusive Disease. Heart Surg Forum 2007; 10:E424-7. [DOI: 10.1532/hsf98.20071107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Reece TB, Gazoni LM, Cherry KJ, Peeler BB, Dake M, Matsumoto AH, Angle J, Kron IL, Tribble CG, Kern JA. Reevaluating the Need for Left Subclavian Artery Revascularization With Thoracic Endovascular Aortic Repair. Ann Thorac Surg 2007; 84:1201-5; discussion 1205. [PMID: 17888970 DOI: 10.1016/j.athoracsur.2007.05.020] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Revised: 05/06/2007] [Accepted: 05/07/2007] [Indexed: 11/23/2022]
Abstract
BACKGROUND With increased utilization of thoracic endovascular aortic repair (TEVAR), the anatomic limitations of proximal device landing zones are being challenged. As our experience has grown with TEVAR involving exclusion of the left subclavian artery (LSA), the need for selective revascularization of the LSA appeared to be more common than we initially anticipated. We hypothesize that for patients undergoing TEVAR requiring coverage of the LSA, the need for LSA revascularization is higher than reported in the literature. METHODS The charts of all patients undergoing TEVAR performed at a single tertiary care center from 1999 to 2006 were reviewed. The review included the preoperative radiographic evaluations, the assessment of comorbidities, the anatomic position of the proximal and distal landing zones, outcomes, complications, and the need for preoperative or postoperative subclavian artery revascularization. RESULTS Sixty-four patients underwent TEVAR and 27 (42%) of these patients required exclusion of the LSA from the thoracic aorta. Seven of these 27 patients (25.9%) required preoperative LSA revascularization. Four patients developed late symptoms, necessitating LSA revascularization. No patients died or developed paraplegia, but three adverse neurological events occurred unrelated to the posterior fossa circulation. No patient developed any left arm disability. CONCLUSIONS The TEVAR coverage of the LSA with selective revascularization was safe for patients, but greater than 11 of 27 (40.7%) required either preoperative or postoperative LSA revascularization. Although this study represents our early experience with TEVAR, these data suggest that selective revascularization after TEVAR exclusion of the origin of the LSA may be required more frequently than previously reported.
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Affiliation(s)
- T Brett Reece
- Department of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia, USA.
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Lettinga-van de Poll T, Schurink GWH, De Haan MW, Verbruggen JPAM, Jacobs MJ. Endovascular treatment of traumatic rupture of the thoracic aorta. Br J Surg 2007; 94:525-33. [PMID: 17443851 DOI: 10.1002/bjs.5795] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Traumatic rupture of the thoracic aorta is a life-threatening event. Open surgical repair is the ‘gold standard’, but is associated with high mortality and morbidity rates. Endovascular repair is emerging as a potentially safer alternative.
Methods
A systematic review was performed of all published literature on this subject, including the authors' own experience. Using Sumsearch, PubMed and cross-references, all published reports up to January 2006 were identified, and analysed for injuries, perioperative morbidity, mortality, operating time, hospital stay and follow-up.
Results
A total of 284 patients were identified. Reported mortality rates range from 0 to 6 per cent. The procedure-related mortality rate is about 1·5 per cent. Some 6·7 per cent of all procedures were complicated by endoleak and the overall procedure-related morbidity rate was 14·4 per cent. These results are promising compared with those of open repair, but individual experience is limited and there may be some publication bias.
Conclusion
Endovascular repair of traumatic rupture of the thoracic aorta seems to reduce morbidity and mortality in patients with multiple trauma. Ideally, both devices and experienced personnel should be available in trauma centres.
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Affiliation(s)
- T Lettinga-van de Poll
- Department of Vascular Surgery, University Hospital Maastricht, Maastricht, The Netherlands
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Leurs LJ, Harris PL, Buth J. Secondary Interventions after Elective Endovascular Repair of Degenerative Thoracic Aortic Aneurysms: Results of the European Collaborators Registry (EUROSTAR). J Vasc Interv Radiol 2007; 18:491-5. [PMID: 17446539 DOI: 10.1016/j.jvir.2007.01.018] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The need for secondary interventions is an important indicator of intermediate and long-term success of endovascular repair of degenerative thoracic aortic aneurysm. The purpose of this study was to analyze the occurrence and consequences of secondary procedures. MATERIALS AND METHODS Data from 213 patients electively subject to operation for degenerative thoracic aortic aneurysm and achieving primary success and who were enrolled in the EUROSTAR registry were analyzed. Secondary procedures were categorized as follows: transfemoral endovascular reintervention, extraanatomic secondary procedures, and transthoracic surgery. RESULTS Overall, 25 (12%) of the patients with an elective treatment for a degenerative thoracic aneurysm had secondary intervention, occurring at a mean of 8 months after the initial procedure. Seventeen (68%) of the secondary interventions were via a transfemoral approach, six (24%) involved a transthoracic procedure, and two (8%) involved extraanatomic bypass. The cumulative percentage of freedom from intervention at 1 and 2 years was 86% and 83%, respectively. Endoleak (relative risk, 5.21) was the most frequent cause for secondary transfemoral intervention. For the other secondary interventions, no principal indication for reintervention could be identified. Patients who needed secondary interventions more frequently suffered from preoperative back pain (20% vs 44%, P = .008), and their thoracic aneurysms had a longer length (mean, 95.6 mm vs 133.2 mm, P = .006). The 2-year cumulative survival rate of patients without secondary intervention was 85% compared with 58% in the patients who received secondary intervention (P = .0001). CONCLUSIONS Regular surveillance after endovascular degenerative thoracic aneurysm repair is needed as secondary interventions were required throughout the follow-up period.
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Affiliation(s)
- Lina J Leurs
- EUROSTAR Data Registry Center, Catharina Hospital, Department of Vascular Surgery, PO Box 1350, 5602 ZA Eindhoven, The Netherlands.
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Schoder M, Czerny M, Cejna M, Rand T, Stadler A, Sodeck GH, Gottardi R, Loewe C, Lammer J. Endovascular Repair of Acute Type B Aortic Dissection: Long-Term Follow-Up of True and False Lumen Diameter Changes. Ann Thorac Surg 2007; 83:1059-66. [PMID: 17307460 DOI: 10.1016/j.athoracsur.2006.10.064] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2006] [Revised: 10/21/2006] [Accepted: 10/24/2006] [Indexed: 11/17/2022]
Abstract
BACKGROUND The aim of this study was to determine the technical success after endovascular treatment of acute type B aortic dissections and to evaluate true and false lumen diameter changes at long-term follow-up. METHODS Twenty-eight patients with acute type B-dissection who were treated by stent graft repair presented with rupture (n = 1), contained rupture (n = 2), compromised branch vessels (n = 14), pleural effusion (n = 11), rapid aortic diameter progression (n = 5), persistent pain (n = 3), refractory hypertension (n = 10), and an aortic diameter of more than 4 cm (n = 4). Taking into account the perfusion status of the false lumen, diameter changes were monitored in the thoracic aorta at the level of the stented segment (L1), distal to the stent graft (L2), and at the level of the celiac trunk (L3). RESULTS Severe complications in 9 patients (32%) resulted in 3 deaths for a 30-day mortality rate of 10.7%. Primary sealing of the entry tear was achieved in 86%. At all levels, the true lumen diameter increased significantly after stent graft placement. At the 1-year follow-up, the false lumen in L1 was thrombosed in 90% and the mean difference of diameter reduction was highly significant. In L2, complete false lumen thrombosis occurred in 60% with a significant diameter decrease. In L3, the false lumen thrombosed in only 22%, and the mean difference of false lumen diameter increase reached significance at the 2-year follow-up. CONCLUSIONS Ninety percent of patients were treated successfully with thrombosis of the false lumen in the stented segment. False lumen perfusion distal to the stent graft resulted in diameter increase in several patients leaving these segments an area of concern.
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Affiliation(s)
- Maria Schoder
- Department of Angiography and Interventional Radiology, Medical University of Vienna, Vienna, Austria.
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Saratzis N, Saratzis A, Melas N, Ginis G, Lioupis A, Lykopoulos D, Lazaridis J, Kiskinis D. Endovascular Treatment of Descending Thoracic Aortic Aneurysms with the EndoFit Stent-Graft. Cardiovasc Intervent Radiol 2007; 30:177-81. [PMID: 17206390 DOI: 10.1007/s00270-006-0168-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the mid-term feasibility, efficacy, and durability of descending thoracic aortic aneurysm (DTAA) exclusion using the EndoFit device (LeMaitre Vascular). METHODS Twenty-three (23) men (mean age 66 years) with a DTAA were admitted to our department for endovascular repair (21 were ASA III+ and 2 refused open repair) from January 2003 to July 2005. RESULTS Complete aneurysm exclusion was feasible in all subjects (100% technical success). The median follow-up was 18 months (range 8-40 months). A single stent-graft was used in 6 cases. The deployment of a second stent-graft was required in the remaining 17 patients. All endografts were attached proximally, beyond the left subclavian artery, leaving the aortic arch branches intact. No procedure-related deaths have occurred. A distal type I endoleak was detected in 2 cases on the 1 month follow-up CT scan, and was repaired with reintervention and deployment of an extension graft. A nonfatal acute myocardial infarction occurred in 1 patient in the sixth postoperative month. Graft migration, graft infection, paraplegia, cerebral or distal embolization, renal impairment or any other major complications were not observed. CONCLUSION The treatment of DTAAs using the EndoFit stent-graft is technically feasible. Mid-term results in this series are promising.
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Affiliation(s)
- N Saratzis
- Department of Surgery, Aristotle University of Thessaloniki Papageorgiou General Hospital, Thessaloniki, Greece
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Brandt M, Walluscheck KP, Jahnke T, Attmann T, Heller M, Cremer J, Müller-Hülsbeck S. Mid-Term Results After Endovascular Stent-Grafting of Descending Aortic Aneurysms in High-Risk Patients. Cardiovasc Intervent Radiol 2006; 29:739-44. [PMID: 16718427 DOI: 10.1007/s00270-004-0183-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE To analyze our experience with endovascular stent-grafting of descending aortic aneurysms in high-risk patients. METHODS Nineteen patients underwent endovascular stent-graft repair of descending aortic aneurysms using the Talent Stent Graft System (Medtronic). All patients were considered high-risk for open surgical repair due to their age, requirement for emergency surgery, and comorbidities. Computed tomography and/or MR tomography were performed at 3, 6 and 12 months postoperatively and thereafter every 12 months. RESULTS Secondary technical success was 100%. Thirty-day mortality was 5%. Incidence of postoperative stroke and paraplegia were 5% each. One patient required a second stent-graft due to a type I endoleak during the same hospital stay (primary technical success 95%). All patients have been followed for a median of 20 months. No migration, wire fractures or endoleak appeared during follow-up. CONCLUSION Endovascular stent-grafting had a low 30-day mortality and morbidity in high-risk patients. One patient developed an aortoesophageal fistula 40 days after stent implantation. Stent-graft repair is a valuable supplement to surgical therapy in high-risk patients.
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Affiliation(s)
- Michael Brandt
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Kiel Campus, Arnold-Heller-Strasse 7, 24105 Kiel, Germany.
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Jones MR, Reid JH. Emergency chest radiology: thoracic aortic disease and pulmonary embolism. IMAGING 2006. [DOI: 10.1259/imaging/81369175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Caronno R, Piffaretti G, Tozzi M, Lomazzi C, Laganà D, Carrafiello G, Cuffari S, Castelli P. Emergency endovascular stent-graft treatment for acute thoracic aortic syndromes. Surgery 2006; 140:58-65. [PMID: 16857443 DOI: 10.1016/j.surg.2006.01.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2005] [Revised: 01/17/2006] [Accepted: 01/21/2006] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We report the results of our ongoing experience of urgent and emergency stent-graft implantation in acute thoracic aortic syndromes. METHODS AND RESULTS In the last 5-years, 19 patients were treated for acute thoracic aortic syndromes. Traumatic rupture was diagnosed in 7 patients, complicated acute type B dissection was present in 5 patients, penetrating ulcer in 4, and symptomatic thoracic aortic aneurysm in 3 patients. There were 17 male patients with a mean age of 54 +/-26 years (range 18-87 ; median 63). Patients were treated in the theatre suite under general anesthesia. Stent-graft placement was technically successful in all patients. The early postoperative mortality was 10.5 %. Neurological events or upper arm ischemia due to overstenting of the left subclavian artery were not observed. Average intensive care unit and hospital stay were 18 and 21 days, respectively. Major complications occurred in 6 patients. Follow-up ranged between 3 and 60 months (mean 25) and included clinical examinations and serial CT-angiography at 1, 4 and 12 months, and every year thereafter. Only one type II endoleak was detected and treated by coil embolization of the left subclavian artery. CONCLUSIONS Our experience suggests emergency stent-graft repair in patients with acute thoracic aortic syndromes is a less-invasive attractive alternative, showing encouraging early and mid-term results.
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Affiliation(s)
- Roberto Caronno
- Vascular Surgery-Department of Surgery, University of Insubria-Varese, Italy
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Bingol H, Iyem H, Akay HT, Ustunsoz B, Bolcal C, Ugurer S, Sirin G, Demirkilic U, Tatar H. Endovascular repair in management of thoracic aortic aneurysms. Int J Cardiovasc Imaging 2006; 23:53-9. [PMID: 16807773 DOI: 10.1007/s10554-006-9109-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2005] [Accepted: 05/18/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Aneurysms of the thoracic aorta are still potentially life-threatening situations. The conventional operation is still associated with morbidity. Endovascular stent graft repair offers an alternative to conventional operation for management of aortic diseases. Our aim was to report our experience with endovascular stent graft repair of thoracic aortic aneurysms. PATIENTS AND METHODS Between November 2002 and October 2005, endovascular stent graft repair was performed in 26 patients: post-traumatic aortic aneurysm (n=4), Type B dissection (n=3) and descending thoracic aortic aneurysm (n=19). The deployed stent graft systems were Talent-Medtronic (n=14) and Excluder-Gore (n=12). RESULTS Successful deployment of the stent grafts in the appropriate position was achieved in all patients. There was neither hospital mortality nor paraplegia. Late and non-procedure related death occurred in only one patient (3.8%). An average of 40% shrinkage of the aneurysmal space was observed. There was no early mortality and endoleaks. The median intensive care unit and hospital stay times were 1 and 7 days (range 4-13 days), respectively. Post-operative computed tomography scans were obtained in all patients and complete thrombosis was observed in the false lumen of dissecan aneurysms (n=3) and sac of saccular aneurysms in 25 patients. Mean follow up time was 17.1+/-5.4 months. CONCLUSIONS Endovascular stent graft treatment for treatment of thoracic aorta aneurysm, Type B dissection and traumatic disease of the thoracic aorta is technically feasible. Although the short and mid-term results are encouraging the long term results will determine the future of this treatment.
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Affiliation(s)
- Hakan Bingol
- Department of Cardiovascular Surgery, Gulhane Military Medical Academy, PK 56, 06552, Cankaya, Ankara, Turkey
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Caffarelli AD, Banovac F, Cheung SC, Fleischmann D, Mitchell RS. Unusual case of late thoracic stent graft failure after cardioversion. Ann Thorac Surg 2006; 81:1875-7. [PMID: 16631691 DOI: 10.1016/j.athoracsur.2005.04.087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2005] [Revised: 03/11/2005] [Accepted: 04/22/2005] [Indexed: 10/24/2022]
Abstract
We report the unusual case of successful endovascular exclusion of a thoracic aortic aneurysm with subsequent thoracic aortic aneurysm reduction, and development of an interval, acute type III endoleak after cardioversion 5 years after stent graft deployment.
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Affiliation(s)
- Anthony D Caffarelli
- Department of Cardiovascular and Thoracic Surgery, Falk Cardiovascular Research Center, Stanford, California, USA
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Gaxotte V, Thony F, Rousseau H, Lions C, Otal P, Willoteaux S, Rodiere M, Negaiwi Z, Joffre F, Beregi JP. Midterm Results of Aortic Diameter Outcomes After Thoracic Stent-Graft Implantation for Aortic Dissection: A Multicenter Study. J Endovasc Ther 2006; 13:127-38. [PMID: 16643066 DOI: 10.1583/04-1416r.1] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE To evaluate aortic diameter outcomes after stent-graft implantation for aortic dissection in the descending thoracic aorta. METHODS Fifty patients with type A dissection after ascending aortic surgery (n = 10), type B dissection (n = 34), or intramural hematoma (n = 6) underwent stent-graft repair in 3 centers. Thrombosis and aortic diameter were analyzed by computed tomographic angiography at different levels of the aorta before stent-graft implantation, at discharge, and at follow-up. Measurements were standardized. RESULTS In all, 67 stent-grafts were implanted for acute (n = 18) and chronic (n = 32) dissection. Stent-graft placement was successfully performed with high technical success (100%) despite 4 major complications (iliac thrombosis in 2 cases, aortic rupture, and a type A dissection) in 3 (6%) patients. Complete thrombosis of the thoracic false lumen was observed in 42% and 63% of cases at discharge and at follow-up (mean 15 months), respectively. At follow-up, the diameters of the entire aorta (mean 5 mm, p < 0.05) and the false lumen (mean 11 mm, p < 0.0001) decreased. Diameters of the abdominal aorta remained stable in association with persistent false lumen perfusion at this level. Aortic diameter results were better in the subgroup of patients with intramural hematoma compared to patients with Marfan syndrome. Three early deaths unrelated to the stent-graft procedure occurred; 2 patients with partial thrombosis of the false lumen died in follow-up secondary to aortic diameter growth. CONCLUSION Complete thrombosis of the false lumen by stent-graft coverage of the entry tear results in decreased diameter of the entire aorta. In patients with partial thrombosis of the false lumen, the aneurysm continues to enlarge.
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Peterson BG, Eskandari MK, Gleason TG, Morasch MD. Utility of left subclavian artery revascularization in association with endoluminal repair of acute and chronic thoracic aortic pathology. J Vasc Surg 2006; 43:433-9. [PMID: 16520151 DOI: 10.1016/j.jvs.2005.11.049] [Citation(s) in RCA: 172] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2005] [Accepted: 11/17/2005] [Indexed: 10/24/2022]
Abstract
BACKGROUND A rapidly increasing number of thoracic aortic lesions are now treated by endoluminal exclusion by using stent grafts. Many of these lesions abut the great vessels and limit the length of the proximal landing zone. Various methods have been used to address this issue. We report our experience with subclavian artery revascularization in association with endoluminal repair of acute and chronic thoracic aortic pathology. METHODS Thirty (43%) of 70 patients undergoing thoracic endovascular stent-graft placement from January 2001 to August 2005 had lesions adjacent to or involving the origin of the subclavian artery. The mean age was 62 years (range, 22-85 years; 63% were men, and 37% were women). This subgroup of 30 patients had indications for repair that included thoracic aortic aneurysm (n = 15), traumatic transection (n = 6), chronic dissection with pseudoaneurysm (n = 5), and acute dissection with intramural hematoma (n = 4). All 30 patients had the subclavian origin covered by the stent graft. In eight cases (27%), no effort was made to revascularize the subclavian artery before or during the endograft placement procedure. Twenty-three (77%) of 30 patients underwent subclavian to carotid artery transposition (n = 21) or bypass (n = 2) before (n = 12; average of 14 days before stent-graft placement), concomitant with (n = 10), or after (n = 1) the endovascular procedure. Physical examination and computed tomography scans were performed after surgery at 1, 6, and 12 months and annually thereafter. The mean follow-up was 18 months (range, 1-51 months). RESULTS Five acute complications occurred in the eight patients (63%) who had the subclavian artery covered without pre-endograft revascularization and included four patients who experienced stroke (accounting for the only death) and one patient who developed symptomatic subclavian-vertebral steal that necessitated transposition 7 months later. Two (9%) of the 23 patients who had subclavian revascularization experienced left-sided vocal cord palsies, and 1 patient (4%) developed lower extremity paraparesis secondary to spinal cord ischemia. No late endoleaks related to retrograde sac perfusion from the most distal great vessel have been identified in any patient. CONCLUSIONS Subclavian revascularization procedures can be performed with relatively low risk. Complications are rare, and patient recovery is rapid. Although this is not necessary in all cases, we advocate subclavian to carotid transposition when the aortic lesion is within 15 mm of the left subclavian orifice to prevent type II endoleak or perfusion of a dissected false lumen when the ipsilateral vertebral artery is patent and dominant or when coronary revascularization using an ipsilateral internal mammary artery is anticipated and in cases that necessitate extensive coverage of intercostals that contribute to spinal cord perfusion. Carotid to subclavian artery bypass should be reserved for patients with a patent internal mammary artery conduit perfusing a coronary vessel and should be combined with proximal subclavian ligation.
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Affiliation(s)
- Brian G Peterson
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA
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41
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Morasch MD, Peterson B. Subclavian artery transposition and bypass techniques for use with endoluminal repair of acute and chronic thoracic aortic pathology. J Vasc Surg 2006; 43 Suppl A:73A-77A. [PMID: 16473175 DOI: 10.1016/j.jvs.2005.10.060] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2005] [Accepted: 10/26/2005] [Indexed: 10/25/2022]
Affiliation(s)
- Mark D Morasch
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill 60611, USA.
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Onitsuka S, Tanaka A, Akashi H, Akaiwa K, Otsuka H, Yokokura H, Aoyagi S. Initial and Midterm Results for Repair of Aortic Diseases With Handmade Stent Grafts. Circ J 2006; 70:726-32. [PMID: 16723794 DOI: 10.1253/circj.70.726] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The purpose of this study was to determine the initial and midterm results for repair of thoracic and abdominal aortic diseases using handmade stent-grafts (SGs). METHODS AND RESULTS Between 1999 and 2004, 41 consecutive patients (31 patients with thoracic and 10 patients with abdominal aortic disease) underwent endovascular stent-graft repair using handmade SGs. The follow-up averaged 24.8+/-17.6 months. The technical and initial clinical success rates were 82.9% (34/41) and 80.5% (33/41), respectively. Primary type I or III endoleaks occurred in 12.2% (5/41) of the patients. The hospital mortality rate was 4.9% (2/41). Persistent type I or III endoleaks occurred in 9.8% (4/41) and SG migrations occurred in 4.9% (2/41) of the patients. Open surgical conversion was undertaken in 12.2% (5/41) of the patients because of an endoleak and/or migration. The mean change observed in the aneurysm diameter was -6.2+/-10.5 mm, and shrinkage in the diameter occurred in 51.4% (18/35) of the cases. There was 1 patient death because of aneurysm rupture. Neither stent fracture nor graft hole was observed. The overall clinical success rate during follow-up was 78.0% (32/41). CONCLUSION The initial and midterm results obtained after repair of the aortic diseases using handmade SGs were considered to be satisfactory. More surgical experience and long-term patient follow-up are both required to further reassess the effect of this treatment.
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Affiliation(s)
- Seiji Onitsuka
- Department of Surgery, Kurume University School of Medicine, Kurume, Japan
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Eggebrecht H, Nienaber CA, Neuhäuser M, Baumgart D, Kische S, Schmermund A, Herold U, Rehders TC, Jakob HG, Erbel R. Endovascular stent-graft placement in aortic dissection: a meta-analysis. Eur Heart J 2005; 27:489-98. [PMID: 16227309 DOI: 10.1093/eurheartj/ehi493] [Citation(s) in RCA: 355] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
AIMS This article summarizes all available published data with respect to clinical success, complications, and outcomes of endovascular stent-graft placement among patients with descending aortic dissection (AD). METHODS AND RESULTS We performed a meta-analysis of all published series on retrograde endovascular stent-graft placement encompassing >or=3 patients with AD. Thirty-nine studies, involving a total of 609 patients, were included. Procedural success was reported in 98.2+/-0.5% of patients. Major complications were reported in 11.1+/-1.4%, with the most dreaded neurologic complications in 2.9+/-0.7% patients. Periprocedural stroke was encountered more frequently than paraplegia (1.9+/-0.6% vs. 0.8+/-0.4%). Overall complications were significantly higher in patients undergoing stent-graft placement for acute AD than in patients with chronic AD (21.7+/-2.8% vs. 9.1+/-2.3%, P=0.005). The overall 30-day mortality was 5.3+/-0.9%, and was three-fold higher in patients with acute AD when compared with chronic AD (9.8+/-2.2% vs. 3.2+/-1.4%, P=0.015). In addition, 2.8+/-0.7% of patients died over a mean follow-up period of 19.5+/-7.1 months. Kaplan-Meier analysis yielded overall survival rates of 90.6+/-1.6% at 6 months, 89.9+/-1.7% at 1 year, and 88.8+/-1.9% at 2 years, respectively. CONCLUSION Endovascular stent-graft placement in type B-AD is technically feasible with success rates of >95% in selected cohort. Although minimally invasive, major complications occurred in 14-18% of patients depending upon the acuity of presentation, with very low incidence of paraplegia. Both, acute and mid-term mortality of this novel treatment strategy appear to favourably compare with surgical treatment but further studies are necessary to compare stent-graft placement with medical treatment in uncomplicated AD.
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Affiliation(s)
- Holger Eggebrecht
- Department of Cardiology, West-German Heart Center Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45122 Essen, Germany.
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Brandt M, Hussel K, Walluscheck KP, Böning A, Rahimi A, Cremer J. Early and Long-term Results of Replacement of the Descending Aorta. Eur J Vasc Endovasc Surg 2005; 30:365-9. [PMID: 15890547 DOI: 10.1016/j.ejvs.2005.04.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2004] [Accepted: 04/06/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The aim of this analysis was to evaluate our results of open surgery on the descending thoracic aorta as benchmark to define indications for endovascular treatment. METHODS Between January 1981 and December 2000, 115 patients underwent replacement of the descending or thoraco-abdominal aorta. Follow-up to 20 years was complete in 98%. RESULTS Early mortality was 19% and paraplegia rate was 7%. Surgery before 1990 and coronary artery disease were independent predictors for early mortality. Thoraco-abdominal repair and normothermia were independent predictors for paraplegia. Ten years survival rate was 63%. CONCLUSIONS Our results confirm that replacement of the descending aorta can be performed today with acceptable low mortality and morbidity and with consistent exclusion of the aneurysm or dissection. Long-term results of endovascular stent-grafts in the descending aorta are unclear. In our opinion endovascular stent-grafts should be reserved for high risk patients, acute dissection or acute aortic rupture.
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Affiliation(s)
- M Brandt
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Estrera AL, Miller CC, Chen EP, Meada R, Torres RH, Porat EE, Huynh TT, Azizzadeh A, Safi HJ. Descending Thoracic Aortic Aneurysm Repair: 12-Year Experience Using Distal Aortic Perfusion and Cerebrospinal Fluid Drainage. Ann Thorac Surg 2005; 80:1290-6; discussion 1296. [PMID: 16181856 DOI: 10.1016/j.athoracsur.2005.02.021] [Citation(s) in RCA: 181] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2004] [Revised: 02/01/2005] [Accepted: 02/03/2005] [Indexed: 11/22/2022]
Abstract
BACKGROUND The benefit of distal aortic perfusion and cerebrospinal fluid drainage over the "clamp and sew" technique during repairs of the descending thoracic aorta is still being debated. The purpose of this report is to analyze our experience with regard to neurologic deficit (paraplegia and paraparesis) and mortality using the adjuncts of distal aortic perfusion and cerebrospinal fluid drainage. METHODS Between February 1991 and September 2004, we repaired 355 descending thoracic aortic aneurysms. Excluded from analysis were 29 patients who required profound hypothermic circulatory arrest as a result of transverse arch involvement and 26 patients with aortic rupture, leaving a group of 300 patients for which outcomes were analyzed. Mean patient age was 67 years, and 102 (34%) of the patients were women. The adjunct group of distal aortic perfusion and cerebrospinal fluid drainage used in 238 (79.3%) patients was compared with a group of 62 patients who underwent simple cross-clamp with or without the addition of a single adjunct. Multivariable data were analyzed by Cox regression. RESULTS The incidence of neurologic deficit after all repairs was 2.3% (7 of 300 patients). The incidence of neurologic deficit (immediate and delayed) in the adjunct group was 1.3% (3 of 238 patients), and in the nonadjunct group was 6.5% (4 of 62 patients; p < 0.02). One case of delayed paraplegia occurred in each group. All neurologic deficits occurred in patients with aneurysmal involvement of the entire descending thoracic aorta (extent C; p < 0.02). Statistically significant predictors for neurologic deficit were the use of the adjunct (odds ratio [OR], 0.19; p = 0.02), previous repaired abdominal aortic aneurysm (OR, 7.0; p = 0.005), type C aneurysm (OR, 13.73; p = 0.02), and cerebrovascular disease history (OR, 4.7; p < 0.03). Thirty-day mortality was 8% (24 of 300 patients). Significant multivariate predictors of 30-day mortality were preoperative renal dysfunction (OR, 4.6; p < 0.01) and female sex (OR, 2.9; p < 0.03). CONCLUSIONS Repairs of the descending thoracic aorta using the adjunct of distal aortic perfusion and cerebrospinal fluid drainage can be performed with a low incidence of neurologic deficit and an acceptable mortality. The use of the adjuncts should be considered during elective repairs of the descending thoracic aorta.
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Affiliation(s)
- Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Houston Medical School, Memorial Hermann Hospital, Houston, Texas, USA
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Garzón G, Fernández-Velilla M, Martí M, Acitores I, Ybáñez F, Riera L. Endovascular Stent-Graft Treatment of Thoracic Aortic Disease. Radiographics 2005; 25 Suppl 1:S229-44. [PMID: 16227493 DOI: 10.1148/rg.25si055513] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Aneurysmal diseases of the thoracic aorta are life-threatening conditions. In such cases, stent-graft treatment has been proposed as an alternative to surgery. The morbidity and mortality associated with endovascular repair are significantly lower than those associated with open surgery. In the largest surgical series, the mortality ranged from 5% to 20%. In studies of endovascular repair, the 30-day mortality was 0%-20% and the periprocedural stroke rate was 0%-7%. Often, open surgery is prohibited in patients with these high-risk lesions; thus, in many cases endovascular treatment is the only alternative. Thoracic aortic diseases that can be treated with endovascular stent-graft placement include aneurysms, dissection, traumatic rupture, traumatic pseudoaneurysms, intramural hematoma, penetrating atherosclerotic ulcers, and aortic rupture. Thorough preprocedure imaging is essential for selecting patients, choosing the stent-graft devices, and planning the intervention. Prerequisites for endovascular stent-graft placement are an adequate neck for graft attachment and adequate vascular access. When the ascending aorta or aortic arch is involved, surgical and endovascular procedures can be combined and performed simultaneously, allowing treatment of a wider range of cases. An experienced interdisciplinary team is needed to manage such cases.
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Affiliation(s)
- Gonzalo Garzón
- Department of Radiology, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046 Madrid, Spain
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López-Benítez R, Richter GM, Luburic A, Böckler D, Kauffmann G, Hallscheidt PJ. False lumen embolization for type B dissection complicated by hemoptysis. Eur J Vasc Endovasc Surg 2005; 30:370-5. [PMID: 15975835 DOI: 10.1016/j.ejvs.2005.04.022] [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: 03/22/2004] [Accepted: 04/18/2005] [Indexed: 10/25/2022]
Abstract
In this report, we describe successful treatment of a patient with hemoptysis by false lumen embolization of a type B aortic dissection.
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Affiliation(s)
- R López-Benítez
- Department of Radiology, Heidelberg University Klinikum, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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Melissano G, Civilini E, de Moura MRL, Calliari F, Chiesa R. Single Center Experience with a New Commercially Available Thoracic Endovascular Graft. Eur J Vasc Endovasc Surg 2005; 29:579-85. [PMID: 15878532 DOI: 10.1016/j.ejvs.2005.01.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2004] [Accepted: 01/18/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE To evaluate the intra-operative performance and clinical outcome of a new commercially available stent-graft for the treatment of thoracic aortic diseases. METHODS AND PATIENTS From January 2003 to October 2004, 45 consecutive patients received endovascular treatment with the Zenith TX1 device for diseases of the thoracic aorta at a single center in northern Italy. Indications included disease of the descending thoracic aorta in 26 cases, of the aortic arch in 17 cases and of the thoraco-abdominal aorta in two cases. We treated 38 atherosclerotic aneurysms, two post-traumatic aortic ruptures, two penetrating ulcers, two chronic dissections and one case was treated for aortic bleeding after voluntary acid ingestion for attempted suicide. General anesthesia was used in 20 cases. Combined or hybrid endovascular and open surgical repair was performed in 11 patients. Mean follow-up was 7 months (range 1-22 months). RESULTS Technical success was obtained in 44 patients (98%). One primary type I endoleak occurred (2%). ICU was used in 12 cases with a mean stay of 1 day. The mean hospital stay was 6 days (range 4-13 days). There were no hospital deaths or strokes but one transient paraplegia (2%). A type II endoleak was observed in one case and resolved spontaneously 1 month later. No aneurysm enlargement, endograft migration or structural failures were observed during follow-up. Two late unrelated-deaths were observed. CONCLUSIONS This stent-graft does not fulfill all the characteristics of the ideal graft, however, it proved to be safe and allowed satisfactory short term results in this group of patients treated at a single center.
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MESH Headings
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Angioplasty, Balloon/instrumentation
- Aortic Aneurysm, Thoracic/diagnosis
- Aortic Aneurysm, Thoracic/therapy
- Aortic Rupture/diagnosis
- Aortic Rupture/therapy
- Aortography
- Blood Vessel Prosthesis
- Equipment Design
- Equipment Safety
- Female
- Follow-Up Studies
- Graft Occlusion, Vascular/diagnosis
- Graft Occlusion, Vascular/mortality
- Humans
- Image Processing, Computer-Assisted
- Imaging, Three-Dimensional
- Male
- Middle Aged
- Outcome Assessment, Health Care/statistics & numerical data
- Postoperative Complications/diagnosis
- Postoperative Complications/mortality
- Stents
- Technology Assessment, Biomedical
- Tomography, Spiral Computed
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Affiliation(s)
- G Melissano
- Department of Vascular Surgery, Vita-Salute University, Scientific Institute H. San Raffaele, 20132 Milan, Italy.
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Yates P, Lloyd G, Fishwick G, Bown M, Sayers R. Endovascular repair of traumatic rupture of the descending aorta. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/j.injury.2004.10.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Imoto K, Uchida K, Suzuki S, Isoda S, Karube N, Kimura K. Stenting of a Left Main Coronary Artery Dissection and Stent-Graft Implantation for Acute Type A Aortic Dissection. J Endovasc Ther 2005; 12:258-61. [PMID: 15823075 DOI: 10.1583/03-1120r.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE To report successful endovascular repair of Stanford type A acute aortic dissection associated with a proximally extended dissection of the left main coronary artery. CASE REPORT A 71-year-old man presented with acute type A aortic dissection. One day after admission, dissection of the left main coronary artery accompanied by severe myocardial ischemia prompted Palmaz stent placement. Three days later, a customized stent-graft was placed across the entry site of the dissection in the descending aorta. The false lumen in the ascending aorta, transverse arch, and the descending thoracic aorta thrombosed, and the left coronary artery remained patent. At 14 months after the procedures, the patient is doing well and has had no cardiac event. CONCLUSIONS This staged procedure may be one option for the management of acute type A aortic dissection complicated by coronary artery dissection.
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Affiliation(s)
- Kiyotaka Imoto
- Department of Cardiovascular Surgery, Yokohama City University, School of Medicine, Medical Center, Yokohama, Japan.
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