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Occlusion of the left subclavian artery with stent grafts is safer with protective reconstruction. Ann Thorac Surg 2009; 88:498-504. [PMID: 19632400 DOI: 10.1016/j.athoracsur.2009.04.042] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2009] [Revised: 04/09/2009] [Accepted: 04/13/2009] [Indexed: 12/20/2022]
Abstract
BACKGROUND Safe fixation of endovascular stent grafts in thoracic aortic disease often requires covering of the left subclavian artery (LSA) with the stent graft. It is controversial whether this occlusion can be done without additional risk of ischemic complications. METHODS In 102 patients treated with endovascular stent grafts, the LSA was covered. In a nonrandomized clinical practice, unprotected occlusion of the LSA was performed in 63 patients (61%), whereas 39 patients underwent extrathoracic subclavian to carotid artery revascularization before (n = 28) or concomitantly with (n = 11) the endovascular procedure. RESULTS Left cerebral ischemia occurred in 11% of the unprotected group and in 5% of the protected group. The difference was not statistically significant. The difference in spinal cord ischemia was insignificant owing to the low incidence in general, but the covered length of the aorta was significantly longer in the protected group. Arm ischemia after unprotected LSA occlusion occurred in 25%. CONCLUSIONS The interpretation of the results remains speculative because many factors contribute to left cerebral ischemia. However, in terms of overall complications, there is a significant difference in favor of the group protected by revascularization of the LSA either before or simultaneously with stent grafting. Arm ischemia is mostly mild and can be managed secondarily. Subclavian revascularization is associated with relatively low risk and should be considered in advance, at least when extended covering of the thoracic aorta is intended.
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Sze DY, van den Bosch MA, Dake MD, Miller DC, Hofmann LV, Varghese R, Malaisrie SC, van der Starre PJ, Rosenberg J, Mitchell RS. Factors Portending Endoleak Formation After Thoracic Aortic Stent-Graft Repair of Complicated Aortic Dissection. Circ Cardiovasc Interv 2009; 2:105-12. [DOI: 10.1161/circinterventions.108.819722] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Daniel Y. Sze
- From the Division of Interventional Radiology (D.Y.S., M.A.A.J.B., M.D.D., L.V.H.), Department of Cardiothoracic Surgery (M.D.D., D.C.M., R.V., S.C.M., R.S.M.), Department of Anesthesia (P.J.A.S.), and Department of Biostatistics (J.R.), Stanford University Medical Center, Stanford, Calif
| | - Maurice A.A.J. van den Bosch
- From the Division of Interventional Radiology (D.Y.S., M.A.A.J.B., M.D.D., L.V.H.), Department of Cardiothoracic Surgery (M.D.D., D.C.M., R.V., S.C.M., R.S.M.), Department of Anesthesia (P.J.A.S.), and Department of Biostatistics (J.R.), Stanford University Medical Center, Stanford, Calif
| | - Michael D. Dake
- From the Division of Interventional Radiology (D.Y.S., M.A.A.J.B., M.D.D., L.V.H.), Department of Cardiothoracic Surgery (M.D.D., D.C.M., R.V., S.C.M., R.S.M.), Department of Anesthesia (P.J.A.S.), and Department of Biostatistics (J.R.), Stanford University Medical Center, Stanford, Calif
| | - D. Craig Miller
- From the Division of Interventional Radiology (D.Y.S., M.A.A.J.B., M.D.D., L.V.H.), Department of Cardiothoracic Surgery (M.D.D., D.C.M., R.V., S.C.M., R.S.M.), Department of Anesthesia (P.J.A.S.), and Department of Biostatistics (J.R.), Stanford University Medical Center, Stanford, Calif
| | - Lawrence V. Hofmann
- From the Division of Interventional Radiology (D.Y.S., M.A.A.J.B., M.D.D., L.V.H.), Department of Cardiothoracic Surgery (M.D.D., D.C.M., R.V., S.C.M., R.S.M.), Department of Anesthesia (P.J.A.S.), and Department of Biostatistics (J.R.), Stanford University Medical Center, Stanford, Calif
| | - Robin Varghese
- From the Division of Interventional Radiology (D.Y.S., M.A.A.J.B., M.D.D., L.V.H.), Department of Cardiothoracic Surgery (M.D.D., D.C.M., R.V., S.C.M., R.S.M.), Department of Anesthesia (P.J.A.S.), and Department of Biostatistics (J.R.), Stanford University Medical Center, Stanford, Calif
| | - S. Chris Malaisrie
- From the Division of Interventional Radiology (D.Y.S., M.A.A.J.B., M.D.D., L.V.H.), Department of Cardiothoracic Surgery (M.D.D., D.C.M., R.V., S.C.M., R.S.M.), Department of Anesthesia (P.J.A.S.), and Department of Biostatistics (J.R.), Stanford University Medical Center, Stanford, Calif
| | - Pieter J.A. van der Starre
- From the Division of Interventional Radiology (D.Y.S., M.A.A.J.B., M.D.D., L.V.H.), Department of Cardiothoracic Surgery (M.D.D., D.C.M., R.V., S.C.M., R.S.M.), Department of Anesthesia (P.J.A.S.), and Department of Biostatistics (J.R.), Stanford University Medical Center, Stanford, Calif
| | - Jarrett Rosenberg
- From the Division of Interventional Radiology (D.Y.S., M.A.A.J.B., M.D.D., L.V.H.), Department of Cardiothoracic Surgery (M.D.D., D.C.M., R.V., S.C.M., R.S.M.), Department of Anesthesia (P.J.A.S.), and Department of Biostatistics (J.R.), Stanford University Medical Center, Stanford, Calif
| | - R. Scott Mitchell
- From the Division of Interventional Radiology (D.Y.S., M.A.A.J.B., M.D.D., L.V.H.), Department of Cardiothoracic Surgery (M.D.D., D.C.M., R.V., S.C.M., R.S.M.), Department of Anesthesia (P.J.A.S.), and Department of Biostatistics (J.R.), Stanford University Medical Center, Stanford, Calif
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Czerny M, Grimm M, Zimpfer D, Rodler S, Gottardi R, Hutschala D, Lammer J, Wolner E, Schoder M. Results After Endovascular Stent Graft Placement in Atherosclerotic Aneurysms Involving the Descending Aorta. Ann Thorac Surg 2007; 83:450-5. [PMID: 17257968 DOI: 10.1016/j.athoracsur.2006.08.031] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2006] [Revised: 08/13/2006] [Accepted: 08/15/2006] [Indexed: 11/24/2022]
Abstract
BACKGROUND The purpose of this study was to determine durability and need for reinterventions after endovascular stent graft placement in atherosclerotic aneurysms involving the descending aorta. METHODS We performed a prospective follow-up analysis of a consecutive series of 79 patients undergoing endovascular stent graft placement due to atherosclerotic aneurysms involving the descending aorta between 1996 and 2006. Acute aortic syndromes were excluded from this analysis. Mean follow-up was 42 months (range, 1 to 108 months). Data were collected for in-hospital mortality, occurrence of early and late endoleaks, reintervention due to early and late endoleaks, and survival. RESULTS In-hospital mortality was 6.3% (n = 5). Two of these patients underwent emergent treatment. Early type I and III endoleaks were observed in 29% of patients (n = 23). The assisted primary endoleak rate was 11%. Late type I or III endoleaks occurred in 21% (n = 17). At 1, 3, and 5 years, overall actuarial survival was 96%, 86%, and 69%, and event-free survival was 90%, 82%, and 65%, respectively. Cox proportional hazard analysis revealed that a short proximal landing zone and a high number of stent grafts used were independent risk factors for early and late endoleak formation. Late endoleak formation was an independent predictor of survival. CONCLUSIONS Endovascular stent graft placement in atherosclerotic aneurysms involving the descending aorta has satisfactory durability. An extensive landing zone is a prerequisite of early and late success. Further clinical investigations are warranted to evaluate long-term durability of this attractive treatment modality.
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Affiliation(s)
- Martin Czerny
- Department of Cardiothoracic Surgery, University of Vienna Medical School, Vienna, Austria.
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