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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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2
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Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
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Huffman J, McSpadden M, Buelter J, Vogel T, Bath J. Left carotid chimney and left subclavian artery laser fenestration for zone 1 thoracic endovascular aortic repair. J Vasc Surg Cases Innov Tech 2023; 9:101283. [PMID: 37662573 PMCID: PMC10474483 DOI: 10.1016/j.jvscit.2023.101283] [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: 06/09/2023] [Accepted: 07/11/2023] [Indexed: 09/05/2023] Open
Abstract
Thoracic endovascular aortic repair has become an increasingly used option for treatment of descending thoracic aortic aneurysms and dissections. Pathology involving the proximal thoracic aorta is more complex and requires revascularization of the subclavian and carotid arteries. We report a case of an arch thoracic aortic pseudoaneurysm repaired via a complete endovascular approach using a left carotid chimney and left subclavian artery laser fenestration.
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Affiliation(s)
- Jen Huffman
- Department of Surgery, University of Missouri, Columbia, MO
| | | | - Joseph Buelter
- School of Medicine, University of Missouri, Columbia, MO
| | - Todd Vogel
- Division of Vascular Surgery, University of Missouri, Columbia, MO
| | - Jonathan Bath
- Division of Vascular Surgery, University of Missouri, Columbia, MO
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Liu Y, Zhang B, Liang S, Dun Y, Guo H, Qian X, Yu C, Sun X. Early and Midterm Outcomes of Type II Hybrid Arch Repair for Complex Aortic Arch Pathology. Front Cardiovasc Med 2022; 9:882783. [PMID: 35722105 PMCID: PMC9201486 DOI: 10.3389/fcvm.2022.882783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background The hybrid arch repair (HAR) is an appealing surgical option in the management of aortic arch diseases. The aim is to evaluate the short and mid-term outcomes of type II HAR involving replacement of the ascending aorta, arch debranching, and zone 0 stent graft deployment in diverse arch pathologies. Methods 200 patients with various diffuse aortic pathologies involving the arch were enrolled between 2016 and 2019. Complex arch diseases included acute type A dissection (n = 129, 64.5%), acute type B dissection (n = 16, 8.0%), aortic arch aneurysm (n = 42, 21.0%) and penetrating arch ulcer (n = 13, 6.5%). Mortality, morbidity, survival and re-intervention were analyzed. Results The overall 30-day mortality rate was 8.0% (16/200). Stroke was present in 3.5% (7/200) of the general cohort and spinal cord injury was occurred in 3.0% (6/200). Multivariable logistic analysis showed that cardiac malperfusion and CPB time were the risk factors associated with 30-day mortality. The mean follow-up duration was 25.9 months (range 1–57.2 months), and the 3-year survival rate was 83.1%. On Cox regression analysis, age, diabetes, cardiac malperfusion and CPB time predicted short and mid-term overall mortality. A total of 3 patients required reintervention during the follow-up due to the thrombosis of epiaortic artificial vessels (n = 1), anastomotic leak at the site of the proximal ascending aorta (n = 1) and the type I endoleak (n = 1). Conclusions Type II HAR was performed with satisfactory early and mid-term outcomes in complex aortic arch pathologies.
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Svensson LG. Our experience with 1000 recent thoracoabdominal aneurysm repairs, including endovascular stenting. J Thorac Cardiovasc Surg 2022; 165:1754-1758. [PMID: 35589422 DOI: 10.1016/j.jtcvs.2022.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 02/14/2022] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Managing patients with thoracoabdominal aneurysms is demanding yet fascinating, and requires a team effort. This invited talk presents lessons learned as our history with open and endovascular procedures evolved for 2578 descending and thoracoabdominal repairs over the past 20 years. METHODS Beginning in 1985 with an analysis of 596 traumatic aortic ruptures and the risk of spinal cord ischemia, the evolution of research and procedures for thoracoabdominal aneurysms progressed. The focus of these studies, medication trials, and procedure adjustments was on lowering the risk of spinal cord ischemia. RESULTS Between January 2002 and December 2021, 2578 aneurysm repairs were performed. The respective mortality rates were 6.8% and 4.0% for all patients treated. The permanent spinal cord ischemia rates were 1.3% for open descending thoracic aortas and 4.9% for open thoracoabdominal aneurysms. A detailed analysis of open and thoracoabdominal repairs showed better long-term outcomes with open repairs. CONCLUSIONS Through multiple randomized trials and innovations with procedures and techniques, the risk of death and spinal cord ischemia have been reduced. Long-term survival has also been improved. The pursuit of reducing the risks of descending and ascending thoracoabdominal repairs is a fascinating endeavor that has resulted in better patient outcomes. Nevertheless, this is a journey, and there will always be more room to achieve even better results.
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Affiliation(s)
- Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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6
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6522720. [DOI: 10.1093/ejcts/ezac051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 12/20/2021] [Accepted: 01/28/2022] [Indexed: 11/13/2022] Open
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Fouquet O, Dang Van S, Ammi M, Daligault M, Baufreton C, Picquet J. STABILISE Technique via a Transapical Approach to Repair Residual Type A Aortic Dissection. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2021; 9:161-164. [PMID: 34560805 PMCID: PMC8642071 DOI: 10.1055/s-0041-1729851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
The stent-assisted balloon-induced intimal disruption and relamination in aortic dissection or STABILISE concept is a novel endovascular strategy in Type A and Type B dissections. We report a case of Type A aortic dissection repair combining, first, an open thoracic aortic surgery with an elephant trunk procedure and, second, an endovascular treatment using the STABILISE technique via a combined transapical approach commonly used for transcatheter aortic valve implantation and a femoral pathway.
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Affiliation(s)
- Olivier Fouquet
- Department of Cardiovascular and Thoracic Surgery, University Hospital, Angers, France.,MITOVASC Institute CNRS UMR 6214, INSERM U1083, University, Angers, France
| | - Simon Dang Van
- Department of Cardiovascular and Thoracic Surgery, University Hospital, Angers, France.,MITOVASC Institute CNRS UMR 6214, INSERM U1083, University, Angers, France
| | - Myriam Ammi
- Department of Cardiovascular and Thoracic Surgery, University Hospital, Angers, France
| | - Mickael Daligault
- Department of Cardiovascular and Thoracic Surgery, University Hospital, Angers, France
| | - Christophe Baufreton
- Department of Cardiovascular and Thoracic Surgery, University Hospital, Angers, France.,MITOVASC Institute CNRS UMR 6214, INSERM U1083, University, Angers, France
| | - Jean Picquet
- Department of Cardiovascular and Thoracic Surgery, University Hospital, Angers, France.,MITOVASC Institute CNRS UMR 6214, INSERM U1083, University, Angers, France
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8
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Smolock CJ, Xiang F, Roselli EE, Blackstone EH, Svensson LG, Artis AS, Liu H, Tong MZ. Health-Related Quality of Life After Extensive Aortic Replacement. Semin Thorac Cardiovasc Surg 2021; 34:793-801. [PMID: 34271093 DOI: 10.1053/j.semtcvs.2021.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 07/07/2021] [Indexed: 01/16/2023]
Abstract
To assess and compare patient-reported long-term health-related quality of life (HRQoL) after combined proximal aortic (arch ± ascending, root) and distal aortic (descending thoracic ± abdominal) replacement using open vs multimodal/endovascular (hybrid) approaches. From 2010 to 2016, 146 adults underwent single- or multi-stage aortic arch plus descending thoracic aorta replacement, 31 open and 115 hybrid. The 2 surgical approach groups had similar preoperative characteristics and extent of surgery. Cross-sectional follow-up revealed 49 deaths (7 open, 42 hybrid). Of the 97 survivors, 72 (74%) responded to the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 survey (18 open, 54 hybrid) a median 6.2 years (15th, 85th percentiles: 3.1, 7.9) after their last aortic surgery. Predictors of HRQoL scores were identified by random forest regression. Overall physical HRQoL T-score was lower than that of population norms (46 vs 50, P < 0.0001); mental HRQoL T-score was similar (50 vs 50, P > 0.9). Neither T-score was significantly different according to surgical approach (P ≥ 0.3). Greater number of postoperative complications and history of chronic obstructive pulmonary disease were the most important predictors of lower physical HRQoL, and prior myocardial infarction was the most important predictor of lower mental HRQoL. Although extensive aortic replacement had a small long-term effect on patient-reported physical HRQoL, both physical and mental HRQoL can be preserved in survivors with both surgical approaches. Surgeons should recommend the approach they believe will yield the best long-term survival, but lifelong follow-up is crucial, and patients should understand that they may require multiple operations.
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Affiliation(s)
| | - Fei Xiang
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Amanda S Artis
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Huan Liu
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Michael Z Tong
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
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Schepens M, Ranschaert W, Vergauwen W, Graulus E, De Vos M. Is the classical elephant trunk better than the frozen elephant trunk? Indian J Thorac Cardiovasc Surg 2021; 38:64-69. [PMID: 35463703 PMCID: PMC8980961 DOI: 10.1007/s12055-020-01131-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/22/2020] [Accepted: 12/23/2020] [Indexed: 01/08/2023] Open
Abstract
Aortic diseases located in the ascending aorta, aortic arch or proximal descending aorta often require more than one surgical intervention depending on the type of pathology and its extent as well as future anticipated aortic problems. These obstacles were tackled in 1983 by Hans Borst with the introduction of the classic elephant trunk (cET). This was an outstanding and straightforward procedure. Since then, the cET was very often the first surgical approach for patients with extensive aortic pathology of the ascending aorta and arch extending into the downstream aorta. Thirteen years later, Suto and Kato introduced the frozen elephant trunk (fET) which was later on perfectionized by industry and applied in various ways by many surgical groups worldwide. Comparing the cET with the fET raises a lot of difficulties. The lack of randomization and the presence of procedural and complication-related limitations for each technique do not allow for definitive conclusions about the ideal procedure to treat complex aortic pathology. It would be very short-sighted to close all future discussions about the subject with this statement of the Hannover group made in 2011. Since both techniques and its results cannot be compared statistically due to the heterogeneity of patient groups, the lack of randomization, the difference in type and extent of pathology, the differences in surgical techniques, the learning curve in gaining experience in both techniques, and the lack of reporting standards, no scientific conclusion can be drawn as to which technique is most successful. Comparisons may even be considered futile. It is the purpose of this paper merely to make a descriptive observation of both techniques, to discuss some important elements of interest and to give some constructive and useful criticism.
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Affiliation(s)
- Marc Schepens
- Department of Cardiac Surgery, AZ St.Jan, Ruddershove 10, 8000 Brugge, Belgium
| | - Willem Ranschaert
- Department of Cardiac Surgery, AZ St.Jan, Ruddershove 10, 8000 Brugge, Belgium
| | - Wim Vergauwen
- Department of Cardiac Surgery, AZ St.Jan, Ruddershove 10, 8000 Brugge, Belgium
| | - Eric Graulus
- Department of Cardiac Surgery, AZ St.Jan, Ruddershove 10, 8000 Brugge, Belgium
| | - Marie De Vos
- Department of Cardiac Surgery, AZ St.Jan, Ruddershove 10, 8000 Brugge, Belgium
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Piffaretti G, Trimarchi S, Gelpi G, Romagnoni C, Ferrarese S, Tozzi M, Bush RL, Lomazzi C. Hybrid repair of extensive thoracic aortic aneurysms. Eur J Cardiothorac Surg 2020; 58:940-948. [DOI: 10.1093/ejcts/ezaa178] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 04/01/2020] [Accepted: 04/03/2020] [Indexed: 11/12/2022] Open
Abstract
Abstract
OBJECTIVES
Our goal was to report the midterm results of hybrid treatment of extensive thoracic aortic aneurysm (ETAA) with the completion of thoracic endovascular aortic repair after proximal ascending-arch graft replacement.
METHODS
This was a multicentre, observational study. Data were collected prospectively between January 2002 and March 2019 and analysed retrospectively. Inclusion criteria for the final analysis were the treatment of elective or urgent ETAA performed in a single-stage or a planned two-stage approach. Early and late survival rates were the primary outcomes.
RESULTS
Indications for repair were degenerative ETAA in 27 (64.3%) patients and dissection-related ETAA in 15 (35.7%). The mean aortic diameter was 68 ± 16 mm (interquartile range 60–75). Five (11.9%) patients had a single-stage repair; and 37 underwent a two-stage approach. Three (7.1%) patients died in-hospital. The median follow-up was 49 months (range 0–204). During the follow-up period, 4 (9.5%) patients underwent aortic reintervention after a median of 32 months; however, no aortic rupture of the treated segment occurred. Overall, the estimated survival rate was 85% ± 6% [95% confidence interval (CI) 70.8–93] at 12 and 36 months and 69.5% ± 9% (95% CI 49.7–84) at 60 months.
CONCLUSIONS
Hybrid repair of ETAA had satisfactory early results in this cohort of patients. At the midterm follow-up, the aneurysm-related mortality rate was acceptable with the reconstruction proving to be durable and safe with few distal aortic events.
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Affiliation(s)
- Gabriele Piffaretti
- Vascular Surgery, Department of Medicine and Surgery, ASST Settelaghi University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
| | - Santi Trimarchi
- Vascular Surgery, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Guido Gelpi
- Cardiac Surgery, ASST Fatebenefratelli Sacco University Teaching Hospital, Milano, Italy
| | - Claudia Romagnoni
- Cardiac Surgery, ASST Fatebenefratelli Sacco University Teaching Hospital, Milano, Italy
| | - Sandro Ferrarese
- Vascular Surgery, Department of Medicine and Surgery, ASST Settelaghi University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
- Cardiac Surgery, Department of Medicine and Surgery, ASST Settelaghi University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
| | - Matteo Tozzi
- Vascular Surgery, Department of Medicine and Surgery, ASST Settelaghi University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
| | - Ruth L Bush
- University of Houston College of Medicine, Houston, TX, USA
| | - Chiara Lomazzi
- Vascular Surgery, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
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Kandola S, Abdulsalam A, Field M, Fisher RK. Frozen elephant trunk repair of aortic aneurysms: How to reduce the incidence of endoleak and reintervention. JTCVS Tech 2020; 3:13-20. [PMID: 34317799 PMCID: PMC8302997 DOI: 10.1016/j.xjtc.2020.06.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 05/26/2020] [Accepted: 06/12/2020] [Indexed: 11/17/2022] Open
Abstract
Background Frozen elephant trunk (FET) enables treatment of arch and proximal descending thoracic aorta aneurysms. In treating patients with single-stage FET, the relationship of distal stent size to endoleak and reintervention has remained unexamined. Methods In this retrospective analysis of 63 cases in which FET was used to repair aneurysms between 2008 and 2019, 36 were intended as single-stage procedures. Effective sizing and sealing of distal stents were analyzed by preoperative and postoperative computed tomography angiography (CTA). Results During a mean of 25.8 ± 5.7 months of CTA follow-up, 10 of 36 (28%) experienced endoleak, and 3 of 36 (8%) had sac expansion. Ultimately, 5 of 13 (38%) underwent thoracic endovascular aneurysm repair. Patients without endoleak or sac expansion were more likely to have stents with >10% oversize and a >30-mm seal in healthy aorta compared with those experiencing these complications (11 of 23 vs 0 of 13; P = .0031). Conversely, 11 of 36 patients (31%) with adequately oversized and sealed stents developed fewer endoleaks compared with those without (0 of 11 vs 10 of 14; P < .0004). Patients with endoleak or sac expansion had smaller mean distal stent oversize and shorter mean sealing length compared with those without endoleak or sac expansion (2.3 ± 3.9% vs 18 ± 2.9% [P = .0023] and 1 ± 0.7 mm vs 34 ± 6 mm [P = .0005], respectively). Conclusions We recommend >10% distal stent oversize and >30-mm sealing length to minimize endoleak and reintervention. Increasing multidisciplinary collaboration with endovascular surgeons will improve distal stent planning.
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Affiliation(s)
- Sandhir Kandola
- Liverpool Vascular and Endovascular Service, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Ahmed Abdulsalam
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Mark Field
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Robert K Fisher
- Liverpool Vascular and Endovascular Service, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
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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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Pellenc Q, Girault A, Roussel A, De Blic R, Cerceau P, Raffoul R, Milleron O, Jondeau G, Castier Y. Optimising Aortic Endovascular Repair in Patients with Marfan Syndrome. Eur J Vasc Endovasc Surg 2020; 59:577-585. [DOI: 10.1016/j.ejvs.2019.09.501] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 09/10/2019] [Accepted: 09/20/2019] [Indexed: 12/20/2022]
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14
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Serra R, Di Virgilio A, Turchino D, Ielapi N, De Franciscis S, Indolfi C, Mastroroberto P. Percutaneous and surgical femoral access for thoracic endovascular aortic repair using local anesthesia. Chirurgia (Bucur) 2019. [DOI: 10.23736/s0394-9508.18.04804-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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15
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Murakami T, Morisaki A, Nishimura S, Takahashi Y, Sakon Y, Nakano M, Sohgawa E, Fujii H, Shibata T. Externalized transapical guidewire technique for complex aortic disease: a single-centre experience. Eur J Cardiothorac Surg 2018; 55:639-645. [DOI: 10.1093/ejcts/ezy349] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 09/06/2018] [Accepted: 09/09/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Takashi Murakami
- Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Akimasa Morisaki
- Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shinsuke Nishimura
- Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yosuke Takahashi
- Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yoshito Sakon
- Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Mariko Nakano
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Etsuji Sohgawa
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiromichi Fujii
- Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Toshihiko Shibata
- Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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16
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Tamura K, Chikazawa G, Hiraoka A, Totsugawa T, Sakaguchi T, Yoshitaka H. The prognostic impact of distal anastomotic new entry after acute type I aortic dissection repair. Eur J Cardiothorac Surg 2018; 52:867-873. [PMID: 28977462 DOI: 10.1093/ejcts/ezx223] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 05/29/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Distal anastomotic new entry (DANE) is considered to be one of the causes of patent false lumen (PFL) after acute type I aortic dissection repair. However, there have been few articles with regard to this important issue. We assessed the influence of PFL caused by DANE on long-term outcomes. METHODS One hundred twenty-two patients underwent emergency surgery for acute type I aortic dissection (2007-12). The in-hospital mortality was 8% (10 patients). Among the survivors, 93 patients (mean age 67 years) underwent enhanced computed tomography within 2 weeks after the operation. These patients were divided into 3 groups according to the status of the residual FL: those with a PFL with DANE (n = 19) or without DANE (n = 27) and those with a thrombosed FL (n = 47). Changes in descending aortic diameter were analysed between early and last follow-up images. RESULTS Aortic growth rate in the PFL with DANE group was greater than that of the other 2 groups (P < 0.05). The PFL with DANE group demonstrated a lower rate of freedom from dissection-related event of distal aorta (66% at 5 years) and enlargement of distal aortic lesions (62% at 5 years). There were no significant differences in late survival among the groups. PFL with DANE was one of the significant risk factors for distal aortic events. CONCLUSIONS PFL caused by DANE after acute type I aortic dissection repair showed greater aortic growth rate of the descending aorta and was one of the significant risk factors for distal aortic events.
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Affiliation(s)
- Kentaro Tamura
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Genta Chikazawa
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Arudo Hiraoka
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Toshinori Totsugawa
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Taichi Sakaguchi
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Hidenori Yoshitaka
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
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Aftab M, Idrees JJ, Cikach F, Navia JL, Hammer D, Roselli EE. Open Distal Fenestration of Chronic Dissection Facilitates Endovascular Elephant Trunk Completion: Late Outcomes. Ann Thorac Surg 2017; 104:1960-1967. [DOI: 10.1016/j.athoracsur.2017.05.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Revised: 04/09/2017] [Accepted: 05/15/2017] [Indexed: 11/17/2022]
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18
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Arokiaraj MC, De Beule M, De Santis G. A novel sax-stent method in treatment of ascending aorta and aortic arch aneurysms evaluated by finite element simulations. JOURNAL DE MÉDECINE VASCULAIRE 2017; 42:39-45. [PMID: 28705446 DOI: 10.1016/j.jdmv.2017.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 11/25/2016] [Indexed: 10/19/2022]
Abstract
OBJECTIVES A novel stent method to simplify treatment of proximal ascending aorta and aortic arch aneurysms was developed and investigated by finite element analysis. Therapy of ascending aortic and aortic arch aneurysms is difficult and challenging and is associated with various complications. METHODS A 55mm wide×120mm long stent was designed without the stent graft and the stent was deployed by an endovascular method in a virtual patient-specific aneurysm model. The stress-strain analysis and deployment characteristics were performed in a finite element analysis using the Abaqus software. RESULTS The stent, when embedded in the aortic wall, significantly reduced aortic wall stresses, while preserving the side coronary ostia and side branches in the aortic arch. When tissue growth was modeled computationally over the stent struts the wall stresses in aorta was reduced. This effect became more pronounced when increasing the thickness of the tissue growth. There were no abnormal stresses in the aorta, coronary ostium and at the origin of aortic branches. The stent reduced aneurysm expansion cause by hypertensive condition from 2mm without stenting to 1.3mm after stenting and embedding. CONCLUSION In summary, we uncovered a simple treatment method using a bare nitinol stent without stent graft in the treatment of the proximal aorta and aortic arch aneurysms, which could eventually replace the complex treatment methods for this disease.
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Affiliation(s)
- M C Arokiaraj
- Cardiology, Pondicherry institute of medical sciences, 605014 Pondicherry, India.
| | - M De Beule
- FEops nv, Technologiepark 3, IBiTech-bioMMeda, University of Ghent (UGent), 9000 Gent, Belgium
| | - G De Santis
- FEops nv, Technologiepark 3, IBiTech-bioMMeda, University of Ghent (UGent), 9000 Gent, Belgium
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Roselli EE, Bakaeen FG, Johnston DR, Soltesz EG, Tong MZ. Role of the frozen elephant trunk procedure for chronic aortic dissection. Eur J Cardiothorac Surg 2017; 51:i35-i39. [PMID: 28108567 DOI: 10.1093/ejcts/ezw338] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 08/26/2016] [Accepted: 08/29/2016] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Considering the chronic and progressive nature of aortic dissection, operative planning must anticipate the need for later interventions. We have increasingly used a modified version of the frozen elephant trunk repair operation to treat these patients. We review the indications, considerations for planning, and important operative details for performing frozen elephant trunk repair for chronic aortic dissection. METHODS Frozen elephant trunk repair is performed using selective antegrade brain perfusion, direct placement of commercially available stent grafts with suture fixation in the aortic arch, and proximal aortic replacement. Details are reviewed. RESULTS We have published details related to the excellent results for the frozen elephant trunk procedure in patients with chronic dissection. CONCLUSIONS The modified frozen elephant trunk repair is particularly well suited for patients with chronic aortic dissection who often require multiple operations to address their extensive disease.
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Affiliation(s)
- Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Aorta Center, Cleveland Clinic, Cleveland, OH, USA
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Aorta Center, Cleveland Clinic, Cleveland, OH, USA
| | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Aorta Center, Cleveland Clinic, Cleveland, OH, USA
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Aorta Center, Cleveland Clinic, Cleveland, OH, USA
| | - Michael Z Tong
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Aorta Center, Cleveland Clinic, Cleveland, OH, USA
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20
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Abstract
Surgery of the aortic arch is arguably one of the most complex areas of cardiac surgery. Despite that, studies and guidelines have not sufficiently addressed the aortic arch specifically. In general, indications for aortic arch intervention parallel those of the ascending aorta. Herein we review indications for aortic arch intervention in various aortic pathologies based on the scant evidence available combined with surgical expertise and expert opinion.
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21
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Yang J, Liu Y, Duan W, Yi D, Yu S, Ma R, Ren J. A feasibility study of total endovascular aortic arch replacement: From stent-graft design to preclinical testing. J Thorac Cardiovasc Surg 2016; 151:1203-12. [DOI: 10.1016/j.jtcvs.2015.10.092] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 10/23/2015] [Accepted: 10/24/2015] [Indexed: 11/26/2022]
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22
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Tokuda Y, Oshima H, Narita Y, Abe T, Mutsuga M, Fujimoto K, Terazawa S, Ito H, Hibino M, Uchida W, Komori K, Usui A. Extended total arch replacement via the L-incision approach: single-stage repair for extensive aneurysms of the aortic arch. Interact Cardiovasc Thorac Surg 2016; 22:750-5. [PMID: 26932664 DOI: 10.1093/icvts/ivw034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 01/08/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Total arch replacement via the L-incision approach (a combination of left anterior thoracotomy and upper median sternotomy) can be used to achieve more extensive replacement. METHODS In the period between 2002 and 2014, 279 total arch replacement procedures were performed. After excluding cases of acute aortic dissection and cases involving concomitant, hybrid or frozen elephant trunk procedures, patients who underwent isolated total arch replacement via an L-incision (n = 29) and via median sternotomy (n = 143) were identified and the data pertaining to their cases were analysed. RESULTS Operative mortality was higher in the L-incision group than in the median sternotomy group (6.9 vs 2.1%); however, the difference was not statistically significant. The L-incision group displayed a higher rate of respiratory complications, including pneumonia (28 vs 7.0%, P = 0.0034), the need for tracheostomy (17 vs 2.1%, P = 0.0038) and pulmonary haemorrhage (6.9 vs 0%, P = 0.028). The rate of paraplegia was similar between the groups (0 vs 1.4%, P = 1.00), despite the wider range replaced via the L-incision approach (7.3 ± 1.5 vs 4.7 ± 0.8 anatomical zones, P < 0.001). The rates of other complications and functional recovery were similar. The long-term survival (73 vs 84% at 5 years) and aortic event-free rates (94 vs 96% at 5 years) were similar in both groups. CONCLUSIONS A combination of left anterior thoracotomy and upper median sternotomy can be applied to the single-stage repair of extended aneurysms with acceptable results in appropriately selected patients.
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Affiliation(s)
- Yoshiyuki Tokuda
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
| | - Hideki Oshima
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
| | - Yuji Narita
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
| | - Tomonobu Abe
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
| | - Masato Mutsuga
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
| | - Kazuro Fujimoto
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
| | - Sachie Terazawa
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
| | - Hideki Ito
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
| | - Makoto Hibino
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
| | - Wataru Uchida
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
| | - Kimihiro Komori
- Department of Vascular Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
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Belov YV, Komarov RN, Karavaykin PA. Cardiovascular surgeon’s role in hybrid aortic surgery (part 2). ACTA ACUST UNITED AC 2016. [DOI: 10.17116/kardio20169134-41] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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24
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Spear R, Sobocinski J, Settembre N, Tyrrell MR, Malikov S, Maurel B, Haulon S. Early Experience of Endovascular Repair of Post-dissection Aneurysms Involving the Thoraco-abdominal Aorta and the Arch. Eur J Vasc Endovasc Surg 2015; 51:488-97. [PMID: 26680449 DOI: 10.1016/j.ejvs.2015.10.012] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 10/18/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Outcomes are reported in management of post-dissection aneurysms involving the aortic arch and/or thoraco-abdominal segment (TAAA) treated with fenestrated and branched (complex) endografts. METHODS This report includes all patients with chronic post-dissection aneurysms >55 mm in diameter, deemed unfit for open surgery, treated using complex endografts between October 2011 and March 2015. When appropriate, staged management strategies including left subclavian artery revascularization, thoracic endografting, dissection flap fenestration or tear enlargement, and other endovascular procedures were performed at least 3 weeks prior to definitive complex endovascular repair. The following outcome data were collected prospectively at discharge, 12 months and annually thereafter: technical success, endoleaks, target vessel patency, false lumen patency, aneurysm diameter, major and minor complications, re-interventions, and mortality. RESULTS The cohort comprised 23 patients with a median age of 65 years. Staged procedures were performed in 14 patients (61%). Seven patients with dissections involving the arch were treated with inner branched endografts, and 16 TAAA patients were treated with fenestrated or branched endografts. The technical success rate was 71% following arch repair and 100% following TAAA repair. During early follow up, one of the arch group patients died and one in the TAAA group suffered spinal cord ischemia. The median follow up was 12 months (range 3-48), during which time one patient died of causes unrelated to aneurysm or treatment. Two early re-interventions were performed in the arch group to correct access vessel complications and there were a further two late re-interventions in the TAAA group to treat endoleaks. All target vessels (n = 72) remained patent. CONCLUSIONS This experience indicates that complex endovascular repair of post-dissection aneurysms is a viable alternative to open repair in patients deemed unfit for open surgery. There are insufficient data to allow comparison with the outcome of open surgery in anatomically similar, but fit, patients.
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Affiliation(s)
- R Spear
- Aortic Center, Hôpital Cardiologique, CHRU Lille, France
| | - J Sobocinski
- Aortic Center, Hôpital Cardiologique, CHRU Lille, France
| | | | | | | | - B Maurel
- Aortic Center, Hôpital Cardiologique, CHRU Lille, France
| | - S Haulon
- Aortic Center, Hôpital Cardiologique, CHRU Lille, France.
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25
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Virvilis D, Eagleton MJ. Endovascular treatment of the aortic arch. Interv Cardiol 2015. [DOI: 10.2217/ica.15.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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26
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Idrees JJ, Roselli EE, Wojnarski CM, Feng K, Aftab M, Johnston DR, Soltesz EG, Sabik JF, Svensson LG. Prophylactic stage 1 elephant trunk for moderately dilated descending aorta in patients with predominantly proximal disease. J Thorac Cardiovasc Surg 2015; 150:1150-5. [PMID: 26433635 DOI: 10.1016/j.jtcvs.2015.07.077] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 07/14/2015] [Accepted: 07/22/2015] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Staged elephant trunk (ET) repair is a commonly performed procedure for extensive aortic disease. A significant proportion of patients with predominantly proximal aortic pathology often have in addition a moderately dilated descending aorta (<5 cm) that can progress over time. Objectives were to characterize patients, determine completion rate after prophylactic stage 1 ET, and assess outcomes. METHODS From 1992 to 2012, a total of 572 patients underwent stage 1 ET for degenerative aneurysm and dissection at Cleveland Clinic. Prophylactic stage 1 ET was performed in 117 (20.5%) who had predominantly proximal disease (5.5 ± 1 cm) with moderate dilation of the descending aorta (4 ± 0.6 cm). Aortic pathology included: aneurysm (n = 56 [48%]); chronic dissection (n = 41 [35%]); pseudoaneurysm (n = 9 [7.7%]); penetrating ulcer (n = 9 [7.7%]); and intramural hematoma (n = 2 [1.7%]). Other diagnoses included connective tissue disorder (12 [10%]); aortitis (20 [17%]); bicuspid aortic valve (9 [7.6%]); and previous type A dissection repair (27 [23%]). RESULTS Operative mortality was 0.8% (1 of 117). This patient suffered postoperative myocardial infarction and mesenteric ischemia, resulting in sepsis and death. Other complications included: stroke (n = 7 [6%]); tracheostomy (n = 6 [5%]); renal dialysis (n = 4 [3.3%]); and reoperation for bleeding (n = 7 [6%]). The mean follow-up time was 4 ± 3 years. Fifty-three (45%) patients completed the stage 2 ET (open: 20 [38%]; endovascular: 33 [62%]) at a median interval of 6 months (9 days-10 years). The mean descending diameter increased from 4.1 ± 0.6 cm to 5 ± 1 cm at the time of stage 2 completion. In 11 patients, stage 2 was performed for acute aortic events. Estimated survival at 1, 5, and 8 years was 94%, 88%, and 74%, respectively. CONCLUSIONS Prophylactic ET for moderately dilated descending aorta is an effective strategy for staged repair, especially in patients with chronic dissection, connective tissue disorder, and aortitis. In addition, this approach can be beneficial for emergency treatment of late distal aortic complications.
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Affiliation(s)
- Jay J Idrees
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Charles M Wojnarski
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ke Feng
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Muhammad Aftab
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joseph F Sabik
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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27
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Wheatley GH. Eskimos, elephants, and endovascular: Body floss technique for hybrid arch procedures. J Thorac Cardiovasc Surg 2015; 150:252-3. [PMID: 25960072 DOI: 10.1016/j.jtcvs.2015.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 04/16/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Grayson H Wheatley
- Division of Cardiovascular Surgery, Temple University School of Medicine, Philadelphia, Pa.
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28
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Shrestha M, Bachet J, Bavaria J, Carrel TP, De Paulis R, Di Bartolomeo R, Etz CD, Grabenwöger M, Grimm M, Haverich A, Jakob H, Martens A, Mestres CA, Pacini D, Resch T, Schepens M, Urbanski PP, Czerny M. Current status and recommendations for use of the frozen elephant trunk technique: a position paper by the Vascular Domain of EACTS. Eur J Cardiothorac Surg 2015; 47:759-69. [DOI: 10.1093/ejcts/ezv085] [Citation(s) in RCA: 211] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 02/02/2015] [Indexed: 01/05/2023] Open
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29
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Anselmi A, Ruggieri VG, Harmouche M, Fouquet O, Kaladji A, Flécher E, Beneux X, Lucas A, Verhoye JP. Combined frozen elephant trunk and endovascular repair for extensive thoracic aortic aneurysms. Ann Vasc Surg 2015; 29:905-12. [PMID: 25728335 DOI: 10.1016/j.avsg.2014.12.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Revised: 12/03/2014] [Accepted: 12/16/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND We describe a 1-step treatment of extensive arch and descending aortic aneurysm by combination of frozen elephant trunk (FET) (hybrid endoprosthesis) and of conventional endoprosthesis deployment. METHODS In a single-center, prospective, treatment-only study, the clinical data of 4 patients receiving combined FET and distal endoprosthesis deployment in the descending aorta were prospectively collected. Thoracic endoprostheses were deployed either retrogradely (off-pump from the femoral arterial access) or antegradely (from the aortic arch during hypothermic arrest). A distal-first approach was used ("trombone" mechanism). Spinal cord protection was achieved by transposition of the left subclavian artery to the left common carotid artery and selective antegrade cerebral perfusion. Preoperative computed tomography scan was performed to identify the collateral circulation. Preoperative planning was assisted by a sizing software (Endosize, Therenva Inc.). RESULTS The aortic coverage was extended down to the orifice of the celiac trunk in one case and to the T8 level in the remainders. There was no operative mortality, 1 transient paraparesis, and 1 case of renal insufficiency. Follow-up results were satisfying (no device migration, no endoleak, no endotension, and no late neurologic complications). CONCLUSIONS The present strategy may abolish the risks connected with the waiting time between the surgical first step and the later completion (aortic-related adverse events and drop-out) and deserves further investigations to determine its safety and feasibility profile.
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Affiliation(s)
- Amedeo Anselmi
- Division of Cardiovascular and Thoracic Surgery, Pontchaillou University Hospital, Rennes, France; INSERM 1099 Research Unit, LTSI University of Rennes 1, Rennes, France
| | - Vito Giovanni Ruggieri
- Division of Cardiovascular and Thoracic Surgery, Pontchaillou University Hospital, Rennes, France; INSERM 1099 Research Unit, LTSI University of Rennes 1, Rennes, France
| | - Majid Harmouche
- Division of Cardiovascular and Thoracic Surgery, Pontchaillou University Hospital, Rennes, France; INSERM 1099 Research Unit, LTSI University of Rennes 1, Rennes, France
| | - Olivier Fouquet
- Division of Cardiac Surgery, Angers University Hospital, Angers, France
| | - Adrien Kaladji
- Division of Cardiovascular and Thoracic Surgery, Pontchaillou University Hospital, Rennes, France; INSERM 1099 Research Unit, LTSI University of Rennes 1, Rennes, France
| | - Erwan Flécher
- Division of Cardiovascular and Thoracic Surgery, Pontchaillou University Hospital, Rennes, France; INSERM 1099 Research Unit, LTSI University of Rennes 1, Rennes, France
| | - Xavier Beneux
- Division of Cardiac Anesthesia, Pontchaillou University Hospital, Rennes, France
| | - Antoine Lucas
- Division of Cardiovascular and Thoracic Surgery, Pontchaillou University Hospital, Rennes, France; INSERM 1099 Research Unit, LTSI University of Rennes 1, Rennes, France
| | - Jean-Philippe Verhoye
- Division of Cardiovascular and Thoracic Surgery, Pontchaillou University Hospital, Rennes, France; INSERM 1099 Research Unit, LTSI University of Rennes 1, Rennes, France.
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Tokuda Y, Oshima H, Narita Y, Abe T, Araki Y, Mutsuga M, Fujimoto K, Terazawa S, Yagami K, Ito H, Yamamoto K, Komori K, Usui A. Hybrid versus open repair of aortic arch aneurysms: comparison of postoperative and mid-term outcomes with a propensity score-matching analysis. Eur J Cardiothorac Surg 2015; 49:149-56. [DOI: 10.1093/ejcts/ezv063] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 01/23/2015] [Indexed: 11/14/2022] Open
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De Backer O, Lönn L, Søndergaard L. Combined surgical and catheter-based treatment of extensive thoracic aortic aneurysm and aortic valve stenosis. Catheter Cardiovasc Interv 2015; 85:E95-8. [PMID: 24989848 DOI: 10.1002/ccd.25592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 06/29/2014] [Indexed: 11/08/2022]
Abstract
An extensive thoracic aortic aneurysm (TAA) is a potentially life-threatening condition and remains a technical challenge to surgeons. Over the past decade, repair of aortic arch aneurysms has been accomplished using both hybrid (open and endovascular) and totally endovascular techniques. Thoracic endovascular aneurysm repair (TEVAR) has changed and extended management options in thoracic aorta disease, including in those patients deemed unfit or unsuitable for open surgery. Accordingly, transcatheter aortic valve replacement (TAVR) is increasingly used to treat patients with symptomatic severe aortic valve stenosis (AS) who are considered at high risk for surgical aortic valve replacement. In this report, we describe the combined surgical and catheter-based treatment of an extensive TAA and AS. To our knowledge, this is the first report of hybrid TAA repair combined with TAVR.
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Affiliation(s)
- Ole De Backer
- Department of Cardiology, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
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Castrovinci S, Murana G, de Maat GE, Smith T, Schepens MA, Heijmen RH, Morshuis WJ. The classic elephant trunk technique for staged thoracic and thoracoabdominal aortic repair: Long-term results. J Thorac Cardiovasc Surg 2015; 149:416-22. [DOI: 10.1016/j.jtcvs.2014.09.078] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 09/04/2014] [Accepted: 09/23/2014] [Indexed: 10/24/2022]
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Review of Molecular and Mechanical Interactions in the Aortic Valve and Aorta: Implications for the Shared Pathogenesis of Aortic Valve Disease and Aortopathy. J Cardiovasc Transl Res 2014; 7:823-46. [DOI: 10.1007/s12265-014-9602-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 10/30/2014] [Indexed: 01/08/2023]
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34
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Schoenhagen P, Hill A. Transcatheter aortic valve implantation and potential role of 3D imaging. Expert Rev Med Devices 2014; 6:411-21. [DOI: 10.1586/erd.09.18] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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35
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Raymond CE, Aggarwal B, Schoenhagen P, Kralovic DM, Kormos K, Holloway D, Menon V. Prevalence and factors associated with false positive suspicion of acute aortic syndrome: experience in a patient population transferred to a specialized aortic treatment center. Cardiovasc Diagn Ther 2014; 3:196-204. [PMID: 24400203 DOI: 10.3978/j.issn.2223-3652.2013.12.06] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 11/11/2013] [Indexed: 11/14/2022]
Abstract
STUDY OBJECTIVE Acute aortic syndrome (AAS) is a medical emergency that requires prompt diagnosis and treatment at specialized centers. We sought to determine the frequency and etiology of false positive activation of a regional AAS network in a patient population emergently transferred for suspected AAS. METHODS We evaluated 150 consecutive patients transferred from community emergency departments directly to our Cardiac Intensive Care Unit (CICU) with a diagnosis of suspected AAS between March, 2010 and August, 2011. A final diagnosis of confirmed acute Type A, acute Type B dissection, and false positive suspicion of dissection was made in 63 (42%), 70 (46.7%) and 17 (11.3%) patients respectively. RESULTS Of the 17 false positive transfers, ten (58.8%) were suspected Type A dissection and seven (41.2%) were suspected Type B dissection. The initial hospital diagnosis in 15 (88.2%) patients was made by a computed tomography (CT) scan and 10 (66.6%) of these patients required repeat imaging with an ECG-synchronized CT to definitively rule out AAS. Five (29.4%) patients had prior history of open or endovascular aortic repair. Overall in-hospital mortality was 9.3%. CONCLUSIONS The diagnosis of AAS is confirmed in most patients emergently transferred for suspected AAS. False positive activation in this setting is driven primarily by uncertainty secondary to motion-artifact of the ascending aorta and the presence of complex anatomy following prior aortic intervention. Network-wide standardization of imaging strategies, and improved sharing of imaging may further improve triage of this complex patient population.
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Affiliation(s)
- Chad E Raymond
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bhuvnesh Aggarwal
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Paul Schoenhagen
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Damon M Kralovic
- Emergency Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kristopher Kormos
- Emergency Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - David Holloway
- Emergency Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Venu Menon
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Roselli EE, Subramanian S, Sun Z, Idrees J, Nowicki E, Blackstone EH, Greenberg RK, Svensson LG, Lytle BW. Endovascular versus open elephant trunk completion for extensive aortic disease. J Thorac Cardiovasc Surg 2013; 146:1408-16; discussion 1416-7. [DOI: 10.1016/j.jtcvs.2013.07.070] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2010] [Revised: 07/15/2013] [Accepted: 07/30/2013] [Indexed: 12/01/2022]
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Hybrid total arch repair without deep hypothermic circulatory arrest for acute type A aortic dissection (R1). J Thorac Cardiovasc Surg 2013; 146:1393-8. [DOI: 10.1016/j.jtcvs.2012.09.041] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2012] [Revised: 07/02/2012] [Accepted: 09/13/2012] [Indexed: 11/21/2022]
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Holubec T, Raupach J, Dominik J, Vojácek J. "Elephant trunk" and endovascular stentgrafting--a hybrid approach to the treatment of extensive thoracic aortic aneurysm. ACTA MEDICA (HRADEC KRÁLOVÉ) 2013; 56:80-2. [PMID: 24069662 DOI: 10.14712/18059694.2014.28] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
A hybrid approach to elephant trunk technique for treatment of thoracic aortic aneurysms combines a conventional surgical and endovascular therapy. Compared to surgery alone, there is a presumption that mortality and morbidity is reduced. We present a case report of a 42-year-old man with a giant aneurysm of the entire thoracic aorta, significant aortic and tricuspid regurgitation and ventricular septum defect. The patient underwent multiple consecutive operations and interventions having, among others, finally replaced the entire thoracic aorta with the use of the hybrid elephant trunk technique.
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Affiliation(s)
- Tomás Holubec
- Department of Cardiac Surgery, Charles University in Prague, Faculty of Medicine and University Hospital, Hradec Králové, Czech Republic.
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Verhoye JP, Anselmi A, Kaladji A, Flécher E, Lucas A, Heautot JF, Beneux X, Fouquet O. Mid-term results of elective repair of extensive thoracic aortic pathology by the Evita Open Plus hybrid endoprosthesis only. Eur J Cardiothorac Surg 2013; 45:812-7. [PMID: 24071863 DOI: 10.1093/ejcts/ezt477] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To describe the early and mid-term clinical and instrumental results of the frozen elephant trunk (FET) procedure using the recent Evita Open Plus hybrid endoprosthesis for elective one-stage treatment of extensive thoracic aortic disease. METHODS We reviewed 16 patients undergoing FET for post-dissection aneurysm (50%), true aneurysm (31%) or other aetiologies (19%), through median sternotomy and hypothermic circulatory arrest. An average 14 ± 7.6-month follow-up with regular contrast-enhanced control computed tomography scans was available. Four patients received preliminary carotid-subclavian bypass to improve spinal cord protection. Distal extension through endovascular deployment of stent-grafts into the descending aorta was performed during the same procedure in 3 patients. Concomitant procedures on the ascending aorta/root were done in 25% of cases. RESULTS There were no cases of operative mortality. Cases of neither cerebral stroke nor postoperative paraplegia were observed. Two cases of transient paraparesis and 1 case of Brown-Séquard syndrome occurred. At follow-up, there were no cases of endoleak or endotension. One patient was reoperated for distal completion (thoracoabdominal aortic replacement). CONCLUSIONS The FET using the Evita Open Plus device is a reliable and versatile treatment for one-step management of extensive disease of the aortic arch and the descending aorta. This strategy should be reserved for patients having limited preoperative comorbidities and good functional status.
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Affiliation(s)
- Jean-Philippe Verhoye
- Department of Thoracic, Cardiac and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
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Vallabhajosyula P, Szeto WY, Desai N, Komlo C, Bavaria JE. Type II arch hybrid debranching procedure. Ann Cardiothorac Surg 2013; 2:378-86. [PMID: 23977611 DOI: 10.3978/j.issn.2225-319x.2013.05.08] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Accepted: 05/20/2013] [Indexed: 11/14/2022]
Abstract
Management of aortic arch aneurysm and dissection continues to evolve as endovascular options play an increasing role in treating thoracic aortopathies. Although conventional open treatment of aortic arch disease with total arch replacement still remains the gold standard, in patients with old age and/or high comorbid disease index, there is significant associated morbidity and mortality. The hybrid arch procedure, which aims to minimize cardiopulmonary bypass and circulatory arrest times, is a particularly appealing surgical option in this cohort of patients. The hybrid arch concept essentially entails three main principles: (I) open debranching of the great vessels; (II) creation of proper proximal (zone 0 landing) and distal landing zones, and; (III) concomitant or delayed endovascular stent grafting of the aortic arch. The classification scheme for hybrid arch debranching procedures is based on the extent of proximal and distal landing zone reconstruction required, and thus the need and extent of cardiopulmonary bypass and circulatory arrest management strategies to be employed. In this illustrated article, we describe the details of the type II hybrid arch debranching procedure, where the ascending aorta and aortic arch pathology is typically treated by reconstruction of ascending aorta ﹢ arch vessel debranching, with concomitant antegrade stent grafting of the aortic arch.
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Affiliation(s)
- Prashanth Vallabhajosyula
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
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41
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Elephant trunk technique for hybrid aortic arch repair. Gen Thorac Cardiovasc Surg 2013; 62:135-41. [PMID: 23943042 DOI: 10.1007/s11748-013-0299-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Indexed: 10/26/2022]
Abstract
The original elephant trunk technique was developed by Borst in 1983 for the treatment of aortic arch aneurysms. This technique reduced operative risks, but was associated with cumulative mortality rates of 6.9 % for the first stage and 7.5 % for the second stage. Patients also waited a long time between two major surgical procedures. Only 50.4 % of patients underwent the second-stage surgery, and there was a significant interval mortality rate of 10.7 %. With the advent of stent-graft techniques, two different hybrid elephant trunk techniques were developed. One technique is first-stage elephant trunk graft placement followed by second-stage endovascular completion. The conventional elephant trunk graft provides a good landing zone for the stent-graft, and endovascular completion is a useful alternative to conventional second-stage surgery. This method has few major complications, and a postoperative paraplegia rate of 1.1 %. The other technique is the frozen elephant trunk technique. This technique eliminates the need for subsequent endovascular completion, and is particularly useful for the treatment of acute type A dissection because it can achieve a secure seal. However, it is associated with a higher rate of spinal cord ischemia than other methods such as the original elephant trunk technique. The left subclavian artery (LSA) is often lost when performing a hybrid elephant trunk procedure. Revascularization of the LSA should be performed to prevent arm ischemia and neurological complications such as paraplegia or stroke, although the level of evidence for this recommendation is low.
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Svensson LG, Rushing GD, Valenzuela ES, Rafael AE, Batizy LH, Blackstone EH, Roselli EE, Gillinov AM, Sabik JF, Lytle BW. Modifications, Classification, and Outcomes of Elephant-Trunk Procedures. Ann Thorac Surg 2013; 96:548-58. [DOI: 10.1016/j.athoracsur.2013.03.082] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 03/13/2013] [Accepted: 03/18/2013] [Indexed: 11/15/2022]
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Abraham CZ, Lioupis C. RETRACTED: Treatment of aortic arch aneurysms with a modular transfemoral multibranched stent-graft: Initial experience. J Thorac Cardiovasc Surg 2013; 145:S110-7. [DOI: 10.1016/j.jtcvs.2012.11.064] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2012] [Accepted: 11/28/2012] [Indexed: 10/27/2022]
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Lin CH. Modified four-branched graft technique without circulatory arrest and antegrade thoracic endovascular aortic repair for extensive thoracic aorta reconstruction. Ann Thorac Surg 2013. [PMID: 23176962 DOI: 10.1016/j.athoracsur.2012.08.084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
A modified technique is described, using four-branched graft for proximal aortic repair without the need of deep hypothermic circulatory arrest, and simultaneously using antegrade stent-graft implantation for thoracic endovascular aortic repair of distal aorta in patients with extensive aortic aneurysm, acute type A aortic dissection, and chronic type B dissecting aneurysm. A good surgical field was obtained in 6 patients in this report, and no hospital mortality developed. The modified four-branched graft technique with no circulatory arrest provided good short-term outcome for proximal aorta repair, and the single-stage operation combined with antegrade thoracic endovascular aortic repair is feasible and effective to extend the repair down to the descending aorta.
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Affiliation(s)
- Chia-Hsun Lin
- Division of Cardiovascular Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.
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46
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Prescott-Focht JA, Martinez-Jimenez S, Hurwitz LM, Hoang JK, Christensen JD, Ghoshhajra BB, Abbara S. Ascending Thoracic Aorta: Postoperative Imaging Evaluation. Radiographics 2013; 33:73-85. [DOI: 10.1148/rg.331125090] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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47
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Mariani AW, Pêgo-Fernandes PM. Minimally invasive surgery: a concept already incorporated. SAO PAULO MED J 2013; 131:69-70. [PMID: 23657507 PMCID: PMC10871723 DOI: 10.1590/s1516-31802013000100015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 01/24/2013] [Accepted: 02/15/2013] [Indexed: 11/21/2022] Open
Affiliation(s)
- Alessandro Wasum Mariani
- IMD, PhD. Thoracic Surgeon, Instituto do Coração (InCor), Hospital das Clínicas (HC), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.
| | - Paulo Manuel Pêgo-Fernandes
- MD, PhD. Associate Professor, Discipline of Thoracic Surgery, Instituto do Coração (InCor), Hospital das Clínicas (HC), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.
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Systematic review of clinical outcomes in hybrid procedures for aortic arch dissections and other arch diseases. J Thorac Cardiovasc Surg 2012; 144:1286-300, 1300.e1-2. [DOI: 10.1016/j.jtcvs.2012.06.013] [Citation(s) in RCA: 141] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 05/20/2012] [Accepted: 06/08/2012] [Indexed: 11/21/2022]
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Andersen ND, Williams JB, Hanna JM, Shah AA, McCann RL, Hughes GC. Results with an algorithmic approach to hybrid repair of the aortic arch. J Vasc Surg 2012. [PMID: 23186868 DOI: 10.1016/j.jvs.2012.09.039] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Hybrid repair of the transverse aortic arch may allow for aortic arch repair with reduced morbidity in patients who are suboptimal candidates for conventional open surgery. We present our results with an algorithmic approach to hybrid arch repair, based on the extent of aortic disease and patient comorbidities. METHODS Between August 2005 and January 2012, 87 patients underwent hybrid arch repair by three principal procedures: zone 1 endograft coverage with extra-anatomic left carotid revascularization (zone 1; n = 19), zone 0 endograft coverage with aortic arch debranching (zone 0; n = 48), or total arch replacement with staged stented elephant trunk completion (stented elephant trunk; n = 20). RESULTS The mean patient age was 64 years, and the mean expected in-hospital mortality rate was 16.3% as calculated by the EuroSCORE II. Of operations, 22% (n = 19) were nonelective. Sternotomy, cardiopulmonary bypass, and deep hypothermic circulatory arrest were required in 78% (n = 68), 45% (n = 39), and 31% (n = 27) of patients to allow for total arch replacement, arch debranching, or other concomitant cardiac procedures, including ascending with or without hemiarch replacement in 17% (n = 8) of patients undergoing zone 0 repair. All stented elephant trunk procedures (n = 20) and 19% (n = 9) of zone 0 procedures were staged, with 41% (n = 12) of patients undergoing staged repair during a single hospitalization. The 30-day/in-hospital rates of stroke and permanent paraplegia or paraparesis were 4.6% (n = 4) and 1.2% (n = 1). Of 27 patients with native ascending aorta zone 0 proximal landing zone, three (11.1%) experienced retrograde type A dissection after endograft placement. The overall in-hospital mortality rate was 5.7% (n = 5); however, 30-day/in-hospital mortality increased to 14.9% (n = 13) owing to eight 30-day out-of-hospital deaths. Native ascending aorta zone 0 endograft placement was found to be the only univariate predictor of 30-day in-hospital mortality (odds ratio, 4.63; 95% confidence interval, 1.35-15.89; P = .02). Over a mean follow-up period of 28.5 ± 22.2 months, 13% (n = 11) of patients required reintervention for type 1A (n = 4), type 2 (n = 6), or type 3 (n = 1) endoleak. Kaplan-Meier estimates of survival at 1 year, 3 years, and 5 years were 73%, 60%, and 51%. CONCLUSIONS Hybrid aortic arch repair can be tailored to patient anatomy and comorbid status to allow complete repair of aortic pathology, frequently in a single stage, with acceptable outcomes. However, endograft placement in the native ascending aorta is associated with high rates of retrograde type A dissection and 30-day/in-hospital mortality and should be approached with caution.
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Affiliation(s)
- Nicholas D Andersen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Shahverdyan R, Gawenda M, Brunkwall J. Triple-barrel graft as a novel strategy to preserve supra-aortic branches in arch-TEVAR procedures: clinical study and systematic review. Eur J Vasc Endovasc Surg 2012; 45:28-35. [PMID: 23123094 DOI: 10.1016/j.ejvs.2012.09.023] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2012] [Accepted: 09/30/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To report our early experience with total endovascular repair of aortic-arch aneurysm using double chimney-grafts and present a literature overview. PATIENTS AND METHODS The double chimney-graft technique was performed in six male patients with contained ruptured aneurysm, dissecting aneurysm, pseudoaneurysm, penetrating aortic ulcer and proximal endoleak after TEVAR. Furthermore, a systematic electronic health database search of available articles was conducted according to PRISMA Guidelines. RESULTS In all cases, all supra-aortic vessels had to be covered with aortic stent-graft to receive a sufficient landing and sealing zone. Chimney-grafts were introduced to the ascending aorta slightly deeper than the thoracic stent-grafts through the cut-down exposure of the common carotid arteries. We deployed aortic stent-grafts and self-expandable chimney-grafts simultaneously and successfully. The patient with contained ruptured aneurysm died due to cardiopulmonary failure on day 19, the others survived. We detected two 'gutter' endoleaks. As a result of literature search, 12 articles met the inclusion criteria. Two articles described the double-chimney technique. CONCLUSIONS The use of double chimney-grafts is possible in high-risk patients where the proximal landing zone of endograft would be in zone 0. The available data is still limited. The long-term follow-up remains to be evaluated with the increased number of patients treated.
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Affiliation(s)
- R Shahverdyan
- Department of Vascular Surgery, University Hospital of Cologne, Kerpener Str. 62, D-50937 Cologne, Germany.
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