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Kim KT, Wang TI, Gregory Conway R, Toursavadkohi S, Cherian J. A direct aorta to segmental artery bypass for prevention of spinal cord ischemia after endovascular aortic repair. J Vasc Surg Cases Innov Tech 2024; 10:101446. [PMID: 38510088 PMCID: PMC10951524 DOI: 10.1016/j.jvscit.2024.101446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/24/2024] [Indexed: 03/22/2024] Open
Abstract
Spinal cord ischemia remains a persistent challenge after endovascular aortic aneurysm repair. We present a novel direct aorta to segmental artery bypass before aneurysm repair in a 64-year-old woman presenting with an enlarging aneurysm following dissection. Through an eighth intercostal incision, a polyester graft was sewn into the aorta using pledgeted sutures. An entry needle was used to directly access the previously treated aortic segment, and the opening was stented and angioplasty was performed to create inflow. Anastomoses were performed to a prominent left T10 segmental artery with a harvested saphenous vein. The patient remained neurologically intact postoperatively and the 1-month follow-up angiography demonstrated bypass patency.
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Affiliation(s)
- Kevin T. Kim
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD
| | - Ting I. Wang
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD
| | - R. Gregory Conway
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Shahab Toursavadkohi
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Jacob Cherian
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD
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Berger C, Greiner A, Brandhorst P, Reimers SC, Kniesel O, Omran S, Treskatsch S. How Would I Treat My Own Thoracoabdominal Aortic Aneurysm: Perioperative Considerations From the Anesthesiologist Perspective. J Cardiothorac Vasc Anesth 2024; 38:1092-1102. [PMID: 38310068 DOI: 10.1053/j.jvca.2023.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 12/12/2023] [Accepted: 12/16/2023] [Indexed: 02/05/2024]
Abstract
A thoracoabdominal aortic aneurysm (TAAA) can be potentially life-threatening due to its associated risk of rupture. Thoracoabdominal aortic aneurysm repair, performed as endovascular repair and/or open surgery, is the recommended therapy of choice. Hemodynamic instability, severe blood loss, and spinal cord or cerebral ischemia are some potential hazards the perioperative team has to face during these procedures. Therefore, preoperative risk assessment and intraoperative anesthesia management addressing these potential hazards are essential to improving patients' outcomes. Based on a presented index case, an overview focusing on anesthetic measures to identify perioperatively and manage these risks in TAAA repair is provided.
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Affiliation(s)
- Christian Berger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Berlin, Germany
| | - Andreas Greiner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Vascular Surgery, Berlin, Germany
| | - Philipp Brandhorst
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Berlin, Germany
| | - Sophie Claire Reimers
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Berlin, Germany
| | - Olaf Kniesel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Berlin, Germany
| | - Safwan Omran
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Vascular Surgery, Berlin, Germany
| | - Sascha Treskatsch
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Berlin, Germany.
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Huynh C, Liu I, Sommer A, Menke L, Reilly L, Gasper W, Hiramoto J. Descending thoracic aortic mural ulceration is associated with postoperative spinal cord ischemia after branched endovascular aortic aneurysm repair. J Vasc Surg 2024; 79:732-739. [PMID: 38036115 DOI: 10.1016/j.jvs.2023.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/17/2023] [Accepted: 11/21/2023] [Indexed: 12/02/2023]
Abstract
OBJECTIVE Paraplegia is one of the most feared complications after thoracoabdominal aortic aneurysm repair. The purpose of this study is to determine whether aortic thrombus characteristics are associated with spinal cord ischemia (SCI) after branched endovascular aneurysm repair (BEVAR). METHODS From April 2011 to April 2020, 62 patients underwent elective BEVAR for thoracoabdominal aortic aneurysm and pararenal aortic aneurysms using a low-profile device and had a complete preoperative computed tomography angiography of the aorta from the sinotubular junction to the aortic bifurcation. Aortic thrombus was evaluated for thrombus thickness ≥5 mm, thrombus >2/3 of aortic circumference, and the presence of an ulcer-like thrombus. One point was assigned at each 5 mm axial image if all 3 criteria were met, resulting in a total "shaggy score" for the entire aorta. Data on demographics, procedural details, and outcomes were collected prospectively. All patients underwent a standard spinal cord protection protocol, including routine cerebrospinal fluid drainage. In July 2016, an insulin infusion protocol (IIP) was initiated to maintain postoperative blood glucose levels <120 mg/dL for 48 hours. The primary clinical end point was postoperative SCI. RESULTS 10 (16%) patients developed postoperative SCI: 6 with transient paraparesis, 2 with persistent paraparesis, and 2 with persistent paraplegia. Patients with SCI were older, had higher shaggy scores, and were less likely to have been on an IIP. There were no significant differences in demographics, aneurysm type, or operative parameters. In a logistic multivariate regression model for SCI, age (odds ratio [OR]: 1.2 [1.1-1.4], P = .02) and shaggy score (OR: 1.2 [1.1-1.4], P = .02) were independently associated with increased risk of SCI, whereas treatment with the IIP was associated with lower risk of SCI (OR: 0.04 [0.006-0.50], P = .05). Of the individual components of the shaggy score, higher descending thoracic aortic ulcer scores were the most strongly associated with postoperative SCI (P = .009). CONCLUSIONS Preoperative characterization of aortic wall thrombus is an important adjunctive tool for individualized clinical decision-making and patient counseling about the risk of SCI after BEVAR.
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Affiliation(s)
- Cindy Huynh
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Iris Liu
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Anne Sommer
- University of California, San Francisco School of Medicine, San Francisco, CA
| | - Laura Menke
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Linda Reilly
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Warren Gasper
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Jade Hiramoto
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA.
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Gross BD, Zhu J, Rao A, Ilonzo N, Storch J, Faries PL, Marin ML, George JM, Tadros RO. Use of Spinal Anesthesia during Thoracic Endovascular Aortic Repair. Ann Vasc Surg 2024; 99:242-251. [PMID: 37802146 DOI: 10.1016/j.avsg.2023.08.017] [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: 05/24/2023] [Revised: 08/06/2023] [Accepted: 08/07/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND The purpose of this study was to assess outcomes after spinal anesthesia (SA) versus general anesthesia (GA) in patients undergoing thoracic endograft placement and to evaluate the adjunctive use of cerebrospinal fluid drainage (CSFD) placement. METHODS A single-center retrospective review of patients that underwent thoracic endograft placement from 2001 to 2019 was performed. Patients were stratified based on the type of anesthesia they received: GA, SA or epidural, GA with CSFD, and SA with CSFD. Primary outcomes included 30-day mortality and length of stay (LOS). Baseline characteristics were analyzed with Student's t-test and Pearson's chi-squared test. Multivariate logistic regression analysis was performed to identify risk factors for 30-day mortality and longer LOS. RESULTS A total of 333 patients underwent thoracic endograft placement; 104 patients received SA, 180 patients received GA, 30 patients received GA and CSFD, and 19 patients received SA and CSFD. Of the total patients, 16.2% underwent thoracic endograft placement for type B aortic dissection, 3.3% for type A aortic dissection, and 12.3% for penetrating ulcer. The mean age of the study population was 68.7 years old. Patients undergoing SA were older with a mean age of 73.4 years versus 64.7 years for patients undergoing GA (P < 0.001). Spinal anesthesia (SA) was preferred in patients at high risk for GA (>75 years old: 52.9% vs. 33.3%, P < 0.001; renal comorbidities: 20.6% vs. 10.6%, P = 0.03, and current smokers: 26.7% vs. 9.6%, P < 0.001). Length of stay (LOS) was decreased in the SA group (4.29 days vs. 9.70 days, P < 0.001). There was a lower incidence of spinal cord ischemia in the SA group (1.0% vs. 2.2%, P = 0.44), as well as significantly decreased 30-day mortality (0% vs. 5.6%, P = 0.01), reintervention (19.2% vs. 26.8%, P = 0.02), and return to the operating room (6.8% vs. 12.7%, P = 0.02). Of the 19 patients that had SA + CSFD, there were no signs and symptoms of spinal cord ischemia and decreased incidence of perioperative complications (0% vs. 33.3%, P = 0.01). There was no difference in the risk for intraoperative complications, neurologic complications, or 30-day mortality between GA + CSFD patients versus SA + CSFD patients. Age >75 (P = 0.002), intraoperative complications (P < 0.001), and perioperative complications (P = 0.02) were associated with increased mortality after thoracic endograft placement per multivariate logistic regression analysis. CONCLUSIONS Spinal anesthesia (SA) in select high-risk patients was associated with reduced 30-day mortality, neurologic complications, and LOS compared to GA. The concurrent use of spinal drainage and SA had satisfactory results compared to spinal drainage and GA.
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Affiliation(s)
- Benjamin D Gross
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jerry Zhu
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Ajit Rao
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nicole Ilonzo
- Division of Vascular and Endovascular Surgery, Weil Cornell Medical College, New York, NY
| | - Jason Storch
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Peter L Faries
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael L Marin
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Justin M George
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rami O Tadros
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY
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Behzadi F, Simon JE, Zielke TJ, Cook JT, Costa RA, Bechara CF, Prabhu VC. Risk Factors Associated with Spinal Cord Ischemia During Aortic Aneurysm Repair. Ann Vasc Surg 2023; 91:36-49. [PMID: 36603707 DOI: 10.1016/j.avsg.2022.12.079] [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: 07/12/2022] [Revised: 10/17/2022] [Accepted: 12/16/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND The risk of spinal cord ischemia (SCI) with aortic aneurysm repair can cause significant neurological morbidity. Prevention of SCI is critical. We sought to identify risk factors that predispose to SCI that may guide strategies to mitigate the occurrence of SCI during and following these procedures. METHODS This study includes all adults who underwent atraumatic, unruptured, thoracic, and suprarenal aortic aneurysm repairs (endovascular or open) at our institution over 11 years (2010-2020). Our database included patient demographics, aneurysm anatomic features, and operative characteristics and an extreme gradient boost (XGB) machine method was used to develop a predictive model for SCI. The model was trained on an 80% randomly stratified cohort of the data and tested on the remaining 20% testing cohort. Shapley values were used to determine the most important predictive factors of SCI and decision trees were used to identify risk factor threshold values and highest risk factor combinations. RESULTS Information was collected for 174 adult patients undergoing thoracic and suprarenal aortic repair from 2010 to 2020. Fifty eight percent of the patients were male. Ninety seven (55.7%) patients had open aortic repair and 87 (44.3%) had endovascular repair. Twenty seven (15%) of all patients had major complications and were considered to have SCI. The XGB model converged over the training cohort with a testing cohort accuracy of 0.841 [Sensitivity = 75%, Specificity = 68%] and area under the curve of receiver operating characteristic of 0.774. The XGB model identified older age (> 65 years), history of neurologic disease, hyperlipidemia, diabetes, coronary artery disease, heart failure, poor renal function, < 6 months since last aortic repair, chronic anticoagulant use, preoperational anemia (Hemoglobin < 9), thrombocytopenia (platelet < 90,000), coagulopathy (prothrombin time > 15s and activated partial thromboplastin time > 40s), hypotension (mean arterial pressure < 70 mm Hg), longer operations (> 100 min), aneurysms longer than 5 cm, and anatomic location of aneurysm caudal to T-11 as risk factors for SCI in all types of aortic repair. Diabetic and heart failure patients undergoing longer operations (> 100 min) with thrombocytopenia or aneurysms longer than 5 cm were at the highest risk. CONCLUSIONS The XGB model accurately identified risk factors of SCI with aortic aneurysm repair that may guide patient selection, timing of surgery, and strategies to minimize the risk of SCI.
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Affiliation(s)
- Faraz Behzadi
- Department of General Surgery, Loyola University Medical Center, Maywood, IL
| | - Joshua E Simon
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, IL
| | - Tara J Zielke
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - John T Cook
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Renzo A Costa
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Carlos F Bechara
- Department of Vascular Surgery, Loyola University Medical Center, Maywood, IL
| | - Vikram C Prabhu
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, IL.
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Oberhuber A, Raddatz A, Betge S, Ploenes C, Ito W, Janosi RA, Ott C, Langheim E, Czerny M, Puls R, Maßmann A, Zeyer K, Schelzig H. Interdisciplinary German clinical practice guidelines on the management of type B aortic dissection. GEFASSCHIRURGIE 2023; 28:1-28. [PMCID: PMC10123596 DOI: 10.1007/s00772-023-00995-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 08/13/2023]
Affiliation(s)
- A. Oberhuber
- German Society of Vascular Surgery and Vascular Medicine (DGG); Department of Vascular and Endovascular Surgery, University Hospital of Münster, Münster, Germany
| | - A. Raddatz
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI); Department of Anaesthesiology, Critical Care and Pain Medicine, Saarland University Hospital, Homburg, Germany
| | - S. Betge
- German Society of Angiology and Vascular Medicine (DGG); Department of Internal Medicine and Angiology, Helios Hospital Salzgitter, Salzgitter, Germany
| | - C. Ploenes
- German Society of Geriatrics (DGG); Department of Angiology, Schön Klinik Düsseldorf, Düsseldorf, Germany
| | - W. Ito
- German Society of Internal Medicine (GSIM) (DGIM); cardiovascular center Oberallgäu Kempten, Hospital Kempten, Kempten, Germany
| | - R. A. Janosi
- German Cardiac Society (DGK); Department of Cardiology and Angiology, University Hospital Essen, Essen, Germany
| | - C. Ott
- German Society of Nephrology (DGfN); Department of Nephrology and Hypertension, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
- Department of Nephrology and Hypertension, Paracelsus Medical University, Nürnberg, Germany
| | - E. Langheim
- German Society of prevention and rehabilitation of cardiovascular diseaese (DGPR), Reha Center Seehof, Teltow, Germany
| | - M. Czerny
- German Society of Thoracic and Cardiovascular Surgery (DGTHG), Department University Heart Center Freiburg – Bad Krozingen, Freiburg, Germany
- Albert Ludwigs University Freiburg, Freiburg, Germany
| | - R. Puls
- German Radiologic Society (DRG); Institute of Diagnostic an Interventional Radiology and Neuroradiology, Helios Klinikum Erfurt, Erfurt, Germany
| | - A. Maßmann
- German Society of Interventional Radiology (DeGIR); Department of Diagnostic an Interventional Radiology, Saarland University Hospital, Homburg, Germany
| | - K. Zeyer
- Marfanhilfe e. V., Weiden, Germany
| | - H. Schelzig
- German Society of Surgery (DGCH); Department of Vascular and Endovascular Surgery, University Hospital of Düsseldorf, Düsseldorf, Germany
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Bhatia M, Kumar PA. Con: Lumbar Drains Should Routinely Be Placed by a Landmark Approach and Not by Fluoroscopic Guidance for Elective Thoracic Aortic Repairs. J Cardiothorac Vasc Anesth 2023; 37:183-186. [PMID: 36280577 DOI: 10.1053/j.jvca.2022.09.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/24/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Meena Bhatia
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Priya A Kumar
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
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Klijn AJ, Heida J, Burger DH, Heyligers JM, Pouwels S. Brown–Séquard Syndrome after Thoracic Endovascular Aortic Repair for a Stanford Type B Aortic Dissection. Vasc Specialist Int 2022; 38:12. [PMID: 35686522 PMCID: PMC9188867 DOI: 10.5758/vsi.220008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We present a case of Brown–Séquard syndrome (BSS) after thoracic endovascular aortic repair (TEVAR) to treat Stanford type B aortic dissection. A 49-year-old male presented to the emergency department with acute tearing pain between the scapulae, connected to respiratory movements. Computed tomography showed Stanford type B aortic dissection from the left subclavian artery to the level of the 11th thoracic vertebra. Conservative treatment was initiated with intravenous antihypertensives. However, due to persistent pain and an increase in the aortic diameter with an intramural hematoma, TEVAR was performed. The patient developed symptoms suspicious of spinal cord ischemia postoperatively. A lesion limited to the left-sided spinal cord was observed on magnetic resonance imaging at the level of the 4th to 5th thoracic vertebra. BSS after TEVAR is a rare phenomenon with a fairly good prognosis, depending on the initial injury severity.
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Affiliation(s)
- Adine J. Klijn
- Departments of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Jennie Heida
- Departments of Neurology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Desiree H.C. Burger
- Departments of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
- Departments of Vascular Surgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Jan M.M. Heyligers
- Departments of Vascular Surgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Sjaak Pouwels
- Departments of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
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Zhang W, Zhang L, Li X, Li M, Qiu J, Wang M, Shu C. Simultaneous Endovascular Repair Is Not Associated With Increased Risk for Thoracic and Abdominal Aortic Pathologies: Early and Midterm Outcomes. Front Cardiovasc Med 2022; 9:883708. [PMID: 35711338 PMCID: PMC9197242 DOI: 10.3389/fcvm.2022.883708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 03/31/2022] [Indexed: 11/30/2022] Open
Abstract
Coexisting multilevel aortic pathologies were caused by atherosclerosis and hypertension and presented in a small subgroup of patients. Endovascular repair is a safe and effective treatment for a variety of aortic pathologies. However, fewer small series and cases were reported using simultaneous thoracic endovascular repair (TEVAR) and endovascular aneurysm repair (EVAR) for both aortic segments. To determine the outcomes of simultaneous and separately TEVAR and EVAR treating for multilevel aortic pathologies. Between 2010 and 2020, 31 patients and 22 patients were treated by one-staged and two-staged repair, respectively at a single center. All patients had the concomitant thoracic and abdominal aortic disease (aortic dissection, aneurysms, and penetrating aortic ulcers). Compared with the patients with two-staged aortic repair, the one-staged repair patients were older (mean age, 68 vs. 57 years; P < 0.001) and had a larger preoperative maximal aortic diameter (67.03 ± 10.65 vs. 57.45 ± 10.36 mm; p = 0.002). The intraoperative and postoperative outcomes show that the procedure times and length of hospital stay (LOS) were longer in the two-staged group. There is no significant difference in postoperative complications between the two groups. In the follow up, the freedom from re–intervention and the mean survival rate for the one-staged group were 100 vs. 100%, 92.4 vs. 95%, and 88 vs. 88% at one, two, and 5 years, respectively, whereas the mean survival rate for the two-staged group was 86.4 vs. 90.5%, 87 vs. 90.5%, and 76 vs. 84% at one, two, and 5 years, respectively, all with no statistical difference. Combined TEVAR and EVAR can be performed successfully with minimal morbidity and mortality. The one-staged repair was not associated with the increased risk for multilevel aortic pathologies treatment.
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Affiliation(s)
- Weichang Zhang
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Vascular Diseases, Central South University, Changsha, China
| | - Lei Zhang
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Vascular Diseases, Central South University, Changsha, China
| | - Xin Li
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Vascular Diseases, Central South University, Changsha, China
| | - Ming Li
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Vascular Diseases, Central South University, Changsha, China
| | - Jian Qiu
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Vascular Diseases, Central South University, Changsha, China
| | - Mo Wang
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Vascular Diseases, Central South University, Changsha, China
| | - Chang Shu
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Vascular Diseases, Central South University, Changsha, China
- Department of Cardiovascular Surgery, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, Beijing, China
- *Correspondence: Chang Shu
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Mascia D, Kahlberg A, Tinaglia S, Pena A, Morgad DE Freitas D, Del Carro U, Bosco L, Monaco F, DE Luca M, Chiesa R, Melissano G. Intraoperative electroneurography-guided intercostal nerve cryoablation for pain control after thoracoabdominal aneurysm open surgical repair. INT ANGIOL 2022; 41:128-135. [PMID: 35112827 DOI: 10.23736/s0392-9590.22.04817-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Postoperative pain after thoracoabdominal (TAAA) or thoracic (TAA) aortic aneurysm open surgical repair may be debilitating and induce limitations in mobilization resulting in a longer length of stay, higher rate of pulmonary adverse events, readmissions and a higher risk of mortality. Commonly employed analgesic strategies do not completely solve this issue and have their own drawbacks. Cryoablation of intercostal nerves has been proposed as an appealing alternative to address the post-operative pain. METHODS Between 2020 and 2021, data of all consecutive patients undergoing TAA or TAAA aortic aneurysms open repair with electroneurography-guided cryoablation of intercostal nerves were collected. Post-operative pain was recorded using patient-reported 0-10 numeric rating scale (NRS). Need for adjunctive opioid drugs and postoperative complications were also recorded. Narcotic usage was calculated as Morphine Milligram Equivalents (MMEs) per day. RESULTS A total of 15 patients (8 males, mean age 61.1-year-old) underwent open surgical repair for TAAA (13 cases) or TAA (2 cases) and received intercostal nerve cryoablation. There were no intraoperative deaths and cases of spinal cord ischemia. Overall, 70 intercostal nerves underwent electroneurography-guided cryoablation, with a a mean of 4.6 nerves per patient. On the first day after extubation, mean NRS was 4.6 and the MMEs calculated was 6.7, decreasing over the days. There was one case of pneumonia and atelectasis requiring bronchoscopy. There were no reported bowel complications. The mean postoperative length of stay was 16 days and in the intensive care unit stay was 6.5 days. CONCLUSIONS Electroneurography-guided cryoablation of intercostal nerves is a safe and reproducible technique which can be used in addition to systemic pain management for TAA and TAAA open repair.
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Affiliation(s)
- Daniele Mascia
- Vascular Surgery, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milano, Italy -
| | - Andrea Kahlberg
- Vascular Surgery, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milano, Italy
| | - Sarah Tinaglia
- Vascular Surgery, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milano, Italy
| | - Americo Pena
- Vascular Surgery, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milano, Italy
| | - Dhaniel Morgad DE Freitas
- Vascular Surgery, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milano, Italy
| | - Ubaldo Del Carro
- Neurology Department, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Luca Bosco
- Neurology Department, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Fabrizio Monaco
- Anesthesiology Department, San Raffaele Scientific Institute, Vita-Salute University School of Medicine, Milano, Italy
| | - Monica DE Luca
- Anesthesiology Department, San Raffaele Scientific Institute, Vita-Salute University School of Medicine, Milano, Italy
| | - Roberto Chiesa
- Vascular Surgery, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milano, Italy
| | - Germano Melissano
- Vascular Surgery, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milano, Italy
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Prior Infrarenal Aortic Surgery is Not Associated with Increased Risk of Spinal Cord Ischemia Following Thoracic Endovascular Aortic Repair and Complex Endovascular Aortic Repair. J Vasc Surg 2021; 75:1152-1162.e6. [PMID: 34742886 DOI: 10.1016/j.jvs.2021.10.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 10/10/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Patients with prior infrarenal aortic intervention represent an increasing demographic of patients undergoing thoracic endovascular aortic repair (TEVAR) and/or complex EVAR. Studies have suggested that prior abdominal aortic surgery is a risk factor for spinal cord ischemia (SCI). However, these results are largely based on single-center experiences with limited multi-institutional and national data assessing clinical outcomes in these patients. The objective of this study was to evaluate the effect of prior infrarenal aortic surgery on SCI. METHODS The Society for Vascular Surgery Vascular Quality Initiative database was retrospectively reviewed to identify all patients ≥18 years old undergoing TEVAR/complex EVAR from January 2012 to June 2020. Patients with previous thoracic or suprarenal aortic repairs were excluded. Baseline and procedural characteristics and postoperative outcomes were compared by group: TEVAR/complex EVAR with or without previous infrarenal aortic repair. The primary outcome was postoperative SCI. Secondary outcomes included postoperative hospital length of stay (LOS), bowel ischemia, renal ischemia, and 30-day mortality. Multivariate regression was used to determine independent predictors of postoperative SCI. Additional analysis was performed for patients undergoing isolated TEVAR. RESULTS A total of 9506 patients met the inclusion criteria: 8691 (91.4%) had no history of infrarenal aortic repair and 815 (8.6%) had previous infrarenal aortic repair. Patients with previous infrarenal repair were older with an increased prevalence of chronic kidney disease (p=0.001) and cardiovascular risk factors including hypertension, chronic obstructive pulmonary disease, and smoking history (p<0.001). These patients presented with larger maximal aortic diameters (6.06±1.47 cm versus 5.15±1.76 cm; p<0.001) and required more stent grafts (p<0.001) with increased intraoperative blood transfusion requirements (p<0.001), and longer procedure times (p<0.001). Univariate analysis demonstrated no difference in postoperative SCI, postoperative hospital LOS, bowel ischemia, or renal ischemia between the two groups. Thirty-day mortality was significantly higher in patients with prior infrarenal repair (p=0.001). On multivariate regression, prior infrarenal aortic repair was not a predictor of postoperative SCI, while aortic dissection (odds ratio [OR] 1.65; 95% confidence interval [CI] 1.26-2.16, p<0.001), number of stent grafts deployed (OR 1.45; 95% CI 1.30-1.62, p<0.001), and units of packed red blood cells transfused intraoperatively (OR 1.33; 95% CI 1.03-1.73, p=0.032) were independent predictors of SCI. CONCLUSIONS Although TEVAR/complex EVAR patients with prior infrarenal aortic repair constituted a sicker cohort with higher 30-day mortality, the rate of SCI was comparable to patients without prior repair. Previous infrarenal repair was not associated with risk of SCI.
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Ahmad M, Ghaly P, Iliopoulos J. Lumbar drain management protocol for use in complex aortic aneurysm repairs. ANZ J Surg 2021; 91:1652-1654. [PMID: 34506064 DOI: 10.1111/ans.16697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 01/30/2021] [Accepted: 02/11/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Mehtab Ahmad
- Liverpool Hospital Vascular Unit, South West Sydney Local Health District, Sydney, New South Wales, Australia
| | - Paul Ghaly
- Liverpool Hospital Vascular Unit, South West Sydney Local Health District, Sydney, New South Wales, Australia
| | - Jim Iliopoulos
- Liverpool Hospital Vascular Unit, South West Sydney Local Health District, Sydney, New South Wales, Australia
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Lyden SP, Ahmed A, Steenberge S, Caputo FJ, Smolock CJ, Kirksey L, Hardy DM, Rowse JW. Spinal drainage complications after aortic surgery. J Vasc Surg 2021; 74:1440-1446. [PMID: 33940078 DOI: 10.1016/j.jvs.2021.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE/BACKGROUND Spinal drain (SD) placement is an adjunct used in open and endovascular aortic surgery to mitigate the risk of spinal cord injury. SD placement can lead to subdural hematoma and intracranial hemorrhage (SDH/ICH). Previous studies have highlighted a correlation between incidence of SDH/ICH and amount of cerebrospinal fluid (CSF) drained. We have two philosophies of SD management in our institution. One protocol allows fluid removal for pressure >10 cm H2O with no volume restriction. A second, similar protocol restricts CSF drainage to <25 mL/h. We examined SD complications and the influence of volume restriction. METHODS Patients were identified according to the Current Procedure Terminology codes for SD placement, thoracic endovascular aortic repair, fenestrated/branched endovascular aortic repair, endovascular abdominal aortic repair, and open thoracic or thoracoabdominal aortic repair between January 1, 2012, and December 31, 2015. Patients' demographics included age, gender, race, body mass index, and comorbidities such as hypertension, chronic obstructive pulmonary disease, stroke, transient ischemic attack, diabetes mellitus, bleeding disorder, and connective tissue disorders. Management protocol was classified as volume independent (VI) or volume dependent (VD) by physician order. Postoperative complications related to the SD were noted. RESULTS We identified 948 patients who had an SD placed during the study period; 473 were done before aortic surgeries. A total of 364 patients (77%) underwent endovascular aortic surgery. The mean age at the time of procedure was 67.2 years, and 66% of patients were male. Thirty-nine patients (8.3%) were noted to have connective tissue disorders. Bloody SD placement occurred in 14 patients (3.1%) requiring rescheduling of the operation. SDH/ICH occurred in 11 patients (2.3%), postoperative blood tinged SD output in 94 patients (19.9 %), and 22 patients (4.7 %) had a CSF leak after SD removal. The incidence of SDH/ICH was not affected by the management protocol (2.6% VI vs 2.0% VD, P = .66), whereas the incidence of postoperative blood tinged SD output was significantly higher in the VI group (25.1% VI vs 15.0% VD, P = .006). Perioperative low-dose aspirin (81 mg) and prophylactic subcutaneous heparin did not increase the incidence of SDH/ICH. Postoperative thrombocytopenia was found to be associated with higher incidence of SDH/ICH (median 86,000 vs 113,000, P = .002). CONCLUSIONS Severe complications of SD placement (SDH/ICH) occur in 2.3% of SD patients undergoing aortic surgery, and the risk is higher in the setting of postoperative thrombocytopenia. SD volume limitation, blood tinged drainage, antiplatelet medication, and low-dose heparin do not affect the risk of SDH/ICH. The risks of spinal drains for aortic surgery should be balanced against potential benefits.
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Affiliation(s)
- Sean P Lyden
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Ayman Ahmed
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Sean Steenberge
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Francis J Caputo
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | | | - Levester Kirksey
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - David M Hardy
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jarrad W Rowse
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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Hong YK, Chang WH, Goo DE, Oh HC, Park YW. Mid-Term Results of Thoracic Endovascular Aortic Repair for Complicated Acute Type B Aortic Dissection at a Single Center. J Chest Surg 2021; 54:172-178. [PMID: 33824229 PMCID: PMC8181695 DOI: 10.5090/jcs.20.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/03/2021] [Accepted: 02/16/2021] [Indexed: 12/02/2022] Open
Abstract
Background Complicated acute type B aortic dissection is a life-threatening condition with high morbidity and mortality. The aim of this study was to report a single-center experience with endovascular stent-graft repair of acute type B dissection of the thoracic aorta and to evaluate the mid-term outcomes. Methods We reviewed 18 patients treated for complicated acute type B aortic dissection by thoracic endovascular aortic repair (TEVAR) from September 2011 to July 2017. The indications for surgery included rupture, impending rupture, limb ischemia, visceral malperfusion, and paraplegia. The median follow-up was 34.50 months (range, 12–80 months). Results The median interval from aortic dissection to TEVAR was 5.50 days (range, 0–32 days). There was no in-hospital mortality. All cases of malperfusion improved except for 1 patient. The morbidities included endoleak in 2 patients (11.1%), stroke in 3 patients (16.7%), pneumonia in 2 patients (11.1%), transient ischemia of the left arm in 1 patient (5.6%), and temporary visceral ischemia in 1 patient (5.6%). Postoperative computed tomography angiography at 1 year showed complete thrombosis of the false lumen in 15 patients (83.3%). Conclusion TEVAR of complicated type B aortic dissection with a stent-graft was effective, with a low morbidity and mortality rate.
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Affiliation(s)
- Young Kwang Hong
- Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Won Ho Chang
- Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Dong Erk Goo
- Department of Radiology, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Hong Chul Oh
- Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Young Woo Park
- Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Seoul Hospital, Seoul, Korea
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Blanco Amil CL, Mestres Alomar G, Guarnaccia G, Luoni G, Yugueros Castellnou X, Vigliotti RC, Ramses R, Riambau V. The Initial Experience on Branched and Fenestrated Endografts in the Aortic Arch. A Systematic Review. Ann Vasc Surg 2021; 75:29-44. [PMID: 33831530 DOI: 10.1016/j.avsg.2021.03.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/01/2021] [Accepted: 03/11/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Branched and fenestrated endografts (fEVAR/bEVAR) are complex techniques used to treat thoracic aorta pathologies involving the aortic arch. This systematic review aims to determine all the reported results regarding these techniques in the aortic arch, in order to describe their clinical outcomes. METHODS A systematic review of the literature was performed, considering all articles published until October 2019. PubMed, Cochrane database resources were used. The protocol of the study was previously registered in the Prospero database (CRD42020147037). Primary exclusion criteria included opinion articles, merely technique descriptions, articles without the follow-up of at least 1 month, studies conducted on animals, mixed treatments, and ongoing trials without published data. Included variables were study design, aortic pathology, type of endovascular technique (fEVAR/bEVAR), endograft manufacturing, number of fenestrations/branches and type of bridge stents. Technical success, complications during surgery and follow-up were also described. RESULTS From a total of 164 articles, 29 (28 retrospective, 1 prospective) were analyzed with a total of 693 cases (341 fEVAR and 352 bEVAR). The most common indications for repair were aneurysm (54.8%) and dissection (40%). Only fEVAR and bEVAR were considered, but different endograft materials and techniques were used and, therefore, reported upon in the current review. Zenith Alpha Thoracic Endovascular Graft was the most representative (24% of cases). Custom made, off-the-shelf, physician modified and in situ fenestrated endografts were also used in 39%, 22.4%, 18.6% and 18.9% of cases, respectively. Bridge stents were implanted in the 50.5% of cases. Technical success rate was 96%. The main intraoperative complication was the endoleak (5.2%) followed by stroke (4.8%). The in-hospital mortality was 2.5%. The mean follow-up was 18.5 months. The mortality related to the main operation during follow-up was 3.2% and not directly related to the main operation was 11.3%. During the follow-up, 92 cases (13.3%) in total had to undergo through a reintervention, 46.7% with endovascular repair and 26.1% with open surgical repair (the rest were not specified). CONCLUSION published experience with bEVAR and fEVAR in the aortic arch showed acceptable short-term effectiveness and safety. More well-conducted prospective clinical studies with long term follow-up, combined with comparative meta-analysis, are needed to elucidate the real benefit of those endovascular techniques in the aortic arch pathology.
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Affiliation(s)
- Carla Lorena Blanco Amil
- Division of Vascular Surgery, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain.
| | - Gaspar Mestres Alomar
- Division of Vascular Surgery, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Giorgio Guarnaccia
- Division of Vascular Surgery, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Giorgio Luoni
- Division of Vascular Surgery, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Xavier Yugueros Castellnou
- Division of Vascular Surgery, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Rossella Chiara Vigliotti
- Division of Vascular Surgery, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Rafic Ramses
- Division of Vascular Surgery, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Vincent Riambau
- Division of Vascular Surgery, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
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Moore K, Bailey DM, Lewis MH, Gordon A, Thomas R, Wood A, White RD, Bashir M, Williams IM. When is extra-anatomical bypass for the left subclavian artery required to prevent ischaemia after thoracic endovascular stent grafting? Asian Cardiovasc Thorac Ann 2021; 29:524-531. [PMID: 33818153 DOI: 10.1177/02184923211008074] [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: 11/17/2022]
Abstract
INTRODUCTION Thoracic endovascular aortic repair (TEVAR) has become an accepted treatment for thoracic aortic disease. However, the principal complications relate to coverage of the thoracic aortic wall and deliberate occlusion of aortic branches over a potentially long segment. Complications include risk of stroke, spinal cord ischaemia (SCI) and arterial insufficiency to the left arm (left arm ischaemia (LAI)). This study specifically scrutinised the development of SCI and LAI after TEVAR for interventions for thoracic aortic disease from 1999 to 2020. In particular, those who underwent extra-anatomical bypass (both immediate and late) were compared to the length of thoracic aortic coverage by the stent graft. MATERIALS AND METHODS Ninety-eight patients underwent TEVAR. The presenting symptoms, pathology, procedural and follow-up data were collected prospectively with particular evidence of stroke, SCI and LAI both immediate onset and after 48 h of graft placement. RESULTS Fifty underwent TEVAR for an aneurysm (thoracoabdominal aortic aneurysm), 22 for dissection, 19 for acute transection and 7 for intramural haematoma/pseudoaneurysm of the thoracic aorta. Twenty-nine (30%) required a debranching procedure to increase the proximal landing zone (1 aorto-carotid subclavian bypass, 10 carotid/carotid subclavian bypass and 18 carotid/subclavian bypass). Ten patients (10%) died within 30 days of TEVAR. Twenty-four grafts covered the left subclavian artery origin without a carotid/subclavian bypass. Five required a delayed carotid/subclavian bypass for LAI (4) and SCI (1). Six developed immediate signs of SCI after TEVAR and these 11 (group i) had a mean (SD) length of coverage of the thoracic aorta of 30.2 (10.6) cm compared to 21.5 (11.2) cm (group g) in those who had no LAI or SCI post TEVAR, p < 0.05. CONCLUSIONS In this series, delayed carotid/subclavian bypass may be required for chronic arm ischaemia and less so for SCI. The length of coverage of thoracic aorta during TEVAR is a factor in the development of delayed SCI and LAI occurrence. Carotid subclavian bypass is required for certain patients undergoing TEVAR (particularly if greater than 20 cm of thoracic aorta is covered).
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Affiliation(s)
- Katherine Moore
- Department of Radiology, University Hospital of Wales, Cardiff, UK
| | - Damian Miles Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Michael Howard Lewis
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Andrew Gordon
- Department of Radiology, University Hospital of Wales, Cardiff, UK
| | - Rhodri Thomas
- Department of Radiology, University Hospital of Wales, Cardiff, UK
| | - Andrew Wood
- Department of Radiology, University Hospital of Wales, Cardiff, UK
| | - Richard D White
- Department of Radiology, University Hospital of Wales, Cardiff, UK
| | - Mohamad Bashir
- Vascular Surgery Department, Royal Blackburn Teaching Hospital, Blackburn, UK
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Walsh K, O'Connor DJ, Weaver F, Trimarchi S, Cao L, Wilderman M, Ratnathicam A, Cook K, Napolitano M, Simonian G. Survival after endovascular therapy in patients with ruptured thoracic aortic diseases: Results from the Global Registry for Endovascular Aortic Treatment Registry. J Vasc Surg 2020; 72:1544-1551. [DOI: 10.1016/j.jvs.2020.02.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 02/09/2020] [Indexed: 12/01/2022]
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Serial Systemic Injections of Endotoxin (LPS) Elicit Neuroprotective Spinal Cord Microglia through IL-1-Dependent Cross Talk with Endothelial Cells. J Neurosci 2020; 40:9103-9120. [PMID: 33051350 DOI: 10.1523/jneurosci.0131-20.2020] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 09/13/2020] [Accepted: 09/17/2020] [Indexed: 12/12/2022] Open
Abstract
Microglia are dynamic immunosurveillance cells in the CNS. Whether microglia are protective or pathologic is context dependent; the outcome varies as a function of time relative to the stimulus, activation state of neighboring cells in the microenvironment or within progression of a particular disease. Although brain microglia can be "primed" using bacterial lipopolysaccharide (LPS)/endotoxin, it is unknown whether LPS delivered systemically can also induce neuroprotective microglia in the spinal cord. Here, we show that serial systemic injections of LPS (1 mg/kg, i.p., daily) for 4 consecutive days (LPSx4) consistently elicit a reactive spinal cord microglia response marked by dramatic morphologic changes, increased production of IL-1, and enhanced proliferation without triggering leukocyte recruitment or overt neuropathology. Following LPSx4, reactive microglia frequently contact spinal cord endothelial cells. Targeted ablation or selective expression of IL-1 and IL-1 receptor (IL-1R) in either microglia or endothelia reveal that IL-1-dependent signaling between these cells mediates microglia activation. Using a mouse model of ischemic spinal cord injury in male and female mice, we show that preoperative LPSx4 provides complete protection from ischemia-induced neuron loss and hindlimb paralysis. Neuroprotection is partly reversed by either pharmacological elimination of microglia or selective removal of IL-1R in microglia or endothelia. These data indicate that spinal cord microglia are amenable to therapeutic reprogramming via systemic manipulation and that this potential can be harnessed to protect the spinal cord from injury.SIGNIFICANCE STATEMENT Data in this report indicate that a neuroprotective spinal cord microglia response can be triggered by daily systemic injections of LPS over a period of 4 d (LPSx4). The LPSx4 regimen induces morphologic transformation and enhances proliferation of spinal cord microglia without causing neuropathology. Using advanced transgenic mouse technology, we show that IL-1-dependent microglia-endothelia cross talk is necessary for eliciting this spinal cord microglia phenotype and also for conferring optimal protection to spinal motor neurons from ischemic spinal cord injury (ISCI). Collectively, these novel data show that it is possible to consistently elicit spinal cord microglia via systemic delivery of inflammogens to achieve a therapeutically effective neuroprotective response against ISCI.
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Preoperative CT Angiography Informs Instrumentation in Anterior Spine Surgery for Idiopathic Scoliosis. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2020; 4:JAAOSGlobal-D-19-00123. [PMID: 32377614 PMCID: PMC7188266 DOI: 10.5435/jaaosglobal-d-19-00123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 01/30/2020] [Indexed: 11/18/2022]
Abstract
The objective of this study is to evaluate whether the artery of Adamkiewicz localization with preoperative CT angiography influences anterior spinal instrumentation. Methods Children with idiopathic scoliosis who underwent anterior instrumentation and with a preoperative CT angiography were evaluated retrospectively. Data included curve type, artery of Adamkiewicz level/laterality, surgical approach laterality, number of instrumented levels and segmental vessels ligated, intraoperative neuromonitoring changes, and postoperative neural complications. Results Thirty-nine girls and eight boys (mean age 12 years [6.7 to 16.8 years]) were analyzed. Instrumented curves indicate 28 thoracic, 14 thoracolumbar, and seven double major. The artery of Adamkiewicz: T6 (left-1), T8 (left-1), T9 (left-4/right-2), T10 (left-11/right-4), T11 (left-4/right-4), T12 (left-1/right-2), L1 (left-2/right-1), and L2 (left-3/right-2). Four had bilateral dominant segmentals, whereas in nine patients, none was identified. T10 (32%) and left side (57%) were most frequent. On average, 7.1 (4 to 11) segmentals were ligated per case (total 355). Dominant vessels were ipsilateral to/within instrumentation levels in 30%. Discussion In children with idiopathic scoliosis who underwent anterior instrumentation, the artery of Adamkiewicz was identified on the left in >50% and at T10 in 32%. In one-third of the patients, the artery was within intended surgical levels and resulted in instrumentation modification.
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King RW, Wooster MD, Ruddy JM, Genovese EA, Anderson JM, Brothers TE, Veeraswamy RK. Previous thoracic aortic repair is not associated with adverse outcomes after thoracic endovascular aortic repair. J Vasc Surg 2020; 71:1097-1108. [PMID: 31619351 PMCID: PMC7189752 DOI: 10.1016/j.jvs.2019.07.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 07/18/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND As many as 20% of patients who have undergone previous thoracic aortic repair will require reintervention, which could entail thoracic endovascular aortic repair (TEVAR). A paucity of data is available on mortality and the incidence of spinal cord ischemia (SCI) and other postoperative complications associated with TEVAR after previous aortic repairs exclusive to the thoracic aorta. The aim of the present study was to assess the effect of previous thoracic aortic repair on the 30-day mortality and SCI outcomes for patients after TEVAR. METHODS The Society for Vascular Surgery Vascular Quality Initiative database was queried for all cases of TEVAR from 2012 to 2018. Patients were excluded if they had undergone previous abdominal aortic repair, the TEVAR had extended beyond aortic zone 5, or SCI data were missing. The 3 cohorts compared were TEVAR with previous ascending aortic or aortic arch repair (group 1), TEVAR with previous descending thoracic aortic repair (group 2), and TEVAR without previous repair (group 3). The primary outcomes of interest were 30-day mortality and SCI. The secondary outcomes included stroke, myocardial infarction, cardiac complications, respiratory complications, postoperative length of stay, and reintervention. The patient variables were compared using χ2 tests, analysis of variance, or Kruskal-Wallis tests, as appropriate. Logistic regression analysis was performed to identify the predictors of 30-day mortality and SCI. RESULTS A total of 4010 patients met the inclusion criteria, with 470 in group 1, 132 in group 2, and 3408 in group 3. The 30-day mortality was 4% (19 of 470) in group 1, 6% (8 of 132) in group 2, and 6% (213 of 3408) in group 3 (P = .17). The incidence of SCI was 3% (14 of 470) in group 1, 3% (4 of 132) in group 2, and 3.8% (128 of 3408) in group 3 (P = .65). Stroke, reintervention, myocardial infarction, and cardiac complications were not significantly different among the 3 groups. The incidence of respiratory complications was greatest for group 3 (11%; 360 of 3408) compared with groups 1 (9%; 44 of 470) and 2 (4%; 5 of 132; P = .034). Similarly, the postoperative length of stay was longest for group 3 (9.6 ± 19.4 days vs 8.2 ± 18.3 days for group 1 and 5.9 ± 8.6 days for group 2; P = .038). The independent predictors of 30-day mortality for all TEVAR patients included units of packed red blood cells transfused intraoperatively, urgent or emergent repairs, older age, increasing serum creatinine level, inability to perform self-care, total procedure time, occlusion of the left subclavian artery intraoperatively, distal endograft landing zone 5, and diabetes. The predictors of SCI included the total procedure time, urgent and emergent repairs, and increasing serum creatinine level. CONCLUSIONS TEVAR after previous thoracic aortic repair was not associated with an increased risk of SCI or 30-day mortality compared with TEVAR without previous aortic repair.
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Affiliation(s)
- Ryan W King
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC.
| | - Mathew D Wooster
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC
| | - Jean M Ruddy
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC; Ralph H. Johnson Department of Veteran Affairs Medical Center, Charleston, SC
| | - Elizabeth A Genovese
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC; Ralph H. Johnson Department of Veteran Affairs Medical Center, Charleston, SC
| | - Joseph M Anderson
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC
| | - Thomas E Brothers
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC; Ralph H. Johnson Department of Veteran Affairs Medical Center, Charleston, SC
| | - Ravi K Veeraswamy
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC
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Pasqualucci A, Al-Sibaie A, Vaidyan KPT, Paladini A, Nadhari MY, Gori F, Greiss HF, Properzi M, Al Ani OSM, Godwin A, Syedkazmi AH, Elhanf OA, Varrassi G. Epidural Corticosteroids, Lumbar Spinal Drainage, and Selective Hemodynamic Control for the Prevention of Spinal Cord Ischemia in Thoracoabdominal Endovascular Aortic Repair: A New Clinical Protocol. Adv Ther 2020; 37:272-287. [PMID: 31721112 DOI: 10.1007/s12325-019-01146-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Indexed: 12/16/2022]
Abstract
INTRODUCTION In patients undergoing thoracoabdominal aorta repair, spinal cord ischemia (SCI) remains one of the most common and important complications resulting in transient paraparesis through to permanent flaccid paraplegia. In this manuscript, after a brief introduction to spinal cord ischemia complication and its prevention in thoracoabdominal endovascular aortic repair (TEVAR), we propose a new clinical protocol potentially able to prevent such complication. METHODS The proposed protocol suggests the use of high dosages of corticosteroids by epidural route, along with drainage of cerebrospinal fluid and controlled vascular hypertension, to reduce the incidence of SCI in TEVAR. Moreover, we paid particular attention to the control of the hemodynamic parameters to obtain adequate peripheral tissue perfusion (oxygen delivery), including in the spinal cord. RESULTS We applied this new protocol in 50 consecutive patients treated with TEVAR for thoracoabdominal aortic aneurysms (TAAs); 47 patients completed the procedure: 27 patients Crawford type I and 20 Crawford type II. Three patients died during surgery because of untreatable aneurysm rupture. The results show that in all patients there were no cases of SCI, after 5 days from TEVAR. DISCUSSION To the best of our knowledge, there are no clinical studies on the use of epidural corticosteroids in patients undergoing treatment of aortic syndrome (both in "open surgery" and endovascular aortic repair). This initial study on 50 consecutive patients has shown that the clinical protocol used could be of great interest to prevent one of the worse complications of TEVAR. Its limitations are the low number of patients studied till now, and the non-randomized protocol adopted. Further studies would be necessary. CONCLUSION Our experience and the results obtained with this new perioperative protocol with epidural corticosteroid and accurate hemodynamic control have been encouraging and it seems a valid proposal to be explored in future by well-structured prospective, randomized protocols.
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Affiliation(s)
- Alberto Pasqualucci
- Department of Surgical and Biomedical Science, University Hospital of Perugia, 06100, Perugia, Italy
- Rashid Hospital, Trauma and Emergency Center (Dubai Health Authority), Dubai, UAE
| | - Ayman Al-Sibaie
- Rashid Hospital, Trauma and Emergency Center (Dubai Health Authority), Dubai, UAE
| | | | | | | | - Fabio Gori
- Department of Surgical and Biomedical Science, University Hospital of Perugia, 06100, Perugia, Italy
| | - Hany Fawzy Greiss
- Rashid Hospital, Trauma and Emergency Center (Dubai Health Authority), Dubai, UAE
| | - Marina Properzi
- Department of Surgical and Biomedical Science, University Hospital of Perugia, 06100, Perugia, Italy
| | | | - Aruna Godwin
- Rashid Hospital, Trauma and Emergency Center (Dubai Health Authority), Dubai, UAE
| | | | - Osama Ahmed Elhanf
- Rashid Hospital, Trauma and Emergency Center (Dubai Health Authority), Dubai, UAE
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Chu MWA, Forbes TL, Kirk Lawlor D, Harris KA, Derose G. Endovascular Repair of Thoracic Aortic Disease: Early and Midterm Experience. Vasc Endovascular Surg 2019; 41:186-91. [PMID: 17595383 DOI: 10.1177/1538574406298512] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Thoracic aorta disease remains a challenging problem, and despite improvements, open repair techniques are still associated with significant morbidity and mortality. This is a retrospective review of 53 consecutive patients with thoracic aortic pathology who were treated with endovascular repair between September 1998 and December 2004 at a tertiary-care hospital. Endovascular stent graft placement was performed on 23 elective and 30 emergent patients (34 male patients, mean age 66 years, 21 to 85 years). Completion angiography revealed no endoleak in 47 (89%) patients, a type I endoleak in 4 patients, and a type II endoleak in 2 patients. Operative 30-day mortality for elective aneurysms (n = 22), emergent aneurysms (n = 10), dissection (n = 3), penetrating aortic ulcers (n = 7), and trauma (n = 11) was 0%, 40%, 0%, 29%, and 9%, respectively. In total, 46 (87%) patients survived 30 days, and 36 (78.3%) of the survivors were discharged home free of complications. Two patients (4%) experienced paraplegia. Median follow-up was 22 months (1 to 72 months). Intermediate-term results revealed 41 (89%) patients free of endoleak, stent migration, or aneurysmal expansion. Two (4%) patients required reintervention with an additional stent graft. There were 2 (4%) patients with late aortic-related deaths and four (9%) patients with non—aorticrelated late deaths. Endovascular stent graft placement for thoracic aorta disease can be performed successfully and safely with good perioperative and intermediate-term outcomes. Stent graft complication and reintervention rates are low, whereas intermediate survival rates are good. Long-term efficacy still needs to be evaluated.
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Affiliation(s)
- Michael W A Chu
- Division of Cardiac Surgery, University of Western Ontario, London, Ontario, Canada
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Hernandez-Gerez E, Fleming IN, Parson SH. A role for spinal cord hypoxia in neurodegeneration. Cell Death Dis 2019; 10:861. [PMID: 31723121 PMCID: PMC6853899 DOI: 10.1038/s41419-019-2104-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/17/2019] [Accepted: 10/21/2019] [Indexed: 01/12/2023]
Abstract
The vascular system of the spinal cord is particularly complex and vulnerable. Damage to the main vessels or alterations to the regulation of blood flow will result in a reduction or temporary cessation of blood supply. The resulting tissue hypoxia may be brief: acute, or long lasting: chronic. Damage to the vascular system of the spinal cord will develop after a traumatic event or as a result of pathology. Traumatic events such as road traffic accidents, serious falls and surgical procedures, including aortic cross-clamping, will lead to an immediate cessation of perfusion, the result of which may not be evident for several days, but may have long-term consequences including neurodegeneration. Pathological events such as arterial sclerosis, venous occlusion and spinal cord compression will result in a progressive reduction of blood flow, leading to chronic hypoxia. While in some situations the initial pathology is exclusively vascular, recent research in neurodegenerative disease has drawn attention to concomitant vascular anomalies in disorders, including amyotrophic lateral sclerosis, spinal muscular atrophy and muscular sclerosis. Understanding the role of, and tissue response to, chronic hypoxia is particularly important in these cases, where inherent neural damage exacerbates the vulnerability of the nervous system to stressors including hypoxia.
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Affiliation(s)
- Elena Hernandez-Gerez
- Institute of Medical Sciences University of Aberdeen Foresterhill Aberdeen, AB25 2ZD, Scotland, UK
| | - Ian N Fleming
- Institute of Medical Sciences University of Aberdeen Foresterhill Aberdeen, AB25 2ZD, Scotland, UK
| | - Simon H Parson
- Institute of Medical Sciences University of Aberdeen Foresterhill Aberdeen, AB25 2ZD, Scotland, UK.
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Piazza M, Squizzato F, Milan L, Miccoli T, Grego F, Antonello M. Incidence and Predictors of Neurological Complications Following Thoracic Endovascular Aneurysm Repair in the Global Registry for Endovascular Aortic Treatment. Eur J Vasc Endovasc Surg 2019; 58:512-519. [DOI: 10.1016/j.ejvs.2019.05.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 05/06/2019] [Accepted: 05/10/2019] [Indexed: 02/05/2023]
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25
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Buczkowski P, Puslecki M, Stefaniak S, Juszkat R, Kulesza J, Misterski M, Urbanowicz T, Ligowski M, Zabicki B, Dabrowski M, Szarpak L, Gorczyca D, Jemielity M, Perek B. Off pump hybrid extra-anatomic techniques for aortic arch repair-own experience. J Thorac Dis 2019; 11:2305-2314. [PMID: 31372267 DOI: 10.21037/jtd.2019.06.10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Treatment of the aortic arch pathologies is technically challenging. In this study we assess early and late outcomes of hybrid aortic arch repairs that comprise extra-anatomic surgical procedures completed by thoracic endovascular interventions [thoracic endovascular aortic repair (TEVAR)]. Methods Since 2007, 21 patients (8 women and 13 men) with a median age of 48 years have undergone hybrid procedures for aortic arch pathologies. All of them were treated without cardio-pulmonary bypass. All survivors were followed up regularly and imaging examination were performed. A technical success, procedural complications as well as the early and late mortality and morbidity rates were evaluated. Results All patients survived surgery and TEVAR was technically successful in all of them. However, 2 individuals died (in-hospital mortality rate 9.5%) during in-hospital stay, both due to multi-organ failure (MOF). Additionally, one patient developed symptoms of cerebral stroke, another one of spinal cord ischemia. During the follow-up that ranged from 6 to 118 months and was completed by 100% of the survivors, one patient died 3 years after procedure because of sepsis (aorto-oesophageal fistula prior to intervention) and late vascular graft occlusions were noted in three cases. Conclusions Hybrid procedures on the aortic arch that comprise surgical and endovascular interventions has become an attractive and safe therapeutic option with acceptable mortality and morbidity rate. They may be considered as a method of choice in treatment of the elderly and high-risk patients.
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Affiliation(s)
- Piotr Buczkowski
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Mateusz Puslecki
- Department of Medical Rescue, Poznan University of Medical Sciences, Poznan, Poland
| | - Sebastian Stefaniak
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Robert Juszkat
- Department of Radiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Jerzy Kulesza
- Department of Radiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Marcin Misterski
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Tomasz Urbanowicz
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Marcin Ligowski
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Bartosz Zabicki
- Department of Radiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Marek Dabrowski
- Department of Medical Education, Poznan University of Medical Sciences, Poznan, Poland
| | | | | | - Marek Jemielity
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Bartłomiej Perek
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
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26
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Buczkowski P, Puślecki M, Majewska N, Urbanowicz T, Misterski M, Juszkat R, Kulesza J, Żabicki B, Stefaniak S, Ligowski M, Szarpak L, Jemielity M, Rivas E, Ruetzler K, Perek B. Endovascular treatment of complex diseases of the thoracic aorta-10 years single centre experience. J Thorac Dis 2019; 11:2240-2250. [PMID: 31372261 PMCID: PMC6626816 DOI: 10.21037/jtd.2019.06.26] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 05/13/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND Introduction of invasive endovascular techniques constituted a real a breakthrough in the treatment of aortic aneurysm dissection and rupture. We assessed the effectiveness and safety of thoracic endovascular aortic repair (TEVAR) in patients with thoracic aortic pathologies. METHODS Between 2007 and 2017, 118 patients with thoracic aortic pathology underwent TEVAR. Among them, 20 (16.9%) patients required hybrid procedures. Stent grafts indication were thoracic aortic aneurysm in 46 (39.0%) patients, type B dissection in 68 (57.6%) patients and other indications in 4 (3.3%). Procedural success rate, in-hospital and late mortality and morbidity were evaluated. RESULTS The patients were followed-up for a mean of 55 months (range, 6-118 months). The technical success rate was 96%. Five patients died during the first 30 days after procedure (mortality 4.2%), four due to ischemic stroke followed by multi-organ failure and another one hemodynamically significant type I endoleak. Most of them were noted in the first years of our study. Five others died during post-discharged period. Four patients developed neurological complications, including stroke (n=2; 1.7%) and paraparesis (n=2; 1.7%). There were 6 (5.1%) primary (5 type I and 1 type II) and 3 (2.5%) secondary endoleaks (1 type I and 2 type III). Secondary interventions were required in 8 subjects. There was one case of stent collapse and two retrograde aortic dissection. CONCLUSIONS Treatment of descending aortic diseases by using stent graft implantation has become the method of choice, decreasing the risk of open surgery, especially in patients with severe clinical state and comorbidities. However, effectiveness and safety may be achieved by experience team.
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Affiliation(s)
- Piotr Buczkowski
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Mateusz Puślecki
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
- Department of Medical Rescue, Poznan University of Medical Sciences, Poznan, Poland
| | - Natalia Majewska
- Department of Radiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Tomasz Urbanowicz
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Marcin Misterski
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Robert Juszkat
- Department of Radiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Jerzy Kulesza
- Department of Radiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Bartosz Żabicki
- Department of Radiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Sebastian Stefaniak
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Marcin Ligowski
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Marek Jemielity
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Eva Rivas
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bartłomiej Perek
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
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See JJ, Lee CW, Lew TWK. Anaesthetic Management of Planned or Emergency Endovascular Stent Graft Surgery for Thoracic Aneurysms and Dissections. Anaesth Intensive Care 2019; 32:510-8. [PMID: 15675211 DOI: 10.1177/0310057x0403200408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We reviewed the intraoperative anaesthetic management and outcome of seven consecutive cases of endovascular stent graft surgery for thoracic aortic aneurysms or dissections over a period of 20 months in our institution. Seven males (median age 63) underwent endovascular stent graft surgery of the thoracic aorta under general anaesthesia. Four were emergency procedures for acute dissection or leaks of thoracic aneurysms. The duration of the procedures ranged from 120 to 300 minutes. Intraoperative stent migration occurred in one patient. Induced hypotension and immobilization were critical during stent deployment. Six out of the seven patients were discharged home between three to 20 days postoperatively. There was no 30-day mortality. One patient died sixty days postoperatively. Anaemia and respiratory complications were the most common postoperative problems encountered. None of the patients sustained spinal cord ischaemia, acute myocardial infarction or renal impairment. Endovascular stent graft surgery of the thoracic aorta is a relatively new alternative to conventional open surgery. Our experience suggests satisfactory short-term outcome even for patients with acute dissection. However, long-term survival and results require further evaluation.
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Affiliation(s)
- J J See
- Department of Anaesthesiology, Tan Tock Seng Hospital, Singapore
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Abstract
Acute low back pain, defined as less than 6 weeks in duration, does not require imaging in the absence of "red flags" that may indicate a cause, such as fracture, infection, or malignancy. When imaging is indicated, it is important to rule out a host of abnormalities that may be responsible for the pain and any associated symptoms. A common mnemonic VINDICATE can help ensure a thorough consideration of the possible causes.
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Affiliation(s)
- Scott M Johnson
- Department of Radiology and Imaging Sciences, University of Utah, 30 North 1900 East, Room 1A71, Salt Lake City, UT 84132, USA
| | - Lubdha M Shah
- Department of Radiology and Imaging Sciences, University of Utah, 30 North 1900 East, Room 1A71, Salt Lake City, UT 84132, USA.
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Harky A, Chan JSK, Wong CHM, Francis C, Bashir M. Current challenges in open versus endovascular repair of ruptured thoracic aortic aneurysm. J Vasc Surg 2018; 68:1582-1592. [DOI: 10.1016/j.jvs.2018.07.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 07/21/2018] [Indexed: 01/15/2023]
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30
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Xue L, Luo S, Ding H, Zhu Y, Liu Y, Huang W, Li J, Xie N, He P, Fan X, Fan R, Nie Z, Luo J. Risk of spinal cord ischemia after thoracic endovascular aortic repair. J Thorac Dis 2018; 10:6088-6096. [PMID: 30622780 DOI: 10.21037/jtd.2018.10.99] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Spinal cord ischemia (SCI) is a recognized grave complication after thoracic endovascular aortic repair (TEVAR). The present study aimed to evaluate the incidence and investigate risk of SCI after TEVAR based on current prophylactic strategies designed against established risk factors. Methods The study retrospectively reviewed a prospectively maintained database to investigate patients who underwent TEVAR successfully between January 2009 and December 2012 in a single cardiovascular center. Detailed assessment of SCI risk was routinely performed for all patients before TEVAR was carried out. Prophylactic measures, including left subclavian artery (LSA) revascularization, blood pressure augmentation and cerebrospinal fluid (CSF) pressure control after TEVAR, were employed in high-risk patients and physical neurological examinations were regularly done to evaluate SCI after TEVAR. Patients were further divided into SCI group and non-SCI group. Results A total of 650 patients were enrolled in the study. Eleven patients (1.69%) developed SCI after TEVAR. Baseline level of hemoglobin was significantly lower in the SCI group (113.00 vs. 128.50, P=0.023). More patients in the SCI patients in the SCI group underwent TEVAR under general anesthesia (45.5% vs. 17.7%, P=0.033). A significantly higher incidence of post TEVAR hypotension was found in the SCI group (2.7% vs. 27.3%, P=0.004). Logistic regression analysis revealed that post-TEVAR hypotension (OR, 8.379; 95% CI, 1.833-38.304; P=0.006) was strongly associated with development of SCI and high normal baseline hemoglobin was a protective factor (OR, 0.969; CI, 0.942-0.998; P=0.037). The mortality in hospital and mortality at 1 year were not significant different between the SCI and the non-SCI group (0% vs. 1.6% P=1.000; 9.1% vs. 3.0%, P=0.294, respectively). While length of post-TEVAR stay (13.00 vs. 7.00 days, P=0.000) and length of hospital stay (20.00 vs. 13.00 days, P=0.001) were significantly greater in the SCI group. Conclusions Our study revealed that, based on current prophylactic measures to curtail SCI, including LSA revascularization, blood pressure augmentation and CSF pressure control after TEVAR, post-TEVAR hypotension remains a major and independent risk factor for SCI and high normal baseline hemoglobin level is protective. SCI results in longer post-TEVAR stay and hospital stay, but not associated with increased mortality. Robust precautions should be taken against underlying causes for post-TEVAR hypotension and low level of hemoglobin should be avoided.
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Affiliation(s)
- Ling Xue
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Songyuan Luo
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Huanyu Ding
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Yi Zhu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Yuan Liu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Wenhui Huang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Jie Li
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Nianjin Xie
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Pengcheng He
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Xiaoping Fan
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Ruixin Fan
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Zhiqiang Nie
- Department of Epidemiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Jianfang Luo
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
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Buczkowski P, Puslecki M, Stefaniak S, Juszkat R, Kulesza J, Perek B, Misterski M, Urbanowicz T, Ligowski M, Zabicki B, Dabrowski M, Szarpak L, Jemielity M. Post-traumatic acute thoracic aortic injury (TAI)-a single center experience. J Thorac Dis 2017; 9:4477-4485. [PMID: 29268517 DOI: 10.21037/jtd.2017.10.104] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background We assess the effectiveness and our experience in emergency thoracic endovascular aortic repair (TEVAR) in patients with post-traumatic acute thoracic aortic injury (TAI) and associated multiorgan trauma. TAI is a life-threatening condition. It usually results from a sudden deceleration caused by vehicle accident, a fall or some other misfortune. Techniques of endovascular aortic repair have become promising methods to treat emergent TAI. Methods Since 2007, 114 patients with thoracic aorta pathologies have been treated by TEVAR. Our study involved 15 (incl. 14 men) of them (13%) who underwent stent graft implantation for post-traumatic either aortic rupture or pseudoaneurysm. The procedural access was limited to small skin incision in one groin and percutaneous puncture of the contralateral femoral artery. We evaluated technical success, early and long-term mortality, complication rate of procedure and throughout clinical and instrumental follow-up. Results Technical success rate was 100%. All patients survived the endovascular interventions. No additional procedures or conversions to open surgery were necessary. After the operation, none of the patients had symptoms of stroke or spinal cord ischemia (SCI). No serious stent-graft-related adverse events such as endoleak, infection or migration were noted during follow-up period that ranged from 6 to 108 months. Conclusions In our department, techniques of TEVAR with stentgraft implantation have become methods of choice in treatment of traumatic TAIs since they have enabled to minimize operational risk, particularly in unstable multitrauma patients in severe clinical status. TEVAR for TAI performed in emergency settings provide favorable long-term results.
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Affiliation(s)
- Piotr Buczkowski
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Mateusz Puslecki
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland.,Department of Medical Rescue, Poznan University of Medical Sciences, Poznan, Poland
| | - Sebastian Stefaniak
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Robert Juszkat
- Department of Radiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Jerzy Kulesza
- Department of Radiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Bartłomiej Perek
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Marcin Misterski
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Tomasz Urbanowicz
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Marcin Ligowski
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Bartosz Zabicki
- Department of Radiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Marek Dabrowski
- Department of Medical Rescue, Poznan University of Medical Sciences, Poznan, Poland
| | - Lukasz Szarpak
- Department of Emergency Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Marek Jemielity
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
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Godet G, Bertrand M, Fléron MH, Goarin JP, Colson P, Cardon A, Koskas F, Verhoye JP, Kieffer E. Cerebrospinal fluid drainage and thoracic endovascular aneurysm repair. Asian Cardiovasc Thorac Ann 2017; 25:608-617. [DOI: 10.1177/0218492317739472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Spinal cord complications including paraplegia and partial neurologic deficits remain a frequent problem during repair of descending thoracic or thoracoabdominal aortic aneurysms. Effective prevention of this dreaded complication is of paramount importance. Among the many adjuncts that have been proposed to prevent spinal cord complications, spinal fluid drainage is one that has been used by numerous teams. The aim of this review is to answer the following question: does spinal fluid drainage afford spinal cord protection during both open and endovascular repair of thoracic or thoracoabdominal aortic aneurysms?
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Affiliation(s)
- Gilles Godet
- Department of Anesthesiology and Intensive Care, and Vascular Surgery Unit, Pontchaillou University Hospital, Rennes, France
| | - Michèle Bertrand
- Department of Anesthesiology and Intensive Care, and Vascular Surgery Unit, Pitié Salpétrière University Hospital, Paris, France
| | - Marie-Hélène Fléron
- Department of Anesthesiology and Intensive Care, and Vascular Surgery Unit, Pitié Salpétrière University Hospital, Paris, France
| | - Jean-Pierre Goarin
- Department of Anesthesiology and Intensive Care, and Vascular Surgery Unit, Pitié Salpétrière University Hospital, Paris, France
| | - Pascal Colson
- Department of Anesthesiology and Intensive Care, Arnaud de Villeneuve University Hospital, Montpellier, France
| | - Alain Cardon
- Department of Cardiovascular and Thoracic Surgery, Pontchaillou University Hospital, Rennes, France
| | - Fabien Koskas
- Department of Vascular Surgery, Pitié Salpétrière University Hospital, Paris, France
| | - Jean-Philippe Verhoye
- Department of Cardiovascular and Thoracic Surgery, Pontchaillou University Hospital, Rennes, France
| | - Edouard Kieffer
- Department of Vascular Surgery, Pitié Salpétrière University Hospital, Paris, France
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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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Awad H, Ramadan ME, El Sayed HF, Tolpin DA, Tili E, Collard CD. Spinal cord injury after thoracic endovascular aortic aneurysm repair. Can J Anaesth 2017; 64:1218-1235. [PMID: 29019146 DOI: 10.1007/s12630-017-0974-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 08/04/2017] [Accepted: 09/13/2017] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Thoracic endovascular aortic aneurysm repair (TEVAR) has become a mainstay of therapy for aneurysms and other disorders of the thoracic aorta. The purpose of this narrative review article is to summarize the current literature on the risk factors for and pathophysiology of spinal cord injury (SCI) following TEVAR, and to discuss various intraoperative monitoring and treatment strategies. SOURCE The articles considered in this review were identified through PubMed using the following search terms: thoracic aortic aneurysm, TEVAR, paralysis+TEVAR, risk factors+TEVAR, spinal cord ischemia+TEVAR, neuromonitoring+thoracic aortic aneurysm, spinal drain, cerebrospinal fluid drainage, treatment of spinal cord ischemia. PRINCIPAL FINDINGS Spinal cord injury continues to be a challenging complication after TEVAR. Its incidence after TEVAR is not significantly reduced when compared with open thoracoabdominal aortic aneurysm repair. Nevertheless, compared with open procedures, delayed paralysis/paresis is the predominant presentation of SCI after TEVAR. The pathophysiology of SCI is complex and not fully understood, though the evolving concept of the importance of the spinal cord's collateral blood supply network and its imbalance after TEVAR is emerging as a leading factor in the development of SCI. Cerebrospinal fluid drainage, optimal blood pressure management, and newer surgical techniques are important components of the most up-to-date strategies for spinal cord protection. CONCLUSION Further experimental and clinical research is needed to aid in the discovery of novel neuroprotective strategies for the protection and treatment of SCI following TEVAR.
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Affiliation(s)
- Hamdy Awad
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Doan Hall 534, 410 West 10th Avenue, Columbus, OH, 43210, USA.
| | - Mohamed Ehab Ramadan
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Doan Hall 534, 410 West 10th Avenue, Columbus, OH, 43210, USA.,Department of Anesthesiology, Theodor Bilharz Research Institute, Giza, Egypt
| | - Hosam F El Sayed
- Division of Vascular Diseases & Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Daniel A Tolpin
- Division of Cardiovascular Anesthesiology, The Texas Heart Institute, Baylor St. Luke's Medical Center, Houston, TX, USA
| | - Esmerina Tili
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Doan Hall 534, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Charles D Collard
- Division of Cardiovascular Anesthesiology, The Texas Heart Institute, Baylor St. Luke's Medical Center, Houston, TX, USA
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Cavalcante LP, Ferreira SG, Pereira DR, Moraes SRD, Simas R, Sannomiya P, Breithaupt-Faloppa AC, Moreira LFP. Acute administration of oestradiol or progesterone in a spinal cord ischaemia–reperfusion model in rats. Interact Cardiovasc Thorac Surg 2017; 26:196-201. [DOI: 10.1093/icvts/ivx314] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 08/11/2017] [Indexed: 01/13/2023] Open
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Gallis K, Kasprzak PM, Cucuruz B, Kopp R. Evaluation of visible spinal arteries on computed tomography angiography before and after branched stent graft repair for thoracoabdominal aortic aneurysm. J Vasc Surg 2017; 65:1577-1583. [DOI: 10.1016/j.jvs.2016.10.118] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 10/27/2016] [Indexed: 11/29/2022]
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Song MG, Cho YK, Lee DY, Cho SB, Yoon HK, Kwon SH, Kim HC, Yoon CJ. Clinical Outcomes for Endovascular Repair of Thoracic Aortic Disease Using the Seal Thoracic Stent Graft: A Korean Multicenter Retrospective Study. J Vasc Interv Radiol 2017; 28:645-654. [PMID: 28258801 DOI: 10.1016/j.jvir.2016.12.1227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 12/08/2016] [Accepted: 12/28/2016] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To investigate the midterm outcomes of thoracic endovascular aneurysm repair (TEVAR) with the use of the Seal stent graft for four categories of thoracic aortic disease. MATERIALS AND METHODS This retrospective multicenter study evaluated the records of 216 Korean patients who underwent TEVAR with the Seal stent graft during 2007-2010. The study outcomes were (i) perioperative death, (ii) endoleak, (iii) repeat intervention, (iv) aortic-related death, and (v) all sudden unexplained late deaths. RESULTS The overall technical success rate was 94% (203 cases), and the disease-specific rates were 97% (88 cases) for aneurysms, 96% (71 cases) for dissections, 82% (32 cases) for traumatic aortic disease, and 100% (12 cases) for intramural hematoma and/or penetrating aortic ulcer. There were 6 acute surgical conversions (2 for aneurysms and 4 for dissections). There were 18 endoleaks, 4 retrograde ascending aortic dissections, and 6 stent graft-induced new entries. The 1-, 3-, and 5-year overall survival rates were 93% ± 3, 90% ± 4, and 90% ± 4, respectively. CONCLUSIONS TEVAR with the Seal thoracic stent graft provided a high technical success rate and low mortality and complication rates during midterm follow-up. However, additional long-term studies are needed to evaluate the durability and late complications associated with this device.
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Affiliation(s)
- Myung Gyu Song
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Young Kwon Cho
- Department of Radiology, Kangdong Seong-Sim Hospital, Hallym University College of Medicine, Seoul, Korea.
| | - Do Yun Lee
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Bum Cho
- Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Hyun-Ki Yoon
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea
| | - Se Hwan Kwon
- Department of Radiology, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, Korea
| | - Hyo-Cheol Kim
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Jin Yoon
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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von Allmen R, Gahl B, Powell J. Editor's Choice – Incidence of Stroke Following Thoracic Endovascular Aortic Repair for Descending Aortic Aneurysm: A Systematic Review of the Literature with Meta-analysis. Eur J Vasc Endovasc Surg 2017; 53:176-184. [DOI: 10.1016/j.ejvs.2016.10.025] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 10/25/2016] [Indexed: 12/30/2022]
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Endovascular treatment of synchronous and metachronous aneurysms of the thoracic aorta. Is there an increase in the procedural risk? ANGIOLOGIA E CIRURGIA VASCULAR 2016. [DOI: 10.1016/j.ancv.2016.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Abstract
Endovascular repair has emerged as a very important treatment modality in the management of a host of serious and relatively frequent thoracic aortic diseases. This minimally invasive approach is certain to revolutionize the entire field of thoracic aortic surgery in the near future. The technologies, however, can still be considered as a “work in progress.” Future refinements, which should be available within the next 1 to 2 years, will address some of the most important needs as yet unmet today: lower profile (<22 F) delivery systems, greater device flexibility, no longitudinal metal bars, and precise deliverability and deployment characteristics that will be conducive to optimal success and safety, especially in the region of the aortic arch.
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Affiliation(s)
- Thomas Zeller
- Department of Angiology, Herz-Zentrum Bad Krozingen, Germany.
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Bradycardia Associated with Steroid Use for Laryngeal Edema in an Adult: A Case Report and Literature Review. Case Rep Cardiol 2016; 2016:9785467. [PMID: 27999689 PMCID: PMC5143689 DOI: 10.1155/2016/9785467] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 10/31/2016] [Indexed: 11/17/2022] Open
Abstract
Steroids are used for specific indications in the perioperative period to reduce laryngeal or spinal cord edema, or for prophylaxis and treatment of postoperative nausea and vomiting. Given the other potential causes for hemodynamic alterations in the perioperative setting, it is important for physicians to be aware of cardiovascular side effects of short term steroids. Changes in blood pressure and heart rate, cardiac dysrhythmias, and even death have been described in patients receiving short term intravenous steroids. Bradycardia has been reported following short term methylprednisolone and dexamethasone therapy in both adult and pediatric patients. There are only two case reports in the literature of bradycardia following short term intravenous dexamethasone use in adult patients. This is the first case report that describes bradycardia following the use of dexamethasone in the postoperative setting for management of laryngeal edema in an adult. Telemetry and twelve lead electrocardiograms revealed sinus bradycardia and correlated directly with administration of dexamethasone in our patient. Bradycardia resolved following discontinuation of dexamethasone. We advocate for hemodynamic monitoring in patients receiving more than one dose of intravenous steroid therapy in the perioperative period, especially those with known cardiac and hepatic comorbidities and those taking medications with negative chronotropic effects.
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Lajos PS, Marin ML. Thoracic Endovascular Aortic Aneurysm Repair. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Paul S. Lajos
- Icahn School of Medicine at Mount Sinai; New York NY USA
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Lindsay H, Srinivas C, Djaiani G. Neuroprotection during aortic surgery. Best Pract Res Clin Anaesthesiol 2016; 30:283-303. [DOI: 10.1016/j.bpa.2016.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 04/21/2016] [Accepted: 05/09/2016] [Indexed: 01/16/2023]
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Ertl M, Schierling W, Kasprzak PM, Kopp R, Brückl C, Schlachetzki F, Pfister K. Sonographic Changes in Optic Nerve Sheath Diameter Associated with Supra- versus Infrarenal Aortic Aneurysm Repair. J Neuroimaging 2016; 27:237-242. [PMID: 27545668 DOI: 10.1111/jon.12385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 07/11/2016] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE Quantification of changes in optic nerve sheath diameter (ONSD) using ocular sonography (OS) constitutes an elegant technique for estimating intracranial and intraspinal pressure. Aortic aneurysm repair (AAR) is associated with a reasonable risk of increased spinal fluid pressure, which is largely dependent on the extent of aneurysm repair (supra- vs. infrarenal). The aim of this study was to compare ONSD measurements in patients with suprarenal AAR (sAAR) or infrarenal AAR (iAAR). METHODS Thirty patients who underwent elective endovascular repair of infrarenal aortic aneurysms (Group iAAR) were included in the study; the characteristics in these cases were prospectively analyzed and compared with those in a previously investigated group of 28 patients treated for suprarenal aortic aneurysms (Group sAAR). Six measurements of ONSDs were performed in each patient at five consecutive time points. Statistical analysis was performed using the Wilcoxon test. A P value < .05 was considered statistically significant. RESULTS A highly significant difference between pre- and postinterventional values could be detected in both patient groups (P < .01). In Group sAAR, there was a mean .3-mm increase of the ONSD, whereas in Group iAAR, a mean .2-mm decrease could be detected. Both groups roughly reached baseline values by the end of their inpatient stay. CONCLUSIONS ONSD changes seem to be a reliable marker to estimate spinal perfusion. Since OS provides a suitable bedside tool for rapid reevaluation, it may guide physicians in the identification and treatment of patients at high risk for spinal cord ischemia.
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Affiliation(s)
- Michael Ertl
- Neurology Department, Klinikum Augsburg, Stenglinstr. 2, 86165, Augsburg, Germany
| | - Wilma Schierling
- Department of Surgery, Vascular and Endovascular Surgery, University of Regensburg, Franz-Josef-Strauss Allee 11, 93053, Regensburg, Germany
| | - Piotr M Kasprzak
- Department of Surgery, Vascular and Endovascular Surgery, University of Regensburg, Franz-Josef-Strauss Allee 11, 93053, Regensburg, Germany
| | - Reinhard Kopp
- Department of Surgery, Vascular and Endovascular Surgery, University of Regensburg, Franz-Josef-Strauss Allee 11, 93053, Regensburg, Germany
| | - Corinna Brückl
- Department of Surgery, Vascular and Endovascular Surgery, University of Regensburg, Franz-Josef-Strauss Allee 11, 93053, Regensburg, Germany
| | - Felix Schlachetzki
- Neurology Department, University of Regensburg, Universitätsstraße 84, 93053, Regensburg, Germany
| | - Karin Pfister
- Department of Surgery, Vascular and Endovascular Surgery, University of Regensburg, Franz-Josef-Strauss Allee 11, 93053, Regensburg, Germany
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Abstract
Although endovascular surgery for aortic aneurysms can be traced to the 19th century, open surgery has dominated during the past 50 years. Indeed, open repair of aneurysms has been one of the most successful developments in vascular surgery. Despite improvements in mortality rates, open repair remains a major operation often undertaken in patients with significant comorbidities. Starting from basic research dating back several decades, the 1990s were noted for very active clinical development of endovascular abdominal aortic repair in an attempt to provide an alternative to open repair, especially for high-risk patients. Early successes with decreased intensive care unit and hospital stays were tempered by technical issues and the “endoleak,” the term given to an incomplete exclusion of the aneurysm from the circulation. This potential for rupture, despite treatment, was cause for concern. The need for long-term surveillance and secondary procedures, if not conversion to open repair, further compounded these issues. Despite these concerns, progress continued, and by the end of 2002, the Food and Drug Administration had approved three devices for marketing. Although surgeons are faced with increasingly complex issues related to endovascular repair, anesthesiologists have found their management of this procedure to be simpler in many ways. The smaller incisions and improved hemodynamic stability have led to a variety of anesthetics being tried, including monitored anesthesia care. Anesthesiologists continue to explore a number of opportunities to improve patient outcome in these procedures. These include selection of the most optimal anesthetic, the most appropriate perioperative renal protection, and the best preparation for and management of a conversion to an open procedure. Whatever the final role for endovascular surgery in the management of abdominal aortic aneurysms, it is an intellectually stimulating and scientifically promising technique for surgeons, anesthesiologists, and the patients they serve.
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Affiliation(s)
- Kenneth F. Kuchta
- Department of Anesthesiology, University of California, Los Angeles Medical Center, Los Angeles, CA
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Velu RB, Halak M, Muhlmann M, Baker S. Stent Grafts for Thoracic Aortic Pathology: Single-Center Experience in Western Australia. Vascular 2016; 13:343-9. [PMID: 16390652 DOI: 10.1258/rsmvasc.13.6.343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The purpose of this article is to report a single-center experience in treating thoracic aortic pathology with stent grafts. This is a retrospective review of cases done within a period of 30 months. Between January 2002 and May 2004, 12 patients were treated in our institution with thoracic stent grafts ( n = 12) for various clinical conditions. There were seven men and five women. Three patients required emergency treatment ( n = 3), two for aortic transection and one for iatrogenic injury during lung biopsy. Others were treated electively ( n = 9). All patients were high risk for open surgery. There was one perioperative death, with a patient with multiple trauma succumbing to head injury 4 weeks after stent graft insertion. There was no incidence of paraplegia. Three patients underwent bypass surgery in the neck to achieve an adequate proximal seal zone prior to stent grafting. One patient with an aneurysm of the descending thoracic aorta required an extension limb below the original graft for an increase in sac size, possibly owing to endotension. Renal failure occurred in one patient and resolved without dialysis. One patient died 18 months after her procedure, possibly owing to aneurysm expansion. Stent grafts are a viable alternative to open surgery for thoracic aortic pathology in high-risk individuals. Visceral and spinal cord ischemia is less prevalent with stent grafts compared with open surgery. The short-term results are promising. Long-term follow-up is awaited. Stent grafts might have greater impact in the thoracic aorta than the abdominal aorta for which they were initially developed.
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Affiliation(s)
- Ramesh B Velu
- Department of Vascular Surgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia.
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Zeng Q, Guo X, Huang L, Sun L. Single-center experience with simultaneous thoracic endovascular aortic repair and abdominal endovascular aneurysm repair. Vascular 2016; 25:157-162. [PMID: 27334106 DOI: 10.1177/1708538116651020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Objective To evaluate the efficacy and outcomes of simultaneous thoracic endovascular aortic repair (TEVAR) and abdominal endovascular aneurysm repair (EVAR). Methods A total of 21 patients (20 men; mean 65 ± 7 years, range 54-77) underwent simultaneous TEVAR and EVAR between September 2010 and June 2015 at a single center were retrospectively reviewed. All patients had concomitant thoracic pathologies (aneurysm, penetrating aortic ulcer, intramural hematoma, or dissection) and abdominal aortic aneurysm. The abdominal aneurysms diameters ranged from 5.9 cm to 10 cm. Thoracic lesions in 17 patients were complicated with acute aortic syndrome, and the remainders had indications for simultaneous repair. All patients were followed up postoperative at 1 month, 6 months, and yearly thereafter. Technique success, procedure-related complications were evaluated. Results All patients received local anesthesia, perioperative relative high arterial pressure (above 130/80 mmHg) maintenance, and prophylactic high-dose corticosteroid. The technical success rate was 100%. Average procedural time was 157.6 ± 45.6 min. The length of thoracic coverage was 20.4 ± 4.7 cm (range 15-27). Two patients required left subclavian artery coverage during TEVAR and two patients required lowest renal artery coverage during EVAR. Chimney stents were deployed simultaneously. Patients were followed between 2 and 59 months postoperatively. No patients developed acute cardiopulmonary complications and contrast-induced nephropathy. Two patients developed transient lower extremity weakness that resolved with blood pressure elevation, cerebrospinal fluid drainage, and intravenous drips of high-dose corticosteroid. The average hospital stay was 10.7 ± 7.9 days (range 4-30). During follow-up, one patient died of aneurysm rupture at postoperative 6 months, two patients developed type Ib endoleak at 9 months and 48 months respectively, one was successfully sealed with iliac stent-graft extension, the other received conservative treatment and is symptom free till now. Conclusion Combined TEVAR and EVAR can be performed safely with minimal morbidity and mortality. When anatomically feasible, simultaneous TEVAR and EVAR can be considered as an acceptable alternative for multilevel aortic diseases.
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Affiliation(s)
- Qinglong Zeng
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vascular Diseases, Beijing, China
| | - Xi Guo
- 2 Interventional Department, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vascular Diseases, Beijing, China
| | - Lianjun Huang
- 2 Interventional Department, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vascular Diseases, Beijing, China
| | - Lizhong Sun
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vascular Diseases, Beijing, China
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Matsagas MI, Papakostas JC, Katsouras CS, Arnaoutoglou E, Lagos N, Xanthopoulos D, Drossos GE, Michalis LK. Endovascular Repair For Thoracic Aortic Disease: Tertiary Single-center Experience In Northwestern Greece. Vascular 2016; 14:212-8. [PMID: 17026912 DOI: 10.2310/6670.2006.00033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The purpose of this article is to report the initial experience with endovascular repair of thoracic aortic disease in a single tertiary vascular unit in northwestern Greece. Between 2003 and 2005, 16 patients were treated with endovascular techniques for various pathologies of the descending thoracic aorta. Twelve patients were treated electively and four emergently. Operative and follow-up data for a mean time of 18.4 months were retrospectively collected and analyzed. Primary technical success was obtained in 14 (87.5%) cases. No early or late deaths occurred, and there was no major operation-related complication. No paraplegia was observed in our patients. Stent graft–related complications occurred in 18.75% (one type 2 and two type 3 endoleaks), but they all had a favorable outcome. No further problems have been reported in any of our patients. Endovascular stent graft repair for diseases of the thoracic aorta seems to be a promising alternative to open surgery, especially for high-risk patients. Long-term results are needed to confirm the early benefit of this treatment option with regard to morbidity and mortality rates. The potential of this technique to be applicable even in relatively small, tertiary vascular centers might be of great benefit to patients.
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Affiliation(s)
- Miltiadis I Matsagas
- Department of Surgery-Vascular Surgery Unit, School of Medicine, University of Ioannina, Ioannina, Grece.
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Carroccio A, Spielvogel D, Ellozy SH, Lookstein RA, Chin IY, Minor ME, Sheahan CM, Teodorescu VJ, Griepp RB, Marin ML. Aortic Arch and Descending Thoracic Aortic Aneurysms: Experience with Stent Grafting for Second-Stage “Elephant Trunk” Repair. Vascular 2016; 13:5-10. [PMID: 15895668 DOI: 10.1258/rsmvasc.13.1.5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Reconstruction of aortic arch and descending thoracic aortic aneurysms (TAAs) is technically challenging and associated with significant morbidity and mortality. We report our experience with extensive TAAs using a two-stage “elephant trunk” repair, with the second stage completed using an endovascular stent graft (ESG). Over 6 years, 111 patients underwent ESG treatment of TAAs at Mount Sinai Medical Center. Twelve of these patients were referred for ESG placement for the second stage of elephant trunk reconstruction because comorbidities placed them at high risk of open surgical repair. Our database was analyzed for technical and clinical success and perioperative complications. The mean follow-up was 11.8 months (range 1–64 months). Twelve patients (five women and seven men) with a mean age of 69 ± 10 years underwent repair of their distal aortic arch and descending TAAs. These aneurysms included nine atherosclerotic aneurysms, one pseudoaneurysm, and two penetrating atherosclerotic ulcers. Three patients were symptomatic. Stent graft repair was technically successful in 91.7% or 11 of 12 patients. Excessive aortic arch tortuosity resulted in failure to deploy a stent graft in one patient. An antegrade approach through the open elephant trunk was used in two patients with severe iliac occlusive disease. Endoleaks (type 2) were identified in two patients with no aneurysm expansion; however, a 14 mm expansion over 1 year occurred in a patient with no identifiable endoleak. One early mortality occurred in a patient with a ruptured 6 cm infrarenal AAA after successful exclusion of the 8 cm TAA. Second-stage elephant trunk reconstruction of an extensive TAA using an ESG is effective in the short term. Its long-term durability remains to be determined.
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Affiliation(s)
- Alfio Carroccio
- Division of Vascular Surgery, Mount Sinai School of Medicine, New York, NY, USA.
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Open versus Endovascular Repair of Arch and Descending Thoracic Aneurysms: A Retrospective Comparison. Ann Vasc Surg 2016; 31:30-8. [DOI: 10.1016/j.avsg.2015.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 08/02/2015] [Accepted: 08/04/2015] [Indexed: 11/21/2022]
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