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Rossi PJ, Desai ND, Malaisrie SC, Lyden SP, Nassiri N, Reece TB, Adams JD, Moanie SL, Shults CC. One-Year Results of a Low-Profile Endograft in Acute, Complicated Type B Aortic Dissection. Ann Thorac Surg 2024; 117:336-343. [PMID: 37769702 DOI: 10.1016/j.athoracsur.2023.08.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 07/26/2023] [Accepted: 08/07/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND The safety and effectiveness of the RelayPro endograft (Terumo Aortic) was assessed for the treatment of acute, complicated type B aortic dissection (TBAD). METHODS A prospective pivotal trial analyzed a primary end point of all-cause mortality at 30 days. Secondary end points included technical success, major adverse events (disabling stroke, renal failure, and paraplegia/paralysis), endoleaks, patency, rupture, device integrity, false lumen perfusion, reinterventions, aortic expansion, and migration evaluated to 5 years. RESULTS The study involved 22 United States centers and enrolled 56 patients (mean age, 59.5 ± 11.4 years) from 2017 to 2021; of whom, 73.2% were men and 53.6% were African American. TBAD was complicated by malperfusion of the kidneys (51.8%), lower extremities (35.7%), and viscera (33.9%), and rupture (10.7%). Dissection extended proximally to zones 1/2 (14.3%) and zone 3 (78.6%) and distally to the iliac arteries (67.3%). Most procedures were percutaneous (85.5%). Technical success was 100%. Median hospitalization was 7 days (interquartile range, 5-12 days). All-cause mortality at 30 days was 1.8% (1 of 56; upper 95% CI, 8.2%; P < .0001). Seven major adverse events occurred in 6 patients (10.7%), consisting of paraplegia (n = 3), paraparesis (n = 2), disabling stroke (n = 1), and renal failure (n = 1). All paraplegia/paraparesis resolved with lumbar drainage. Kaplan-Meier analysis estimated a freedom from major adverse events of 89.1% at each interval from 30 days to 3 years. There was 1 endoleak (Type Ia), 2 retrograde dissections, and aortic diameter growth occurred in 2. There has been no rupture, fistula, component separation, patency loss, stenosis, kinking, twisting, bird beak, loss of device integrity, or fracture. CONCLUSIONS RelayPro is safe and effective in acute, complicated TBAD. Follow-up is ongoing to evaluate longer-term outcomes and durability.
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Affiliation(s)
- Peter J Rossi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - S Chris Malaisrie
- Department of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois
| | - Sean P Lyden
- Department of Vascular Surgery and Aortic Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Naiem Nassiri
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - T Brett Reece
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Joshua D Adams
- Carilion Clinic Aortic Center, Virginia Tech Carilion School of Medicine, Temple University School of Medicine, Roanoke, Virginia
| | - Sina L Moanie
- Department of Cardiothoracic Surgery, St. Vincent Heart Center of Indiana, Indianapolis, Indiana
| | - Christian C Shults
- Georgetown University School of Medicine, Medstar Washington Hospital Center, Washington, District of Columbia
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Azogui R, Porto A, Castelli M, Omnes V, De Masi M, Bartoli M, Piquet P, Gariboldi V, Busa T, Jacquier A, Bal L, Gaudry M. In Marfan Syndrome and Related Diseases, STABILISE Technique Should Be Used with Care: Results from a Volumetric Comparative Study of Endovascular Treatment for Aortic Dissection. J Clin Med 2023; 12:4378. [PMID: 37445413 DOI: 10.3390/jcm12134378] [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: 05/25/2023] [Revised: 06/20/2023] [Accepted: 06/24/2023] [Indexed: 07/15/2023] Open
Abstract
Objectives: Aortic dissection in patients with Marfan and related syndromes (HTAD) is a serious pathology whose treatment by thoracic endovascular repair (TEVAR) is still under debate. The aim of this study was to assess the results of the TEVAR for aortic dissection in patients with HTAD as compared to a young population without HTAD. Methods: The study received the proper ethical oversight. We performed an observational exposed (confirmed HTAD) vs. non-exposed (<65 years old) study of TEVAR-treated patients. The preoperative, 1 year, and last available CT scans were analyzed. The thoracic and abdominal aortic diameters, aortic length, and volumes were measured. The entry tears and false lumen (FL) status were assessed. The demographic, clinical, and anatomic data were collected during the follow-up. Results: Between 2011 and 2021, 17 patients were included in the HTAD group and 22 in the non-HTAD group. At 1 year, the whole aortic volume increased by +21.2% in the HTAD group and by +0.2% the non-HTAD groups, p = 0.005. An increase in the whole aortic volume > 10% was observed in ten cases (58.8%) in the HTAD group and in five cases (22.7%) in the non-HTAD group (p = 0.022). FL thrombosis was achieved in nine cases (52.9%) in the HTAD group vs. twenty (90.9%) cases in the non-HTAD group (p < 0.01). The risk factors for unfavorable anatomical evolution were male gender and the STABILISE technique. With a linear model, we observed a significantly different aortic volume evolution between the two groups (p < 0.01) with the STABILISE technique; this statistical difference was not found in the TEVAR subgroup. In the HTAD patients, there was a significant difference in the total aortic volume evolution progression between the patients treated with the STABILISE technique and the patients treated with TEVAR (+160.1 ± 52.3% vs. +47 ± 22.5%, p < 0.01 and +189.5 ± 92.5% vs. +58.6 ± 34.8%, p < 0.01 at 1 year and at the end of follow-up, respectively). Conclusions: TEVAR in the HTAD patients seemed to be associated with poorer anatomical outcomes at 1 year. This result was strongly related to the STABILISE technique which should be considered with care in these specific patients.
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Affiliation(s)
- Ron Azogui
- Timone Aortic Center, Department of Vascular Surgery, APHM, Timone Hospital, 13005 Marseille, France
| | - Alizee Porto
- Department of Cardiac Surgery, APHM, Timone Hospital, 13005 Marseille, France
| | - Maxime Castelli
- Department of Radiology, APHM, Timone Hospital, 13005 Marseille, France
| | - Virgile Omnes
- Timone Aortic Center, Department of Vascular Surgery, APHM, Timone Hospital, 13005 Marseille, France
| | - Mariangela De Masi
- Timone Aortic Center, Department of Vascular Surgery, APHM, Timone Hospital, 13005 Marseille, France
| | - Michel Bartoli
- Timone Aortic Center, Department of Vascular Surgery, APHM, Timone Hospital, 13005 Marseille, France
| | - Philippe Piquet
- Timone Aortic Center, Department of Vascular Surgery, APHM, Timone Hospital, 13005 Marseille, France
| | - Vlad Gariboldi
- Department of Cardiac Surgery, APHM, Timone Hospital, 13005 Marseille, France
| | - Tiffany Busa
- Department of Genetic, APHM, Timone Hospital, 13005 Marseille, France
| | - Alexis Jacquier
- Timone Aortic Center, Department of Vascular Surgery, APHM, Timone Hospital, 13005 Marseille, France
- Department of Radiology, APHM, Timone Hospital, 13005 Marseille, France
| | - Laurence Bal
- Timone Aortic Center, Department of Vascular Surgery, APHM, Timone Hospital, 13005 Marseille, France
- Timone Aortic Center, APHM, Centre de Référence Marfan et Apparentés, 13005 Marseille, France
| | - Marine Gaudry
- Timone Aortic Center, Department of Vascular Surgery, APHM, Timone Hospital, 13005 Marseille, France
- Timone Aortic Center, APHM, Centre de Référence Marfan et Apparentés, 13005 Marseille, France
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Sorber R, Tsai LL, Hicks CW, Black JH. Midterm outcomes of isolated thoracic aortic replacement in congenital versus degenerative aortopathy in a 15-year institutional cohort. J Vasc Surg 2023; 77:20-27. [PMID: 36055553 PMCID: PMC9884488 DOI: 10.1016/j.jvs.2022.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 05/10/2022] [Accepted: 05/19/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Open aortic replacement represents the only approved option to address thoracic aortopathy among patients with connective tissue disorders (CTD). The aim of our study was to investigate contemporary midterm outcomes of isolated thoracic aortic replacement in patients with CTD versus degenerative pathology in a large institutional cohort. METHODS All patients undergoing isolated open thoracic aortic replacement at a single academic center from 2005 to 2020 were included. Patients were classified as having CTD or not having CTD based on documented genetic mutations associated with congenital aortopathy. In-hospital and midterm outcomes, including mortality, paraplegia, development of new arterial pathology on surveillance imaging, and the need for future operations, were compared between groups using descriptive statistics and Kaplan-Meier survival analysis. RESULTS Overall, 62 patients were included with a median follow-up of 58 months (range, 19-81 months) (59 months for those with CTD vs 51.5 months for those without CTD). CTD was present in 18 patients (29%), with 16 having Marfan syndrome (77.8%). Patients with CTD were younger than patients without CTD (45.8 years vs 60.9 years) and had lower rates of smoking (5.6% vs 56.8%) and hypertension (97.7% vs 72.2%; all P < .01). Patients with CTD were more likely to have a dissection component at the time of repair compared with patients without CTD (100% vs 59.1%) and underwent repair at smaller aortic diameters (5.9 cm vs 6.6 cm; both P < .05). There were no differences in in-hospital outcomes between the two groups, including mortality (4.5% vs 5.6%) and paraplegia (2.3% vs 0%; both P > .05). At 5 years, patients with CTD were more likely to have developed aneurysmal changes distal to their thoracic repair (88.9% vs 47.7%) and extra-aortic arterial aneurysms (41.2% vs 2.3%; both P < .05). However, on survival analysis, there were no differences in freedom from additional vascular procedures (hazard ratio,1.76; P = .333) or, specifically, additional aortic procedures (hazard ratio, 1.81; P = .380) between the two groups. There was only one anastomotic complication identified on longitudinal follow-up, which occurred in a patient without CTD 8 years after the index operation. CONCLUSIONS Although carrying significant operative risks and the potential for morbidity, open thoracic aortic replacement represents a well-tolerated, durable treatment option for patients with congenitally mediated thoracic aortic disease. Because both patients with and without CTD who required thoracic aortic replacement often need future aortic intervention, vigilant surveillance is warranted. Equivalent intervention rates between the two groups suggest remodeling of the CTD aorta is almost universally characterized by initial postrepair dilation, but the majority of these changes successfully stabilize and do not progress to higher rates of intervention.
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Affiliation(s)
- Rebecca Sorber
- Department of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Hospital, Baltimore, MD.
| | - Lillian L Tsai
- Department of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Hospital, Baltimore, MD
| | - Caitlin W Hicks
- Department of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Hospital, Baltimore, MD; Johns Hopkins Surgery Center for Outcomes Research (JSCOR), Johns Hopkins University School of Medicine, Baltimore, MD
| | - James H Black
- Department of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Hospital, Baltimore, MD
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Steinmetz LM, Coselli JS. Endovascular Repair in Patients with Marfan Syndrome: Concerns Amid Controversy. Ann Vasc Surg 2022:S0890-5096(22)00236-9. [PMID: 35595210 DOI: 10.1016/j.avsg.2022.04.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 04/21/2022] [Indexed: 11/25/2022]
Abstract
Endovascular aortic repair is widely used to treat patients with degenerative aneurysms or aortic dissection within the distal aorta. Thoracic endovascular aortic repair (TEVAR) is generally associated with fewer short-term complications than open surgical repair, which is particularly important for older patients with significant comorbid conditions. However, for patients with Marfan syndrome, a heritable thoracic aortic disease associated with aortic dilatation, dissection, and rupture, the utility of endovascular aortic repair remains questionable. Marfan patients have friable aortic tissue and are typically treated at a relatively young age; they therefore need a durable solution. Furthermore, those who need distal aortic repair tend to have chronic aortic dissection. Although TEVAR is generally superior to open surgery with regard to short-term complications, it is less durable, and TEVAR reintervention rates are highest in patients with chronic aortic dissection. Thus, Marfan patients seeking definitive aortic repair are often better served by open repair. Nonetheless, TEVAR may be useful in patients with Marfan syndrome as a bridge to open repair or as treatment for late complications of previous open repair.
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Affiliation(s)
- Leah M Steinmetz
- Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas, USA; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas, USA.
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Rhodes JF, Veeraswamy R. Expanding Transcatheter Pulmonary Valve Therapies. JACC Cardiovasc Interv 2021; 13:2766-2768. [PMID: 33303114 DOI: 10.1016/j.jcin.2020.09.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 09/08/2020] [Indexed: 11/27/2022]
Affiliation(s)
- John F Rhodes
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina, Congenital Heart Center, Charleston, South Carolina, USA.
| | - Ravikumar Veeraswamy
- Division of Vascular Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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