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Li HL, Kwan KJS, Chan YC, Cheng SW. Contemporary Outcomes of Endovascular and Open Surgical Repair for Mycotic Aortic Aneurysms: A Systematic Review. Ann Vasc Surg 2024; 100:172-183. [PMID: 37898457 DOI: 10.1016/j.avsg.2023.08.039] [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: 07/24/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND To perform a systematic review on contemporary outcomes of endovascular repair and open surgical repair (OSR) for the treatment of mycotic aortic aneurysm (MAA). METHODS A comprehensive literature search on the management of MAAs with endovascular repair or OSR was performed between January 1998 and January 2023. Patient demographics, early and late outcomes were analyzed with respect to treatment modality and MAA location. RESULTS Forty-eight articles were included, encompassing a total of 1,358 patients (75.8% male; mean age 66.9 years; 1,372 aneurysms) treated by open (49.8%) or endovascular (50.2%) repair. Salmonella spp., and Staphylococcus spp. were the most prevalent pathogens in Asian and European countries respectively. An increasing number of descending thoracic MAAs were managed by endovascular repair (27.9% vs. 12.8%). Early mortality rates for supra- and infra-renal MAAs managed by endovascular repair were lower than OSR (suprarenal 5.4% vs. 43.2%; infrarenal 1.8% vs. 16.7%). Overall, endovascular repair demonstrated lower intraoperative (1.0% vs. 1.8%) and early mortality (6.5% vs. 15.9) rates than OSR. However, endovascular repair was associated with higher late sepsis rate (5.7% vs. 0.9%) and reintervention rate (17.6% vs. 7.3%). Pooled survival rates at 1- and 5-year were similar between the 2 groups. CONCLUSIONS Current literature suggest that endovascular repair is an effective and safe alternative to OSR for descending thoracic, suprarenal, and infrarenal MAAs. However, endovascular repair is associated with higher risk of infection-related complications and reintervention during follow-up.
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Affiliation(s)
- Hai-Lei Li
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong - Shenzhen Hospital, Shenzhen, China
| | - Kristine J S Kwan
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong - Shenzhen Hospital, Shenzhen, China; Shanghai Medical College, Fudan University, Shanghai, China
| | - Yiu Che Chan
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong - Shenzhen Hospital, Shenzhen, China; Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China.
| | - Stephen W Cheng
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong - Shenzhen Hospital, Shenzhen, China; Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China
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Lima GB, Breite M, Pochettino A, Bonnichsen C, DeMartino RR, Mendes BC. Endovascular repair of an ascending aortic pseudoaneurysm. J Vasc Surg Cases Innov Tech 2023; 9:101279. [PMID: 37767350 PMCID: PMC10520440 DOI: 10.1016/j.jvscit.2023.101279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 07/10/2023] [Indexed: 09/29/2023] Open
Affiliation(s)
- Guilherme B. Lima
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Matthew Breite
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Alberto Pochettino
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Crystal Bonnichsen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | | | - Bernardo C. Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
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Rockley M, Rommens KL, McClure RS, Herget EJ, Smith HN, Moore RD. Aortic arch endovascular branch and fenestrated repair: Initial Canadian experience with novel technology. J Vasc Surg Cases Innov Tech 2023; 9:101274. [PMID: 37822947 PMCID: PMC10562848 DOI: 10.1016/j.jvscit.2023.101274] [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: 05/15/2023] [Accepted: 06/27/2023] [Indexed: 10/13/2023] Open
Abstract
Objective The objective is to describe the initial Canadian experience using novel aortic arch branched endograft technologies. Methods We performed a retrospective consecutive case series of all patients undergoing aortic arch branched repair with newly available endograft technology since 2020 at our site. We describe the patient characteristics, treatment characteristics, and postoperative outcomes. Results Eleven patients received arch branched endografts, indicated for penetrating aortic ulcer in seven patients (64%), arch degeneration after prior aortic dissection repair in three (27%), and acute aortobronchial fistula in one patient (9%). Their average age was 72 ± 7 years. Complete arch repair from zone 0 to 4 was performed in six cases (55%); the remaining repairs landed proximally in zones 1 or 2. Seven repairs used a single retrograde facing inner branch (thoracic branch endoprosthesis; W.L. Gore & Associates), three used double antegrade inner branch (Bolton Relay; Terumo Interventional Systems), and one emergent case used double in situ fenestrations. Seven repairs (64%) used an adjunctive extra-anatomic bypass to complete great vessel perfusion, two of which were created during a prior aortic repair. Inferior vena cava balloon inflow occlusion during deployment was used in all cases. No mortalities, transient or permanent spinal cord paralysis, myocardial infarction, dialysis dependence, venous thromboembolism, or bleeding requiring reintervention occurred. No patient undergoing elective arch branch repair experienced a stroke. The one patient undergoing emergent repair did suffer a stroke. The median length of stay was 5 days (interquartile range, 2-8 days). Two endoleaks developed: a type Ia endoleak successfully treated with a Palmaz stent (Cordis) during the index admission, and a type II endoleak with ongoing sac regression on postoperative follow-up. Postoperatively, one patient suffered a suspected aortic graft infection that was treated with lifelong antibiotics. During a mean radiographic follow-up of 7.2 months, no cases of branch vessel instability (ie, no migration, reintervention, arterial rupture, intraluminal thrombus, occlusion, stenosis, or kinking of the branch grafts) developed. Three patients experienced sac regression of >5 mm, and no patient experienced continued postoperative dilation. Conclusions To the best of our knowledge, this is the largest reported Canadian volume of aortic arch repair using novel branched or fenestrated technology. The series demonstrates that a multidisciplinary program and properly selected patients can yield excellent results using endovascular repair for complex aortic arch pathology.
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Affiliation(s)
- Mark Rockley
- Division of Vascular Surgery, Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Kenton L Rommens
- Division of Vascular Surgery, Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - R Scott McClure
- Division of Cardiac Surgery, Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Eric J Herget
- Division of Interventional Radiology, Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Holly N Smith
- Division of Cardiac Surgery, Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Randy D Moore
- Division of Vascular Surgery, Department of Surgery, University of Calgary, Calgary, AB, Canada
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Effectiveness and Minimal-Invasiveness of Zone 0 Landing Thoracic Endovascular Aortic Repair Using Branched Endograft. J Clin Med 2022; 11:jcm11236981. [PMID: 36498553 PMCID: PMC9738699 DOI: 10.3390/jcm11236981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/16/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
Background: Zone 0 landing thoracic endovascular aortic repair (TEVAR) for the treatment of aortic arch diseases has become a topic of interest. This study aimed to verify whether branced TEVAR (bTEVAR) is an effective and a more minimally invasive treatment by comparing the outcomes of bTEVAR and hybrid TEVAR (hTEVAR) in landing zone 0. Methods: This retrospective, single-center, observational cohort study included 54 patients (bTEVAR, n = 25; hTEVAR, n = 29; median age, 78 years; median follow-up period, 5.4 years) from October 2012 to June 2018. The logistic Euro-SCORE was significantly higher in the bTEVAR group than in the hTEVAR group (38% vs. 21%, p < 0.001). Results: There was no significant difference the in-hospital mortality between the bTEVAR and hTEVAR groups (0% vs. 3.4%, p = 1.00). The operative time (220 vs. 279 min, p < 0.001) and length of hospital stay (12 vs. 17 days, p = 0.013) were significantly shorter in the bTEVAR group than in the hTEVAR group. The 7-year free rates of aorta-related deaths (bTEVAR [95.5%] vs. hTEVAR [86.9%], Log-rankp = 0.390) and aortic reintervention (bTEVAR [86.3%] vs. hTEVAR [86.9%], Log-rankp = 0.638) were not significantly different. Conclusions: The early and mid-term outcomes in both groups were satisfactory. bTEVAR might be superior to hTEVAR in that it is less invasive. Therefore, bTEVAR may be considered an effective and a more minimally invasive treatment for high-risk patients.
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Ohki T, Maeda K, Baba T, Kaneko K, Shukuzawa K, Hara M, Omori M, Ozawa H. Early Clinical Outcomes of Retrograde In-Situ Branched Stent Grafting for Complex Aortic Arch Aneurysms. J Vasc Surg 2021; 75:803-811.e2. [PMID: 34742885 DOI: 10.1016/j.jvs.2021.10.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/13/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To evaluate the early outcomes of retrograde in-situ branched stent grafting (RIBS) using the gutter balloon technique for complex aortic arch aneurysms (CAAs). METHODS The RIBS technique is an in-situ needle fenestration procedure during thoracic endovascular aortic repair (TEVAR) with the reconstruction of cervical branches. The Double-RIBS (D-RIBS) for the reconstruction of the left common carotid artery and the brachiocephalic artery using the gutter balloon technique was performed in 30 high-risk patients. We describe the early clinical results of the D-RIBS technique for CAAs. Primary endpoints were technical success and 30-day mortality. Secondary endpoints were postoperative complications, rates of endoleaks, overall survival, aneurysm-related death, and re-interventions. RESULTS The mean age was 77.1±6.6 years and the mean maximum minor-axis aneurysmal diameter was 65.9±8.9 mm. Twenty six patients underwent D-RIBS for elective arch aortic aneurysm and four patients were for reintervention after Zone 2 TEVAR failure. Stent graft puncture was performed 60 times from the common carotid arteries and technical success was achieved in all cases (100%). Postoperative complications included cerebral infarction in 2 patients (6.7%), recurrent nerve palsy in one patient (3.3%). The 30-day mortality was 0%. During the median follow-up period of 14 months (6-56), overall survival at 12 months was 92.3% without any aneurysm-related death. Type 1b and type 2 endoleaks were observed in one each and no reintervention was encountered. CONCLUSION Early clinical outcomes of the D-RIBS for high-risk patients with CAAs are acceptable. The gutter balloon method enables safe and reliable fenestration. Further studies and dedicated devices are warranted.
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Affiliation(s)
- Takao Ohki
- Division of Vascular Surgery, Department of Surgery, the Jikei University School of Medicine, Tokyo, Japan.
| | - Koji Maeda
- Division of Vacular Surgery, International University of Health and Welfare, Narita, Japan
| | - Takeshi Baba
- Division of Vascular Surgery, Department of Surgery, the Jikei University School of Medicine, Tokyo, Japan
| | - Kenjirou Kaneko
- Department of Surgery, Shinyurigaoka General Hospital, Kawasaki, Japan
| | - Kota Shukuzawa
- Division of Vascular Surgery, Department of Surgery, the Jikei University School of Medicine, Tokyo, Japan
| | - Masayuki Hara
- Division of Vascular Surgery, Department of Surgery, the Jikei University School of Medicine, Tokyo, Japan
| | - Makiko Omori
- Division of Vascular Surgery, Department of Surgery, the Jikei University School of Medicine, Tokyo, Japan
| | - Hirotsugu Ozawa
- Division of Vascular Surgery, Department of Surgery, the Jikei University School of Medicine, Tokyo, Japan
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6
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Wallen T, Carter T, Habertheuer A, Badhwar V, Jacobs JP, Yerokun B, Wallace A, Milewski K, Szeto WY, Bavaria JE, Vallabhajosyula P. National Outcomes of Elective Hybrid Arch Debranching with Endograft Exclusion versus Total Arch Replacement Procedures: Analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2021; 9:21-29. [PMID: 34607380 PMCID: PMC8489998 DOI: 10.1055/s-0041-1724003] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Hybrid arch procedures (arch vessel debranching with thoracic endovascular aneurysm repair [TEVAR] coverage of arch pathology) have been presented as an alternative to total arch replacement (TAR). But multicenter-based analyses of these two procedures are needed to benchmark the field and establish areas of improvement. METHODS The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database from July 2014 to December 2015 was queried for elective TAR and hybrid arch procedures. Demographics and operative characteristics were compared and stepwise variable selection was used to create a risk-set used for adjustment of all multivariable models. RESULTS A total of 1,011 patients met inclusion criteria, 884 underwent TAR, and 127 had hybrid arch procedures. TAR patients were younger (mean age: 62.7 ± 13.3 vs. 66.7 ± 11.9 years; p = 0.001) and had less peripheral vascular disease (34.0 vs. 49.6%; p < 0.001) and preoperative dialysis (1.7 vs. 4.7%; p = 0.026), but similar history of stroke (p = 0.91)/cerebrovascular disease (p = 0.52). TAR patients had more concomitant procedures (60 vs. 34.6%; p < 0.0001). TAR patients had lower mortality (6.7 vs. 12.6%; p = 0.02), stroke (6.9 vs. 15%; p = 0.002), paralysis (1.8 vs. 7.1%; p = 0.002), renal failure (4.6 vs. 8.7%; p = 0.045), and STS morbidity (34.2 vs. 42.5%; p = 0.067). Composite mortality, stroke, and paralysis were significantly lower with TAR (11.5 vs. 25.2%; p = 0.0001). After risk adjustment, analysis showed hybrid arch procedures imparted an increased odds of mortality (odds ratio [OR] = 1.91, p = 0.046), stroke (OR = 2.3, p = 0.005), and composite endpoint of stroke or mortality (OR = 2.31, p = 0.0002). CONCLUSION TAR remains the gold standard for elective aortic arch pathologies. Despite risk adjustment, hybrid arch procedures were associated with increased risk of mortality and stroke, advocating for careful adoption of these strategies.
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Affiliation(s)
- Tyler Wallen
- Division of Cardiovascular Surgery, The University of Florida, Gainesville, Florida
| | - Timothy Carter
- Division of Cardiovascular Surgery, The University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Andreas Habertheuer
- Division of Cardiovascular Surgery, The University of Florida, Gainesville, Florida
| | - Vinay Badhwar
- Division of Cardiac Surgery, West Virginia University Heart and Vascular Institute, Morgantown, West Virginia
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, The University of Florida, Gainesville, Florida
| | | | | | - Karianna Milewski
- Division of Cardiovascular Surgery, The University of Florida, Gainesville, Florida
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, The University of Florida, Gainesville, Florida
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, The University of Florida, Gainesville, Florida
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Xie E, Wu J, Qiu J, Dai L, Qiu J, Luo Q, Jiang W, Cao F, Zhao R, Fan S, Gao W, Guo H, Sun X, Yu C. Early Outcomes of Three Total Arch Replacement Strategies for DeBakey Type I Aortic Dissection. Front Cardiovasc Med 2021; 8:638420. [PMID: 33937356 PMCID: PMC8081908 DOI: 10.3389/fcvm.2021.638420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 03/17/2021] [Indexed: 11/13/2022] Open
Abstract
Background: This study employed three surgical techniques: total arch replacement (TAR) with frozen elephant trunk (FET), aortic balloon occlusion technique (ABO) and hybrid aortic arch repair (HAR) on patients with type I aortic dissection in Fuwai Hospital, aiming to compare the early outcomes of these surgical armamentariums. Methods: From January 2016 to December 2018, an overall 633 patients (431 of TAR+FET, 122 of HAR, and 80 of ABO) with type I aortic dissection were included in the study. Thirty-day mortality, stroke, paraplegia, re-exploration for bleeding, and renal replacement therapy were compared using the matching weight method (MWM). Results: After MWM process, the baseline characteristics were comparable among three TAR groups. It showed that ABO group had the longest cardiopulmonary bypass (p < 0.001) and aortic cross-clamp time (p < 0.001), while the operation time was longest in the HAR group (p = 0.039). There was no significant difference in 30-day mortality among groups (p = 0.783). Furthermore, the incidence of stroke (p = 0.679), paraplegia (p = 0.104), re-exploration for bleeding (p = 0.313), and CRRT (p = 0.834) demonstrated no significant difference. Of note, no significant differences were found regarding these outcomes even before using MWM. Conclusions: Based on the early outcomes, the three TAR approaches were equally applicable to type I aortic dissection. We may choose the specific procedure relatively flexibly according to patient status and surgeon's expertise. Importantly, long-term investigations are warranted to determine whether above approaches remain to be of equivalent efficacy and safety.
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Affiliation(s)
- Enzehua Xie
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinlin Wu
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Juntao Qiu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lu Dai
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiawei Qiu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qipeng Luo
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenxiang Jiang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fangfang Cao
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rui Zhao
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuya Fan
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Gao
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongwei Guo
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaogang Sun
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Cuntao Yu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Kudo T, Kuratani T, Shimamura K, Sawa Y. Determining the Optimal Proximal Landing Zone for TEVAR in the Aortic Arch: Comparing the Occurrence of the Bird-Beak Phenomenon in Zone 0 vs Zones 1 and 2. J Endovasc Ther 2020; 27:368-376. [DOI: 10.1177/1526602820914269] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To identify the optimal proximal landing zone for thoracic aortic endovascular repair (TEVAR) of aortic arch pathologies so as to avoid the bird-beak phenomenon that leads to type Ia endoleak. Materials and Methods: A retrospective single-center review was conducted of 164 patients (mean age 70.3±10.8 years, range 29–93; 127 men) who underwent repairs of the aortic arch using hybrid TEVAR from April 2008 to March 2017. The patients were divided into 2 groups according to the proximal landing zone: 43 zone 0 patients (26.2%) had total debranching TEVAR (n=18) or total endovascular aortic repair (n=25) while 121 patients (73.8%) had TEVAR landing in zones 1 (n=41) or 2 (n=80). Bird-beak configurations, endoleaks, and stent migrations were assessed on the postoperative and latest computed tomography angiography (CTA) scans. Overall survival and freedom from the bird-beak configuration, aorta-related death, and aortic events were estimated using the Kaplan-Meier method. Hazard ratios (HR) were calculated with the 95% confidence interval (CI). Results: All procedures were successful, without any 30-day mortality. There were 3 early complications (1.8%; all strokes) and 10 early endoleaks (6.1%; no type Ia). On the first postoperative CTA, 42 patients (25.6%) had a bird-beak configuration. The zone 0 patients had significantly fewer (p<0.001), shorter (p<0.004), and less angulated (p<0.001) bird-beak configurations than in zones 1–2. The mean follow-up period was 4.2 years (range 0.5–8.8). There were 18 late deaths (11.0%); only one was related to the aorta (rupture due to a type Ib endoleak in a zone 0 patient). The 5-year freedom from aorta-related death was not significantly different between groups (zone 0: 96.9% vs zones 1–2: 100%, p=0.080). On the latest CTA, 51 (31.0%) patients had a bird-beak configuration; of those, 22 (13.4%) showed >3-mm progression. The freedom from bird-beak configuration estimate was significantly higher in the zone 0 group (95.4%) vs zones 1–2 (57.8%; HR 0.10, 95% CI 0.02 to 0.31, p<0.001). There were 9 late endoleaks (4 type Ia; none in the zone 0 group). The rate of stent-graft migration was significantly lower in the zone 0 group (2.3% vs 14.1% in zones 1–2, p=0.035). Conclusion: Early and most late results in zone 0 TEVAR were equal to those in zones 1 and 2; however, there were no late type Ia endoleaks and fewer bird-beak configurations associated with zone 0 TEVAR, which suggests that zone 0 landing is advantageous for preventing these complications.
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Affiliation(s)
- Tomoaki Kudo
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Toru Kuratani
- Department of Minimally Invasive Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kazuo Shimamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Abjigitova D, Mokhles MM, Papageorgiou G, Bekkers JA, Bogers AJJC. Outcomes of different aortic arch replacement techniques. J Card Surg 2019; 35:367-374. [PMID: 31816120 PMCID: PMC7003787 DOI: 10.1111/jocs.14386] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Consensus on the best treatment for aortic arch pathology is unresolved due to an emerging variety of procedures. We aimed to compare the outcomes of two major techniques for open aortic arch replacement involving the supra‐aortic branches and to identify the risk factors for specific adverse events. Methods Between 1974 and 2017, 172 patients were treated with either the en bloc (island, n = 59; 34.3%) or branched graft technique (n = 113, 65.7%). Most of the patients were treated in an emergent/urgent setting (52.4%). Results Patients who underwent the en bloc procedure had significantly shorter cardiopulmonary bypass (median: 241 vs 271 minutes, P = .041) and aortic cross clamp times (median: 124 vs 168 minutes, P = .005) than patients who underwent the separate graft technique. Overall, the hospital mortality was lower in the en bloc group, 8.5% vs 19.5%, although the difference was not significant (P = .077). No difference was found in the survival between the separate graft and en bloc groups at 1 (77.0 vs 86.3%), 5 (67.7 vs 66.3%) and 10 years (42.4 vs 51.3%), (P = .63). The postoperative stroke rate was comparable between the en bloc and separate graft cohorts (14.3 vs 19.6%, P = .52). Diabetics and those who underwent an elephant trunk procedure were at a higher risk for reintervention. Conclusions The separate graft technique, which is more common today, showed no difference from the en bloc technique with regard to hospital mortality and morbidity. Furthermore, the late survival and reintervention rates were similar after both procedures.
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Affiliation(s)
- Djamila Abjigitova
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Mostafa M Mokhles
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Grigorios Papageorgiou
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Biostatistics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jos A Bekkers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
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10
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Open aortic arch surgery: the gold standard method. Indian J Thorac Cardiovasc Surg 2019; 35:130-135. [PMID: 33061078 DOI: 10.1007/s12055-018-0732-1] [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] [Received: 06/05/2018] [Revised: 08/09/2018] [Accepted: 08/15/2018] [Indexed: 10/28/2022] Open
Abstract
Aortic arch pathologies are complex and treating them requires close team collaboration and technical skills to provide safe outcomes with low morbidity and mortality rates. Such challenges are facing both aortic and vascular surgeons. Open aortic arch repair has been the standard method of practice in all cases of aortic arch pathologies for the last four decades since the very first successful published case series by Griepp et al. during 1975. However, since then, repair of multi-segmented thoracic aortic pathologies has been explored through endovascular techniques; this is with or without open repair as a one-stage procedure especially in high-risk and elderly patients. Although the role of endovascular techniques in thoracoabdominal aorta is well established, its utilization as solo technique in aortic arch pathologies remains debatable. In this review, we highlight current evidences behind using open, endovascular, and hybrid procedures in aortic arch surgery.
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11
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Srivastava S, Bhan A. Aortic arch aneurysms and dissection-open repair is the gold standard. Indian J Thorac Cardiovasc Surg 2019; 35:136-155. [PMID: 33061079 DOI: 10.1007/s12055-019-00819-w] [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: 12/09/2018] [Revised: 03/08/2019] [Accepted: 03/13/2019] [Indexed: 10/26/2022] Open
Abstract
The aortic arch repair is one of the most complex surgeries and carries a high risk of complications as well as mortality. Since 1975, when the arch repair was first done by Randall B. Griepp using hypothermic circulatory arrest, many new technologies were introduced. But even with the use of antegrade and retrograde perfusion techniques and improvement of surgical techniques and grafts, the rate of mortality, cerebral, spinal, and visceral damage was much higher as compared to any other cardiac surgeries. With further developments aimed at less invasive approaches, thoracic endovascular aortic repair (TEVAR) along with de-branching of supra-aortic vessels or the frozen elephant trunk was introduced. Here, in this article, we review the myriad of approaches to the aortic arch and have come to a conclusion that while traditional open surgery is considered as the gold standard for treatment of extensive aortic arch pathologies, one school of thought suggests hybrid techniques such as the frozen elephant trunk and aortic arch vessel de-branching as more appropriate procedures for high-risk patients, where co-morbidities may contraindicate cardiopulmonary bypass and longer operative times required for traditional repair. No randomized trials are present to compare between open and hybrid or endovascular procedure in normal or high-risk patients. The meta-analysis of most of the studies defines open surgery as the gold standard for arch pathology because the hybrid procedures did not provide any proven survival benefits or decrease in stroke rate and spinal ischemia when compared to open surgery in early, mid, or long-term results.
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Affiliation(s)
- Swarnika Srivastava
- Department of cardiothoracic surgery, Medanta The Medicity hospital, Gurugram, India.,Noida, India
| | - Anil Bhan
- Department of cardiothoracic surgery, Medanta The Medicity hospital, Gurugram, India
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Joo HC, Youn YN, Kim JH, Lee SH, Lee S, Yoo KJ. Surgical Repair of Distal Aortic Arch Aneurysm With Distal Extension: Sternotomy Versus Thoracotomy. Ann Thorac Surg 2018; 107:1139-1145. [PMID: 30448483 DOI: 10.1016/j.athoracsur.2018.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 08/26/2018] [Accepted: 10/01/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND There is no consensus as to whether a median approach or a lateral approach is better for distal aortic arch aneurysms with distal extensions. The aim of this study was to compare clinical outcomes of these two approaches for distal aortic arch aneurysms with distal extensions. METHODS From January 2001 to December 2017, 212 consecutive patients with distal aortic arch aneurysms with distal extensions underwent surgery using different approaches: hemiarch and descending thoracic aneurysm replacement through thoracotomy (group 1, n = 91); and total arch and descending thoracic aneurysm replacement through sternotomy (group 2, n = 121). Early and late outcomes were compared using scores and inverse probability of treatment adjustments to reduce treatment selection bias. RESULTS The in-hospital mortality was 9.89% (9 of 91) in the thoracotomy group and 2.48% (3 of 121) in the sternotomy group (p = 0.02). The sternotomy group had a lower incidence of permanent stroke (2.48%, 3 of 121) compared with the thoracotomy group (10.99%, 10 of 91, p = 0.01). After adjustment, patients who underwent thoracotomy were at a greater risk of hospital mortality (odds ratio 5.0, p = 0.01), permanent stroke (odds ratio 6.83, p < 0.01), and pneumonia (odds ratio 2.99, p = 0.04), compared with patients who underwent sternotomy. The overall survival at 10 years was 69.8% ± 7.0% for the thoracotomy group and 83.0% ± 5.0% for the sternotomy group (unadjusted p = 0.049, adjusted p = 0.034). CONCLUSIONS The sternotomy approach showed better outcomes in terms of operative mortality, stroke, and pneumonia, as well as long-term survival compared with the thoracotomy approach. These results suggested that the sternotomy approach was more appropriate for patients with distal aortic arch aneurysms with distal extensions.
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Affiliation(s)
- Hyun-Chel Joo
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea.
| | - Young-Nam Youn
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Jung-Hwan Kim
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Seung Hyun Lee
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Sak Lee
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Kyung-Jong Yoo
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
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Chakos A, Jbara D, Yan TD, Tian DH. Long-term survival and related outcomes for hybrid versus traditional arch repair-a meta-analysis. Ann Cardiothorac Surg 2018; 7:319-327. [PMID: 30155410 DOI: 10.21037/acs.2018.05.07] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Surgical interventions for aortic aneurysm and dissection remain associated with high risk of mortality and morbidity. Advances in operative techniques have led to a variety of options for the cardiac surgeon, including endovascular and hybrid approaches. Debate remains over which of these techniques provide optimal outcomes for the patient. The present systematic review and meta-analysis aims to evaluate long term patient survival and identify short-term outcomes for conventional (open) aortic arch repair and hybrid aortic arch repair (HAR). Methods An electronic literature search was conducted according to predefined inclusion criteria for hybrid and conventional aortic arch repair surgery. Digitized survival data was extracted from identified studies' Kaplan-Meier curves and used to re-create individual patient data for aggregated survival analysis. Post-operative morbidity and mortality were analyzed using random-effects model meta-analysis. Results Nine studies were included, containing 841 hybrid arch repair and 1,182 conventional arch repair patients. Pooled Kaplan-Meier analysis of all patients demonstrated higher survival in hybrid arch repair patients than conventional arch repair patients, however, this was noted to be sensitive to results from a particular study. Overall results showed for the hybrid repair cohort, survival at 1, 2, 3, 5 and 7 years was 87%, 85%, 83%, 78% and 75%, respectively. Survival in the conventional repair cohort at 1, 2, 3, 5 and 7 years was 84%, 82%, 80%, 75% and 71%, respectively. Statistically significant findings from meta-analysis showed hybrid arch repair was associated with lower risk of re-operation for bleeding, while conventional arch repair was associated with reduced risk of spinal cord injury. Conclusions Pooled Kaplan-Meier analysis of all studies showed long-term survival outcomes for hybrid and conventional aortic arch repair patients are heterogeneous and sensitive to the results of particular studies. Superior results from particular centres and the low number of comparative studies mean that more data is required to make definitive findings with regards to the long-term survival outcomes of either procedure. Hybrid arch repair was associated with lower risk of re-operation for bleeding, while conventional arch repair was associated with lower risk of spinal cord injury. Surgeons should consider their own center's experience and patient suitability when deciding between hybrid or conventional aortic repair techniques.
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Affiliation(s)
- Adam Chakos
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Dean Jbara
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Tristan D Yan
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - David H Tian
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.,Royal North Shore Hospital, Sydney, Australia
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Kudo T, Kuratani T, Shimamura K, Sakamoto T, Kin K, Masada K, Shijo T, Torikai K, Maeda K, Sawa Y. Type 1a endoleak following Zone 1 and Zone 2 thoracic endovascular aortic repair: effect of bird-beak configuration†. Eur J Cardiothorac Surg 2017; 52:718-724. [DOI: 10.1093/ejcts/ezx254] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 04/30/2017] [Indexed: 11/12/2022] Open
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Glorion M, Coscas R, McWilliams RG, Javerliat I, Goëau-Brissonniere O, Coggia M. A Comprehensive Review of In Situ Fenestration of Aortic Endografts. Eur J Vasc Endovasc Surg 2016; 52:787-800. [PMID: 27843111 DOI: 10.1016/j.ejvs.2016.10.001] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Accepted: 10/10/2016] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Despite technical advances of fenestrated and branched endografts, endovascular exclusion of aneurysms involving renal, visceral, and/or supra-aortic branches remains a challenge. In situ fenestration (ISF) of standard endografts represents another endovascular means to maintain perfusion to such branches. This study aimed to review current indications, technical descriptions, and results of ISF. METHOD A review of the English language literature was performed in Medline databases, Cochrane Database, Web of Science, and Scopus using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Sixty-seven relevant papers were selected. Thirty-three papers were excluded, leaving 34 articles as the basis of the present review. RESULTS Most experimental papers evaluated ISF feasibility and assessed the consequences of ISF on graft fabric. Regarding clinical papers, 73 ISF procedures have been attempted in 58 patients, including 26 (45%) emergent and three (5%) bailout cases. Sixty-five (89%) ISF were located at the level of the arch, and eight (11%) in the abdominal aorta. Graft perforation was performed by physical, mechanical, or unspecified means in 33 (45%), 38 (52%), and two vessels (3%), respectively. ISF was technically successful in 68/73 (93%) arteries. At 30 days, two (3.4%) patients died in the setting of an aorto-bronchial fistula and an aorto-oesophageal fistula, respectively. No post-operative death, major complication, or endoleak was described as secondary to the ISF procedure. With follow-up between 0 and 72 months, four (6.9%) late deaths were noted, unrelated to the aorta. One (1.7%) LSA stent was stenosed without symptoms. CONCLUSIONS Although there may be publication bias, multiple techniques were described to perform ISF with satisfactory short-term results. Long-term data remain scarce. Aortic endograft ISF is an off-label procedure that should not be used outside emergent bailout techniques or investigational studies. A comparison with alternative techniques of preserving aortic side branches is needed.
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Affiliation(s)
- M Glorion
- Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Boulogne-Billancourt, France; Faculté de Médecine Paris-Ile de France-Ouest, UFR des sciences de la santé Simone Veil, Université Versailles Saint-Quentin en Yvelines, Montigny-le-Bretonneux, France
| | - R Coscas
- Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Boulogne-Billancourt, France; Faculté de Médecine Paris-Ile de France-Ouest, UFR des sciences de la santé Simone Veil, Université Versailles Saint-Quentin en Yvelines, Montigny-le-Bretonneux, France; UMR 1018, Inserm-Paris11 - CESP, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Paul Brousse Hospital, Villejuif, France.
| | - R G McWilliams
- Radiology Department, Royal Liverpool University Hospital, Liverpool, UK
| | - I Javerliat
- Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Boulogne-Billancourt, France
| | - O Goëau-Brissonniere
- Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Boulogne-Billancourt, France; Faculté de Médecine Paris-Ile de France-Ouest, UFR des sciences de la santé Simone Veil, Université Versailles Saint-Quentin en Yvelines, Montigny-le-Bretonneux, France; UMR 1018, Inserm-Paris11 - CESP, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Paul Brousse Hospital, Villejuif, France
| | - M Coggia
- Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Boulogne-Billancourt, France; Faculté de Médecine Paris-Ile de France-Ouest, UFR des sciences de la santé Simone Veil, Université Versailles Saint-Quentin en Yvelines, Montigny-le-Bretonneux, France
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Can the Streamliner multilayer flow modulator really streamline the solution to complex arch and thoracoabdominal aortic pathology? J Thorac Cardiovasc Surg 2016; 152:1319-1320. [PMID: 27476031 DOI: 10.1016/j.jtcvs.2016.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 06/27/2016] [Indexed: 11/23/2022]
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Arnaoutakis GJ, Szeto WY. Hybrid aortic arch repair: The ultimate solution or a stop along the way to a total endovascular arch reconstruction? J Thorac Cardiovasc Surg 2016; 152:169-70. [PMID: 27343911 DOI: 10.1016/j.jtcvs.2016.03.064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 03/31/2016] [Indexed: 11/28/2022]
Affiliation(s)
- George J Arnaoutakis
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa.
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Bibiloni Lage I, Calsina Juscafresa L, Delgado Domínguez C, Bilbao Jaureguizar JI, Bastarrika G, Rábago Juan-Aracil G. Hybrid Repair of Aortic Arch Aneurysms with Endografting of the Ascending Aorta. J Card Surg 2016; 31:341-7. [PMID: 27005830 DOI: 10.1111/jocs.12735] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Different "hybrid" techniques that combine open debranching of the supra-aortic vessels with endografting of the aortic arch have emerged as alternatives to the open arch repair in high-risk patients. This study aims to review the early and mid-term results of single-stage hybrid arch repair with ascending aorta stent graft deployment for aortic arch aneurysms and dissections. METHODS Between June 2006 and May 2015, five consecutive patients, with an age range of 54-78 years, with complex aortic arch diseases, were treated with a hybrid approach in which the endograft had a proximal landing zone in the ascending aorta. Indications included: acute and chronic type A aortic dissections and three arch aneurysms associated with distal aortic pathology. Length of postoperative clinical and imaging follow-up ranged from 10 to 121 months and was completed in all patients. RESULTS Technical success of the endografting was achieved in all cases. There was one in-hospital mortality secondary to pulmonary embolism, one case of retrograde type A aortic dissection (RTAD) detected before discharge and one case of late type Ib endoleak that required an endografting procedure. No postoperative stroke or transient or permanent spinal cord ischemia occurred. CONCLUSION Hybrid arch repair with endograft landing in zone 0 may decrease mortality and morbidity in high-risk patients. doi: 10.1111/jocs.12735 (J Card Surg 2016;31:341-347).
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Affiliation(s)
| | | | | | | | - Gorka Bastarrika
- Department of Radiology, Clínica Universidad de Navarra, Pamplona, Spain
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