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Ulsaker H, Halvorsen H, Braaten AO, Dorenberg E, Rikken Lindberg B, Nordhus KC, Jakobsen Ø, Brekken R, Seternes A, Manstad-Hulaas F. Early and mid-term results after endovascular repair of thoracoabdominal aortic aneurysms using the off-the-shelf multibranched t-Branch device: a national multi-center study. SCAND CARDIOVASC J 2024; 58:2335906. [PMID: 38613333 DOI: 10.1080/14017431.2024.2335906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/24/2024] [Indexed: 04/14/2024]
Abstract
Objective: The multibranched off-the-shelf Zenith® t-Branch (Cook Medical, Bloomington, IN) device is commonly chosen for endovascular repair of thoracoabdominal aortic aneurysms. The aim of this study was to report early and mid-term outcomes in all patients treated with the t-Branch in Norway; Design and Methods: A retrospective multicenter study with Norwegian centers performing complex endovascular aortic repair was undertaken. T-Branch patients from 2014 to 2020 were included. All postoperative computed tomography angiography images were reviewed, and demographic, anatomical, perioperative and follow-up data were analyzed; Results: Seventy patients were treated in a single-step (n = 55) or staged (n = 15) procedure. Symptomatic presentation was seen in 20 patients, six of which had a contained rupture. Technical success was 87% (n = 59), with failures caused by unsuccessful bridging of target vessels (n = 4), target vessel bleeding (n = 3), persisting type 1c endoleak (n = 1) and t-Branch malrotation (n = 1). 30-day mortality was 9% (n = 6) and was associated with high BMI (p = .038). The spinal cord ischemia rate was 21% (n = 15) and was associated with type II aneurysms (OR 5.4, 95% CI 1.1-26.7, p = .04), smoking (OR 6.0, 95% CI 1.3-27.6, p = .02) and intraoperative blood loss (OR 1.1, 95% CI 1.0-1.3, p = .01). Survival at one, two and three years was 84 ± 4%, 70 ± 6% and 67 ± 6%, respectively. Freedom from aortic-related reinterventions at one, two and three years was 80 ± 5%, 65 ± 7% and 50 ± 8%, respectively; Conclusion: The study showed low early mortality (9%) and satisfactory mid-term survival. Technical success was achieved in acceptable 87% of procedures. The rate of spinal cord ischemia was high, occurring in 21% of patients.
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Affiliation(s)
- Håvard Ulsaker
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Norwegian National Research Centre for Minimally Invasive and Image-guided Diagnostics and Therapy, St. Olavs Hospital, Trondheim, Norway
| | | | | | - Eric Dorenberg
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | | | | | - Øyvind Jakobsen
- Department of Cardiothoracic and Vascular Surgery, University Hospital of North, Norway
| | - Reidar Brekken
- Norwegian National Research Centre for Minimally Invasive and Image-guided Diagnostics and Therapy, St. Olavs Hospital, Trondheim, Norway
- Department of Health Research, SINTEF, Trondheim, Norway
| | - Arne Seternes
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Surgery, St. Olavs University Hospital, Trondheim, Norway
| | - Frode Manstad-Hulaas
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Norwegian National Research Centre for Minimally Invasive and Image-guided Diagnostics and Therapy, St. Olavs Hospital, Trondheim, Norway
- Department of Radiology, St. Olavs University Hospital, Trondheim, Norway
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Köksoy C, Rebello KR, Green SY, Amarasekara HS, Moon MR, LeMaire SA, Coselli JS. Independent associations with early mortality after open repair of Crawford extent IV thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg 2024; 168:1-12.e2. [PMID: 36931557 DOI: 10.1016/j.jtcvs.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 02/14/2023] [Accepted: 03/06/2023] [Indexed: 03/19/2023]
Abstract
OBJECTIVE We aimed to identify outcomes and factors that independently associate with early mortality after open repair of Crawford extent IV thoracoabdominal aortic aneurysms, defined as aneurysms confined to the segment below the diaphragm. METHODS This retrospective analysis included 721 extent IV thoracoabdominal aortic aneurysm repairs performed in our institution from 1986 to 2021. Indications for repair were aneurysm without dissection in 627 cases (87.0%) and aortic dissection in 94 cases (13.0%). Overall, 466 patients (64.6%) were symptomatic preoperatively; 124 (17.2%) procedures were performed in patients with acute presentation, including 58 (8.0%) ruptured aneurysms. RESULTS Operative death occurred after 49 (6.8%) repairs. Persistent renal failure necessitating dialysis occurred after 43 (6.0%) repairs. Binary logistic regression modeling revealed that previous extent II thoracoabdominal aortic aneurysm repair, chronic kidney disease, previous myocardial infarction, urgent or emergency repair, and longer crossclamp times during surgery were independently associated with operative mortality. Among early survivors (n = 672), competing risk analysis revealed that cumulative incidence of mortality and reintervention rates at 10 years were 74.8% (95% confidence interval, 71.4%-78.5%) and 3.3% (95% confidence interval, 2.2%-5.1%), respectively. CONCLUSIONS Although patient comorbidities contributed to operative mortality, factors associated with the repair, such as urgent or emergency status, the duration of aortic crossclamping, and certain types of complex reoperation, also played prominent roles. Patients who survive the operation can expect a durable repair that usually is free from late reintervention. Expanding our collective knowledge regarding patients who undergo open repair of extent IV thoracoabdominal aortic aneurysms will enable clinicians to establish best practices and improve patient outcomes.
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Affiliation(s)
- Cuneyt Köksoy
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Kimberly R Rebello
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Hiruni S Amarasekara
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex.
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
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3
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Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K, Siepe M, Estrera AL, Bavaria JE, Pacini D, Okita Y, Evangelista A, Harrington KB, Kachroo P, Hughes GC. EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ. Ann Thorac Surg 2024; 118:5-115. [PMID: 38416090 DOI: 10.1016/j.athoracsur.2024.01.021] [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] [Indexed: 02/29/2024]
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany.
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria; Medical Faculty, Sigmund Freud Private University, Vienna, Austria.
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France; EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy; Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, Texas
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany; The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom; National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany; Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
| | - Matthias Siepe
- EACTS Review Coordinator; Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Anthony L Estrera
- STS Review Coordinator; Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Joseph E Bavaria
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Davide Pacini
- Division of Cardiac Surgery, S. Orsola University Hospital, IRCCS Bologna, Bologna, Italy
| | - Yutaka Okita
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Arturo Evangelista
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Vall d'Hebron Institut de Recerca, Barcelona, Spain; Biomedical Research Networking Center on Cardiovascular Diseases, Instituto de Salud Carlos III, Madrid, Spain; Departament of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain; Instituto del Corazón, Quirónsalud-Teknon, Barcelona, Spain
| | - Katherine B Harrington
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - Puja Kachroo
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Duke University, Durham, North Carolina
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Figueroa AV, Tanenbaum MT, Timaran CH, Oderich GS, Eagleton MJ, Schanzer A, Farber MA, Beck AW, Schneider DB, Gasper W, Sweet MP, Lee A, Cantor RS, Li X. Postdissection aortic aneurysm sac enlargement after fenestrated and branched endovascular aortic aneurysm repair. J Vasc Surg 2024:S0741-5214(24)01092-9. [PMID: 38909915 DOI: 10.1016/j.jvs.2024.04.066] [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: 04/14/2024] [Revised: 04/29/2024] [Accepted: 04/29/2024] [Indexed: 06/25/2024]
Abstract
OBJECTIVES Aneurysm sac changes after fenestrated-branched endovascular aneurysm repair (FBEVAR) for postdissection thoracoabdominal aortic aneurysms (PD-TAAs) are poorly understood. Partial thrombosis of the false lumen and endoleaks may impair sac regression. To characterize sac changes after FBEVAR for PD-TAAs, this study examined midterm results and predictors for sac enlargement. METHODS FBEVARs performed for PD-TAAs in 10 physician-sponsored investigational device exemption studies from 2008 to 2023 were analyzed. The maximum aortic aneurysm diameter was compared between the 30-day computed tomography angiogram and follow-up imaging studies. Aneurysm sac enlargement was defined as an increase in diameter of ≥5 mm. Kaplan-Meier curves and Cox regression were used to evaluate sac enlargement and midterm FBEVAR outcomes. RESULTS Among 3296 FBEVARs, 290 patients (72.4% male; median age, 68.4 years) were treated for PD-TAAs. Most aneurysms treated were extent II (72%) and III (12%). Mean aneurysm diameter was 66.5 ± 11.2 mm. Mortality at 30 days was 1.4%. At a mean follow-up of 2.9 ± 1.9 years, at least one follow-up imaging study revealed sac enlargement in 43 patients (15%), sac regression in 115 patients (40%), and neither enlargement nor regression in 137 (47%); 5 (2%) demonstrated both expansion and regression during follow-up. Freedom from aneurysm sac enlargement was 93%, 82%, and 80% at 1, 3, and 5 years, respectively. Overall, endoleaks were detected in 27 patients (63%) with sac enlargement and 143 patients (58%) without enlargement (P = .54). Sac enlargement was significantly more frequent among older patients (mean age at the index procedure, 70.2 ± 8.9 years vs 66.5 ± 11 years; P = .04) and those with type II endoleaks at 1 year (74% vs 52%; P = .031). Cox regression revealed age >70 years at baseline (hazard ratio [HR], 2.146; 95% confidence interval [CI], 1.167-3.944; P = .010) and presence of type II endoleak at 1 year (HR, 2.25; 95% CI, 1.07-4.79; P = .032) were independent predictors of sac enlargement. Patient survival was 92%, 81%, and 68% at 1, 3, and 5 years, respectively. Cumulative target vessel instability was 7%, and aneurysm-related mortality was 2% at 5 years. At least 42% of patients required secondary interventions. Sac enlargement did not affect patient survival. CONCLUSIONS Aneurysm sac enlargement occurs in 15% of patients after FBEVAR for PD-TAAs. Elderly patients (>70 years at baseline) and those with type II endoleaks at 1 year may need closer monitoring and secondary interventions to prevent sac enlargement. Despite sac enlargement in some patients, aneurysm-related mortality at 5 years remains low and overall survival was not associated with sac enlargement.
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Affiliation(s)
- Andres V Figueroa
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Mira T Tanenbaum
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Carlos H Timaran
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
| | - Gustavo S Oderich
- Division of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andres Schanzer
- Division of Vascular and Endovascular Surgery, University of Massachusetts Memorial Hospital, Worcester, MA
| | - Mark A Farber
- Division of Vascular Surgery, University of North Carolina, Chapel Hill, NC
| | - Adam W Beck
- Division of Vascular and Endovascular Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Darren B Schneider
- Division of Vascular and Endovascular Surgery, University of Pennsylvania, Philadelphia, PA
| | - Warren Gasper
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA
| | - Matthew P Sweet
- Division of Vascular and Endovascular Surgery, University of Washington, Seattle, WA
| | - Anthony Lee
- Division of Vascular Surgery, Boca Raton Regional Hospital, Boca Raton, FL
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Piazza M, Squizzato F, Ferri M, Pratesi G, Gatta E, Orrico M, Giudice R, Antonello M. Outcomes of off-the-shelf preloaded inner branch device for urgent endovascular Thoraco-Abdominal Aortic repair in the ItaliaN Branched Registry of E-nside EnDograft. J Vasc Surg 2024:S0741-5214(24)01235-7. [PMID: 38908806 DOI: 10.1016/j.jvs.2024.05.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/21/2024] [Accepted: 05/28/2024] [Indexed: 06/24/2024]
Abstract
OBJECTIVES To report the outcomes of endovascular urgent thoracoabdominal aortic (TAAA) repair, using an off-the-shelf preloaded inner branch device (E-nside, Artivion - Kennesaw, GA - USA). METHODS Data from a physician-initiated national multicenter registry, including patients treated with E-nside endograft (INBREED) were prospectively collected (2020-2024); only urgent cases were included in this study. Primary outcomes were technical success and mortality at 30 days. Secondary outcomes were spinal cord ischemia rate, stroke rate, major adverse events (MAE) as also branch instability at 12 months. RESULTS Of 185 patients enrolled in the INBREED, 64 (34.5%) were treated in a urgent setting and were included in the study. Reason for urgent repair was presence of aneurysm-related symptoms in 31 (48.4%) patients, a contained rupture in 8 (12.5%), and a large aneurysm >80 mm in 25 (39.1%). Extent of repair was I-III in 32 patients (50% and IV in 32 (50%); 18 (28%) had a narrow (<25 mm) paravisceral aortic lumen. An adjunctive proximal thoracic endograft was deployed in 29 patients (45.3%); a distal bifurcated abdominal endograft was used in 33 (51.5%). Two-hundred-forty-nine (97.2%) target vessels were successfully incorporated through an inner branch from an upper arm (81.2%) or femoral (18.8%) access. A balloon expandable stent was used in 184 (75.7%) target vessels, a self expandable stent in 59 (24.3%). Mean time for target vessel bridging was 39.9±28.4 min per target vessel. Thirty-days cumulative MAE rate was 28% and mortality occurred in 5 patients (9.1%). There were 1 postoperative stroke (1.6%) and SCI rate was 8% (n=5). For the 249 target vessels successfully incorporated through an inner branch, one-year freedom from target vessel instability was 93±3% after 1 year. CONCLUSION The E-nside represents a valid solution for the urgent treatment of TAAAs, including symptomatic and ruptured TAAAs, as well as large asymptomatic TAAAs that cannot wait for a custom-made device. The preloaded inner branches and available proximal and distal graft diameters might be useful in urgent settings, and provided satisfactory early and 1-year results, in terms of both endograft and target vessel stability. Further studies are required to assess the clinical role of E-nside for urgent TAAA repair.
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Affiliation(s)
- Michele Piazza
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
| | - Francesco Squizzato
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Michelangelo Ferri
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Giovanni Pratesi
- Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Emanuele Gatta
- Vascular and Endovascular Surgery Unit, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Matteo Orrico
- Department of Vascular Surgery, Ospedale San Camillo-Forlanini, Rome, Italy
| | - Rocco Giudice
- Vascular and Endovascular Surgery Unit, San Giovanni Addolorata Hospital, Rome, Italy
| | - Michele Antonello
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
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Vigezzi GP, Barbati C, Blandi L, Guddemi A, Melloni A, Salvati S, Bertoglio L, Odone A. Efficacy and Safety of Endovascular Fenestrated and Branched Grafts Versus Open Surgery in Thoracoabdominal Aortic Aneurysm Repair: An Updated Systematic Review, Meta-analysis, and Meta-regression. Ann Surg 2024; 279:961-972. [PMID: 38214159 DOI: 10.1097/sla.0000000000006190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
OBJECTIVE To provide an updated systematic review and meta-analysis with meta-regression of efficacy and safety of fenestrated/branched endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) compared with open repair. BACKGROUND Endovascular repair of TAAAs may be a promising alternative to open surgery by reducing invasiveness and expanding the eligible population, but evidence remains limited. METHODS We applied "Prepared Items for Systematic Reviews and Meta-analysis" guidelines to retrieve, quantitatively pool, and critically evaluate the efficacy and safety (including 30-day mortality, reintervention, spinal cord injury [SCI], and renal injury) of both approaches. Original studies were retrieved from PubMed, Embase, and Cochrane Library until April 20, 2022, excluding papers reporting <10 patients. Pooled proportions and means were determined using a random-effect model. Heterogeneity between studies was evaluated with I2 statistics. RESULTS Sixty-four studies met the predefined inclusion criteria. Endovascular cohort patients were older and had higher rates of comorbidities. Endovascular repair was associated with similar proportions of mortality (0.07, 95% confidence intervals [CI]: 0.06-0.08) compared with open repair (0.09, 95% CI: 0.08-0.12; P = 0.22), higher proportions of reintervention (0.19, 95% CI: 0.13-0.26 vs 0.06, 95% CI: 0.04-0.10; P < 0.01), similar proportions of transient SCI (0.07, 95% CI: 0.05-0.09 vs 0.06, 95% CI: 0.05-0.08; P = 0.28), lower proportions of permanent SCI (0.04, 95% CI: 0.03-0.05 vs 0.06, 95% CI: 0.05-0.07; P < 0.01), and renal injury (0.08, 95% CI: 0.06-0.10 vs 0.13, 95% CI: 0.09-0.17; P = 0.02). Results were affected by high heterogeneity and potential publication bias. CONCLUSIONS Despite these limitations and the lack of randomized trials, this meta-analysis suggests that endovascular TAAA repair could be a safer alternative to the open approach.
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Affiliation(s)
- Giacomo Pietro Vigezzi
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
- Collegio Ca' della Paglia, Fondazione Ghislieri, Pavia, Italy
| | - Chiara Barbati
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Lorenzo Blandi
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Annalisa Guddemi
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Andrea Melloni
- Department of Surgical and Clinical Sciences, Division of Vascular Surgery, University of Brescia, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Simone Salvati
- Division of Vascular Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Luca Bertoglio
- Department of Surgical and Clinical Sciences, Division of Vascular Surgery, University of Brescia, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Anna Odone
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
- HTA Committee, IRCCS San Raffaele Hospital, Milan, Italy
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Fan EY, Schanzer A, Beck AW, Eagleton MJ, Farber MA, Gasper WJ, Lee WA, Oderich GS, Parodi FE, Schneider DB, Sweet MP, Timaran CH, Simons JP. Practice patterns of antiplatelet and anticoagulant therapy after fenestrated/branched endovascular aortic repair. J Vasc Surg 2024:S0741-5214(24)01220-5. [PMID: 38796031 DOI: 10.1016/j.jvs.2024.05.041] [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: 12/27/2023] [Revised: 04/02/2024] [Accepted: 05/20/2024] [Indexed: 05/28/2024]
Abstract
OBJECTIVE Antiplatelet and/or anticoagulant therapy are commonly prescribed after fenestrated/branched endovascular aortic repair (F/BEVAR). However, the optimal regimen remains unknown. We sought to characterize practice patterns and outcomes of antiplatelet and anticoagulant use in patients who underwent F/BEVAR. METHODS Consecutive patients enrolled (2012-2023) as part of the United States Aortic Research Consortium (US-ARC) from 10 independent physician-sponsored investigational device exemption studies were evaluated. The cohort was characterized by medication regimen on discharge from index F/BEVAR: (1) Aspirin alone OR P2Y12 alone (single-antiplatelet therapy [SAPT]); (2) Anticoagulant alone; (3) Aspirin + P2Y12 (dual-antiplatelet therapy [DAPT]); (4) Aspirin + anticoagulant OR P2Y12 + anticoagulant (SAPT + anticoagulant); (5) Aspirin + P2Y12 + anticoagulant (triple therapy [TT]); and (6) No therapy. Kaplan-Meier analysis and Cox proportional hazards modeling were used to compare 1-year outcomes including survival, target artery patency, freedom from bleeding complication, freedom from all reinterventions, and freedom from stent-specific reintervention. RESULTS Of the 1525 patients with complete exposure and outcome data, 49.6% were discharged on DAPT, 28.8% on SAPT, 13.6% on SAPT + anticoagulant, 3.2% on TT, 2.6% on anticoagulant alone, and 2.2% on no therapy. Discharge medication regimen was not associated with differences in 1-year survival, bleeding complications, composite reintervention rate, or stent-specific reintervention rate. However, there was a significant difference in 1-year target artery patency. On multivariable analysis comparing with SAPT, DAPT conferred a lower hazard of loss of target artery patency (hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.27-0.84; P = .01). On sub-analyses of renal stents alone or visceral stents alone, DAPT no longer had a significantly lower hazard of loss of target artery patency (renal: HR, 0.66; 95% CI, 0.35-1.27; P = .22; visceral: HR, 0.31; 95% CI, 0.05-1.9; P = .21). Lastly, duration of DAPT therapy (1 month, 6 months, or 1 year) did not significantly affect target artery patency. CONCLUSIONS Practice patterns for antiplatelet and anticoagulant regimens after F/BEVAR vary widely across the US-ARC. There were no differences in bleeding complications, survival or reintervention rates among different regimens, but higher branch vessel patency was noted in the DAPT cohort. These data suggest there is a benefit in DAPT therapy. However, the generalizability of this finding is limited by the retrospective nature of this data, and the clinical significance of this finding is unclear, as there is no difference in survival, bleeding, or reintervention rates amongst the different regimens. Hence, an "optimal" regimen, including the duration of such regimen, could not be clearly discerned. This suggests equipoise for a randomized trial, nested within this cohort, to identify the most effective antiplatelet/anticoagulant regimen for the growing number of patients being treated globally with F/BEVAR.
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8
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Raulli SJ, Gomes VC, Parodi FE, Vasan P, Sun D, Marston WA, Pascarella L, McGinigle KL, Wood JC, Farber MA. Five-year outcomes of fenestrated and branched endovascular repair of complex aortic aneurysms based on aneurysm extent. J Vasc Surg 2024:S0741-5214(24)00959-5. [PMID: 38608964 DOI: 10.1016/j.jvs.2024.04.017] [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: 01/29/2024] [Revised: 03/31/2024] [Accepted: 04/04/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVE The aim of this study was to evaluate the 5-year outcomes of fenestrated/branched endovascular aortic repair (F/BEVAR) for the treatment of complex aortic aneurysms stratified by the aneurysm extent. METHODS Patients with the diagnosis of complex aortic aneurysm, who underwent F/BEVAR at a single center were included in this study and retrospectively analyzed. The cohort was divided according to the aneurysm extent, comparing group 1 (types I-III thoracoabdominal aneurysms [TAAAs]), group 2 (type IV TAAAs), and group 3 (juxtarenal [JRAAs], pararenal [PRAAs], or paravisceral [PVAAs] aortic aneurysms). The primary endpoints were 30-day and 5-year survival. The secondary endpoints were technical success, occurrence of spinal cord ischemia, primary patency of the visceral arteries, freedom from target vessel instability, and secondary interventions. RESULTS Of 436 patients who underwent F/BEVAR between July 2012 and May 2023, 131 presented with types I to III TAAAs, 69 with type IV TAAAs, and 236 with JRAAs, PRAAs, or PVAAs. All cases were treated under a physician-sponsored investigational device exemption protocol with a patient-specific company-manufactured or off-the-shelf device. Group 1 had significantly younger patients than group 2 or 3 respectively (69.6 ± 8.7 vs 72.4 ± 7.1 vs 73.2 ± 7.3 years; P < .001) and had a higher percentage of females (50.4% vs 21.7% vs 17.8%; P < .001). Prior history of aortic dissection was significantly more common among patients in group 1 (26% vs 1.4% vs 0.9%; P < .001), and mean aneurysm diameter was larger in group 1 (64.5 vs 60.7 vs 63.2 mm; P = .033). Comorbidities were similar between groups, except for coronary artery disease (P < .001) and tobacco use (P = .003), which were less prevalent in group 1. Technical success was similar in the three groups (98.5% vs 98.6% vs 98.7%; P > .99). The 30-day mortality was 4.5%, 1.4%, and 0.4%, in groups 1, 2, and 3, respectively, and was significantly higher in group 1 when compared with group 3 (P = .01). The incidence of spinal cord ischemia was significantly higher in group 1 compared with group 3 (5.3% vs 4.3% vs 0.4%; P = .004). The 5-year survival was significantly higher in group 3 when compared with group 1 (P = .01). Freedom from secondary intervention was significantly higher in group 3 when compared with group 1 (P = .003). At 5 years, there was no significant difference in freedom from target vessel instability between groups or primary patency in the 1652 target vessels examined. CONCLUSIONS Larger aneurysm extent was associated with lower 5-year survival, higher 30-day mortality, incidence of secondary interventions, and spinal cord ischemia. The prevalence of secondary interventions in all groups makes meticulous follow-up paramount in patients with complex aortic aneurysm treated with F/BEVAR.
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Affiliation(s)
- Stephen J Raulli
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC.
| | - Vivian Carla Gomes
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - F Ezequiel Parodi
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Priya Vasan
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Dichen Sun
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - William A Marston
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Luigi Pascarella
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Katharine L McGinigle
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Jacob C Wood
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Mark A Farber
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
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Branzan D, Geisler A, Steiner S, Scheinert D, Funk K, Schmidt A. Endovascular occlusion of segmental arteries feeding the anterior spinal artery to stage endovascular thoracoabdominal aortic repair. JTCVS OPEN 2024; 18:1-8. [PMID: 38690411 PMCID: PMC11056496 DOI: 10.1016/j.xjon.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 01/23/2024] [Accepted: 02/07/2024] [Indexed: 05/02/2024]
Abstract
Objective Minimally invasive segmental artery coil embolization was introduced to prevent spinal cord ischemia after endovascular repair of thoracoabdominal aortic aneurysms. There is no consensus on whether the endovascular occlusion of segmental arteries feeding directly the anterior radiculomedullary artery and anterior spinal artery can be safely performed without causing spinal cord ischemia. Our aim was to investigate the feasibility and clinical impact of endovascular occlusion of segmental arteries supplying the anterior spinal artery during minimally invasive segmental artery coil embolization in patients with thoracoabdominal aortic aneurysms. Methods Between January 2018 and July 2020, 54 patients (36 male; mean age, 71.1 ± 9.3 years) underwent direct embolization of segmental arteries feeding the anterior radiculomedullary artery before endovascular repair of thoracoabdominal aortic aneurysms. End points included technical success of minimally invasive segmental artery coil embolization of segmental arteries, anterior radiculomedullary artery, neurological complications, and in-hospital mortality after minimally invasive segmental artery coil embolization and endovascular repair of thoracoabdominal aortic aneurysms. Results The thoracoabdominal aortic aneurysm classification was type I (n = 8), type II (n = 24), type III (n = 11), and type IV (n = 11). During minimally invasive segmental artery coil embolization, 388 segmental arteries were occluded, each patient having 7.2 ± 3.1 coiled segmental arteries occluding 64.5% (25-100%) of open segmental arteries within the treated aortic segment. Altogether, 66 anterior radiculomedullary arteries were seen originating between Th8 and L3 levels from 85 (21.9%) segmental arteries. In 10 patients (18.5%), 2 large anterior radiculomedullary arteries were identified, and 1 patient (1.9%) showed 3 anterior radiculomedullary arteries on the spinal arteriography. No spinal cord ischemia or procedure-related complications occurred after minimally invasive segmental artery coil embolization. After 47.9 ± 39.4 days, all patients received endovascular repair of their thoracoabdominal aortic aneurysms. There was no in-hospital mortality. One male patient developed incomplete temporary spinal cord ischemia after endovascular repair. Conclusions Minimally invasive segmental artery coil embolization of segmental arteries feeding the anterior spinal artery in patients with thoracoabdominal aortic aneurysms to prevent spinal cord ischemia after endovascular repair is feasible and clinically safe.
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Affiliation(s)
- Daniela Branzan
- Department of Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
- Helmholtz Institute for Metabolic, Obesity and Vascular Research (HI-MAG) of the Helmholtz Zentrum München at the University of Leipzig and University Hospital Leipzig, Leipzig, Germany
| | - Antonia Geisler
- Department of Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Sabine Steiner
- Helmholtz Institute for Metabolic, Obesity and Vascular Research (HI-MAG) of the Helmholtz Zentrum München at the University of Leipzig and University Hospital Leipzig, Leipzig, Germany
- Division of Interventional Angiology, Department of Internal Medicine, Neurology and Dermatology, University Hospital Leipzig, Leipzig, Germany
| | - Dierk Scheinert
- Division of Interventional Angiology, Department of Internal Medicine, Neurology and Dermatology, University Hospital Leipzig, Leipzig, Germany
| | - Katharina Funk
- Department of Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Andrej Schmidt
- Division of Interventional Angiology, Department of Internal Medicine, Neurology and Dermatology, University Hospital Leipzig, Leipzig, Germany
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10
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O'Donnell TFX, Dansey KD, Patel VI, Beck AW, Zettervall SL, Schermerhorn ML. Outcomes of Staged Repairs of Complex Endovascular Repairs of Thoracoabdominal Aortic Aneurysms. Ann Vasc Surg 2024; 101:62-71. [PMID: 38154495 DOI: 10.1016/j.avsg.2023.10.031] [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: 09/27/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Endovascular treatment allows for the staging of thoracoabdominal aortic aneurysm repairs (eTAAAs) in an effort to decrease the risk of spinal cord ischemia (SCI), but data are limited. METHODS We studied all eTAAAs in the Vascular Quality Initiative from 2014 to 2021. Inverse probability weighting was used to compare perioperative and long-term outcomes of staged and single-stage repairs. Thoracoabdominal life-altering events (TALEs) are the composite endpoint consisting of death/stroke/permanent SCI/permanent dialysis. RESULTS There were 3,258 total operations during the study period. In total, 841 cases (26%) were staged repairs, and 2,417 (74%) were completed in a single stage, but in the cohort of patients with extensive aneurysms, 44% were staged. Staging methods included thoracic endograft (78%), branch (23%), and iliac (5%). Staged repairs were more often employed by high-volume surgeons at high-volume centers; for larger, more extensive aneurysms, with higher rates of prior aortic surgery. After adjustment, staged repair and single-stage treatment were associated with similar odds of all perioperative outcomes and including mortality, TALE, acute kidney injury, stroke, dialysis, and SCI, as well as long-term survival. This was consistent in the subgroups of patients with extensive aneurysms undergoing elective procedures. Of note, first-stage thoracic endografts were associated with 2.6% mortality, 7.3% TALE, 1.5% dialysis, and 4.1% SCI, and 25% of patients did not undergo a second stage. First-stage procedures accounted for one-third of perioperative complications including half of the deaths in the staged cohort. CONCLUSIONS Staged eTAAA repairs were associated with similar perioperative and long-term complications to single-stage treatments. However, first stage procedures are associated with significant morbidity and mortality, and one-quarter of patients never complete their repairs. These data demonstrate the necessity of evaluating the outcomes of all patients planned for staged procedures, not only those who make it to the final stage. More data are needed as to the optimal method of spinal cord protection for these challenging aneurysms.
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Affiliation(s)
- Thomas F X O'Donnell
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian/Columbia University Irving Medical Center/Columbia University Vagelos College of Physicians & Surgeons, New York, NY.
| | - Kirsten D Dansey
- Division of Vascular and Endovascular Surgery, University of Washington, Seattle WA
| | - Virendra I Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian/Columbia University Irving Medical Center/Columbia University Vagelos College of Physicians & Surgeons, New York, NY
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, University of Washington, Seattle WA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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11
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Adam DJ, Juszczak M, Vezzosi M, Claridge M, Quinn D, Senanayake E, Clift P, Mascaro J. The Complementary Roles of Open and Endovascular Repair of Extent I - III Thoraco-abdominal Aortic Aneurysms in a United Kingdom Aortic Centre. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00190-4. [PMID: 38403184 DOI: 10.1016/j.ejvs.2024.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 02/07/2024] [Accepted: 02/22/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVE A multidisciplinary approach offering both open surgical repair (OSR) and complex endovascular aortic repair (cEVAR) is essential if patients with thoraco-abdominal aortic aneurysms (TAAAs) are to receive optimal care. This study reports early and midterm outcomes of elective and non-elective OSR and cEVAR for extent I - III TAAA in a UK aortic centre. METHODS Retrospective study of consecutive patients treated between January 2009 and December 2021. Primary endpoint was 30 day/in hospital mortality. Secondary endpoint was Kaplan-Meier estimates of midterm survival. Data are presented as median (interquartile range [IQR]). RESULTS In total, 296 patients (176 men; median age 71 years [IQR 65, 76]; median aneurysm diameter 66 mm [IQR 61, 75]) underwent repair (222 elective, 74 non-elective). OSR patients (n = 66) were significantly younger with a higher incidence of heritable disease and chronic dissection, while cEVAR patients (n = 230) had a significantly higher prevalence of coronary, pulmonary, and renal disease. Overall, in hospital mortality after elective and non-elective repair was 3.2% (n = 7) and 23.0% (n = 17), respectively, with no significant difference between treatment modalities (elective OSR 6.5% vs. cEVAR 2.3%, p = .14; non-elective OSR 25.0% vs. cEVAR 20.3%, p = .80). Major non-fatal complications occurred in 15.3% (33/215) after elective repair (OSR 39.5%, 17/43, vs. cEVAR 9.3%, 16/172; p < .001) and 14% (8/57) after non-elective repair (OSR 26.7%, 4/15, vs. cEVAR 9.5%, 4/42; p = .19). Median follow up was 52 months (IQR 23, 78). Estimated survival ± standard error at 1, 3, and 5 years for the entire cohort was 89.6 ± 2.0%, 76.6 ± 2.9%, and 69.0% ± 3.2% after elective repair, and 67.6 ± 5.4%, 52.1 ± 6.0%, and 41.0 ± 6.2% after non-elective repair. There was no difference in 5 year survival comparing modalities after elective repair for patients younger than 70 years and those with post-dissection aneurysms. CONCLUSION A multidisciplinary approach offering OSR and cEVAR can deliver comprehensive care for extent I - III TAAA with low early mortality and good midterm survival. Further studies are required to determine the optimal complementary roles of each treatment modality.
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Affiliation(s)
- Donald J Adam
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Maciej Juszczak
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Massimo Vezzosi
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Martin Claridge
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - David Quinn
- Department of Cardiac Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Eshan Senanayake
- Department of Cardiac Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Paul Clift
- Department of Cardiac Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jorge Mascaro
- Department of Cardiac Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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12
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Mahmood DN, Rocha R, Ouzounian M, Teng Tan K, Forbes SM, Chung JCY, Lindsay TF. Thoracoabdominal Aortic Aneurysm Repair Using Fenestrated and Branched Endovascular Grafts for High-Risk Patients: Evolving yet Safe. J Endovasc Ther 2024:15266028241229005. [PMID: 38339966 DOI: 10.1177/15266028241229005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
PURPOSE The purpose was to investigate outcomes of high-risk patients undergoing thoracoabdominal aortic aneurysm (TAAA) repair using fenestrated or branched endovascular aneurysm repair (F/BEVAR) devices at a single center in Canada. MATERIALS AND METHODS A retrospective review of all patients undergoing endovascular TAAA repair with F/BEVAR from June 2007 to July 2020. Imaging and clinical endpoints of interest including death, reintervention, and target vessel patency were reported. RESULTS Ninety-five consecutive patients underwent endovascular TAAA repair using F/BEVAR stent grafts (63 males, median age 74 [interquartile range 70, 78] years). Repairs included 81 elective and 14 urgent/emergent cases (6 ruptures and 8 symptomatic). Graft deployment was 100% successful. Intraoperative target vessel revascularization was successful in 336/355 (94.6%) vessels with the celiac having the lowest success rate 72/82 (87.8%). In-hospital mortality was 9.5% (7.4% elective and 21.4% urgent/emergent, p=0.125) and permanent paraplegia was 4.2% (3.7% elective and 7.1% urgent/emergent, p=0.458). In-hospital complications included stroke in 5.3%, acute myocardial infarction in 8.4%, and bowel ischemia in 5.3%. No patients required permanent dialysis or tracheostomy during their hospital stay. However, 22 (23.2%) patients required additional unplanned procedures for various indications (branch occlusion, endoleaks, realignment) during their hospital stay. Patients were followed up for a mean of 3.6 ± 3.0 years. Clinical follow-up was 100%, with 80/86 (93%) having surveillance imaging. On follow-up imaging, 43 (50%) patients had at least 1 endoleak identified and 337/341 (98.8%) of the target vessels were found to be patent. At 5 years, cumulative probability of reintervention was 46.3% (95% confidence interval [CI], 36.1-56.4). Survival at 5 and 8 years was 50.1% (95% CI, 38.4-65.4) and 34.4% (95% CI, 22.5-52.8), respectively. Progression of aneurysmal disease leading to rupture on follow-up was confirmed in 1 patient at 10 years. CONCLUSION Endovascular TAAA repair provides a safe treatment option with a high technical success rate and low pulmonary and renal complications. Long-term survival is similar to previous literature; however, high rates of secondary reintervention reaffirm the need for ongoing patient follow-up and further technical improvements. CLINICAL IMPACT This study demonstrates that endovascular repair of TAAAs can be performed in a high-risk elderly population with acceptable rates of mortality, TALE and SCI, using evolving technology. The incidences of post-operative respiratory failure and renal dysfunction were lower in patients who underwent endovascular repair compared with open repair. Future technical and procedural refinements in addition to increasing surgical experience are expected to lead to further improvements in short- and long-term outcomes exceeding those of open repair.
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Affiliation(s)
- Daniyal N Mahmood
- Division of Vascular Surgery, Department of Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Rodolfo Rocha
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Kong Teng Tan
- Division of Interventional Radiology, Toronto General Hospital, Toronto, ON, Canada
| | - Samantha M Forbes
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jennifer C-Y Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Department of Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
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Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K. EACTS/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ. Eur J Cardiothorac Surg 2024; 65:ezad426. [PMID: 38408364 DOI: 10.1093/ejcts/ezad426] [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: 07/16/2023] [Revised: 09/15/2023] [Accepted: 12/19/2023] [Indexed: 02/28/2024] Open
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria
- Medical Faculty, Sigmund Freud Private University, Vienna, Austria
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France
- EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
- Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, TX, USA
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany
- The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
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14
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Wan Z, Wang T, Lu P, Shu C. Bibliometric analysis of the top 100 most-cited articles on branch reconstruction in endovascular aortic repair. Asian J Surg 2024; 47:486-496. [PMID: 37423856 DOI: 10.1016/j.asjsur.2023.06.124] [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: 02/11/2023] [Revised: 05/07/2023] [Accepted: 06/30/2023] [Indexed: 07/11/2023] Open
Abstract
With the global acceptance of endovascular aortic repair (EVAR) for aortic diseases, one of the most common issues in EVAR is the preservation of critical aortic branches. Despite the fact that many studies on EVAR-assisted endovascular branch reconstruction techniques have been published. There were few bibliometric analyses that focused on branch rebuilding in endovascular aortic repair. In this study, we aim to analyze the characteristics of the 100 most-cited articles on branch reconstruction in Endovascular Aortic Repair. The most popular articles retrospectively searched on the Web of Science were published between 1999 and 2018, with 10480 citations in total (an average of 551.58 citations per year). The top-cited article was 281 citations. The peak years of citations was 2019 (1051 citations). Journal of Vascular Surgery published the most articles (46 articles) and was the most-cited journal (5055 citations), and the United States was the country with the greatest number of publications (43 articles). Cleveland Clinic was the most influential institution with 20 articles. Fenestration technique was the major topic area of interest and trend (63 articles mentioned). Customised device was the most widely used endograft (52 articles mentioned). Renal artery was the most frequently reconstructed branch of aorta (70 articles mentioned). Our analysis showed the endovascular branch reconstruction in EVAR developed rapidly over the past 20 years. Continued exploration and cooperation between specialties and manufacturers on endograft design and modifications will further enhance knowledge of disease intervention and treatment.
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Affiliation(s)
- Zicheng Wan
- Department of Vascular Surgery, The 2nd Xiang-ya Hospital of Central South University, Changsha, China; Angiopathy Institute of Central South University, Changsha, China
| | - Tun Wang
- Department of Vascular Surgery, The 2nd Xiang-ya Hospital of Central South University, Changsha, China; Angiopathy Institute of Central South University, Changsha, China
| | - Peng Lu
- Department of Vascular Surgery, The 2nd Xiang-ya Hospital of Central South University, Changsha, China; Angiopathy Institute of Central South University, Changsha, China
| | - Chang Shu
- Department of Vascular Surgery, The 2nd Xiang-ya Hospital of Central South University, Changsha, China; Angiopathy Institute of Central South University, Changsha, China; Department of Cardiovascular Surgery, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, Xicheng District, Beijing, China.
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15
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Chen Y, Liu Z, Wang S, D'Oria M, Zhang X, Bi J, Cui D, Dai X. Systematic Review and Meta-analysis of Short-term and Mid-term Outcomes After Use of t-Branch Off-the-shelf Multibranched Endograft for Elective and Urgent Treatment of Thoracoabdominal Aortic Aneurysms. J Endovasc Ther 2023:15266028231220322. [PMID: 38158706 DOI: 10.1177/15266028231220322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
OBJECTIVE To conduct a meta-analysis to assess the safety and efficacy of t-Branch off-the-shelf multibranched endograft for the treatment of thoracoabdominal aortic aneurysm (TAAA). DATA SOURCES PubMed, Embase, and Web of Science. REVIEW METHODS Online databases were searched from June 2012 to March 2023. The data were pooled together using a random-effects model of proportions. The outcomes overall included technical success, spinal cord ischemia, target vessel occlusion, type I or III endoleak, reintervention, early mortality (30-day), and mid-term outcomes. Subgroup meta-analyses and meta-regression were performed to explore variation among studies. RESULTS A total of 15 studies containing 1238 patients were included in the meta-analysis. The overall study quality assessment was found to be moderate to good. The pooled technical success was 97.0% (95% confidence interval [CI]=95.5-98.6, I2=53.01%, 1185/1238 cases, 15 studies). Overall, early mortality was 7.3% (95% CI=4.4-10.1, I2=74.48%, 124/1238 cases, 15 studies). Early spinal cord ischemia was 13.4% (95% CI=9.6-17.2, I2=67.24%, 160/1238 cases, 15 studies), and early type I or III endoleak was 6.0% (95% CI=3.4-8.5, I2=53.71%, 68/1032 cases, 9 studies). Mid-term outcomes showed target vessel occlusion was 4% (95% CI=1.4-6.5, I2=65.18%, 28/528 cases, 10 studies, 5-21.2 months), type I or III endoleak was 4.7% (95% CI=2-7.5, I2=49.74%, 38/512 cases, 10 studies, 5-21.2 months), reintervention was 11.2% (95% CI=8.1-14.3, I2=31.06%, 85/650 cases, 10 studies, 5-21.2 months), and pooled mortality was 13.9% (95% CI=7.2-20.7, I2=76.32%, 84/550 cases, 11 studies, 5-21.2 months). Meta-regression found a significant linear association between higher technical success and earlier publication year (p=0.014) and studies with anatomic inclusion criteria (p=0.037). Urgent patients (p=0.021) and later publication year (p=0.048) were significantly associated with higher early mortality. CONCLUSION The use of the off-the-shelf t-Branch multibranched endograft for elective or urgent endovascular TAAA repair is associated with high technical success rates and proved to be safe and effective at early and mid-term follow-up. However, the heterogeneity between the included studies is high, and prospective, randomized studies along with future larger studies with long-term follow-up are needed. CLINICAL IMPACT The Zenith t-Branch (Cook Medical, Bloomington, Ind) was approved as a commercially available device in Europe in June 2012. Although a decade has past, the outcomes of t-Branch have rarely been synthesized at the global level. This meta-analysis included 15 studies containing 1238 patients. The meta-analyses included technical success, major adverse events, reintervention, early mortality, and mid-term outcomes. The outcome was very meaningful and representative for the use of t-Branch. It is helpful for endovascular surgeons to make decisions on the treatment of TAAA patients.
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Affiliation(s)
- Yonghui Chen
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Zongwei Liu
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Shuaishuai Wang
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardio-thoraco-vascular Department, University Hospital of Trieste Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Xiaoxing Zhang
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Jiaxue Bi
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Dongsheng Cui
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiangchen Dai
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
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16
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Bacri C, Ata Ozdemir B, Hireche K, Alric P, Canaud L. Zone 2 Aortic Arch Repair With Single-Fenestrated Physician-Modified Endografts, at Least 3 Years of Follow-up. J Endovasc Ther 2023:15266028231215779. [PMID: 38049943 DOI: 10.1177/15266028231215779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
OBJECTIVE The aim of this study is to report the efficiency and safety of single-fenestrated physician-modified endografts (PMEGs) in zone 2 aortic arch pathologies with at least 3 years of follow-up. METHODS All consecutive patients with a pathological aortic arch who underwent aortic repair combined with homemade single-fenestrated stent-graft from 2015 to 2020 were reviewed. The patients with a target vessel different from the left subclavian artery (LSA) were excluded. RESULTS A total of 63 patients were treated for a pathological arch in zone 2 with a single-fenestrated PMEG. 73% were male, and the mean age was 65 years old. 25% were treated for a degenerative aneurysm, 19% for a post dissection aneurysm and 24% for an acute type B dissection. 52% of the patients were treated as an emergency and half of those for an aortic rupture. The LSA fenestration was stented in 70%. During 30 days of follow-up, 2 strokes (3%) were reported, 6 patients (10%) died with 4 of those treated for aortic rupture and 1 had a retrograde aortic dissection. During at least 3 years of follow-up (median 49 months), no reintervention was needed for endoleaks, there was no stent fracture or stent migration. No patient died from an aortic cause. Subgroup analysis comparing the endovascular treatment for various aortic pathologies did not find significant differences in death rate or comorbidity including stroke. When comparing emergent and elective aortic repair, operating time was similar (64 vs 65 minutes), and the LSA fenestration was less frequently stented (52%) in the emergency group. There was no difference in stroke frequency. There was a higher rate of death in the emergency group at 30 days of follow-up, but no patient died from aortic cause in the long-term follow-up. CONCLUSIONS Aortic arch repair with single-fenestrated PMEGs for zone 2 pathological arch disease is associated with acceptable early and midterm major morbidity and mortality. It is suitable for emergency situations. CLINICAL IMPACT Single-fenestrated PMEG for the left subclavian artery is a safe and efficient option in the short and medium term for the treatment of the aortic arch in zone 2 with 98% technical success. It allows for aortic repair and subclavian artery revascularization in a single step for all patients. It is suitable for a range of main pathologies, including degenerative, dissection-related, isthmus rupture, and embolic pathologies. Additionally, it is always available and easily utilized in emergency cases.
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Affiliation(s)
- Christoph Bacri
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Baris Ata Ozdemir
- Department of Vascular Surgery, North Bristol National Health Service Trust, University of Bristol, Bristol, UK
| | - Kheira Hireche
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
- Physiology and Experimental Medicine of the Heart and Muscles, University of Montpellier, CNRS, INSERM, University Hospital of Montpellier, Montpellier, France
| | - Pierre Alric
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
- Physiology and Experimental Medicine of the Heart and Muscles, University of Montpellier, CNRS, INSERM, University Hospital of Montpellier, Montpellier, France
| | - Ludovic Canaud
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
- Physiology and Experimental Medicine of the Heart and Muscles, University of Montpellier, CNRS, INSERM, University Hospital of Montpellier, Montpellier, France
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Laczynski DJ, Gallop J, Sicard GA, Sidawy AN, Rowse JW, Lyden SP, Smolock CJ, Kirksey L, Quatromoni JG, Caputo FJ. Benchmarking a Center of Excellence in Vascular Surgery: Using Acute Physiology and Chronic Health Evaluation II to Validate Outcomes in a Tertiary Care Institute. Vasc Endovascular Surg 2023; 57:856-862. [PMID: 37295071 DOI: 10.1177/15385744231183744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The Society of Vascular Surgery (SVS) has made it a top priority to implement verification of vascular "centers of excellence". Our institutional aortic network was established in 2008 in order to standardize care of patients with suspected acute aortic pathology. The implementation and success of this program has been previously reported. We sought to use our experience as a benchmark for which to develop prognostic modeling to quantify clinical status upon admission and help predict outcomes. Our objective was to validate the Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system using a cohort of aortic emergencies transferred by an organized transfer network. METHOD This was a retrospective, single institution review of patients transferred through an institutional aortic network for acute aortic pathology from 2017-2018. Demographics, comorbidities, aortic diagnosis, APACHE II score, as well as 30-day mortality were recorded. Associations with 30-day mortality were evaluated using two-sample t-tests, ANOVA models, Pearson chi-square tests and Fisher exact tests. Receiver operating characteristic (ROC) curves were fit overall and by pathology to predict 30-day mortality by Apache II total score. RESULTS There were 395 consecutive transfers were identified. The mean age was 64.7 years. Diagnoses included Type A Dissection (n = 134), Type B (n = 81), Aortic Aneurysm (n = 122), and PAU/IMH (n = 27). Mean APACHE II score on arrival was 12. Overall there were 53 deaths (13.4%) in the cohort. Patients that died had significantly higher Apache II total scores (11.3 vs 16.5, P < .001). The area under the receiver operator characteristic (ROC) curve (AUC) was .66 for the full cohort, indicating a poor clinical prediction test. CONCLUSION APACHE II score is a poor predictor of 30-day mortality in a large transfer network accepting all aortic emergencies. The authors believe further refining a prognostic model for diverse population will not only help in predicting outcomes but to objectively quantify illness severity in order to have a basis for comparison among institutions and verification of "centers of excellence".
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Affiliation(s)
- D J Laczynski
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - J Gallop
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - G A Sicard
- Division of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - A N Sidawy
- Division of Vascular Surgery, Department of Surgery, George Washington University, Washington, DC, USA
| | - J W Rowse
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - S P Lyden
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - C J Smolock
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - L Kirksey
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - J G Quatromoni
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - F J Caputo
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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18
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Frankort J, Mees B, Doukas P, Keszei A, Kontopodis N, Antoniou GA, Jacobs MJ, Gombert A. Systematic Review of the Effect of Cerebrospinal Fluid Drainage on Outcomes After Endovascular Descending Thoracic/Thoraco-Abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2023; 66:501-512. [PMID: 37182608 DOI: 10.1016/j.ejvs.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 04/07/2023] [Accepted: 05/05/2023] [Indexed: 05/16/2023]
Abstract
OBJECTIVE This study aimed to investigate whether prophylactic use of cerebrospinal fluid (CSF) drainage in endovascular descending thoracic aortic aneurysm (DTAA) and thoraco-abdominal aortic aneurysm (TAAA) repair contributes to a lower rate of post-operative spinal cord ischaemia (SCI). DATA SOURCES MEDLINE, Embase, and CINAHL. REVIEW METHODS A literature review was conducted in accordance with PRISMA guidelines (PROSPERO registration no. CRD42021245893). Risk of bias was assessed through the Newcastle-Ottawa scale (NOS), and the certainty of evidence was graded using the GRADE approach. A proportion meta-analysis was conducted to calculate the pooled rate and 95% confidence interval (CI) of both early and late onset SCI. Pooled outcome estimates were calculated using the odds ratio (OR) and associated 95% CI. The primary outcome was SCI, both early and lateonset. Secondary outcomes were complications of CSF drainage, length of hospital stay, and peri-operative (30 day or in hospital) mortality rates. RESULTS Twenty-eight observational, retrospective studies were included, reporting 4 814 patients (2 599 patients with and 2 215 without CSF drainage). The NOS showed a moderate risk of bias. The incidence of SCI was similar in patients with CSF drainage (0.05, 95% CI 0.03 ‒ 0.08) and without CSF drainage (0.05, 95% CI 0.00 ‒ 0.14). No significant decrease in SCI was found when using CSF drainage (OR 0.67, 95% CI 0.29 ‒ 1.55, p = .35). The incidence rate of CSF drainage related complication was 0.10 (95% CI 0.04 ‒ 0.19). The 30 day and in hospital mortality rate with CSF drainage was 0.08 (95% CI 0.05 ‒ 0.12). The 30 day and in hospital mortality rate without CSF drainage and comparison with late mortality and length of hospital stay could not be determined due to lack of data. The quality of evidence was considered very low. CONCLUSION Pre-operative CSF drainage placement was not related to a favourable outcome regarding SCI rate in endovascular TAAA and DTAA repair. Due to the low quality of evidence, no clear recommendation on pre-operative use of CSF drainage placement can be made.
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Affiliation(s)
- Jelle Frankort
- Department of Vascular Surgery, European Vascular Centre Aachen-Maastricht, RWTH Aachen, Aachen, Germany; Department of Vascular Surgery, European Vascular Centre Maastricht-Aachen, MUMC Maastricht, Maastricht, The Netherlands.
| | - Barend Mees
- Department of Vascular Surgery, European Vascular Centre Maastricht-Aachen, MUMC Maastricht, Maastricht, The Netherlands
| | - Panagiotis Doukas
- Department of Vascular Surgery, European Vascular Centre Aachen-Maastricht, RWTH Aachen, Aachen, Germany
| | - Andràs Keszei
- Centre for Translational & Clinical Research Aachen (CTC-A), University Hospital RWTH Aachen, Aachen, Germany
| | - Nikolaos Kontopodis
- Vascular Surgery Department, Medical School, University of Crete, Heraklion, Crete, Greece
| | - George A Antoniou
- Department of Vascular and Endovascular Surgery, Manchester University NHS Foundation Trust, Manchester, UK; Division of Cardiovascular Sciences, School of Medical Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Michael J Jacobs
- Department of Vascular Surgery, European Vascular Centre Aachen-Maastricht, RWTH Aachen, Aachen, Germany; Department of Vascular Surgery, European Vascular Centre Maastricht-Aachen, MUMC Maastricht, Maastricht, The Netherlands
| | - Alexander Gombert
- Department of Vascular Surgery, European Vascular Centre Aachen-Maastricht, RWTH Aachen, Aachen, Germany
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19
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Stoklasa K, Menges AL, Reutersberg B, Meuli L, Zimmermann A. Hospital Incidence, Treatment, and Outcome of 885 Patients with Thoracoabdominal Aortic Aneurysms Treated in Switzerland over 10 Years-A Secondary Analysis of Swiss DRG Data. J Clin Med 2023; 12:5213. [PMID: 37629255 PMCID: PMC10455290 DOI: 10.3390/jcm12165213] [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: 07/03/2023] [Revised: 08/02/2023] [Accepted: 08/06/2023] [Indexed: 08/27/2023] Open
Abstract
Despite the development of fenestrated and branched endovascular aortic repair (f/bEVAR), the surgical management of thoraco-abdominal aortic aneurysms (TAAAs) remains a major challenge. The aim of this study was to analyse the hospital incidence and hospital mortality of patients treated for TAAAs in Switzerland. Secondary data analysis was performed using nationwide administrative discharge data from 2009-2018. Standardised incidence rates and adjusted mortality rates were calculated. A total of 885 cases were identified (83.2% nonruptured (nrTAAA), 16.8% ruptured (rTAAA)), where 69.3% were male. The hospital incidence rate for nrTAAA was 0.4 per 100,000 women and 0.9 per 100,000 men in 2009, which had doubled for both sexes by 2018. For rTAAA, there was no trend over the years. The most common procedure was f/bEVAR (44.2%), followed by OAR (39.5%), and 9.8% received a hybrid procedure. There was a significant increase in endovascular procedures over time. The all-cause mortality was 7.1% with nrTAAA and 55% with rTAAA. The mortality was lower for rTAAA when f/bEVAR or hybrid procedures were used. A ruptured aneurysm and higher comorbidity were associated with higher hospital mortality. This study demonstrates that the treatment approach has changed significantly over the observed period. The use of f/bEVAR nearly tripled in nrTAAA and doubled in rTAAA during this decade.
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20
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Verhagen M, Eefting D, van Rijswijk C, van der Meer R, Hamming J, van der Vorst J, van Schaik J. Increased Aortic Exclusion in Endovascular Treatment of Complex Aortic Aneurysms. J Clin Med 2023; 12:4921. [PMID: 37568323 PMCID: PMC10420108 DOI: 10.3390/jcm12154921] [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: 06/06/2023] [Revised: 07/19/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
PURPOSE Perioperative risk assessments for complex aneurysms are based on the anatomical extent of the aneurysm and do not take the length of the aortic exclusion into account, as it was developed for open repair. Nevertheless, in the endovascular repair (ER) of complex aortic aneurysms, additional segments of healthy aorta are excluded compared with open repair (OR). The aim of this study was to assess differences in aortic exclusion between the ER and OR of complex aortic aneurysms, to subsequently assess the current classification for complex aneurysm repair. METHODS This retrospective observational study included patients that underwent complex endovascular aortic aneurysm repair by means of fenestrated endovascular aneurysm repair (FEVAR), fenestrated and branched EVAR (FBEVAR), or branched EVAR (BEVAR). The length of aortic exclusion and the number of patent segmental arteries were determined and compared per case in ER and hypothetical OR, using a Wilcoxon signed-rank test. RESULTS A total of 71 patients were included, who were treated with FEVAR (n = 44), FBEVAR (n = 8), or BEVAR (n = 19) for Crawford types I (n = 5), II (n = 7), III (n = 6), IV (n = 7), and V (n = 2) thoracoabdominal or juxtarenal (n = 44) aneurysms. There was a significant increase in the median exclusion of types I, II, III, IV, and juxtarenal aneurysms (p < 0.05) in ER, compared with hypothetical OR. The number of patent segmental arteries in the ER of type I-IV and juxtarenal aneurysms was significantly lower than in hypothetical OR (p < 0.05). CONCLUSION There are significant differences in the length of aortic exclusion between ER and hypothetical OR, with the increased exclusion in ER resulting in a lower number of patent segmental arteries. The ER and OR of complex aortic aneurysms should be regarded as distinct modalities, and as each approach deserves a particular risk assessment, future efforts should focus on reporting on the extent of exclusion per treatment modality, to allow for appropriate comparison.
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Affiliation(s)
- Merel Verhagen
- Department of Vascular Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (M.V.); (D.E.); (J.H.); (J.v.d.V.)
| | - Daniel Eefting
- Department of Vascular Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (M.V.); (D.E.); (J.H.); (J.v.d.V.)
| | - Carla van Rijswijk
- Department of Radiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (C.v.R.); (R.v.d.M.)
| | - Rutger van der Meer
- Department of Radiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (C.v.R.); (R.v.d.M.)
| | - Jaap Hamming
- Department of Vascular Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (M.V.); (D.E.); (J.H.); (J.v.d.V.)
| | - Joost van der Vorst
- Department of Vascular Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (M.V.); (D.E.); (J.H.); (J.v.d.V.)
| | - Jan van Schaik
- Department of Vascular Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (M.V.); (D.E.); (J.H.); (J.v.d.V.)
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21
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Aucoin VJ, Motyl CM, Novak Z, Eagleton MJ, Farber MA, Gasper W, Oderich GS, Mendes B, Schanzer A, Tenorio E, Timaran CH, Schneider DB, Sweet MP, Zettervall SL, Beck AW. Predictors and Outcomes of Spinal Cord Injury following Complex Branched/Fenestrated Endovascular Aortic Repair in the US Aortic Research Consortium. J Vasc Surg 2023; 77:1578-1587. [PMID: 37059239 DOI: 10.1016/j.jvs.2023.01.205] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/22/2023] [Accepted: 01/23/2023] [Indexed: 04/16/2023]
Abstract
OBJECTIVE Spinal cord ischemia (SCI) is a well-known complication of thoracoabdominal aortic aneurysm (TAAA) repair and is associated with profound morbidity and mortality. The purpose of this study was to describe predictors for the development of SCI, as well as outcomes for patients who develop SCI, after branched/fenestrated endovascular aortic repair (FB-EVAR) in a large cohort of centers with adjudicated physician-sponsored investigational device exemption studies. METHODS We utilized a pooled dataset from 9 United States Aortic Research Consortium (US ARC) centers involved in investigational device exemption (IDE) trials for treatment of suprarenal and thoracoabdominal aortic aneurysms. SCI was defined as new transient weakness (paraparesis) or permanent paraplegia after repair without other potential neurologic etiologies. Multivariable analysis was performed to identify predictors of SCI, and life-table analysis and Kaplan-Meier methodology were used to evaluate survival differences. RESULTS A total of 1,681 patients underwent FB-EVAR over the period 2005-2020. The overall rate of SCI was 7.1% (3% transient and 4.1% permanent). Predictors of SCI on multivariable analysis were Crawford Extent I, II, and III distribution of aortic disease (OR 4.79 95% CI 4.77- 4.81, P<.001), age ≥70 (OR 1.64, 95% CI, 1.63-1.64, P=.029), packed red blood cell transfusion (OR 2.00, 95% CI, 1.99-2.00, P=.001), and history of PVD (OR 1.65, 95% CI, 1.64-1.65, P=.034). Median survival was significantly worse for patients with any degree of SCI compared to those without SCI (any SCI - 40.4 vs no SCI - 60.3 months, Log Rank <.001), and also worse in those with a permanent deficit (24.1 months) vs. those with a transient deficit (62.4 months) (Log Rank <0.001). One year survival for patients who developed no SCI was 90.8%, compared to 73.9% in patients who developed any SCI. When stratified by degree of deficit, survival was 84.8% at one year for those who developed paraparesis, and 66.2% for those who developed permanent deficits. CONCLUSIONS The overall rates of any SCI at 7.1% and permanent deficit at 4.1% observed in this study compare favorably to those reported in contemporary literature. Our findings confirm that increased length of aortic disease is associated with SCI and those with Crawford Extent I-III TAAAs are at highest risk. The long-term impact on patient mortality underscores the importance of preventive measures and rapid implementation of rescue protocols if and when deficits develop.
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Affiliation(s)
| | - Claire M Motyl
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Zdenek Novak
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - Warren Gasper
- University of California at San Francisco, San Franscisco, CA, USA
| | | | | | - Andres Schanzer
- University of Massachusetts (UMass) Memorial Medical Center, MA, USA
| | | | | | | | | | | | - Adam W Beck
- University of Alabama at Birmingham, Birmingham, AL, USA.
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Gu C, Kong F, Zeng J, Geng X, Sun Y, Chen X. Remote ischemic preconditioning protects against spinal cord ischemia-reperfusion injury in mice by activating NMDAR/AMPK/PGC-1α/SIRT3 signaling. Cell Biosci 2023; 13:57. [PMID: 36927808 PMCID: PMC10018930 DOI: 10.1186/s13578-023-00999-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 02/27/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND To study the protective effects of delayed remote ischemic preconditioning (RIPC) against spinal cord ischemia-reperfusion injury (SCIRI) in mice and determine whether SIRT3 is involved in this protection and portrayed its upstream regulatory mechanisms. METHODS In vivo, WT or SIRT3 global knockout (KO) mice were exposed to right upper and lower limbs RIPC or sham ischemia. After 24 h, the abdominal aorta was clamped for 20 min, then re-perfused for 3 days. The motor function of mice, number of Nissl bodies, apoptotic rate of neurons, and related indexes of oxidative stress in the spinal cord were measured to evaluate for neuroprotective effects. The expression and correlation of SIRT3 and NMDAR were detected by WB and immunofluorescence. In vitro, primary neurons were exacted and OGD/R was performed to simulate SCIRI in vivo. Neuronal damage was assessed by observing neuron morphology, detecting LDH release ratio, and flow cytometry to analyze the apoptosis. MnSOD and CAT enzyme activities, GSH and ROS level were also measured to assess neuronal antioxidant capacity. NMDAR-AMPK-PGC-1α signaling was detected by WB to portray upstream regulatory mechanisms of RIPC regulating SIRT3. RESULTS Compared to the SCIRI mice without RIPC, mice with RIPC displayed improved motor function recovery, a reduced neuronal loss, and enhanced antioxidant capacity. To the contrary, the KO mice did not exhibit any effect of RIPC-induced neuroprotection. Similar results were observed in vitro. Further analyses with spinal cord tissues or primary neurons detected enhanced MnSOD and CAT activities, as well as increased GSH level but decreased MDA or ROS production in the RIPC + I/R mice or NMDA + OGD/R neurons. However, these changes were completely inhibited by the absence of SIRT3. Additionally, NMDAR-AMPK-PGC-1α signaling was activated to upregulate SIRT3 levels, which is essential for RIPC-mediated neuroprotection. CONCLUSIONS RIPC enhances spinal cord ischemia tolerance in a SIRT3-dependent manner, and its induced elevated SIRT3 levels are mediated by the NMDAR-AMPK-PGC-1α signaling pathway. Combined therapy targeting SIRT3 is a promising direction for treating SCIRI.
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Affiliation(s)
- Changjiang Gu
- Spine Center, Department of Orthopaedics, Changzheng Hospital, Naval Medical University (Second Military Medical University), Shanghai, 200003, People's Republic of China
| | - Fanqi Kong
- Spine Center, Department of Orthopaedics, Changzheng Hospital, Naval Medical University (Second Military Medical University), Shanghai, 200003, People's Republic of China
| | - Junkai Zeng
- Spine Center, Department of Orthopaedics, Changzheng Hospital, Naval Medical University (Second Military Medical University), Shanghai, 200003, People's Republic of China
| | - Xiangwu Geng
- Spine Center, Department of Orthopaedics, Changzheng Hospital, Naval Medical University (Second Military Medical University), Shanghai, 200003, People's Republic of China
| | - Yanqing Sun
- Department of Orthopaedics, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 85 Wujin Road, 200080, Shanghai, PR China.
| | - Xiongsheng Chen
- Spine Center, Department of Orthopaedics, Changzheng Hospital, Naval Medical University (Second Military Medical University), Shanghai, 200003, People's Republic of China. .,Department of Orthopaedics, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 85 Wujin Road, 200080, Shanghai, PR China.
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Mizushima S, Mine T, Abe M, Sekine T, Fujii M, Hayashi H, Ikeda S, Happoh S, Takashi Y, Kumita SI. Comparison of slow-infusion magnetic resonance angiography with sequential k-space filling and computed tomography angiography to detect the Adamkiewicz artery. Ann Vasc Surg 2023:S0890-5096(23)00127-9. [PMID: 36868460 DOI: 10.1016/j.avsg.2023.02.027] [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: 11/11/2022] [Revised: 01/31/2023] [Accepted: 02/22/2023] [Indexed: 03/05/2023]
Abstract
OBJECTIVE Radiographic detection of the Adamkiewicz artery (AKA) before aortic surgery helps to avoid spinal cord ischemia (SCI). We applied magnetic resonance angiography (MRA) using gadolinium enhancement (Gd-MRA) by means of the slow-infusion method with sequential k-space filling and compared AKA detectability with that of computed tomography angiography (CTA). METHODS A total of 63 patients with thoracic or thoracoabdominal aortic disease (30 with aortic dissection [AD] and 33 with aortic aneurysm) who underwent both CTA and Gd-MRA to detect AKA were evaluated. The detectability of the AKA using Gd-MRA and CTA were compared among all patients and subgroups based on anatomical features. RESULTS The detection rates of the AKAs using Gd-MRA and CTA were higher in all 63 patients (92.1% vs. 71.4%, p = 0.003). In AD cases, the detection rates using Gd-MRA and CTA were higher in all 30 patients (93.3% vs. 66.7%, p = 0.01) as well as in seven patients whose AKA originated from false lumens (100% vs. 0%). In aneurysm cases, the detection rates using Gd-MRA and CTA were higher in 22 patients whose AKA originated from the non-aneurysmal parts (100% vs. 81.8%, p = 0.03). In clinical, SCI was observed in 1.8% of cases after open or endovascular repair. CONCLUSION Despite the longer examination time and more complicated imaging techniques compared to those of CTA, the high spatial resolution of slow-infusion MRA may be preferable for detecting AKA before performing various thoracic and thoracoabdominal aortic surgeries.
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Affiliation(s)
- Shohei Mizushima
- Department of Radiology, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba 270-1694, Japan.
| | - Takahiko Mine
- Department of Radiology, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba 270-1694, Japan
| | - Masashi Abe
- Department of Radiology, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba 270-1694, Japan
| | - Tetsuro Sekine
- Department of Radiology, Nippon Medical School Musashi Kosugi Hospital, 1-383 Kosugimachi, Nakahara, Kawasaki, Kanagawa 211-8533, Japan
| | - Masahiro Fujii
- Department of Cardiovascular Surgery, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba 270-1694, Japan
| | - Hiromitsu Hayashi
- Department of Radiology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8602, Japan
| | - Shinpei Ikeda
- Department of Radiology, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba 270-1694, Japan
| | - Seigoh Happoh
- Department of Radiology, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba 270-1694, Japan
| | - Yukiko Takashi
- Department of Radiology, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba 270-1694, Japan
| | - Shin-Ichiro Kumita
- Department of Radiology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8602, Japan
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Alslaim H, Sanampudi S, Raissi D, Fu W, Behr AY, Issa M, Sheppard MB, Weintraub NL, Winkler M. A Comprehensive Research Schema for the Characterization of Aortic Aneurysms. Int J Angiol 2023; 32:34-42. [PMID: 36727146 PMCID: PMC9886451 DOI: 10.1055/s-0042-1744275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
A robust, accurate, and standardized approach to measurement of the aorta is critical to improve the predictive accuracy of these aortic measurements, and to investigate other aortic imaging biomarkers. Developing a comprehensive and generic schema for characterization of the aorta to enable investigators to standardize data that are collected across all aorta research. A systematic review of the literature was conducted to identify and assess schemata of aortic measurement and description. The schemata were reported and discussed to guide the synthesis of a comprehensive schema. We propose the International College of Angiology Aortic Research Schema as a comprehensive design that fills the gaps left behind by previously reported schemata. It is intended to be applicable for all clinically relevant purposes, including endograft development for aneurysm repair and for the accurate characterization of the aortic anatomy. This schema divides the aorta into 14 segments and 2 sections (thoracic and abdominal aortas). The segmentation proposed can be used in addition to specific measurements taken for any aneurysm including the neck, and maximal and minimal diameters of the aneurysm.
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Affiliation(s)
- Hossam Alslaim
- Department of Surgery, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Sreeja Sanampudi
- Department of Radiology, School of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Driss Raissi
- Department of Radiology, University of Kentucky Medical Center, Lexington, KY, USA
| | - Weibo Fu
- Department of Radiology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Amanda Y. Behr
- Department of Medical Illustration, College of Allied Health Sciences, Augusta University, Augusta, GA, USA
| | - Mohamed Issa
- Department of Radiology, University of Kentucky Medical Center, Lexington, KY, USA
| | - Mary B. Sheppard
- Department of Surgery, University of Kentucky Medical Center, Lexington, KY, USA
- Department of Family Medicine, University of Kentucky Medical Center, Lexington, KY, USA
| | - Neal L. Weintraub
- Department of Internal Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
- Vascular Biology Center, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Michael Winkler
- Department of Radiology, Medical College of Georgia, Augusta University, Augusta, GA, USA
- Department of Internal Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
- School of Art and Visual Studies, College of Fine Arts, University of Kentucky, Lexington, KY, USA
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25
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Current status of adult cardiac surgery-part 2. Curr Probl Surg 2023; 60:101245. [PMID: 36642488 DOI: 10.1016/j.cpsurg.2022.101245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 10/13/2022] [Indexed: 12/13/2022]
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26
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Giustiniano E, Nisi F, Palma S, Pisciotta W, Ruggieri N, Barbieri F, Civilini E, Maurizio C. Near-infrared spectroscopy to monitor spinal cord oxygenation in οpen thoraco-abdominal aortic surgery. A case series. HELLENIC JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2022:111-119. [DOI: 10.59037/hjves.v4i4.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
Objectives. We adopted the near-infrared spectroscopy (NIRS) technology to monitor the spinal oxygen supply through the paraspinous muscles oxygenation in agreement with the concept of “collateral network” circulation. We retrospectively investigated our database of subjects who underwent thoraco-abdominal aorta open repair assessing for the reliability of this monitoring to predict spinal cord injury.
Methods. Consecutive patients who underwent elective thoraco-abdominal aorta open repair between March 2019
and September 2021. In addition to standard monitoring, patients received the monitoring of the paraspinous muscles
oxygenation by NIRS.
Results. In one patient a significant drop of the mean arterial pressure (49 mmHg) and the spinal-cord perfusion pressure
(31 mmHg) occurred after the aortic clamping, with a contemporary lowering of the left-side oxygenation of paraspinous muscles (<40%). Both the blood pressure and the spinal cord perfusion pressure were restored within 10 minutes, but the oxygenation remained at an unsafe level (<55%) until the end of the surgery. This same patient experienced a lower-limb paralysis post-operatively. It did not happen in the other 11 cases of the sample.
Conclusions. The main finding of our retrospective analysis indicates reliability of this technology to monitor the spinal
cord oxygenation during open thoraco-abdominal aortic surgery and possibly predict spinal cord injury. Still, several
questions need to be addressed about the suitability of this technology to the anatomic and pathophysiology of the
spinal cord circulation
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Affiliation(s)
- Enrico Giustiniano
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
| | - Fulvio Nisi
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
| | - Sergio Palma
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
| | - Walter Pisciotta
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
| | - Nadia Ruggieri
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
| | - Francesca Barbieri
- Vascular Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
| | - Efrem Civilini
- Vascular Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
| | - Cecconi Maurizio
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
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Ebeling C, Cheruku S. Anesthetic Management for Endovascular Repair of Thoracic and Abdominal Aortic Aneurysms. Anesthesiol Clin 2022; 40:719-735. [PMID: 36328625 DOI: 10.1016/j.anclin.2022.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Aortic aneurysms-both abdominal and thoracic-are a significant cause of death and disability in the United States. Endovascular aneurysm repair has since become the preferred operative treatment of most thoracic and abdominal aneurysms because of a lower rate of complications and better outcomes compared with the open approach. Patients who present for endovascular aneurysm repair often have comorbid conditions related to their aortic pathology. These conditions should be evaluated and optimized before the procedure.
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Affiliation(s)
- Callie Ebeling
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Mail Code 9068, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
| | - Sreekanth Cheruku
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Mail Code 9068, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
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28
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Sénémaud J, Becquemin JP, Chakfé N, Touma J, Desgranges P, Cochennec F. Midterm Results of Physician-Modified Stent Grafts for Thoracoabdominal and Complex Abdominal Aortic Aneurysms Repair. Ann Vasc Surg 2022:S0890-5096(22)00762-2. [PMID: 36460175 DOI: 10.1016/j.avsg.2022.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 10/28/2022] [Accepted: 11/07/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND To assess midterm results of physician-modified stent grafts (PMSG) for the treatment of emergent complex abdominal and thoracoabdominal aortic aneurysms (TAAA) in high-risk patients. METHODS All consecutive patients with emergent complex abdominal or TAAA undergoing PMSG technique between January 2012 and July 2019 were retrospectively included. Indications for PMSG were symptomatic aneurysms and rapidly growing aneurysms >70 mm. Ruptured aneurysms were excluded. RESULTS Thirty-three patients (mean age: 74 +/- 11 years) were included. The mean aneurysm diameter was 76 +- 20 mm. Patients presented with TAAA (n = 20, 61%), complex abdominal aortic aneurysms (CAAA, n = 9, 27%), type I endoleak after previous endovascular aneurysm repair (n = 3, 9%) and intramural aortic hematoma (n = 1, 3%). Chimney technique was performed in addition to PMSG in seven cases (21%). Intraoperative adverse events were recorded in seven cases (35%) in the TAAA group and one case (11%) in the CAAA group. In-hospital mortality rate was 15% (n = 3) in the TAAA group and 11% (n = 1) in the CAAA group. Moderate to severe complications were recorded in 45% of cases (n = 15). Spinal cord ischemia occurred in two cases (6%, one case without residual deficit and one with minor motor deficit). One (3%) patient required transient hemodialysis. One patient presented with early aortic rupture and required an open conversion. The mean follow-up duration was 31 months (1-79). Overall survival estimates were 81.4% (95% confidence interval [CI]: 63.1.-91.2) at 1 year and 71.6% (95% CI: 52.6-84.1) at 2 years. Freedom from reintervention rates at 1 and 2 years were 61.2% (95% CI: 41.7-75.9) and 57.4% (95% CI: 37.9-72.8). Target vessel primary patency rates at 1 and 2 years were 99.2% (95% CI: 94.2-99.9) and 97.7% (95% CI: 90.7-99.4). CONCLUSIONS PMSG for high-risk patients with complex aneurysms provided acceptable technical success and excellent target vessel patency rates but were associated with a 12% in-hospital mortality rate. Reinterventions were frequent. This technique should be limited to selected high-risk patients for whom the risk of rupture in the short-term is deemed too high to wait for graft manufacturing of custom-made device.
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Affiliation(s)
- Jean Sénémaud
- Department of Vascular Surgery, Henri Mondor University Hospital (Assistance Publique-Hopitaux de Paris - APHP), Créteil, France
| | - Jean-Pierre Becquemin
- Department of Vascular Surgery, Henri Mondor University Hospital (Assistance Publique-Hopitaux de Paris - APHP), Créteil, France
| | - Nabil Chakfé
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Joseph Touma
- Department of Vascular Surgery, Henri Mondor University Hospital (Assistance Publique-Hopitaux de Paris - APHP), Créteil, France
| | - Pascal Desgranges
- Department of Vascular Surgery, Henri Mondor University Hospital (Assistance Publique-Hopitaux de Paris - APHP), Créteil, France
| | - Frédéric Cochennec
- Department of Vascular Surgery, Henri Mondor University Hospital (Assistance Publique-Hopitaux de Paris - APHP), Créteil, France.
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29
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Lenzini L, Caroccia B, Seccia TM, Rossi GP. Peptidergic G Protein-Coupled Receptor Regulation of Adrenal Function: Bench to Bedside and Back. Endocr Rev 2022; 43:1038-1050. [PMID: 35436330 DOI: 10.1210/endrev/bnac011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Indexed: 11/19/2022]
Abstract
An altered secretion of adrenocortical and adrenomedullary hormones plays a role in the clinical syndromes of primary aldosteronism (PA), Cushing, and pheochromocytoma. Moreover, an altered production of adrenocortical hormones and/or an abnormal release of factors by the adrenal medulla are involved in several other diseases, including high blood pressure, congestive heart failure, liver cirrhosis, nephrotic syndrome, primary reninism, renovascular hypertension, Addison disease, Bartter, Gitelman, and virilization syndromes. Understanding the regulation of adrenal function and the interactions between adrenal cortex and medulla is, therefore, the prerequisite for mechanistic understanding of these disorders. Accumulating evidence indicates that the modulation of adrenal hormone biosynthesis is a process far more complex than originally thought, as it involves several factors, each cooperating with the other. Moreover, the tight vascular and neural interconnections between the adrenal cortex and medulla underlie physiologically relevant autocrine/paracrine interactions involving several peptides. Besides playing a pathophysiological role in common adrenal diseases, these complex mechanisms could intervene also in rare diseases, such as pheochromocytoma concomitant with adrenal Cushing or with PA, and PA co-occurring with Cushing, through mechanisms that remain to be fully understood at the molecular levels. Heterodimerization of G protein-coupled receptors (GPCRs) induced by peptide signaling is a further emerging new modulatory mechanism capable of finely tuning adrenal hormones synthesis and release. In this review we will examine current knowledge on the role of peptides that act via GPCRs in the regulation of adrenal hormone secretion with a particular focus on autocrine-paracrine signals.
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Affiliation(s)
- Livia Lenzini
- Emergency Medicine Unit, Center for blood pressure disorders -Regione Veneto and Specialized Center of Excellence for Hypertension of the European Society of Hypertension, Department of Medicine-DIMED, University of Padua, 35126 Padua, Italy
| | - Brasilina Caroccia
- Emergency Medicine Unit, Center for blood pressure disorders -Regione Veneto and Specialized Center of Excellence for Hypertension of the European Society of Hypertension, Department of Medicine-DIMED, University of Padua, 35126 Padua, Italy
| | - Teresa Maria Seccia
- Emergency Medicine Unit, Center for blood pressure disorders -Regione Veneto and Specialized Center of Excellence for Hypertension of the European Society of Hypertension, Department of Medicine-DIMED, University of Padua, 35126 Padua, Italy
| | - Gian Paolo Rossi
- Emergency Medicine Unit, Center for blood pressure disorders -Regione Veneto and Specialized Center of Excellence for Hypertension of the European Society of Hypertension, Department of Medicine-DIMED, University of Padua, 35126 Padua, Italy
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30
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Thompson MA, Lowry AM, Caputo F, Johnston DR, Smolock C, Vargo P, Blackstone EH, Roselli EE. Ultra-Hybrid Repair: Open Thoracoabdominal Completion After Descending Stent Grafting. Semin Thorac Cardiovasc Surg 2022; 36:137-147. [PMID: 36243238 DOI: 10.1053/j.semtcvs.2022.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 10/04/2022] [Indexed: 11/09/2022]
Abstract
To characterize patient risk profiles and outcomes associated with staged ultra-hybrid repair of extensive aortic disease, in which open thoracoabdominal completion was performed after thoracic stent grafting. From 1/2006 to 1/2021, 92 patients underwent open thoracoabdominal repair of chronic dissection (n=58, 63%), degenerative aneurysm (n=28, 30%), endoleak (n=4, 4.3%), or symptomatic acute type B dissection (n=2, 2.2%) after descending thoracic stent grafting (69, 75%), frozen elephant trunk (5, 5%), or both (18, 20%). The surgical graft was sewn to the distal endovascular device in situ, reducing the extent of the open procedure and eliminating the need for hypothermic circulatory arrest. Mean age was 58±13 years, 89 (97%) were hypertensive, 38 (43%) had chronic obstructive pulmonary disease, 63 (72%) were smokers, 20 (24%) had a prior stroke, and 33 (36%) had a suspected or confirmed heritable aortic condition. Hospital mortality was 7.6% (n=7). Complications included dialysis (16, 20%), tracheostomy (8, 8.7%), stroke (5, 5.7%), and permanent paralysis (6, 6.9%). Survival at 1, 3, and 5 years was 80%, 71%, and 66%, respectively. Mortality was associated with higher blood urea nitrogen and longer distance between the distal endograft edge and proximal patent visceral vessel (P=0.004 and .01, respectively). Patients with extensive aortic disease undergoing open aortic repair after thoracic stent grafting are often young with chronic dissection, multiple comorbidities, or a heritable aortic condition. Success of staged ultra-hybrid operations demonstrates open and endovascular repair strategies are complementary, even when performed in a high-risk patient population.
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Affiliation(s)
- Matthew A Thompson
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Ashley M Lowry
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Francis Caputo
- Aorta Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Vascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Douglas R Johnston
- Aorta Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Christopher Smolock
- Aorta Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Vascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Patrick Vargo
- Aorta Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Aorta Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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31
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Tan SZCP, Surkhi AO, Singh S, Jubouri M, Bailey DM, Williams IM, Bashir M. Favorable neurological outcomes in thoracic endovascular aortic repair with RELAY™ branched-An international perspective. J Card Surg 2022; 37:3556-3563. [PMID: 36124429 DOI: 10.1111/jocs.16957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 08/19/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND While open surgical repair continues to be the mainstay option for aortic arch reconstruction, the associated mortality, morbidity, and high turn-down rates have led to a need for the development of minimally invasive options for aortic arch repair. Though RELAY™ Branched (Terumo Aortic, Inchinnan, UK) represents a promising option for complex endovascular aortic arch repair, neurological complications remain a pertinent risk. Herein we seek to present multicenter data from Europe documenting the neurological outcomes associated with RELAY™ Branched. METHODS Prospective data collected between January 2019 and January 2022 associated with patients treated with RELAY™ single-, double-, and triple-branched endoprostheses from centers across Europe was retrospectively analyzed with descriptive and distributive analysis. Follow-up data from 30 days and 6, 12, and 24 months postoperatively were included. Patient follow-up was evaluated for the onset of disabling stroke (DS) and non-disabling stroke (NDS). RESULTS Technical success was achieved in 147 (99.3%) cases. Over 24 months period, in total, six (4.1%) patients suffered DS, and eight (5.4%) patients suffered NDS after undergoing aortic arch repair with RELAY™. All patients that developed postoperative DS had been treated with the double-branched RELAY™ endoprosthesis. DISCUSSION The data presented herein demonstrates that RELAY™ Branched is associated with favorable neurological outcomes and excellent technical success rates. Key design features of the endoprosthesis and good perioperative management can contribute greatly to mitigating neurological complications following endovascular aortic arch repair.
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Affiliation(s)
- Sven Z C P Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Sidhant Singh
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Matti Jubouri
- Hull-York Medical School, University of York, Heslington, UK
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Newport, UK
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Newport, UK
| | - Mohamad Bashir
- Vascular and Endovascular Surgery, Velindre University NHS Trust, Health Education and Improvement Wales, Cardiff, UK
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32
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Effectiveness of endovascular repair versus open surgery for the treatment of thoracoabdominal aneurysm: A systematic review and meta analysis. Ann Med Surg (Lond) 2022; 81:104477. [PMID: 36147154 PMCID: PMC9486727 DOI: 10.1016/j.amsu.2022.104477] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/14/2022] [Accepted: 08/19/2022] [Indexed: 11/22/2022] Open
Abstract
Background Thoracoabdominal aortic aneurysms (TAAAs) are associated with significant comorbidities. The aim of our study is to compare the outcomes of open repair versus endovascular repair of TAAAs. Methods A thorough literature search was conducted on MEDLINE, Embase, and Cochrane Central databases. The analysis included observational studies comparing the outcomes of surgical vs endovascular aneurysm repair (EVAR) of TAAA. Mortality, spinal cord ischemia (SCI), renal failure, stroke, paraplegia, and respiratory and cardiac problems were all included in the studies. The results were provided as relative risks (RRs) with 95% confidence intervals (CIs). These were then aggregated using an inverse variance weighted random-effects model, and the pooled analysis was displayed using forest plots. Results This meta-analysis compromising of twelve studies revealed significant results, favoring endovascular repair versus open surgery for all-cause mortality (HR = 1.91; 95% CI: 1.68–2.18; P < 0.00001), SCI (HR = 1.62; 95% CI: 1.18–2.21; P = 0.003), respiratory complications (HR = 2.22; 95% CI: 1.78–2.77; P < 0.00001), and cardiac complications (HR = 1.66; 95% CI: 1.38–2.00; P < 0.00001). Upon subgroup analysis based on propensity matched, results were consistent and significant for the outcomes of all-cause mortality, cardiac complications, and respiratory complications. For the propensity unmatched subgroup, the incidence of all-cause mortality, SCI, respiratory complications, and cardiac complications were lower among endovascular repair cohort. Conclusion Current evidence supports the use of endovascular repair over open surgery. However, there is a need to conduct dedicated randomized controlled trials to effectively compare and determine the benefits and risk of both strategies. Current findings support endovascular repair over open surgery for the treatment of thoracoabdominal aneurysms (TAAA). Endovascular repair for TAAA can help reduce the risk of all-cause mortality, respiratory and cardiac complications. Consistent results were noted upon subgroup analyses. Dedicated randomized controlled trials are warranted to compare the benefits and risk of both strategies.
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Thoracoabdominal Aortic Disease and Repair: JACC Focus Seminar, Part 3. J Am Coll Cardiol 2022; 80:845-856. [PMID: 35981828 DOI: 10.1016/j.jacc.2021.05.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/03/2021] [Accepted: 05/25/2021] [Indexed: 11/21/2022]
Abstract
Thoracoabdominal aortic disease is a rare but life-threatening condition that requires expert multidisciplinary collaborative management. Intervention is indicated in patients with symptomatic aneurysms or when an aneurysm reaches a certain threshold of diameter or rate of expansion. The strategies for spinal cord and end-organ protection have evolved over several decades, resulting in improved outcomes after repair. Open repair, although invasive, provides definitive and durable repair. Endovascular approaches are rapidly evolving, and the results with fenestrated and branched endografts are promising. Both open repair and endovascular repair require highly specialized expertise, and outcomes are best when repair is undertaken in an elective setting by a dedicated team. Patients with degenerative thoracoabdominal aortic aneurysms and chronic dissections should be followed up closely and referred for elective repair when indicated.
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De Paulis S, Arlotta G, Calabrese M, Corsi F, Taccheri T, Antoniucci ME, Martinelli L, Bevilacqua F, Tinelli G, Cavaliere F. Postoperative Intensive Care Management of Aortic Repair. J Pers Med 2022; 12:jpm12081351. [PMID: 36013300 PMCID: PMC9410221 DOI: 10.3390/jpm12081351] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/12/2022] [Accepted: 08/19/2022] [Indexed: 11/16/2022] Open
Abstract
Vascular surgery patients have multiple comorbidities and are at high risk for perioperative complications. Aortic repair surgery has greatly evolved in recent years, with an increasing predominance of endovascular techniques (EVAR). The incidence of cardiac complications is significantly reduced with endovascular repair, but high-risk patients require postoperative ST-segment monitoring. Open aortic repair may portend a prohibitive risk of respiratory complications that could be a contraindication for surgery. This risk is greatly reduced in the case of an endovascular approach, and general anesthesia should be avoided whenever possible in the case of endovascular repair. Preoperative renal function and postoperative kidney injury are powerful determinants of short- and long-term outcome, so that preoperative risk stratification and secondary prevention are critical tasks. Intraoperative renal protection with selective renal and distal aortic perfusion is essential during open repair. EVAR has lower rates of postoperative renal failure compared to open repair, with approximately half the risk for acute kidney injury (AKI) and one-third of the risk of hemodialysis requirement. Spinal cord ischemia used to be the most distinctive and feared complication of aortic repair. The risk has significantly decreased since the beginning of aortic surgery, with advances in surgical technique and spinal protection protocols, and is lower with endovascular repair. Endovascular repair avoids extensive aortic dissection and aortic cross-clamping and is generally associated with reduced blood loss and less coagulopathy. The intensive care physician must be aware that aortic repair surgery has an impact on every organ system, and the importance of early recognition of organ failure cannot be overemphasized.
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Affiliation(s)
- Stefano De Paulis
- Fondazione Policlinico Gemelli IRCCS, 00168 Rome, Italy
- Correspondence:
| | | | | | - Filippo Corsi
- Fondazione Policlinico Gemelli IRCCS, 00168 Rome, Italy
| | | | | | - Lorenzo Martinelli
- Fondazione Policlinico Gemelli IRCCS, 00168 Rome, Italy
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | | | - Giovanni Tinelli
- Fondazione Policlinico Gemelli IRCCS, 00168 Rome, Italy
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Franco Cavaliere
- Fondazione Policlinico Gemelli IRCCS, 00168 Rome, Italy
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Addas JAK, Mafeld S, Mahmood DN, Sidhu A, Ouzounian M, Lindsay TF, Tan KT. Minimally Invasive Segmental Artery Coil Embolization (MISACE) Prior to Endovascular Thoracoabdominal Aortic Aneurysm Repair. Cardiovasc Intervent Radiol 2022; 45:1462-1469. [PMID: 35927497 DOI: 10.1007/s00270-022-03230-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 07/15/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE Minimally Invasive Segmental Artery Coil Embolization (MISACE) is a novel approach to reduce paraplegia risk in Thoracoabdominal aortic aneurysm (TAAA) repair with limited data. We report our experience with MISACE as a method of spinal cord pre-conditioning to prevent spinal cord ischemia following endovascular repair of TAAA. MATERIAL AND METHODS A retrospective analysis of 17 patients who had an attempted MISACE prior to endovascular TAAA repair with mean follow-up of 350 days (2017-2020). Baseline patient and aneurysm characteristics along with procedural technique and outcomes were analyzed. RESULTS Mean age of 69 years and 76.5% were males. TAAA Crawford classification were II, n = 6 (35.3%), III, n = 4 (23.5%) and IV, n = 5 (29.4%). The mean aortic diameter was 70.6 ± 10.9 mm. Staged repair was performed on 9 patients. Technically successful embolization occurred in 14 patients (82.4%) and was unsuccessful in 3 patients. The median number of embolized arteries was 3 and 71% of the target arteries were between T9 and T12. Mean fluoroscopy time was 51.5 ± 22.5 min and mean contrast volume used was 132.8 ± 56.1 mL. Average number of catheters used was 4.6 and 3.5 wires. No complications related to the procedure. Mean interval between embolization to endovascular TAAA repair was 51.2 days (5-110 days). All patients received spinal drainage at the time of repair. Postoperatively, 2/14 of patients developed paraparesis in the MISACE successful group and 1/3 patients developed paraplegia in the unsuccessful group. CONCLUSIONS MISACE is a promising strategy to prevent SCI. This data demonstrates the technique is feasible and safe but anatomic challenges remain.
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Affiliation(s)
- Jamil A K Addas
- Department of Vascular and Interventional Radiology, University Health Network, Toronto, Canada.
| | - Sebastian Mafeld
- Department of Vascular and Interventional Radiology, University Health Network, Toronto, Canada
| | - Daniyal N Mahmood
- Division of Vascular Surgery, University Health Network, Toronto, Canada
| | - Arshdeep Sidhu
- Department of Vascular and Interventional Radiology, University Health Network, Toronto, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, University Health Network, Toronto, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, University Health Network, Toronto, Canada
| | - Kong Teng Tan
- Department of Vascular and Interventional Radiology, University Health Network, Toronto, Canada
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Forsythe RO, Eng C, Roy C, Cafferkey J, Clinch D, Ventham N, Tambyraja AL, Burns PJ, Falah O, Chalmers RTA. Open extent IV thoracoabdominal aneurysm repair: 22-year experience of the Scottish National Service. Br J Surg 2022; 109:711-716. [PMID: 35716129 PMCID: PMC10364699 DOI: 10.1093/bjs/znac049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/17/2021] [Accepted: 01/26/2022] [Indexed: 08/02/2023]
Abstract
BACKGROUND Since 1999, the Scottish National Service for Thoracoabdominal Aneurysms has offered repair of thoracoabdominal aneurysms (TAAAs) to a population of 5.5 million people. The open operation most commonly performed by the service is the extent IV TAAA repair. METHODS All extent IV open TAAA repairs performed at the Scottish National Service for TAAAs from June 1999 until April 2021 were evaluated for clinical features, technical details, and clinical outcomes. The primary outcome measure was 30-day mortality; secondary outcomes included short-term (90 days, 6 months, 1 and 2 years) and long-term (5 and 10 years) survival, perioperative complications, and reintervention. Survival was assessed using Kaplan-Meier analysis. RESULTS Some 248 patients underwent extent IV TAAA repair, with elective surgery in 204 (82.3 per cent). A totally abdominal transperitoneal approach was used for all patients, with a median visceral ischaemia time of 40 (i.q.r. 35-48) min. Overall, 18 patients (7.3 per cent) died within 30 days. The proportion of patients surviving at 90 days, 6 months, 1, 2, 5, and 10 years was 0.91, 0.90, 0.89, 0.85, 0.72, and 0.41, respectively. Ten patients (4.0 per cent) required a reintervention while in hospital, four (1.6 per cent) experienced permanent spinal cord ischaemia, 19 (7.9 per cent) required temporary renal replacement therapy (RRT), and four (1.6 per cent) required permanent RRT. CONCLUSION Open extent IV TAAA repair performed in a high-volume national centre is associated with favourable short- and long-term survival, and acceptable complication rates.
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Affiliation(s)
- Rachael O Forsythe
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Calvin Eng
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Chloe Roy
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - John Cafferkey
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Darja Clinch
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nicholas Ventham
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Andrew L Tambyraja
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Phillipa J Burns
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Orwa Falah
- Correspondence to: Orwa Falah, Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK (e-mail: )
| | - Roderick T A Chalmers
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
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Motor evoked potential-guided segmental artery revascularization during open thoracoabdominal aortic aneurysm surgery after coil embolization as a part of the minimally invasive staged segmental artery coil embolization concept. J Vasc Surg Cases Innov Tech 2022; 8:206-209. [PMID: 35493346 PMCID: PMC9043849 DOI: 10.1016/j.jvscit.2022.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/16/2022] [Indexed: 11/25/2022] Open
Abstract
Sacrifice of the segmental arteries during thoracoabdominal aortic repair carries the risk of spinal cord injury. Staged embolization of segmental arteries has been discussed as an option for preconditioning the spinal cord vascular network. In the present case, periprocedural monitoring of motor-evoked potentials detected spinal cord ischemia after aortic cross-clamping, although embolization of eight segmental arteries had been performed in advance. Implantation of an intercostal artery bypass restored spinal cord perfusion and normalized the motor-evoked potentials. Thus, the preconditioning strategy to stimulate creation of a spinal cord collateral network as an adjunctive method to prevent paraplegia is not perfect.
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Ulsaker H, Seternes A, Brekken R, Manstad-Hulaas F. Midterm Outcomes for Endovascular Repair of Thoracoabdominal Aortic Aneurysms. EJVES Vasc Forum 2022; 56:6-10. [PMID: 35572162 PMCID: PMC9092505 DOI: 10.1016/j.ejvsvf.2022.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 02/08/2022] [Accepted: 03/29/2022] [Indexed: 11/18/2022] Open
Abstract
Objective To investigate technical and clinical outcomes in patients with thoraco-abdominal aortic aneurysms treated with the multibranched off the shelf Zenith t-Branch stent graft or a custom made device (CMD). Methods A retrospective study was conducted of patients operated on at a single tertiary vascular centre in Norway. Twenty eight t-Branch and 17 CMD patients were identified. Demographic, aneurysm, and peri-operative data were summarised and compared. Results Thirty day mortality was 4% (2/45), with mortality rates of 7% (2/28) and 0 in t-Branch and CMD patients, respectively (p = .52). Technical success was 87% (39/45), with a non-significant difference between t-Branch and CMD procedures of 89% (25/28) and 82% (14/17), respectively (p = .63). Stent graft coverage was significantly longer in t-Branch patients (p = .020). Paraparesis or paraplegia developed in 18% (5/28) of t-Branch patients and 12% (2/17) of CMD patients (p = .69), and spinal cord ischaemia was associated with Crawford type II aneurysms (p = .010) and aortic coverage >400 mm (p = .050). The estimated survival at one and two years for t-Branch patients was 93% and 88%, and 100% and 92% for CMD patients. Freedom from re-intervention was estimated at 70% and 43% at one and two years for t-Branch patients, and 58% and 50% for CMD patients. Conclusion The study showed low 30 day mortality rates, acceptable technical success rates, high medium term survival, and no statistically significant differences in clinically relevant outcomes between t-Branch and CMD patients. Clinical outcomes do not vary significantly between t-Branch and CMD patients. 30 day mortality was low among both t-Branch and CMD patients. Midterm survival was high in both groups.
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Sultan S, Concannon J, Veerasingam D, Tawfick W, McHugh P, Jordan F, Hynes N. Endovascular versus conventional open surgical repair for thoracoabdominal aortic aneurysms. Cochrane Database Syst Rev 2022; 4:CD012926. [PMID: 35363887 PMCID: PMC9370075 DOI: 10.1002/14651858.cd012926.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Thoracoabdominal aortic aneurysms (TAAAs) are a life-threatening condition which remain difficult to treat. Endovascular and open surgical repair (OSR) provide treatment options for patients, however, due to the lack of clinical trials comparing these, the optimum treatment option is unknown. OBJECTIVES To assess the effectiveness and safety of endovascular repair versus conventional OSR for the treatment of TAAAs. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 26 April 2021. We also searched references of relevant articles retrieved from the electronic search for additional citations. SELECTION CRITERIA We considered all published and unpublished randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing endovascular repair to OSR for TAAAs for inclusion in the review. The main outcomes of interest were prevention of aneurysm rupture (participants without aneurysm rupture up to 5 years from intervention), aneurysm-related mortality (30 days and 12 months), all-cause mortality, spinal cord ischaemia (paraplegia, paraparesis), visceral arterial branch compromise causing mesenteric ischaemia or renal failure, and rate of reintervention. DATA COLLECTION AND ANALYSIS Two review authors independently screened all titles and abstracts identified from the searches to identify those that met the inclusion criteria. We planned to undertake data collection, risk of bias assessment, and analysis in accordance with Cochrane recommendations. We planned to assess the certainty of the evidence using GRADE. MAIN RESULTS No RCTs or CCTs met the inclusion criteria for this review. AUTHORS' CONCLUSIONS Due to the lack of RCTs or CCTs, we were unable to determine the safety and effectiveness of endovascular compared to OSR in patients with TAAAs and are unable to provide any evidence on the optimal surgical intervention for this cohort of patients. High-quality RCTs or CCTs addressing this objective are necessary, however conducting such studies will be logistically and ethically challenging for this life-threatening disease.
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Affiliation(s)
- Sherif Sultan
- Vascular Surgery, Galway University Hospital, Galway, Ireland
| | - Jamie Concannon
- Biomedical Engineering, Vascular and Endovascular Surgery, National University of Ireland Galway, Galway, Ireland
| | - Dave Veerasingam
- Cardiothoracic Surgery, Galway University Hospital, Galway, Ireland
| | - Wael Tawfick
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University College Hospital, Galway, Ireland
| | - Peter McHugh
- Mechanical and Biomedical Engineering, National University of Ireland Galway, Galway, Ireland
| | - Fionnuala Jordan
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Niamh Hynes
- CURAM, SFI Research Centre for Medical Devices, National University of Ireland Galway, Galway, Ireland
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Spinella G, Finotello A, Pisa FR, Conti M, Pratesi G, Pane B, Lanzarone E. Temporary Reperfusion of the Aneurysm Sac as a Prevention of Spinal Cord Ischemia After Endovascular Treatment of Thoracoabdominal Aortic Aneurysm: Systematic Review and Meta-analysis. J Endovasc Ther 2022; 30:323-335. [PMID: 35287499 DOI: 10.1177/15266028221082008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Spinal cord ischemia (SCI) is still a feared complication for patients suffering from thoracoabdominal aortic aneurysm (TAAA) who undergo endovascular treatment. The aims of this work are to review the available literature on different reperfusion methods of the aneurysm sac, and to analyze whether the different reperfusion methods, also in combination with other factors, are effective in reducing SCI risk and if the impact varies with the patient's age. METHODS PubMed/MEDLINE library was searched for studies published until November 2020 concerning TAAA, endovascular repair, and SCI preventive measures. Systematic review and meta-analysis were conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses criteria. Primary outcome consisted of correlation between endovascular repair techniques (type A: single step; type B: staged approach with reperfusion branches; type C: staged sequential approach with positioning of the thoracic component). A logistic-weighted regression for each event (SCI, transient, and permanent) was then performed with type of treatment, age, and interaction between them as input factors. Finally, another logistic-weighted regression was performed to analyze the other relevant factors for which observations are available together with the endovascular technique. RESULTS Data from 53 studies with a total of 3095 patients were analyzed. Type A, type B, and type C endovascular strategies were adopted in 75%, 13%, and 12% of studied patients, respectively. Data showed that both type B and type C treatments are associated with lower risk of SCI, with a higher reduction of type C with respect to type B, although this positive trend is limited for elder patients. Moreover, a greater aortic diameter, a reduced aneurysm extent, and the absence of cerebrospinal fluid drainage positioning contribute to lower the risk of SCI. Concerning permanent SCI, both type B and type C are effective in reducing percentages for all ages, with type C treatment more beneficial for younger patients and type B for elder ones. CONCLUSION According to the anatomy and the endovascular repair feasibility criteria, staged endovascular treatment appears to offer relevant advantages over single-step treatment in reducing the risk of SCI, regardless of the reperfusion method adopted.
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Affiliation(s)
- Giovanni Spinella
- Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Alice Finotello
- Department of Surgical and Integrated Diagnostic Sciences, University of Genoa, Genoa, Italy.,Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | - Fabio Riccardo Pisa
- Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Michele Conti
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | - Giovanni Pratesi
- Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Bianca Pane
- Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Ettore Lanzarone
- Department of Management, Information and Production Engineering, University of Bergamo, Bergamo, Italy
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Scott CK, Driessen AL, Gonzalez MS, Malekpour F, Guardiola GG, Baig MS, Kirkwood ML, Timaran CH. Perioperative neurologic outcomes of right versus left upper extremity access for fenestrated-branched endovascular aortic aneurysm repair. J Vasc Surg 2022; 75:794-802. [PMID: 34597786 PMCID: PMC9013472 DOI: 10.1016/j.jvs.2021.08.093] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/23/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Upper extremity (UE) access is frequently used for fenestrated-branched endovascular aortic aneurysm repair (F-BEVAR), particularly for complex repairs. Traditionally, left-side UE access has been used to avoid crossing the arch and the origin of the supra-aortic vessels, which could potentially result in cerebral embolization and an increased risk of perioperative cerebrovascular events. More recently, right UE has been more frequently used as it is more convenient and ergonomic. The purpose of this study was to assess the outcomes and cerebrovascular events after F-BEVAR with the use of right- vs left-side UE access. METHODS During an 8-year period, 453 patients (71% male) underwent F-BEVAR at a single institution. UE access was used in more complex repairs. Left UE access was favored in the past, whereas right UE access is currently the preferred UE access side. Brachial artery cutdown was used in all patients for the placement of a 12F sheath. Outcomes were compared between patients undergoing right vs left UE access. End points included cerebrovascular events, perioperative mortality, technical success, and local access-related complications. RESULTS UE access was used in 361 (80%) patients. The right side was used in 232 (64%) and the left side in 129 (36%) patients for the treatment of 88 (25%) juxtarenal, 135 (38%) suprarenal, and 137 (38%) thoracoabdominal aortic aneurysms. Most procedures were elective (94%). Technical success was achieved in 354 patients (98%). In-patient or 30-day mortality was 3.3%. Five (1%) perioperative strokes occurred in patients undergoing right UE access, of which three were ischemic and two were hemorrhagic. No transient ischemic attacks occurred perioperatively. Two hemorrhagic strokes were associated with permissive hypertension to prevent spinal cord ischemia. No perioperative strokes occurred in patients undergoing left UE access (P = .16). Overall, perioperative strokes occurred with similar frequency in patients undergoing UE (5, 1%) and femoral access only (1, 1%) (P = .99). Arm access-related complications occurred in 15 (5%) patients, 11 (4.8%) on the right side and 4 (6%) on the left side (P = .74). CONCLUSIONS Right UE access can be used for F-BEVAR with low morbidity and minimal risk of perioperative ischemic stroke or transient ischemic attacks. In general, UE access is not associated with an increased risk of perioperative stroke compared with femoral access only. Tight blood pressure control is, however, critical to avoid intracranial bleeding related to uncontrolled hypertension.
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Affiliation(s)
- Carla K. Scott
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Anna L. Driessen
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Marilisa Soto Gonzalez
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Fatemeh Malekpour
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Gerardo G. Guardiola
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mirza S. Baig
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Melissa L. Kirkwood
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Carlos H. Timaran
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Panesar H, Simonian G, O'Connor D. GORE ® TAG ® conformable thoracic stent graft for the treatment of descending aortic pathologies. Future Cardiol 2022; 18:431-441. [PMID: 35040336 DOI: 10.2217/fca-2021-0029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Endovascular repair of the descending thoracic aorta has gained widespread acceptance as a primary treatment modality for thoracic aortic disease due to its minimally invasive approach and improved survival rates. GORE® TAG® Conformable Thoracic Stent Graft was designed for descending thoracic aortic aneurysms, penetrating ulcers, aortic transections and type B aortic dissections, which are accepted indications for endovascular therapy. The aim of this review is to summarize the clinical literature, focusing mainly on the publications that came from manufacturer's pre-market and post-market studies. Including the Global Registry for Endovascular Aortic Treatment (GREAT), sponsored by WL Gore & Associates (Flagstaff, AZ, USA), which is a large database of endovascular repair of various thoracic, abdominal and thoraco-abdominal aortic pathologies to identify and evaluate only those with isolated thoracic aortic pathology (arch and descending thoracic).
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Affiliation(s)
| | - Gregory Simonian
- Division of Vascular Surgery, Heart and Vascular Hospital, Hackensack University Medical Center, Hackensack, NJ 07601, USA
| | - David O'Connor
- Division of Vascular Surgery, Heart and Vascular Hospital, Hackensack University Medical Center, Hackensack, NJ 07601, USA
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Steffner KR, Cheung AT. Preservation of Spinal Cord Function. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00023-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Endovascular Repair of a Descending Thoracic Aortic Aneurysm in a Pediatric Patient with Tuberous Sclerosis: A Case Report and Review of the Literature. Pediatr Cardiol 2022; 43:238-243. [PMID: 34468774 DOI: 10.1007/s00246-021-02717-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/21/2021] [Indexed: 10/20/2022]
Abstract
Aortic aneurysm in children is rare, but has been described in the tuberous sclerosis complex (TSC) population. While surgical repair has been utilized as the primary means of intervention, we present the first known case reporting exclusion of a descending thoracic aortic aneurysm with percutaneous covered stent implantation in a pediatric patient with TSC. A review of the literature is also included herein.
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Zhang Z, Zhou Y, Lin S, Xiao J, Ai W, Zhang WW. Systematic review and meta-analysis of association of prophylactic cerebrospinal fluid drainage in preventing spinal cord ischemia after thoracic endovascular aortic repair. J Vasc Surg 2021; 75:1478-1489.e5. [PMID: 34793925 DOI: 10.1016/j.jvs.2021.10.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 10/27/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We conducted a systemic review and meta-analysis to compare the association between prophylactic cerebrospinal fluid drainage (CSFD) vs non-CSFD in preventing spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) for aneurysm and dissection. METHODS The MEDLINE, Embase, and Cochrane databases were systematically searched to identify all relevant studies reported before April 1, 2020. A systematic review and meta-analysis were performed. We assessed the association between CSFD strategies, including routine CSFD vs selective CSFD or no CSFD, and the SCI rates after TEVAR for patients with aortic dissection (AD), solitary thoracic aortic aneurysm (TAA), or thoracoabdominal aortic aneurysm (TAAA). Subgroup analyses were conducted to assess the association between different aortic pathologies, including AD and thoracic aneurysms, and SCI rates after TEVAR with and without prophylactic CSFD. The data are presented as the pooled event rates (ERs) and 95% confidence intervals (CIs). RESULTS A total of 34 studies of 3561 patients (2671 with TAA or TAAA and 890 with type B AD) were included in the present analysis. The data are presented as the pooled ERs and 95% CIs. The overall SCI rate for patients who had undergone TEVAR with prophylactic CSFD for AD (ER, 1.80%; 95% CI, 0.88%-2.72%) was significantly lower than that for the aortic aneurysm group (ER, 5.73%; 95% CI, 4.20%-7.27%; P < .0001). The SCI rate after TEVAR with prophylactic CSFD was not significantly different from that without CSFD for AD (P = .51). No association was found between the rates of SCI after TEVAR with routine prophylactic CSFD vs selective prophylactic CSFD for aortic aneurysms (P = .76) and AD (P = .70). The SCI rate after TEVAR without CSFD for aortic aneurysms, including isolated TAA and TAAA (ER, 3.49%; 95% CI, 0.23%-6.76%) was not significantly different from that for AD (ER, 3.20%; 95% CI, 0.00%-7.20%; P = .91). For the patients with TAAAs, the rate of SCI after TEVAR with routine prophylactic CSFD was significantly lower than that with selective prophylactic CSFD (P = .04). CONCLUSIONS Our systematic review and meta-analysis has shown that SCI occurs more often after TEVAR for aortic aneurysms than for AD. Routine prophylactic CSFD, compared with selective CSFD, was associated with a lower rate of postoperative SCI after TEVAR for TAAAs. No significant association was found between the SCI rate and routine prophylactic CSFD for patients undergoing TEVAR for isolated TAA or AD.
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Affiliation(s)
- Zhihui Zhang
- Department of Vascular Surgery, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yang Zhou
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Shaomang Lin
- Department of Vascular Surgery, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jianbin Xiao
- Department of Vascular Surgery, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wenjia Ai
- Department of Vascular Surgery, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wayne W Zhang
- Division of Vascular and Endovascular Surgery, University of Washington and Puget Sound Veterans Affairs Health Care System, Seattle, Wash.
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Lella SK, Waller HD, Pendleton A, Latz CA, Boitano LT, Dua A. A Systematic Review of Spinal Cord Ischemia Prevention and Management After Open and Endovascular Aortic Repair. J Vasc Surg 2021; 75:1091-1106. [PMID: 34740806 DOI: 10.1016/j.jvs.2021.10.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 10/24/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Spinal cord ischemia (SCI) is one of the most devastating complications after descending thoracic aortic (DTA) and thoracoabdominal aortic (TAA) repairs. Patients who develop SCI have a poor prognosis with mortality rates reaching 75% within the first year after surgery. Many factors have been shown to increase the risk of this complication, including extent of TAA repair, length of aortic and collateral network coverage, embolization, and reduced spinal cord perfusion pressure. As a result, a variety of treatment strategies have evolved. We aimed to provide an up-to-date review of SCI rates with associated treatment algorithms from open and endovascular DTA and TAA repairs. METHODS Using PRISMA guidelines, a literature review with the Medical Subject Headings (MeSH) terms "spinal cord ischemia; spinal cord ischemia prevention and mitigation strategies; spinal cord ischemia rates; spinal cord infarction" was performed in the Cochrane and PubMed databases to seek all peer-reviewed studies of DTA and TAA repairs with SCI complications, limited to 2012-2021 and the English language. MeSH subheadings including diagnosis, complications, physiopathology, surgery, mortality, and therapy were used to further restrict the articles. Studies were excluded if they were not in humans, not pertaining to SCI in DTA/TAA operative repairs, and if the study primarily discussed neuromonitoring techniques. Additionally, studies with <40 patients or limited information regarding SCI protection strategies were excluded. Each study was individually reviewed by two researchers to assess for type and extent of aortic pathology, operative technique, SCI protection or mitigation strategies, rates of overall and permanent SCI symptoms, associations with SCI on multivariate analysis, and mortality. RESULTS Of 450 studies returned by the MeSH search strategy, 41 met inclusion criteria and were included in the final analysis. For endovascular DTA repair patients, overall SCI rates ranged from 0-10.6% with permanent SCI symptoms ranging from 0-5.1%. Endovascular and open TAA repairs had rates of overall SCI of 0-35%. Permanent SCI symptom rate was reported by only one open study at 1.1% while endovascular TAA repairs had between 2-20.5%. CONCLUSION This review provides an up-to-date review of current rates of SCI as well as prevention and mitigation strategies for DTA and TAA repairs. We find that a multimodal approach, including a bundled institutional protocol, staging of multiple repairs, preservation of collateral blood flow network, augmented spinal cord perfusion, selective cerebrospinal fluid drainage, and distal aortic perfusion in open TAA repairs, appears to be important in reducing the risk of SCI.
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Affiliation(s)
- Srihari K Lella
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass.
| | - Harold D Waller
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Alaska Pendleton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Christopher A Latz
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
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Li H, Wang P, Tang L, Sun J, Zhang Y, Luo W, Luo C, Hu Z, Yang L. Distinct Polarization Dynamics of Microglia and Infiltrating Macrophages: A Novel Mechanism of Spinal Cord Ischemia/Reperfusion Injury. J Inflamm Res 2021; 14:5227-5239. [PMID: 34675600 PMCID: PMC8521441 DOI: 10.2147/jir.s335382] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 10/02/2021] [Indexed: 12/01/2022] Open
Abstract
Purpose Recent studies indicate that microglia and monocyte-derived macrophages (MDMs) have different roles in diseases such as stroke and spinal cord injury, yet their respective polarized phenotypes and roles remain unclear in spinal cord ischemia/reperfusion injury (SCIRI). Methods We established a mouse model of SCIRI by transient aortic occlusion followed by reperfusion. Basso mouse scale (BMS) scores were used to test the locomotor functions. The histopathological changes in spinal cord were assessed by hematoxylin-eosin staining and NF-200 immunohistochemistry. Real-time PCR, immunofluorescence and flow cytometry were employed to analyze the polarized phenotypes of the microglia and infiltrating MDMs, and the resulting inflammatory responses. Furthermore, the role of infiltrating MDMs were investigated by MDMs depletion using systemic administration of clodronate-liposomes. Results SCIRI significantly impaired locomotor function of mice, accompanied with progressed necrosis, infiltration of inflammatory cells and neuron loss in the spinal cord. M1-related pro-inflammatory markers (iNOS, CD16, CD86 and TNF-α) increased dramatically in the early phase following SCIRI. In contrast, M2-related anti-inflammatory markers (CD204 and CD206) elevated at later stage. Besides, the invading MDMs were principally pro-inflammatory M1 type, transiently restricted to the first week after SCIRI. In contrast, microglia were the main source of anti-inflammatory M2 type. Furthermore, depletion of MDMs by clodronate-liposomes significantly preserved neurological functions and relieved neuronal damage caused by SCIRI. Conclusion These findings suggested distinct polarized status of resident microglia and MDMs following SCIRI. Inhibition of the invading MDMs may represent a novel approach for SCIRI treatment.
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Affiliation(s)
- Hui Li
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, People's Republic of China.,Hunan Province Center for Clinical Anesthesia and Anesthesiology, Research Institute of Central South University, Changsha, People's Republic of China
| | - Pengfei Wang
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, People's Republic of China.,Hunan Province Center for Clinical Anesthesia and Anesthesiology, Research Institute of Central South University, Changsha, People's Republic of China
| | - Lin Tang
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, People's Republic of China.,Hunan Province Center for Clinical Anesthesia and Anesthesiology, Research Institute of Central South University, Changsha, People's Republic of China
| | - Jingjing Sun
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, People's Republic of China.,Hunan Province Center for Clinical Anesthesia and Anesthesiology, Research Institute of Central South University, Changsha, People's Republic of China
| | - Yanling Zhang
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, People's Republic of China.,Hunan Province Center for Clinical Anesthesia and Anesthesiology, Research Institute of Central South University, Changsha, People's Republic of China
| | - Wei Luo
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, People's Republic of China.,Hunan Province Center for Clinical Anesthesia and Anesthesiology, Research Institute of Central South University, Changsha, People's Republic of China
| | - Cong Luo
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, People's Republic of China.,Hunan Province Center for Clinical Anesthesia and Anesthesiology, Research Institute of Central South University, Changsha, People's Republic of China
| | - Zhaolan Hu
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, People's Republic of China.,Hunan Province Center for Clinical Anesthesia and Anesthesiology, Research Institute of Central South University, Changsha, People's Republic of China
| | - Lin Yang
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, People's Republic of China.,Hunan Province Center for Clinical Anesthesia and Anesthesiology, Research Institute of Central South University, Changsha, People's Republic of China
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Concannon J, Moerman KM, Hynes N, Sultan S, McGarry JP. Influence of shape-memory stent grafts on local aortic compliance. Biomech Model Mechanobiol 2021; 20:2373-2392. [PMID: 34541627 PMCID: PMC8595172 DOI: 10.1007/s10237-021-01514-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/18/2021] [Indexed: 12/19/2022]
Abstract
The effect of repair techniques on the biomechanics of the aorta is poorly understood, resulting in significant levels of postoperative complications for patients worldwide. This study presents a computational analysis of the influence of Nitinol-based devices on the biomechanical performance of a healthy patient-specific human aorta. Simulations reveal that Nitinol stent-grafts stretch the artery wall so that collagen is stretched to a straightened high-stiffness configuration. The high-compliance regime (HCR) associated with low diastolic lumen pressure is eliminated, and the artery operates in a low-compliance regime (LCR) throughout the entire cardiac cycle. The slope of the lumen pressure–area curve for the LCR post-implantation is almost identical to that of the native vessel during systole. This negligible change from the native LCR slope occurs because the stent-graft increases its diameter from the crimped configuration during deployment so that it reaches a low-stiffness unloading plateau. The effective radial stiffness of the implant along this unloading plateau is negligible compared to the stiffness of the artery wall. Provided the Nitinol device unloads sufficiently during deployment to the unloading plateau, the degree of oversizing has a negligible effect on the pressure–area response of the vessel, as each device exerts approximately the same radial force, the slope of which is negligible compared to the LCR slope of the native artery. We show that 10% oversizing based on the observed diastolic diameter in the mid descending thoracic aorta results in a complete loss of contact between the device and the wall during systole, which could lead to an endoleak and stent migration. 20% oversizing reaches the Dacron enforced area limit (DEAL) during the pulse pressure and results in an effective zero-compliance in the later portion of systole.
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Affiliation(s)
- J Concannon
- Biomedical Engineering, College of Engineering and Informatics, National University of Ireland, Galway, Ireland
| | - K M Moerman
- Biomedical Engineering, College of Engineering and Informatics, National University of Ireland, Galway, Ireland
| | - N Hynes
- Western Vascular Institute, National University of Ireland Galway, Galway, Ireland
| | - S Sultan
- Western Vascular Institute, National University of Ireland Galway, Galway, Ireland
| | - J P McGarry
- Biomedical Engineering, College of Engineering and Informatics, National University of Ireland, Galway, Ireland.
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Eleshra A, Hatm M, Spanos K, Panuccio G, Rohlffs F, Debus ES, Behrendt CA, Tsilimparis N, Kölbel T. Early outcomes of t-Branch off-the-shelf multibranched stent-graft in urgent and emergent repair of thoracoabdominal aortic aneurysms. J Vasc Surg 2021; 75:416-424.e2. [PMID: 34480993 DOI: 10.1016/j.jvs.2021.07.237] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 07/29/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We compared the outcomes between elective, urgent, and emergent treatment of thoracoabdominal aortic aneurysms (TAAAs) using the t-Branch off-the-shelf multibranched stent-graft (Cook Medical, Bloomington, Ind). METHODS All consecutive patients treated for TAAAs using the t-Branch between September 2012 and June 2019 were included in the present study. The patients were divided into three groups according to the urgency of repair: (1) elective, (2) urgent, and (3) emergent. The periprocedural details and 30-day outcomes were analyzed. Survival and reinterventions were analyzed using Kaplan-Meier curves and log-rank tests. RESULTS The t-Branch stent-graft was used for 100 patients during the study period. Of the 100 patients, 30 (73% male; mean age, 65 ± 10 years) were treated electively, 49 (54% male; mean age, 72 ± 7 years) urgently, and 21 (81% male; mean age, 75 ± 9 years) emergently. Transfemoral access with a steerable sheath was used more frequently for target vessel catheterization in the elective group (57%) than in the urgent (8%) and emergent (5%) groups (P = .021). The total number of targeted vessels was 111 of 120 (93%) in the elective group vs 185 of 196 (94%) in the urgent group and 82 of 84 (98%) in the emergent group. The corresponding technical success rates were 97% (29 of 30), 98% (48 of 49), and 95% (20 of 21). The median intensive care unit stay was shorter in the elective group (3 days; range, 1-41 days) than in the urgent group (5 days; range, 1-41 days) and emergent group (11 days; range, 3-37 days; P = .004). The 30-day mortality rate was lower in the elective group (2 of 30; 7%) than in the urgent group (8 of 49; 16%) and emergent group (5 of 21; 24%; P = .049). The acute kidney injury rate was lower in the elective group (2 of 30; 7%) than in the urgent group (11 of 49; 22%) and emergent group (8 of 21; 38%; P = .002). The spinal cord ischemia rate was also lower in the elective group (5 of 30; 17%) than in the urgent group (5 of 49; 10%) and emergent group (8 of 21; 38%; P = .051). The median follow-up was 8 months (interquartile range, 3.2-18.5 months). The cumulative survival rate was 95%, 87%, and 87% at 6, 12, and 24 months, respectively. The cumulative freedom from reintervention during follow-up was 92%, 86%, and 77% at 6, 12, and 24 months, respectively. CONCLUSIONS The technical success of TAAA repair using t-Branch stent-graft was not affected by an urgent or emergent presentation. However, the occurrence of worse periprocedural morbidity and mortality was significantly associated with an urgent or emergent presentation.
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Affiliation(s)
- Ahmed Eleshra
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany.
| | - Mohamed Hatm
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Konstantinos Spanos
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - E Sebastian Debus
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Christian-A Behrendt
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Nikolaos Tsilimparis
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
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Bashir M, Munir W, Davies H, Bailey DM, Williams IM. The retroperitoneal approach for contemporary open abdominal aortic aneurysm surgery: The anatomical reasoning. Asian Cardiovasc Thorac Ann 2021; 29:654-660. [PMID: 34409877 DOI: 10.1177/02184923211039799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In current practice, the place of open surgery in managing abdominal aortic aneurysm is a contentious issue. The principal reason being greater applications of endovascular techniques treating increasingly complicated aortic disease. Development of branched and fenestrated devices enabled this, with numbers increasing annually. This meant a good risk patient with a long infrarenal aortic neck and normal diameter non-tortuous iliac arteries may be suitable for both endovascular and open techniques. However, indications for open surgery are becoming increasingly unclear nowadays due to short-term gains in morbidity and mortality. Exact aortic anatomical morphologies optimum for open or endovascular techniques remains unclear. As graft technology evolves, possibilities for endovascular options are expanding. Currently, establishing optimum treatment plans for complicated abdominal aortic aneurysm (little or no infrarenal neck) is difficult without considering general fitness of the patient. Hence, two sets of possible postoperative complications and follow-up protocols must be explained to patients before either approach. Complicating matters is the optimum surgical approach used for any open repair. The standard approach for open abdominal aortic aneurysm surgery has been transperitoneal as this provides excellent access to the infrarenal aorta and iliac arteries. However, although less commonly used, the retroperitoneal approach has advantages particularly when location of proximal aortic disease indicates suprarenal clamp might be optimum. This paper scrutinises benefits of the retroperitoneal approach performed purely for anatomical reasons where stent graft may be considered complicated. Also, long-term outcomes are examined in terms of endo-leak and subsequent development of true and false aneurysm following both endovascular and open repair.
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Affiliation(s)
- Mohamad Bashir
- Vascular and Endovascular, Health education and Improvement Wales, UK
| | - Wahaj Munir
- 105711Barts and The London School of Medicine and Dentistry, Queen Mary University of London, UK
| | - Huw Davies
- Vascular Surgery, 97609University Hospital of Wales, UK
| | - Damian M Bailey
- Neurovascular Research Laboratory, 102493Faculty of Life Sciences and Education, University of South Wales, UK
| | - Ian M Williams
- Vascular Surgery, 97609University Hospital of Wales, UK.,Neurovascular Research Laboratory, 102493Faculty of Life Sciences and Education, University of South Wales, UK
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