1
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Xie X, Shu X, Zhang W, Guo D, Zhang WW, Wang L, Fu W. A Comparison of Clinical Outcomes of Endovascular Repair Versus Open Surgery for Ruptured Descending Thoracic Aorta. J Endovasc Ther 2021; 29:307-318. [PMID: 34779300 DOI: 10.1177/15266028211057087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The comparisons between thoracic endovascular aortic repair for ruptured thoracic aorta (TEVAR) and open surgery (OS) have not been well documented, although both procedures have been widely utilized. We performed a systematic review and meta-analysis to investigate the effectiveness and safety between TEVAR and OS in the repair of ruptured descending thoracic aorta. METHODS PubMed, Embase, and Cochrane Library databases were searched to find relevant studies to assess TEVAR and OS outcomes. The comparative parameters were perioperative mortality (30 day/in-hospital), 1 year mortality, paraplegia or paraparesis, renal insufficiency, stroke, pulmonary embolism, re-intervention rate, pulmonary complications, and cardiac complications. A fixed-effects model was applied to calculate the odds ratio (OR) with a 95% confidence interval (CI) on pooled outcomes from different studies. RESULTS Eighteen observational trials involving 2088 patients were evaluated (TEVAR=560; OS=1528). Meta-analysis showed that TEVAR in repairing the ruptured descending thoracic aorta was associated with lower perioperative mortality (OR=0.47; 95% CI: 0.34-0.66; p<0.01), 1 year mortality (OR=0.46; 95% CI: 0.29-0.75; p<0.01), renal insufficiency incidence (OR=0.56; 95% CI: 0.33-0.93; p=0.03), and pulmonary complications (OR=0.69; 95% CI: 0.52-0.92; p=0.01) when compared with OS. There was no significant difference between TEVAR and OS in terms of paraplegia, stroke, pulmonary embolism, cardiac complications, and early re-intervention rates. However, the late re-intervention rate was higher in the TEVAR group than that in the OS group. CONCLUSIONS When repairing the ruptured descending thoracic aorta, TEVAR may be performed rapidly and safely. TEVAR is associated with lower rates of perioperative morbidity and early postoperative complications than OS.
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Affiliation(s)
- Xinsheng Xie
- Department of Vascular Surgery, Xiamen Branch, Zhongshan hospital, Fudan University, Xiamen, China
| | - Xiaolong Shu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Vascular Surgery Institute of Fudan University, Shanghai, China
| | - Wei Zhang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Vascular Surgery Institute of Fudan University, Shanghai, China
| | - Daqiao Guo
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Vascular Surgery Institute of Fudan University, Shanghai, China
| | - Wayne W Zhang
- Division of Vascular and Endovascular Surgery, University of Washington, Seattle, WA, USA
| | - Lixin Wang
- Department of Vascular Surgery, Xiamen Branch, Zhongshan hospital, Fudan University, Xiamen, China.,Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Vascular Surgery Institute of Fudan University, Shanghai, China
| | - Weiguo Fu
- Department of Vascular Surgery, Xiamen Branch, Zhongshan hospital, Fudan University, Xiamen, China.,Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Vascular Surgery Institute of Fudan University, Shanghai, China
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2
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İslim F, Erbahçeci Salık A, Güven K, Bakuy V, Çukurova Z. Endovascular repair of thoracic and abdominal aortic ruptures: a single-center experience. Diagn Interv Radiol 2014; 20:259-66. [PMID: 24412816 DOI: 10.5152/dir.2013.13165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We aimed to present our preliminary single-center experience of the endovascular management of thoracic and abdominal aortic ruptures. MATERIALS AND METHODS Between September 2010 and May 2012, 11 consecutive patients (nine males, two females; age range, 26-80 years) with thoracic and abdominal aortic ruptures underwent endovascular repair in our unit. Thoracoabdominal computed tomography (CT) angiography was performed for diagnosis and follow-up. Patients were selected for endovascular repair by a cardiovascular surgeon, anesthesiologist, and interventional radiologist. All repairs were performed using commercially available stent-grafts. The patients were followed up with CT angiography before discharge, at six months, and yearly thereafter. RESULTS Three patients died by day 30. One patient died due to an unsuccessful procedure and hemodynamic instability; two patients died because of comorbidities. The other eight patients were followed for six to 24 months after the procedure. No endoleaks or late ruptures were observed during the follow-up period. The patient with iatrogenic thoracic aortic rupture developed paraplegia after the procedure. CONCLUSION Reduced mortality due to aortic rupture has been reported with the expanding use of endovascular repair. Reports of small centers are important because of the rarity of these pathologies, and because transferring patients with aortic rupture to a referral center is not usually possible.
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Affiliation(s)
- Filiz İslim
- From the Departments of Radiology İstanbul University Istanbul Faculty of Medicine, İstanbul, Turkey.
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3
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Jing Q, Guo L, Wang X, Luan B, Wang G, Liu X, Jin H, Han Y. Percutaneous transluminal intervention and antiplatelet therapy following endovascular graft exclusion for Stanford B thoracic aortic dissection. Int J Cardiol 2013; 165:478-82. [PMID: 21963212 DOI: 10.1016/j.ijcard.2011.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2009] [Revised: 07/16/2011] [Accepted: 09/05/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To evaluate the safety and feasibility of percutaneous coronary intervention and antiplatelet therapy in patients who have undergone endovascular graft exclusion. METHODS From January 2005 to July 2007, percutaneous transluminal intervention (PCI) was performed in 13 patients who had undergone endovascular graft exclusion for the treatment of either acute or chronic Stanford B aortic dissection. Anticoagulant and antiplatelet treatments were administered according to the standard protocol. Patients were followed up for a mean period of 11 months. Clinical characteristics, false lumen thrombosis and angiographic data were collected. RESULTS PCI was technically successful in all 13 patients and no severe complications, including death, paraplegia or renal failure occurred during hospitalization. Complete false lumen thrombosis was observed in all patients within 6 months. There were no major complications such as death, dissection rupture, or aneurysm development during the follow-up period. CONCLUSION Our data suggested that PCI and standard antiplatelet therapy are feasible and safe in patients who have undergone endovascular stent graft exclusion for Stanford B aortic dissection.
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Affiliation(s)
- Quanmin Jing
- Department of Cardiology, Shenyang Northern Hospital, Shenyang 110016, China
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4
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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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5
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Demirpolat G, Ozturk N, Parildar M, Posacioğlu H, Tamsel S. Duplex ultrasound evaluation of endoluminally treated aortic aneurysms with emphasis on diameter measurement: A comparison with computed tomography. JOURNAL OF CLINICAL ULTRASOUND : JCU 2011; 39:263-269. [PMID: 21425274 DOI: 10.1002/jcu.20802] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Accepted: 01/11/2011] [Indexed: 05/30/2023]
Abstract
PURPOSE The aim of this study was to determine the accuracy of color Doppler ultrasound (CDUS) for endoleak detection and measurement of the aneurysm diameter after endovascular aortic aneurysm repair. METHODS Forty-eight CDUS and computed tomographic angiography (CTA) examinations performed concurrently on 29 patients who were treated with endovascular stent grafts for abdominal aortic aneurysms were included in the study. CTA and CDUS findings were retrospectively compared for aneurysm diameter, patency of the graft, and the presence of leaks in the aneurysm's lumen (the so-called "endoleaks"). RESULTS The stent graft was patent in all patients. Including the follow-up examinations, endoleaks were detected in a total of 17 CTA studies. The sensitivity, specificity, and positive and negative predictive values for CDUS compared with CTA as the gold standard were 100%, 96%, 94.4%, and 100%, respectively. Kappa statistics showed a high level of agreement between CDUS ant CTA examinations (χ = 0.95). The aneurysm diameters measured with CDUS and CTA were significantly different, but within 5 mm of each other in 83% of patients. CONCLUSIONS Provided that a strict CDUS protocol including spectral analysis of perigraft flow is used, CDUS is comparable to CTA for endoleak detection and measurement of the aneurysm diameter.
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Affiliation(s)
- Gulgun Demirpolat
- Ege University, School of Medicine, Department of Radiology, İzmir, Turkey
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6
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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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7
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Hartley MC, Langan EM, Cull DL, Taylor SM, Carsten CG, Blackhurst DW. Evaluation of the diameter of the proximal descending thoracic aorta with age: implications for thoracic aortic stent grafting. Ann Vasc Surg 2009; 23:639-44. [PMID: 19616402 DOI: 10.1016/j.avsg.2009.05.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Revised: 04/24/2009] [Accepted: 05/09/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Long-term anatomical changes of the thoracic aorta which may affect long-term outcome of blunt aortic injuries treated with endovascular stent grafts are unknown. The purpose of this study was to examine the natural history of thoracic aortic diameter with progressing age. METHODS One thousand consecutive thoracic computed tomographic scans performed for nonthoracic aortic pathology on patients aged 15-99 (mean 59.4) were examined, and thoracic aortic diameter immediately adjacent to the left subclavian artery was measured. Factors possibly influencing diameter, including age by decade of life, race, gender, history of hypertension (HTN), diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), and tobacco use, were examined. Factors were compared using Student's t-test. RESULTS The differences in mean diameters of the thoracic aorta by gender (male=27.1 vs. female=26.0, p=0.87), race (Caucasian=26.6 vs. non-Caucasian=26.3, p=0.10), presence of HTN (yes=25.8 vs. no=24.9, p=0.36), COPD (yes=26.3 vs. no=25.4, p=0.21), DM (yes=26.1 vs. no=25.3, p=0.12), and tobacco use (yes=26.3 vs. no=25.0, p=0.18) were not significant. However, differences in mean diameter increased significantly over time with age. Patients under 40 years old had mean aortic diameters of 22.92 mm compared to 27.09 mm (p<0.001) for patients over 40. The mean aortic isthmus diameter showed an approximately 1cm increase when comparing octogenarians to teenagers. CONCLUSION The diameter of the aortic isthmus increases substantially with age. These findings suggest that long-term surveillance is warranted for trauma patients with aortic stent grafts, to monitor the natural history and to assess for possible late complications.
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Affiliation(s)
- Michael C Hartley
- Academic Department of Surgery, Greenville Hospital System University Medical Center, Greenville, SC 29605, USA.
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8
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Endovascular Repair for Diverse Pathologies of the Thoracic Aorta: An Initial Decade of Experience. J Am Coll Surg 2009; 208:802-16; discussion 816-8. [DOI: 10.1016/j.jamcollsurg.2008.12.021] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2008] [Accepted: 12/02/2008] [Indexed: 11/17/2022]
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9
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Lindblad B, Holst J, Kölbel T, Ivancev K. What to Do When Evidence is Lacking — Implications on Treatment of Aortic Ulcers, Pseudoaneurysms and Aorto-Enteric Fistulae. Scand J Surg 2008; 97:165-73. [DOI: 10.1177/145749690809700220] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Present knowledge on natural history and how to treat penetrating aortic ulcers or different forms of pseudoaneurysms with or without infection is limited as there are only case reports and small series of unusual aortic pathology and its treatment available. Material: From our centre we collected 65 patients treated with open (n=15) or endovascular reconstruction (n=50) during a 20-year period in the abdominal aorta. These patients are presented including a review of contemporary treatment. Results: Endovascular reconstructions seem to reduce morbidity and mortality compared to otherwise extensive open surgery. Even for patients with infectious etiology (mycotic aneurysms, aorto-enteric fistula) endovascular treatment may be a first-hand option bridging to a more elective open repair. However, a large proportion of patients being unfit for further open surgery were solely treated endovascularly and had no major infectious complications in the follow-up. Registers of cases with unusual aortic pathology, not only of those treated but also of those managed conservatively, are needed to define who to treat and if endovascular or open repair should be recommended. Conclusion: Endovascular technique is a promising technique for treatment of aortic pseudoaneurysms of different etiologies. We firmly recommend, despite the lack of evidence, that the work up of patients with penetrating aortic ulcers, mycotic or other types of pseudoanerysms as well as aorto-enteric fistulae should enclose both endovascular and open (or combined) treatment modalities. However, our knowledge of the natural history is limited. Therefore, registers of cases with unusual aortic pathology, not only of those treated but also of those managed conservatively, are needed to define who to treat and if endovascular or open repair should be recommended.
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Affiliation(s)
- B. Lindblad
- Centre of Vascular Disease, Malmö University Hospital, Lund University, Malmö, Sweden
| | - J. Holst
- Centre of Vascular Disease, Malmö University Hospital, Lund University, Malmö, Sweden
| | - T. Kölbel
- Centre of Vascular Disease, Malmö University Hospital, Lund University, Malmö, Sweden
| | - K. Ivancev
- Centre of Vascular Disease, Malmö University Hospital, Lund University, Malmö, Sweden
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10
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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: 546] [Impact Index Per Article: 34.1] [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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11
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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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12
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Wildhaber BE, Kalangos A, Le Coultre C, Genin B. Traumatic isthmic aortic rupture associated with renal fracture in a child. ACTA ACUST UNITED AC 2007; 62:1501-3. [PMID: 17563674 DOI: 10.1097/01.ta.0000222535.28206.30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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13
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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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14
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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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15
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Weigang E, Hartert M, Siegenthaler MP, Beckmann NA, Sircar R, Szabò G, Etz CD, Luehr M, von Samson P, Beyersdorf F. Perioperative Management to Improve Neurologic Outcome in Thoracic or Thoracoabdominal Aortic Stent-Grafting. Ann Thorac Surg 2006; 82:1679-87. [PMID: 17062227 DOI: 10.1016/j.athoracsur.2006.05.037] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2006] [Revised: 05/08/2006] [Accepted: 05/11/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Thoracic or thoracoabdominal aortic stent-graft repair has shown a reduction in morbidity and mortality rates due to the procedure's advantages (no aortic cross-clamping, continuous distal aortic perfusion, no reperfusion injury). However, 3% to 12% of the patients are at risk of spinal cord ischemia. We investigated spinal cord protective measures with evoked potentials, cerebrospinal fluid drainage, and prevention of hypotension to minimize postoperative neurologic deficit. METHODS Between November 2000 and July 2005, vital parameters and spinal cord function were monitored, including cerebrospinal fluid pressure and transcranial motor-evoked and somatosensory-evoked potentials in 36 stent-graft procedures (31 patients) on the thoracic or thoracoabdominal aorta. RESULTS Stent-graft placement was technically successful in all patients. We achieved a survival rate of 100% without neurologic deficit after fast-track extubation. Eleven of 31 patients exhibited changes in evoked potentials during stent-graft deployment. In 12 of 31 patients (including the 11 with evoked potential alterations), cerebrospinal fluid pressure exceeded 15 mm Hg. Cerebrospinal fluid drainage and vital parameter adjustment were executed in those instances. We observed intraoperative evoked potential total recovery in 10 of 11 patients after these interventions. CONCLUSIONS Interventions to improve spinal cord perfusion led to total recovery of spinal function in most patients (10/11). Therefore, spinal cord protective measures with motor- and somatosensory-evoked potential monitoring, cerebrospinal fluid drainage, and prevention of hypotension can reduce the incidence of spinal cord ischemia and improve the neurologic outcome of patients undergoing endovascular thoracic or thoracoabdominal aortic repair.
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Affiliation(s)
- Ernst Weigang
- Department of Cardiovascular Surgery, University Hospital Freiburg, Freiburg, Germany.
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16
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Delis KT, Gloviczki P, Bjarnason H, Sullivan TM, McKusick MA, Kalra M, Bower TC. Endovascular Repair of Ruptured Saccular Aneurysms of the Descending Thoracic Aorta. J Vasc Interv Radiol 2006; 17:1527-33. [PMID: 16990474 DOI: 10.1097/01.rvi.0000235695.76762.3f] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Open repair of ruptured aneurysms of the descending thoracic aorta (DTA) is associated with early mortality rates of 20%-60% and severe morbidity rates exceeding 40%. The present report describes three octogenarian patients and one sexagenarian patient at poor surgical risk admitted with acutely ruptured saccular DTA aneurysms (two of four were anastomotic) unrelated to trauma or infection who underwent successful endovascular therapy, which involved the use of aortic endovascular cuffs in three cases. Mean intensive care unit and total hospital stay durations were 1.75 days (range, 1-4 d) and 6 days (range, 3-13 d), respectively. At 30 days, all patients were alive and free of repeat intervention, with aneurysm exclusion achieved in all cases but one, which featured a marginal type II endoleak. These data support endovascular therapy for ruptured saccular DTA aneurysms enabling short-term outcomes that otherwise would have been unrealistic.
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Affiliation(s)
- Konstantinos T Delis
- Division of Vascular Surgery, Gonda Vascular Center, Mayo Clinic, 200 First Street Southwest, Rochester, Minnesota 55905, USA
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17
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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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18
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Stahel PF, Schneider P, Buhr HJ, Kruschewski M. [Emergency management of thoracic trauma]. DER ORTHOPADE 2005; 34:865-79. [PMID: 16044335 DOI: 10.1007/s00132-005-0845-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Thoracic injuries are a major cause of mortality during the "golden hour" of trauma. Many patients with chest trauma die after reaching the hospital. Less than 10% of all blunt thoracic injuries require a thoracotomy, and many potentially life-threatening conditions can be relieved by simple procedures, such as chest tube insertion.Thus, many cases of traumatic deaths due to chest injury may be prevented by prompt diagnosis and a standardized therapeutic approach in the emergency room. A high index of suspicion for lethal injury patterns, based on the mechanism of trauma and the clinical presentation, is a crucial prerequisite for an adequate initial assessment and management of patients with chest trauma. The worldwide implementation of standardized diagnostic and therapeutic guidelines, such as the "Advanced Trauma Life Support" (ATLS) protocol, has led to a significant reduction of early deaths attributed to thoracic injuries.
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Affiliation(s)
- P F Stahel
- Klinik für Unfall- und Wiederherstellungschirurgie, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany.
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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: 48] [Impact Index Per Article: 2.5] [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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Sayed S, Thompson MM. Endovascular repair of the descending thoracic aorta: evidence for the change in clinical practice. Vascular 2005; 13:148-57. [PMID: 15996372 DOI: 10.1258/rsmvasc.13.3.148] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The purpose was to review outcome data following endovascular repair of the descending thoracic aorta from reports published between 1994 and 2004. To accomplish this task, 1,518 patients underwent endovascular repair for thoracic aortic disease; 810 thoracic aortic aneurysms, 500 type B thoracic aortic dissections, and 106 traumatic ruptures. The 30-day mortality rate was 5.5% and 6% for late postoperative deaths. The primary technical success rate was 97%, with only 15 patients requiring open conversion. Neurologic deficits occurred in 29 patients. In total, 118 endoleaks were reported; 29 were restented, and the remainder required surgical intervention. Graft infection occurred in 6 cases, and migrations were detected in 10. The conclusion reached is that endovascular repair of descending thoracic aortic disease is feasible and can be achieved with low rates of perioperative morbidity and mortality. As few long-term data exist on the durability of thoracic stent grafts, lifelong surveillance remains necessary.
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Affiliation(s)
- Saiqa Sayed
- Department of Vascular Surgery, St George's Hospital Medical School, London, United Kingdom
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Porcu P, Chavanon O, Sessa C, Thony F, Aubert A, Blin D. Esophageal fistula after endovascular treatment in a type B aortic dissection of the descending thoracic aorta. J Vasc Surg 2005; 41:708-11. [PMID: 15874937 DOI: 10.1016/j.jvs.2004.12.052] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We report a type B aortic dissection treated with stenting of the descending thoracic aorta that subsequently developed an ischemic necrosis of the esophagus with a posterior mediastinum abscess. The surgical treatment consisted of an extra-anatomic bypass to revascularize the supra-aortic trunks and the distal abdominal aorta through a middle sternal laparotomy, the resection of the thoracic aorta, and the drainage of the mediastinal abscess. Despite this aggressive surgical approach and an initial favorable postoperative course, the patient suddenly died 3 weeks later, likely from a rupture of the aortic stump.
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Affiliation(s)
- Paolo Porcu
- Cardiac Surgery Department, Grenoble University Hospital, France
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Martín M, Morís C, Lozano Í, Llaneza JM, Vega F, Fernández F, Llosa JC, Suárez E, Valle JM. Tratamiento percutáneo de las afecciones de la aorta torácica. Una labor multidisciplinaria. Rev Esp Cardiol 2005. [DOI: 10.1157/13070505] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
The advent and success of endovascular repair of abdominal aneurysms had led to the development of catheter-based techniques to treat thoracic aortic pathology. Such diseases, including thoracic aortic aneurysms, acute and chronic type B dissections,penetrating aortic ulcers, and traumatic aortic transection, challenge surgeons to perform complex operative repairs in high-risk patients. The minimally invasive nature of thoracic endografting may provide an attractive alternative therapy especially in patients deemed unfit for thoracotomy. A worldwide review of thoracic endografting demonstrates encouraging short- and midterm outcomes with significant reductions in morbidity and early mortality.Long-term surveillance will be crucial to discover complications unique to thoracic endovascular interventions and to determine which patients are appropriate candidates for stent-graft therapy.
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Affiliation(s)
- Jason T Lee
- Division of Vascular Surgery H3600, Stanford University Medical Center, 300 Pasteur Drive, Stanford, CA 94305-5642, USA.
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Affiliation(s)
- John J Ricotta
- Department of Surgery, State University of New York at Stony Brook, Room 020, University Hospital, Stony Brook, NY 11794, USA
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