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Takazawa A, Asakura T, Nakazawa K, Kinoshita O, Nakajima H, Yoshitake A. Long-term results of etiology-based thoracic endovascular aortic repair: a single-center experience. Heart Vessels 2024; 39:746-753. [PMID: 38592490 PMCID: PMC11271366 DOI: 10.1007/s00380-024-02392-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 03/07/2024] [Indexed: 04/10/2024]
Abstract
The use of thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysm (TAA) and Stanford type B aortic dissection (TBAD) has been increasing; however, in terms of etiology, the differences of long term after TEVAR outcomes remain unexplored. Thus, we investigated etiology-specific long-term results of TEVAR for TAA and TBAD. A total of 421 TEVAR procedures were performed at our institution from July 2007 to December 2021; 249 TAA cases and 172 TBAD cases were included. Traumatic aortic dissection and aortic injury cases were excluded. The mean observation duration was 5.7 years. The overall 30-day mortality rate was 1.4% (n = 6), with 1.2% (n = 3) in the TAA group and 1.7% (n = 3) in the TBAD group. The overall incidence of postoperative stroke was 0.9% (n = 4), with 1.2% (n = 3) and 0.6% (n = 1) in the TAA and TBAD groups, respectively (p = 0.90). Paraplegia developed in 1.7% (n = 7) of patients, with 2.4% (n = 6) in the TAA group and 0.6% (n = 1) in the TBAD group. Freedom from aortic-related death was not significantly different between the two etiologies; however, thoracic reintervention was more common in the TBAD group (p = 0.003), with endoleak being the most common indication for reintervention. Additionally, retrograde type A aortic dissection occurred in four TBAD cases, while migration occurred in three TAA cases. The perioperative results of TEVAR for TAA and TBAD were satisfactory. The long-term results were unfavorable owing to the occurrence of etiology-specific and common complications. In terms of the high frequency of reintervention, the long-term complications associated with TEVAR are etiology specific.
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Affiliation(s)
- Akitoshi Takazawa
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Yamane, Hidaka City, Saitama, 1397-1, Japan.
| | - Toshihisa Asakura
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Yamane, Hidaka City, Saitama, 1397-1, Japan
| | - Ken Nakazawa
- Department of Radiology, Saitama Medical University International Medical Center, Hidaka City, Japan
| | - Osamu Kinoshita
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Yamane, Hidaka City, Saitama, 1397-1, Japan
| | - Hiroyuki Nakajima
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Yamane, Hidaka City, Saitama, 1397-1, Japan
| | - Akihiro Yoshitake
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Yamane, Hidaka City, Saitama, 1397-1, Japan
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Salem O, El Beyrouti H, Mulorz J, Schelzig H, Ibrahim A, Oberhuber A, Dorweiler B. Predictors for reintervention and survival during long-term follow-up after TEVAR for descending thoracic aortic aneurysm. J Vasc Surg 2024:S0741-5214(24)01658-6. [PMID: 39069015 DOI: 10.1016/j.jvs.2024.07.087] [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: 04/06/2024] [Revised: 07/16/2024] [Accepted: 07/21/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Several studies have reported short- and intermediate-term outcomes after TEVAR for descending thoracic aortic aneurysm (DTAA), however, reports on long-term (10 years) outcomes are sparse. Therefore, the aim of this study was to analyze predictors impacting long-term outcome following thoracic endovascular aortic repair (TEVAR) for DTAA. MATERIALS AND METHODS Databases from four academic institutions were reviewed and consecutive cases of TEVAR for DTAA between 1999 and 2021 were included in this retrospective multicenter study (Case series). Ethical approval from Institutional review board was obtained and patient demographics, treatment data as well as follow-up information were retrieved and analyzed. RESULTS 305 patients (mean age 72±10 years) treated with TEVAR for degenerative DTAA with mean aortic diameter of 64mm were identified. Altogether 445 endografts were implanted via femoral access (93%) with a technical success of 94%. Operative mortality, stroke rate and rate of spinal cord ischemia were 6% (5% for intact, 12% for ruptured DTAA), 4% and 3%, respectively. Kaplan-Meier estimates for overall survival rates were 76%, 59% and 34% at 1, 5 and 10 years and freedom from reintervention rates were 84%, 73% and 58% at 1, 5 and 10 years, respectively. In multivariate analysis, ASA grade 3-5 and non-elective case were identified as predictors for death, wheres as fusiform DTAA, proximal landing zone 2 and hypertension but not device generation were predictive for reintervention. CONCLUSION This is to date the largest study reporting long-term (10 years) outcome on TEVAR for DTAA. We found acceptable rates for long-term survival and freedom-from reintervention that were independent of endovascular device generation.
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Affiliation(s)
- Oroa Salem
- Department of Vascular and Endovascular Surgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Hazem El Beyrouti
- Department of Cardiac and Vascular Surgery, University Medical Center Mainz, Germany
| | - Joscha Mulorz
- Clinic for Vascular and Endovascular Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Hubert Schelzig
- Clinic for Vascular and Endovascular Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany; Cardiovascular Research Institute Düsseldorf (CARID), Heinrich Heine University, Düsseldorf, Germany
| | - Abdelhakim Ibrahim
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, Germany
| | - Alexander Oberhuber
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, Germany
| | - Bernhard Dorweiler
- Department of Vascular and Endovascular Surgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany.
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Amedi A, Meena RA, Garcia-Toca M, Ramos CR, Benarroch-Gampel J, H'Doubler PB, Duwayri Y, Leshnower BG, Rajani RR. Aggressive Treatment Strategy at Index Thoracic Endovascular Aortic Surgery is Associated with Reduced Need for Short-Term Reintervention in Patients with Aortic Dissection. Ann Vasc Surg 2024; 108:141-147. [PMID: 38942367 DOI: 10.1016/j.avsg.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 05/21/2024] [Accepted: 05/22/2024] [Indexed: 06/30/2024]
Abstract
INTRODUCTION Thoracic endovascular aortic surgery (TEVAR) is the modern standard of treatment for patients with Type B aortic dissection, however it is unclear how the initial length of treated aorta affects long-term outcomes. This study aims to elucidate risk factors for secondary intervention after TEVAR for aortic dissection, focusing on length of aortic treatment at index operation. METHODS A retrospective multihospital chart review was completed for patients treated between 2011 and 2022 who underwent TEVAR for aortic dissection with at least 1 year of post-TEVAR imaging and follow-up. Patient demographics and characteristics were analyzed. In this study, aortic zones treated only included those managed with a covered stent graft. The primary outcome measure was any need for secondary intervention. RESULTS A total of 151 patients were identified. Demographics included a mean age of 57 years, with 31.8% of the patients being female. Forty-three patients (28.5%) underwent secondary intervention after TEVAR, with a mean follow-up of 1.6 years. The most common indication for secondary intervention was aneurysmal degeneration of the residual false lumen (76%). There was a significant difference in the number of aortic zones treated in patients who did and did not require secondary intervention (2.3 ± 1 vs. 2.7 ± 1, P = 0.04). Additionally, patients with 3 or more aortic zones of treatment had a significant difference in the need for reintervention (32% secondary intervention versus 52% no secondary intervention, P = 0.02). CONCLUSIONS At least 3 zones of aortic treatment at index TEVAR is associated with a decreased need for overall reintervention. Modern treatment of acute and subacute type B dissection should stress an aggressive initial repair, balanced by the potential increased risk of spinal cord ischemia.
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Affiliation(s)
- Alan Amedi
- Emory University School of Medicine, Atlanta GA.
| | - Richard A Meena
- Department of Surgery, Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA
| | - Manuel Garcia-Toca
- Department of Surgery, Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA; Grady Memorial Hospital, Atlanta, GA
| | - Christopher R Ramos
- Department of Surgery, Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA; Grady Memorial Hospital, Atlanta, GA
| | - James Benarroch-Gampel
- Department of Surgery, Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA; Grady Memorial Hospital, Atlanta, GA
| | - Peter B H'Doubler
- Department of Surgery, Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA
| | - Yazan Duwayri
- Department of Surgery, Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA
| | - Bradley G Leshnower
- Department of Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Ravi R Rajani
- Department of Surgery, Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA; Grady Memorial Hospital, Atlanta, GA
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Sachs C, Vecchini F, Corniquet M, Bartoli M, Barral PA, De Masi M, Omnes V, Piquet P, Alsac JM, Gaudry M. Preemptive treatment in the acute and early subacute phase of uncomplicated type B aortic dissections with poor prognosis factors. Front Cardiovasc Med 2024; 11:1362576. [PMID: 38737713 PMCID: PMC11082266 DOI: 10.3389/fcvm.2024.1362576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 02/27/2024] [Indexed: 05/14/2024] Open
Abstract
Objective Due to its favorable outcome regarding late morbidity and mortality, thoracic endovascular repair (TEVAR) is becoming more popular for uncomplicated type B aortic dissection (TBAD). This study aimed to compare preemptive endovascular treatment and optimal medical treatment (OMT) and OMT alone in patients presenting uncomplicated TBAD with predictors of aortic progression. Design Retrospective multicenter study. Methods We analyzed patients with uncomplicated TBAD and risk factors of progression in two French academic centers. Aortic events [defined as aortic-related (re)intervention or aortic-related death after initial hospitalization], postoperative complications, non-aortic events, and radiologic aortic progression and remodeling were recorded and analyzed. Analysis was performed on an intention-to-treat basis. Results Between 2011 and 2021, preemptive endovascular procedures at the acute and early subacute phase (<30 days) were performed on 24 patients (group 1) and OMT alone on 26 patients (group 2). With a mean follow-up of 38.08 ± 24.53 months, aortic events occurred in 20.83% of patients from group 1 and 61.54% of patients from group 2 (p < .001). No patient presented aortic-related death during follow-up. There were no differences in postoperative events (p = 1.00) and non-aortic events (p = 1.00). OMT patients had significantly more aneurysmal progression of the thoracic aorta (p < .001) and maximal aortic diameter (p < .001). Aortic remodeling was found in 91.67% of patients in group 1 and 42.31% of patients in group 2 (p < .001). A subgroup analysis of patients in group 1 showed that patients treated with preemptive TEVAR and STABILISE had reduced maximum aortic diameters at the 1-year (p = .010) and last follow-up (p = .030) compared to those in patients treated with preemptive TEVAR alone. Conclusion Preemptive treatment of uncomplicated TBAD with risk factors of progression reduces the risk of long-term aortic events. Over 60% of medically treated patients will require intervention during follow-up, with no benefit in terms of postoperative events. Even after surgical treatment, patients in the OMT group had significantly more aneurysmal progression, along with poorer aortic remodeling.
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Affiliation(s)
- Charlotte Sachs
- Department of Vascular Surgery, APHM, Timone Hospital, Marseille, France
- Aortic Center, APHM, Timone Hospital, Marseille, France
| | - Fabien Vecchini
- Department of Vascular Surgery, APHM, Timone Hospital, Marseille, France
- Aortic Center, APHM, Timone Hospital, Marseille, France
| | - Marie Corniquet
- Department of Vascular Surgery, APHP, Georges Pompidou European Hospital, Paris, France
| | - Michel Bartoli
- Department of Vascular Surgery, APHM, Timone Hospital, Marseille, France
| | | | - Mariangela De Masi
- Department of Vascular Surgery, APHM, Timone Hospital, Marseille, France
- Aortic Center, APHM, Timone Hospital, Marseille, France
| | - Virgile Omnes
- Department of Vascular Surgery, APHM, Timone Hospital, Marseille, France
- Aortic Center, APHM, Timone Hospital, Marseille, France
| | - Philippe Piquet
- Department of Vascular Surgery, APHM, Timone Hospital, Marseille, France
- Aortic Center, APHM, Timone Hospital, Marseille, France
| | - Jean-Marc Alsac
- Department of Vascular Surgery, APHP, Georges Pompidou European Hospital, Paris, France
| | - Marine Gaudry
- Department of Vascular Surgery, APHM, Timone Hospital, Marseille, France
- Aortic Center, APHM, Timone Hospital, Marseille, France
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5
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Reutersberg B, Gleason T, Desai N, Ehrlich M, Evangelista A, Braverman A, Myrmel T, Chen EP, Estrera A, Schermerhorn M, Bossone E, Pai CW, Eagle K, Sundt T, Patel H, Trimarchi S, Eckstein HH. Neurological event rates and associated risk factors in acute type B aortic dissections treated by thoracic aortic endovascular repair. J Thorac Cardiovasc Surg 2024; 167:52-62.e5. [PMID: 35260280 DOI: 10.1016/j.jtcvs.2022.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 01/14/2022] [Accepted: 02/01/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Thoracic endovascular aortic repair is the method of choice in patients with complicated type B acute aortic dissection. However, thoracic endovascular aortic repair carries a risk of periprocedural neurological events including stroke and spinal cord ischemia. We aimed to look at procedure-related neurological complications within a large cohort of patients with type B acute aortic dissection treated by thoracic endovascular aortic repair. METHODS Between 1996 and 2021, the International Registry of Acute Aortic Dissection collected data on 3783 patients with type B acute aortic dissection. For this analysis, 648 patients with type B acute aortic dissection treated by thoracic endovascular aortic repair were included (69.4% male, mean age 62.7 ± 13.4 years). Patients were excluded who presented with a preexisting neurologic deficit or received adjunctive procedures. Demographics, clinical symptoms, and outcomes were analyzed. The primary end point was the periprocedural incidence of neurological events (defined as stroke, spinal cord ischemia, transient neurological deficit, or coma). Predictors for perioperative neurological events and follow-up outcomes were considered as secondary end points. RESULTS Periprocedure neurological events were noted in 72 patients (11.1%) and included strokes (n = 29, 4.6%), spinal cord ischemias (n = 21, 3.3%), transient neurological deficits (n = 16, 2.6%), or coma (n = 6, 1.0%). The group with neurological events had a significantly higher in-hospital mortality (20.8% vs 4.3%, P < .001). Patients with neurological events were more likely to be female (40.3% vs 29.3%, P = .077), and aortic rupture was more often cited as an indication for thoracic endovascular aortic repair (38.8% vs 16.5%, P < .001). In patients with neurological events, more stent grafts were used (2 vs 1 stent graft, P = .002). Multivariable logistic regression analysis showed that aortic rupture (odds ratio, 3.12, 95% confidence interval, 1.44-6.78, P = .004) and female sex (odds ratio, 1.984, 95% confidence interval, 1.031-3.817, P = .040) were significantly associated with perioperative neurological events. CONCLUSIONS In this highly selected group from dedicated aortic centers, more than 1 in 10 patients with type B acute aortic dissection treated by thoracic endovascular aortic repair had neurological events, in particular women. Further research is needed to identify the causes and presentation of these events after thoracic endovascular aortic repair, especially among women.
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Affiliation(s)
- Benedikt Reutersberg
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Thomas Gleason
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Nimesh Desai
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Marek Ehrlich
- Department of Cardiothoracic Surgery, University of Vienna, Vienna, Austria
| | | | - Alan Braverman
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St Louis, Mo
| | | | - Edward P Chen
- Division of Cardiovascular Surgery, Duke University School of Medicine, Durham, NC
| | - Anthony Estrera
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Tex
| | - Marc Schermerhorn
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Eduardo Bossone
- Department of Cardiology, San Giovanni e Ruggi, Salerno, Italy
| | - Chih-Wen Pai
- Department of Medicine and Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Mich
| | - Kim Eagle
- Department of Medicine and Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Mich
| | - Thoralf Sundt
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Himanshu Patel
- Cardiac Surgery, University of Michigan Health System, Ann Arbor, Mich
| | - Santi Trimarchi
- Department of Clinical and Community Sciences, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
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Chellasamy RT, Krishnaswami M. Reinterventions after TEVAR. Indian J Thorac Cardiovasc Surg 2023; 39:325-332. [PMID: 38093920 PMCID: PMC10713966 DOI: 10.1007/s12055-023-01646-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 12/17/2023] Open
Abstract
Thoracic cardiovascular aortic repair is an alternative procedure to open surgery for degenerative thoracic aortic aneurysm and thoracic aortic dissection. The advancements in graft design and imaging techniques have expanded its utility. However, the long-term patency of thoracic endovascular aortic repair (TEVAR) graft is still a concern. This review delves into the literature on re-intervention following TEVAR, highlighting factors that influence the re-intervention rate.
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Affiliation(s)
| | - Murali Krishnaswami
- Department of Radiology, Institute of Cardiac and Aortic Disorders, SIMS Hospital, Chennai, 600026 India
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Al-Tawil M, Geragotellis A, Jubouri M, Tan SZ, Mohammed I, Williams I, Bashir M. Population risk profile analysis of acute uncomplicated type B aortic dissection patients undergoing thoracic endovascular aortic repair. Asian Cardiovasc Thorac Ann 2023; 31:549-556. [PMID: 35532028 DOI: 10.1177/02184923221099771] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
BACKGROUND Uncomplicated type B aortic dissection (unTBAD) comprises the estimated majority of type B aortic dissection (TBAD), presenting without any of the complications associated with complicated TBAD (coTBAD). Although first-line treatment for coTBAD is thoracic endovascular aortic repair (TEVAR), and despite the fact that TEVAR has proven its safety and effectiveness in the treatment of unTBAD, unTBAD is still being predominantly managed conservatively with medical therapy, with a small proportion of patients being offered TEVAR. AIMS The main scope of this review is to highlight the evidence in the literature of the demographic characteristics and associated co-morbidities of unTBAD patients undergoing TEVAR in order to produce a risk stratification system to achieve favourable outcomes. METHODS A comprehensive literature search was conducted using multiple electronic databases including PubMed, Ovid, Scopus, and EMBASE. RESULTS Multiple demographic characteristics and associated co-morbidities of unTBAD patients affecting TEVAR outcomes were identified, assessed, and investigated, including age, gender, race, genetics, medical conditions, such as hypertension and diabetes, and lifestyle factors such as smoking. Most factors were associated with increased risks of mortality and morbidity, while others, such as race, were identified as being protective against those when it comes to TEVAR. CONCLUSION Despite the favourable results yielded by TEVAR in unTBAD, there remains a grey area concerning its management. Thus, it is important to incorporate the demographics and co-morbidities of unTBAD patients' when into clinical judgement when assessing indications for TEVAR intervention to ensure optimum results can be achieved.
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Affiliation(s)
| | | | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Sven Zcp Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, UK
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Ian Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Mohamad Bashir
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
- Vascular & Endovascular Surgery, Velindre University NHS Trust, Health Education & Improvement Wales (HEIW), Cardiff, UK
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Frisiras A, Giannas E, Bobotis S, Kanella I, Arjomandi Rad A, Viviano A, Spiliopoulos K, Magouliotis DE, Athanasiou T. Comparative Analysis of Morbidity and Mortality Outcomes in Elderly and Nonelderly Patients Undergoing Elective TEVAR: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:5001. [PMID: 37568406 PMCID: PMC10420243 DOI: 10.3390/jcm12155001] [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: 06/11/2023] [Revised: 07/14/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
OBJECTIVE Due to an ever-increasing ageing population and limited available data around the use of thoracic endovascular aortic repair (TEVAR) in elderly patients, investigating its efficacy and safety in this age cohort is of vital importance. We thus reviewed the existing literature on this topic to assess the feasibility of TEVAR in elderly patients with severe thoracic aortic pathologies. METHODS We identified all original research studies that assessed TEVAR in elderly patients published up to 2023. Morbidity, as assessed by neurological and respiratory complications, endoleaks, and length of stay, was the primary endpoint. Short-term mortality and long-term survival were the secondary endpoints. The Mantel-Haenszel random and fixed effects methods were used to calculate the odds ratios for each outcome. Further sensitivity and subgroup analyses were performed to validate the outcomes. RESULTS Twelve original studies that evaluated elective TEVAR outcomes in elderly patients were identified. Seven studies directly compared the use of TEVAR between an older and a younger patient group. Apart from a shorter hospital stay in older patients, no statistically significant difference between the morbidity outcomes of the two different cohorts was found. Short-term mortality and long-term survival results favoured the younger population. CONCLUSIONS The present meta-analysis indicates that, due to a safe perioperative morbidity profile, TEVAR should not be contraindicated in patients based purely on old age. Further research using large patient registries to validate our findings in elderly patients with specific aortic pathologies and both elective and emergency procedures is necessary.
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Affiliation(s)
- Angelos Frisiras
- Faculty of Medicine, Imperial College London, Charing Cross Hospital, London W6 8RF, UK; (A.F.); (E.G.); (S.B.); (I.K.)
| | - Emmanuel Giannas
- Faculty of Medicine, Imperial College London, Charing Cross Hospital, London W6 8RF, UK; (A.F.); (E.G.); (S.B.); (I.K.)
| | - Stergios Bobotis
- Faculty of Medicine, Imperial College London, Charing Cross Hospital, London W6 8RF, UK; (A.F.); (E.G.); (S.B.); (I.K.)
| | - Ilektra Kanella
- Faculty of Medicine, Imperial College London, Charing Cross Hospital, London W6 8RF, UK; (A.F.); (E.G.); (S.B.); (I.K.)
| | | | - Alessandro Viviano
- Department of Cardiothoracic Surgery, Imperial College NHS Trust, Hammersmith Hospital, London W12 0HS, UK;
| | - Kyriakos Spiliopoulos
- Department of Cardiothoracic Surgery, University of Thessaly, Biopolis, 41 110 Larissa, Greece;
| | - Dimitrios E. Magouliotis
- Unit of Quality Improvement, Department of Cardiothoracic Surgery, University of Thessaly, Biopolis, 41 110 Larissa, Greece;
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital, London W2 1NY, UK
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9
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Ramakrishnan G, Beliveau L, Shinn K, Gable C, Brinkman W, Shutze W, Gable D. Real-world comparative claims analysis of a novel single-branched aortic stent graft device versus thoracic endograft placement with extra-anatomic debranching/revascularization in zone 2 aortic disease. Proc AMIA Symp 2023; 36:422-426. [PMID: 37334086 PMCID: PMC10269387 DOI: 10.1080/08998280.2023.2212585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 04/14/2023] [Accepted: 05/07/2023] [Indexed: 06/20/2023] Open
Abstract
Background Thoracic endovascular aortic repair (TEVAR) involving landing zone 2 can require extra-anatomic debranching (SR-TEVAR) to ensure left subclavian artery perfusion, resulting in increased costs. A single-branch device (Thoracic Branch Endoprosthesis [TBE], WL Gore, Flagstaff, AZ) provides a total endovascular solution. Comparative cost analysis of patients undergoing zone 2 TEVAR requiring left subclavian artery preservation with TBE versus SR-TEVAR is presented. Methods A single-center retrospective cost analysis was performed for aortic diseases requiring a zone 2 landing zone (TBE vs. SR-TEVAR) from 2014 to 2019. Facility charges were collected from the universal billing form UB-04 (form CMS 1450). Results Twenty-four patients were included in each arm. There were no significant differences in the overall mean procedural charges between the two groups: TBE, $209,736 ($57,761) vs. SR-TEVAR $209,025 ($93,943), P = 0.94. TBE resulted in reduced operating room charges ($36,849 [$8750] vs. $48,073 [$10,825], P = 0.02) and reduced intensive care unit and telemetry room charges, which did not reach statistical significance (P = 0.23 and 0.12, respectively). Device/implant charges were the primary cost driver in both groups. Charges associated with TBE were significantly higher: $105,525 ($36,137) vs. $51,605 ($31,326), P > 0.01. Conclusions TBE had similar overall procedural charges despite higher device/implant-related expenses and reduced facility resource utilization (lower operating room, intensive care unit, telemetry, and pharmacy charges).
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Affiliation(s)
- Ganesh Ramakrishnan
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Lauren Beliveau
- Division of Vascular and Endovascular Surgery, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - Kathryn Shinn
- Division of Vascular and Endovascular Surgery, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - Cara Gable
- Department of Biomedical Sciences, Texas A&M University, College Station, Texas
| | - William Brinkman
- Division of Cardiac and Thoracic Surgery, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - William Shutze
- Division of Vascular and Endovascular Surgery, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - Dennis Gable
- Division of Vascular and Endovascular Surgery, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
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dos Reis JMC, Ribeiro FRCDM, Koury A, Melo GDS, de Oliveira MV, Gomes VHGA, dos Santos JVF, Sarquis SG. Traumatic aorta injuries in a rural area: late manifestations and review of therapeutic aspects. J Vasc Bras 2023; 22:e20220014. [PMID: 37346376 PMCID: PMC10281037 DOI: 10.1590/1677-5449.202200142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 02/05/2023] [Indexed: 06/23/2023] Open
Abstract
Traumatic thoracic aortic injuries (TTAI) are associated with high rates of morbidity and mortality. They are classified according to the extent of damage and computed tomography angiography has the highest sensitivity and specificity for identifying the degree of injury and potential associated lesions. Treatment strategies for TTAI are based on the type and extent of injury and associated lesions. The patient's degree of stability can also help to define the choice of treatment, which can be conventional or endovascular surgery (EVAR) or even conservative management in selected cases. Among patients with adequate vascular anatomy, endovascular surgery is associated with better survival and fewer risks. The objective of this article is to describe a series of four cases followed up at a tertiary service in a Brazilian state that has few centers that provide high complexity care. Endovascular therapy was employed as the preferred method. All four patients had favorable outcomes, with no complications up to discharge, and are currently in outpatient follow-up.
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Affiliation(s)
- José Maciel Caldas dos Reis
- Centro Universitário Metropolitano da Amazônia - UNIFAMAZ, Belém, PA, Brasil.
- Hospital de Clínicas Gaspar Vianna - HCGV, Belém, PA, Brasil.
| | | | - Adib Koury
- Hospital de Clínicas Gaspar Vianna - HCGV, Belém, PA, Brasil.
| | | | | | | | - José Victor Figueiredo dos Santos
- Centro Universitário Metropolitano da Amazônia - UNIFAMAZ, Belém, PA, Brasil.
- Hospital de Clínicas Gaspar Vianna - HCGV, Belém, PA, Brasil.
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11
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Rastogi V, Romijn ASC, Yadavalli SD, Marcaccio CL, Jongkind V, Zettervall SL, Quiroga E, Saillant NN, Verhagen HJM, Schermerhorn ML. Males and females have similar mortality after thoracic endovascular aortic repair for blunt thoracic aortic injury. J Vasc Surg 2023; 77:997-1005. [PMID: 36565777 DOI: 10.1016/j.jvs.2022.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 12/06/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Prior literature has demonstrated worse outcomes for female patients after abdominal aortic aneurysm repair. Also, prior studies in the context of thoracic endovascular aneurysm repair (TEVAR) for thoracic aortic aneurysms have reported conflicting results regarding sex-related outcomes. Because the influence of sex on the outcomes after TEVAR for blunt thoracic aortic injuries (BTAIs) remains understudied, we evaluated the association between sex and outcomes after TEVAR for BTAI. METHODS We identified patients who had undergone TEVAR for BTAIs in the Vascular Quality Initiative registry from 2013 to 2022 and included those who had undergone TEVAR within zones 2 to 5 of the thoracic aorta. Patients with missing information regarding the aortic injury grade (Society for Vascular Surgery aortic injury grading system) were excluded. We performed multivariable logistic regression and Cox regression to determine the influence of sex on the perioperative outcomes and long-term mortality, respectively. RESULTS We identified 1311 patients, of whom 27% were female. The female patients were significantly older (female, 47 years [interquartile range (IQR), 30-63 years]; male, 38 years [IQR, 28-55 years]; P < .001) with higher rates of comorbidities. Although the female patients had had higher Glasgow coma scale scores (median, 15 [IQR, 11-15]; vs 14 [IQR, 8-15]; P = .028), no differences were found in the aortic injury grade or other coexisting traumatic injuries between the sexes. Apart from the longer procedure duration for the female patients (median, 79 minutes [IQR, 52-119 minutes]; vs 69 minutes [IQR, 48-106 minutes]; P = .008), the procedural characteristics were comparable. After adjustment, no significant association was found between female sex and perioperative mortality (7.1% vs 8.1%; odds ratio, 0.76; 95% confidence interval [CI], 0.43-1.3; P = .34). The male and female patients had had comparable rates of postoperative complications (26% vs 29%; odds ratio, 0.89; 95% CI: 0.52-1.5]; P = .26) including access-related complications (0.5% vs 0.8%; P=.83). However, females had a significantly higher risk for reintervention during the index admission (odds ratio, 2.5; 95% CI, 1.1-5.5; P = .024). No significant difference was found between the male and female patients with respect to 5-year mortality (hazard ratio, 0.87; 95% CI, 0.57-1.35; P = .50). CONCLUSIONS Unlike the sex-based outcome disparities observed after thoracic aortic aneurysm repair, we found no significant association between sex and perioperative outcomes or long-term mortality after TEVAR for BTAIs. This contrast in the sex-related outcomes after other vascular pathologies might be explained by differences in the pathology, demographics, and anatomic factors in these patients.
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Affiliation(s)
- Vinamr Rastogi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Anne-Sophie C Romijn
- Division of Trauma and Emergency Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Surgery, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - Sai Divya Yadavalli
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vincent Jongkind
- Department of Surgery, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - Sara L Zettervall
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Elina Quiroga
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Noelle N Saillant
- Division of Trauma and Emergency Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Hence J M Verhagen
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - 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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12
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Hasan IS, Brown JA, Serna-Gallegos D, Aranda-Michel E, Yousef S, Wang Y, Sultan I. Association of Thoracic Aortic Aneurysm Versus Aortic Dissection on Outcomes After Thoracic Endovascular Aortic Repair. J Am Heart Assoc 2023; 12:e027641. [PMID: 36892050 PMCID: PMC10111510 DOI: 10.1161/jaha.122.027641] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
Background Because thoracic endovascular aortic repair (TEVAR) has become the standard of care for complicated type B aortic dissection (TBAD) and descending thoracic aortic (DTA) aneurysm, it is important to understand outcomes and use of TEVAR across thoracic aortic pathologies. Methods and Results This was an observational study of patients with TBAD or DTA undergoing TEVAR from 2010 to 2018, using the Nationwide Readmissions Database. In-hospital mortality, postoperative complications, admission costs, and 30- and 90-day readmissions were compared between the groups. Mixed model logistic regression was used to identify variables associated with mortality. An estimated total of 12 824 patients underwent TEVAR nationally, of which 6043 had an indication of TBAD and 6781 of DTA. Patients with aneurysms were more likely to be older, women, have cardiovascular disease, and have chronic pulmonary disease compared with patients with TBAD. Weighted in-hospital mortality was higher for TBAD (8% [1054/12 711] versus 3% [433/14 407], P<0.001), compared with DTA, as were all postoperative complications. Patients with TBAD had a higher cost of care during their index admission (57.3 versus 38.8 × $1000, P<0.001), compared with DTA. The 30-day and 90-day weighted readmissions were more frequent for the TBAD group compared with DTA (20% [1867/12 711] and 30% [2924/12 711] versus 15% [1603/14 407] and 25% [2695/14 407], respectively, P<0.001). On multivariable adjustment, TBAD was independently associated with mortality (odds ratio, 2.06 [95% CI, 1.68-2.52]; P<0.001). Conclusions After TEVAR, patients who presented with TBAD had higher rates of postoperative complications, in-hospital mortality, and cost compared with DTA. The incidence of early readmission was substantial for patients undergoing TEVAR, faring worse for those undergoing TEVAR for TBAD as compared with DTA.
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Affiliation(s)
- Irsa S Hasan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery University of Pittsburgh PA USA
| | - James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery University of Pittsburgh PA USA
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery University of Pittsburgh PA USA
- Heart and Vascular Institute University of Pittsburgh Medical Center PA USA
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery University of Pittsburgh PA USA
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery University of Pittsburgh PA USA
| | - Yisi Wang
- Heart and Vascular Institute University of Pittsburgh Medical Center PA USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery University of Pittsburgh PA USA
- Heart and Vascular Institute University of Pittsburgh Medical Center PA USA
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Gallo M, van den Berg JC, Torre T, Riggi M, Demertzis S, Ferrari E. LONG-TERM OUTCOMES AND RISK FACTORS ANALYSIS FOR PATIENTS UNDERGOING THORACIC ENDOVASCULAR AORTA REPAIR (TEVAR), ACCORDING TO THE AORTIC PATHOLOGIES. Ann Vasc Surg 2023:S0890-5096(23)00112-7. [PMID: 36907507 DOI: 10.1016/j.avsg.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 03/14/2023]
Abstract
OBJECTIVE Thoracic endovascular aortic repair (TEVAR) has become a standard treatment for acute and chronic thoracic aorta diseases. We analysed long-term outcomes and risk factors of TEVAR procedures according to the aortic pathology. METHODS Demographics, indications, technical details, and outcomes of patients undergoing TEVAR procedures in our institutions were prospectively collected and retrospectively analyzed. Overall survival was determined using Kaplan-Meier methods while Log-rank tests were used to compare the survival between groups. Cox regression analysis was used to identify risk factors. RESULTS Between June 2002 and April 2020, 116 patients underwent TEVAR for different thoracic aorta diseases. Among them, 47 patients (41%) underwent TEVAR for aneurysmatic aortic disease, 26 (22%) for type-B aortic dissection, 23 (20%) for penetrating aortic ulcer, 11 (9%) after previous type-A dissection treatment and 9 (8%) for traumatic aortic injury. Patients with post-traumatic aortic injury were younger (p<0.01), with less hypertension (p<0.01), diabetes (p<0.01) and prior cardiac surgery (p<0.01). Survival was different based on indication for TEVAR (log rank 0.024). Patients after previous type-A dissection treatment had the worst survival rate (50% at 5 years) while survival for aneurysmatic aortic disease was 55% at 5 years. No late death occurred in the traumatic group. Cox-regression model identified independent predictors for mortality: age (HR 1.05, 95% CI 1.01-1.09, p= 0.006), male gender (HR 3.2, 95% CI 1.1-9.2, p=0.028), moderate COPD (HR 2.1, 95% CI 1.02-4.55, p=0.043), previous cardiac surgery (HR 2.1, 95% CI 1.008-4.5, p=0.048), and treatment indication for aneurysm (HR 2.6, 95% CI 1.2-5.2, p=0.008). CONCLUSIONS TEVAR is a safe and effective procedure with excellent long-term results in case of traumatic aortic injury. The overall long-term survival is affected by aortic pathology, associated comorbidities, gender and previous cardiac surgery.
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Affiliation(s)
- Michele Gallo
- Cardiac Surgery. Cardiocentro Ticino Institute, EOC, Lugano, Switzerland
| | - Jos C van den Berg
- Centro Vascolare Ticino, Ospedale Regionale di Lugano, EOC, Lugano, Switzerland; Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie, Inselspital, Universitätsspital Bern, Bern, Switzerland
| | - Tiziano Torre
- Cardiac Surgery. Cardiocentro Ticino Institute, EOC, Lugano, Switzerland
| | - Manuela Riggi
- Cardiac Surgery. Cardiocentro Ticino Institute, EOC, Lugano, Switzerland; Department of Cardiovascular Surgery, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Stefanos Demertzis
- Cardiac Surgery. Cardiocentro Ticino Institute, EOC, Lugano, Switzerland; University of Italian Switzerland (USI), Biomedical Faculty, Lugano, Switzerland
| | - Enrico Ferrari
- Cardiac Surgery. Cardiocentro Ticino Institute, EOC, Lugano, Switzerland; University of Italian Switzerland (USI), Biomedical Faculty, Lugano, Switzerland.
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Geragotellis A, Al-Tawil M, Jubouri M, Tan SZCP, Williams I, Bashir M. Risk profile analysis of uncomplicated type B aortic dissection patients undergoing thoracic endovascular aortic repair: Laboratory and radiographic predictors. J Card Surg 2022; 37:2811-2820. [PMID: 35652486 DOI: 10.1111/jocs.16655] [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: 04/16/2022] [Accepted: 04/22/2022] [Indexed: 01/16/2023]
Abstract
BACKGROUND There is emerging evidence to support pre-emptive thoracic endovascular aortic repair (TEVAR) intervention for uncomplicated type B aortic dissection (unTBAD). Pre-emptive intervention would be particularly beneficial in patients that have a higher baseline risk of progressing to complicated TBAD (coTBAD). There remain debate on the optimal clinical, laboratory, morphological, and radiological parameters, which would identify the highest-risk patients that would benefit most from pre-emptive TEVAR. AIM This review summarizes evidence on the clinical, laboratory, and morphological parameters that increase the risk profiles of unTBAD patients. METHODS A comprehensive literature search was carried out on multiple electronic databases including PubMed, EMBASE, Ovid, and Scopus to collate all research evidence on the clinical, laboratory, and morphological parameters that increase the risk profiles of unTBAD patients RESULTS: At present, there are no clear clinical guidelines using risk-stratification to inform the selection of unTBAD patients for TEVAR. However, there are noticeable literature trends that can assist with the identification of the most at-risk unTBAD patients. Patients are at particular risk when they have refractory pain and/or hypertension, elevated C-reactive protein (CRP), larger aortic diameter, and larger entry tears. These risks should be considered alongside factors that increase the procedural risk of TEVAR to create a well-balanced approach. Advances in biomarkers and imaging are likely to identify more pertinent parameters in the future to optimize the development of balanced, risk-stratified treatment protocols. CONCLUSION There are a variety of risk profiling parameters that can be used to identify the high-risk unTBAD patient, with novel biomarkers and imaging parameters emerging. Longer-term evidence verifying these parameters would be ideal. Further randomized controlled trials and multicentre registry analyses are also warranted to guide risk-stratified selection protocols.
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Affiliation(s)
| | | | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Sven Z C P Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ian Williams
- Department of Vascular Surgery, Heath Park, University Hospital of Wales, Cardiff, UK
| | - Mohamad Bashir
- Vascular & Endovascular Surgery, Health Education & Improvement Wales (HEIW), Velindre University NHS Trust, Cardiff, UK
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15
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Steinmetz LM, Coselli JS. Endovascular Repair in Patients with Marfan Syndrome: Concerns Amid Controversy. Ann Vasc Surg 2022:S0890-5096(22)00236-9. [PMID: 35595210 DOI: 10.1016/j.avsg.2022.04.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 04/21/2022] [Indexed: 11/25/2022]
Abstract
Endovascular aortic repair is widely used to treat patients with degenerative aneurysms or aortic dissection within the distal aorta. Thoracic endovascular aortic repair (TEVAR) is generally associated with fewer short-term complications than open surgical repair, which is particularly important for older patients with significant comorbid conditions. However, for patients with Marfan syndrome, a heritable thoracic aortic disease associated with aortic dilatation, dissection, and rupture, the utility of endovascular aortic repair remains questionable. Marfan patients have friable aortic tissue and are typically treated at a relatively young age; they therefore need a durable solution. Furthermore, those who need distal aortic repair tend to have chronic aortic dissection. Although TEVAR is generally superior to open surgery with regard to short-term complications, it is less durable, and TEVAR reintervention rates are highest in patients with chronic aortic dissection. Thus, Marfan patients seeking definitive aortic repair are often better served by open repair. Nonetheless, TEVAR may be useful in patients with Marfan syndrome as a bridge to open repair or as treatment for late complications of previous open repair.
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Affiliation(s)
- Leah M Steinmetz
- Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas, USA; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas, USA.
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16
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Liisberg M, Baudier F, Akgül C, Lindholt JS. Long-term Thoracic Endovascular Repair follow-up from 1999-2019 - a Single-Center Experience. Ann Vasc Surg 2022; 86:399-407. [PMID: 35460855 DOI: 10.1016/j.avsg.2022.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 02/22/2022] [Accepted: 04/06/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Thoracic endovascular aortic repair (TEVAR) was introduced in the early 1990's, and long-term follow-up studies are warranted in current guidelines. METHODS Patients undergoing TEVAR were consecutively included from 1999-2019. Thoracic aortic disease includes thoracic aortic aneurysms, aortic dissection, traumatic rupture, penetrating aortic ulcer (PAU) and intramural hematoma (IMH). Our prospective database recorded baseline characteristics, endoleak or aneurysm growth and death. Patients were included at time of treatment and censored at death, or first reintervention depending on the analysis. Primary endpoint was all-cause death, secondary endpoint was reintervention. Survival and failure analysis were done using StataIC 16.0® and truncated at 15 years of follow-up. RESULTS 256 patients were included - 63% were men. Their mean age at intervention was 66.2 ± 14.5 years and they were followed for a mean of 5.2 ± 4.5 years. Indications for TEVAR were acute aortic syndrome 40.6%, chronic aortic disease 44.5%, and traumatic rupture in 14.8 %. Technical success was seen in 94.1 % of the operations, and the left subclavian artery was covered in 27.7%. 30-day mortality rate was 21.2% (22/104) and 1.75% (2/114) (p<0.001) for urgent and elective patients, respectively. Twelve patients (4.7%) died within 24 hours of treatment. Overall, long-term mortality recorded112 (43,8%) deaths, 29 patients had reinterventions (11.3 % (95% confidence interval: 7.7-15.9)), aneurysms accounted for 62.1% of all reinterventions. 24 (82.8%) reinterventions occurred within the first 5 years. CONCLUSION This long-term follow-up study shows excess mortality in patients treated for acute aortic syndrome compared to chronic aortic disease, within the first 30 days, this difference diminishes at the end of follow-up. Most endoleak occur within the first five years, though new endoleak continue to develop decades after in previous endoleak-free patients calling for lifelong surveillance.
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Affiliation(s)
- Mads Liisberg
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Denmark; Elite Research Centre of Individualised Treatment of Arterial Diseases (CIMA), Odense University Hospital, Denmark; Clinical Institute, University of Southern Denmark, Denmark.
| | - Francois Baudier
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Denmark; Elite Research Centre of Individualised Treatment of Arterial Diseases (CIMA), Odense University Hospital, Denmark
| | - Cengiz Akgül
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Denmark; Elite Research Centre of Individualised Treatment of Arterial Diseases (CIMA), Odense University Hospital, Denmark
| | - Jes S Lindholt
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Denmark; Elite Research Centre of Individualised Treatment of Arterial Diseases (CIMA), Odense University Hospital, Denmark; Clinical Institute, University of Southern Denmark, Denmark
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Williams ML, de Boer M, Hwang B, Wilson B, Brookes J, McNamara N, Tian DH, Shiraev T, Preventza O. Thoracic endovascular repair of chronic type B aortic dissection: a systematic review. Ann Cardiothorac Surg 2022; 11:1-15. [PMID: 35211380 PMCID: PMC8807414 DOI: 10.21037/acs-2021-taes-25] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/04/2021] [Indexed: 04/12/2024]
Abstract
BACKGROUND At present, the optimal management strategy for chronic type B aortic dissection (CTBAD) remains unknown, as equipoise remains regarding medical management versus endovascular treatment versus open surgery. However, the results over recent years of thoracic endovascular aortic repair (TEVAR) in CTBAD appear promising. The aim of this systematic review was to provide a comprehensive analysis of the available data reporting outcomes and survival rates for TEVAR in CTBAD. METHODS Electronic searches of six databases were performed from inception to April 2021. All studies reporting outcomes, specifically 30-day mortality rates, for endovascular repair of CTBAD were identified. Relevant data were extracted, and a random-effects meta-analysis of proportions or means was performed to aggregate the data. Survival data were pooled using data derived from original Kaplan-Meier curves, which allows reconstruction of individual patient data. RESULTS Forty-eight studies with 2,641 patients were identified. Early (<30 days) all-cause and aortic-related mortality rates were low at 1.6% and 0.5%, respectively. Incidence of retrograde type A dissection in the post-operative period was only 1.4%. There were also low rates of cerebrovascular accidents and spinal cord injury (1.1% and 0.9%, respectively). Late follow-up all-cause mortality was 8.0%, however, late aortic-related mortality was only 2.4%. Reintervention rates were 10.1% for endovascular and 6.7% for surgical reintervention. Pooled rates of overall survival at 1-, 3-, 5- and 10-year were 91.5%, 84.7%, 77.7% and 56.3%, respectively. CONCLUSIONS The significant heterogeneity in the available evidence and absence of consensus reporting standards are important considerations and concern when interpreting the data. Evaluation of the evidence suggests that TEVAR for CTBAD is a safe procedure with low rates of complications. However, the optimal treatment strategy for CTBAD remains debatable and requires further research. Evidence from high-quality registries and clinical trials are required to address these challenges.
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Affiliation(s)
- Michael L. Williams
- Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, Australia
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Madeleine de Boer
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Bridget Hwang
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Bruce Wilson
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - John Brookes
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
- Department of Cardiothoracic Surgery, University Hospital Geelong, Geelong, Australia
| | - Nicholas McNamara
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - David H. Tian
- Department of Anaesthesia and Perioperative Medicine, Westmead Hospital, Sydney, Australia
| | - Timothy Shiraev
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA
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18
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Bissacco D, Domanin M, Weaver FA, Azizzadeh A, Miller CC, Gable DR, Piffaretti G, Lomazzi C, Trimarchi S. Differences in Mid-Term Outcomes Between Patients Undergoing Thoracic Endovascular Aortic Repair for Aneurysm or Acute Aortic Syndromes: Report From the Global Registry for Endovascular Aortic Treatment. J Endovasc Ther 2021; 29:731-738. [PMID: 34911391 DOI: 10.1177/15266028211064819] [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] [Indexed: 11/15/2022]
Abstract
PURPOSE To analyze differences in baseline characteristics, overall mortality, device-related mortality, and re-intervention rates in patients who underwent thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm (DTAA) with atherosclerotic/degenerative cause or acute aortic syndrome (AAS), using the Global Registry For Endovascular Aortic Treatment (GREAT). MATERIALS AND METHODS Patients submitted to TEVAR for AAS or DTAA, included in GREAT, were eligible for this analysis. Primary outcome was 30-day all-cause mortality rate. Secondary outcomes were 30-day aorta-related mortality and re-intervention rate, 1-year and 3-year all-cause mortality, aorta-related mortality and re-intervention rate. RESULTS Five-hundred and seventy-five patients were analyzed (305 DTAA and 270 AAS). Thirty-day mortality rate was 1.3% and 1.8% for DTAA and AAS, respectively (p=0.741). One-year and 3-year mortality rates were 6.2% versus 9.3 and 17.3% versus 15.9% for DTAA and AAS, respectively (p=0.209 and p=0.655, respectively). Aorta-related mortality rates at 30 days, 1 year and 3 years were 1.3%, 1.3%, and 2.6% for DTAA, 1.8%, 4.2%, and 4.2% for AAS (p=ns). Re-intervention rates at 30 days, 1 year, and 3 years were 1.3%, 4.3%, and 7.5% for DTAA, 3.3%, 8.1%, and 10.7% for AAS (p=ns). Furthermore, a specific analysis with similar outcomes was performed dividing follow-up in 3 periods (1-30 days, 31-365 days, 366-1096 days) and describing mutual differences between 2 groups and temporal trends in each group. CONCLUSION Patients who underwent TEVAR for DTAA or AAS experienced different mortality and re-intervention rates among years during mid-term follow-up. Although all-cause related deaths within 30 days were TEVAR-related, aorta-related deaths were more common for AAS patients within 1 year. A greater re-intervention rate was described for AAS patients, although only 1 year after TEVAR.
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Affiliation(s)
- Daniele Bissacco
- Vascular Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Domanin
- Vascular Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Fred A Weaver
- Division of Vascular Surgery and Endovascular Therapy, University of Southern California, Los Angeles, CA, USA
| | - Ali Azizzadeh
- Division of Vascular Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Charles C Miller
- McGovern Medical School, Department of Cardiothoracic & Vascular Surgery, University of Texas Health Science Center, Houston, TX, USA
| | - Dennis R Gable
- Division of Vascular and Endovascular Surgery, Baylor Scott & White Heart Hospital, Plano, TX, USA
| | - Gabriele Piffaretti
- Vascular Surgery Unit, ASST Sette Laghi, Varese, Italy.,Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Chiara Lomazzi
- Vascular Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Santi Trimarchi
- Vascular Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical and Community Sciences, University of Milan, Milan, Italy
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Kan Y, Huang L, Shi Z, Guo D, Si Y, Fu W. Aortic-related Readmission after Thoracic Endovascular Aortic Repair for Type B Aortic Dissection Patients: A Single-center Retrospective Study. Ann Vasc Surg 2021; 82:284-293. [PMID: 34902468 DOI: 10.1016/j.avsg.2021.10.072] [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: 06/07/2021] [Revised: 10/05/2021] [Accepted: 10/28/2021] [Indexed: 11/01/2022]
Abstract
OBJECTIVES This study aimed to investigate the characteristics of and risk factors for aortic-related readmission after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD). METHODS Data from TBAD patients who underwent TEVAR from 2009-2018 at a Chinese tertiary center were retrospectively collected and analyzed. Enrolled patients were categorized into two groups according to whether aortic-related readmission occurred during follow-up, which was defined as hospitalization at least once after the initial procedure due to events that were related to or caused by aortic dissection or the initial procedure. RESULTS A total of 1 288 TBAD patients were enrolled, and 99 patients experienced aortic-related readmissions (7.7%), among whom chronic patients had the highest readmission rate (9.8%). The yearly proportion of readmission during the first year after initial procedure revealed a decreasing trend with a -9.7% annual percentage change. Seventy-one patients underwent reintervention (71.7%). Distal aneurysmal degeneration (43.7%) and distal stent graft-induced new entries (32.4%) were two major causes for reintervention. Fourteen patients in the reintervention subgroup underwent a second reintervention (19.7%). In-hospital mortality was 1.0% during the readmission and 14.3% during the second readmission. The overall survival was comparable between two groups (p=.93). CONCLUSIONS This study highlighted the importance of surveillance after initial procedure for TBAD patients with potential risk factors for aortic-related readmission, and the predisposition of patients with reintervention to multiple readmissions deserves attention.
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Affiliation(s)
- Yuanqing Kan
- Department of Vascular Surgery, Zhongshan Hospital Fudan University, National Clinical Research Center for Interventional Medicine, Shanghai, China, 200032
| | - Lihong Huang
- Department of Vascular Surgery, Zhongshan Hospital Fudan University, National Clinical Research Center for Interventional Medicine, Shanghai, China, 200032.; Department of Biostatistics, Zhongshan Hospital Fudan University, Shanghai, China, 200032
| | - Zhenyu Shi
- Department of Vascular Surgery, Zhongshan Hospital Fudan University, National Clinical Research Center for Interventional Medicine, Shanghai, China, 200032
| | - Daqiao Guo
- Department of Vascular Surgery, Zhongshan Hospital Fudan University, National Clinical Research Center for Interventional Medicine, Shanghai, China, 200032
| | - Yi Si
- Department of Vascular Surgery, Zhongshan Hospital Fudan University, National Clinical Research Center for Interventional Medicine, Shanghai, China, 200032..
| | - Weiguo Fu
- Department of Vascular Surgery, Zhongshan Hospital Fudan University, National Clinical Research Center for Interventional Medicine, Shanghai, China, 200032..
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20
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Xie X, Shu X, Zhang W, Guo D, Zhang WW, Wang L, Fu W. A Comparison of Clinical Outcomes of Endovascular Repair Versus Open Surgery for Ruptured Descending Thoracic Aorta. J Endovasc Ther 2021; 29:307-318. [PMID: 34779300 DOI: 10.1177/15266028211057087] [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
OBJECTIVE The comparisons between thoracic endovascular aortic repair for ruptured thoracic aorta (TEVAR) and open surgery (OS) have not been well documented, although both procedures have been widely utilized. We performed a systematic review and meta-analysis to investigate the effectiveness and safety between TEVAR and OS in the repair of ruptured descending thoracic aorta. METHODS PubMed, Embase, and Cochrane Library databases were searched to find relevant studies to assess TEVAR and OS outcomes. The comparative parameters were perioperative mortality (30 day/in-hospital), 1 year mortality, paraplegia or paraparesis, renal insufficiency, stroke, pulmonary embolism, re-intervention rate, pulmonary complications, and cardiac complications. A fixed-effects model was applied to calculate the odds ratio (OR) with a 95% confidence interval (CI) on pooled outcomes from different studies. RESULTS Eighteen observational trials involving 2088 patients were evaluated (TEVAR=560; OS=1528). Meta-analysis showed that TEVAR in repairing the ruptured descending thoracic aorta was associated with lower perioperative mortality (OR=0.47; 95% CI: 0.34-0.66; p<0.01), 1 year mortality (OR=0.46; 95% CI: 0.29-0.75; p<0.01), renal insufficiency incidence (OR=0.56; 95% CI: 0.33-0.93; p=0.03), and pulmonary complications (OR=0.69; 95% CI: 0.52-0.92; p=0.01) when compared with OS. There was no significant difference between TEVAR and OS in terms of paraplegia, stroke, pulmonary embolism, cardiac complications, and early re-intervention rates. However, the late re-intervention rate was higher in the TEVAR group than that in the OS group. CONCLUSIONS When repairing the ruptured descending thoracic aorta, TEVAR may be performed rapidly and safely. TEVAR is associated with lower rates of perioperative morbidity and early postoperative complications than OS.
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Affiliation(s)
- Xinsheng Xie
- Department of Vascular Surgery, Xiamen Branch, Zhongshan hospital, Fudan University, Xiamen, China
| | - Xiaolong Shu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Vascular Surgery Institute of Fudan University, Shanghai, China
| | - Wei Zhang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Vascular Surgery Institute of Fudan University, Shanghai, China
| | - Daqiao Guo
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Vascular Surgery Institute of Fudan University, Shanghai, China
| | - Wayne W Zhang
- Division of Vascular and Endovascular Surgery, University of Washington, Seattle, WA, USA
| | - Lixin Wang
- Department of Vascular Surgery, Xiamen Branch, Zhongshan hospital, Fudan University, Xiamen, China.,Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Vascular Surgery Institute of Fudan University, Shanghai, China
| | - Weiguo Fu
- Department of Vascular Surgery, Xiamen Branch, Zhongshan hospital, Fudan University, Xiamen, China.,Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Vascular Surgery Institute of Fudan University, Shanghai, China
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21
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Anastasiadou C, Trellopoulos G, Kastora S, Kakisis I, Papapetrou A, Galyfos G, Geroulakos G, Megalopoulos A. A systematic review of therapies for aortobronchial fistulae. J Vasc Surg 2021; 75:753-761.e3. [PMID: 34624495 DOI: 10.1016/j.jvs.2021.08.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 08/22/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of the study was to summarize epidemiologic data about aortobronchial fistulas and compare outcomes (mortality, recurrence, re-operation) of open, staged, and endovascular repair of aortobronchial fistula. METHODS A systematic literature review was conducted to identify eligible studies published between January of 1999 and December of 2019. The Cochrane Library, PubMed and Scopus databases were used as search engines. Eligible studies included articles reporting postoperative outcomes (death/follow-up). Literature review revealed only case reports and small case series and thus, only descriptive data with data heterogeneity was available. The corresponding authors were contacted to provide additional information or outcome updates (recurrence/reoperation/death). RESULTS Overall, 214 patients (90 studies) underwent 271 procedures (including re-do procedures and staged procedures). Most of the patients were treated by endovascular means (72.42%). Open surgical repair was performed in 21.96% and staged procedures in 5.6%. Aortobronchial fistulae located most often in the descending thoracic aorta (Zone 3,4) (64,6%) and in Zone 2 (23,8%). Fourteen percent of aortobronchial fistulae developed after thoracic endovascular aneurysm repair. Recurrence or infection occurred in 20% (43 patients). Recurrences were at some extend associated with the presence of endoleak. Long-term antibiotic administration (>1 month) was instituted in 63 patients (29.4%), whilst 90 patients (42%) did not receive antibiotics beyond hospitalization. From the remaining 61, 3 received life-long antibiotics and for 58 patients data were not available. Considering outcomes, mean follow-up was 25.1 months (0-188 months) and not significantly different among treatments. LIMITATIONS Literature review has revealed only case reports and small case series and thus, only descriptive data were available. Randomized controlled trials are not available due to the rarity of the disease which significantly decreases the power of the present study. Also, this study reflects significant data heterogeneity due to the nature of the analyzed manuscripts and would benefit from large patient cohort studies which till today have not been conducted. CONCLUSION Aortobronchial fistula is a complex disease. Endoleaks may be involved in the development and in recurrence process and they should not be disregarded. Considering major outcomes (length of follow-up), the available treating strategies are equal and thus, surgeons should feel confident to apply the treatment of their choice, taking in mind their experience, patient's age, and clinical condition.
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Affiliation(s)
| | - George Trellopoulos
- Department of Vascular Surgery - General Hospital of Thessaloniki "Georgios Papanikolaou"
| | | | - Ioannis Kakisis
- Department of Vascular Surgery -"Attikon" University Hospital, Medical School, National and Kapodistrian University of Athens
| | | | - George Galyfos
- Department of Vascular Surgery - General Hospital of Attica "KAT"
| | - George Geroulakos
- Department of Vascular Surgery -"Attikon" University Hospital, Medical School, National and Kapodistrian University of Athens
| | - Angelos Megalopoulos
- Department of Vascular Surgery - General Hospital of Thessaloniki "Georgios Papanikolaou"
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22
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Guo T, Fang Z, Yang G, Zhou Y, Ding N, Peng W, Gong X, He H, Pan X, Chai X. Machine Learning Models for Predicting In-Hospital Mortality in Acute Aortic Dissection Patients. Front Cardiovasc Med 2021; 8:727773. [PMID: 34604356 PMCID: PMC8484712 DOI: 10.3389/fcvm.2021.727773] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 08/24/2021] [Indexed: 01/01/2023] Open
Abstract
Background: Acute aortic dissection is a potentially fatal cardiovascular disorder associated with high mortality. However, current predictive models show a limited ability to efficiently and flexibly detect this mortality risk, and have been unable to discover a relationship between the mortality rate and certain variables. Thus, this study takes an artificial intelligence approach, whereby clinical data-driven machine learning was utilized to predict the in-hospital mortality of acute aortic dissection. Methods: Patients diagnosed with acute aortic dissection between January 2015 to December 2018 were voluntarily enrolled from the Second Xiangya Hospital of Central South University in the study. The diagnosis was defined by magnetic resonance angiography or computed tomography angiography, with an onset time of the symptoms being within 14 days. The analytical variables included demographic characteristics, physical examination, symptoms, clinical condition, laboratory results, and treatment strategies. The machine learning algorithms included logistic regression, decision tree, K nearest neighbor, Gaussian naive bayes, and extreme gradient boost (XGBoost). Evaluation of the predictive performance of the models was mainly achieved using the area under the receiver operating characteristic curve. SHapley Additive exPlanation was also implemented to interpret the final prediction model. Results: A total of 1,344 acute aortic dissection patients were recruited, including 1,071 (79.7%) patients in the survivor group and 273 (20.3%) patients in non-survivor group. The extreme gradient boost model was found to be the most effective model with the greatest area under the receiver operating characteristic curve (0.927, 95% CI: 0.860-0.968). The three most significant aspects of the extreme gradient boost importance matrix plot were treatment, type of acute aortic dissection, and ischemia-modified albumin levels. In the SHapley Additive exPlanation summary plot, medical treatment, type A acute aortic dissection, and higher ischemia-modified albumin level were shown to increase the risk of hospital-based mortality.
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Affiliation(s)
- Tuo Guo
- Department of Emergency Medicine, The Second Xiangya Hospital, Central South University, Changsha, China.,Emergency Medicine and Difficult Diseases Institute, Central South University, Changsha, China.,Trauma Center, Changsha, China
| | - Zhuo Fang
- College of Information Science and Engineering, Hunan Normal University, Changsha, China
| | - Guifang Yang
- Department of Emergency Medicine, The Second Xiangya Hospital, Central South University, Changsha, China.,Emergency Medicine and Difficult Diseases Institute, Central South University, Changsha, China.,Trauma Center, Changsha, China
| | - Yang Zhou
- Department of Emergency Medicine, The Second Xiangya Hospital, Central South University, Changsha, China.,Emergency Medicine and Difficult Diseases Institute, Central South University, Changsha, China.,Trauma Center, Changsha, China
| | - Ning Ding
- Department of Emergency Medicine, The Second Xiangya Hospital, Central South University, Changsha, China.,Emergency Medicine and Difficult Diseases Institute, Central South University, Changsha, China.,Trauma Center, Changsha, China
| | - Wen Peng
- Department of Emergency Medicine, The Second Xiangya Hospital, Central South University, Changsha, China.,Emergency Medicine and Difficult Diseases Institute, Central South University, Changsha, China.,Trauma Center, Changsha, China
| | - Xun Gong
- Department of Emergency Medicine, The Second Xiangya Hospital, Central South University, Changsha, China.,Emergency Medicine and Difficult Diseases Institute, Central South University, Changsha, China.,Trauma Center, Changsha, China
| | - Huaping He
- Department of Emergency Medicine, The Second Xiangya Hospital, Central South University, Changsha, China.,Emergency Medicine and Difficult Diseases Institute, Central South University, Changsha, China.,Trauma Center, Changsha, China
| | - Xiaogao Pan
- Department of Emergency Medicine, The Second Xiangya Hospital, Central South University, Changsha, China.,Emergency Medicine and Difficult Diseases Institute, Central South University, Changsha, China.,Trauma Center, Changsha, China
| | - Xiangping Chai
- Department of Emergency Medicine, The Second Xiangya Hospital, Central South University, Changsha, China.,Emergency Medicine and Difficult Diseases Institute, Central South University, Changsha, China.,Trauma Center, Changsha, China
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23
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Makhija RR, Mukherjee D. Endovascular therapies for Type B Aortic Dissection. Cardiovasc Hematol Disord Drug Targets 2021; 21:167-178. [PMID: 34565325 DOI: 10.2174/1871529x21666210924141446] [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: 02/26/2021] [Revised: 07/30/2021] [Accepted: 08/20/2021] [Indexed: 11/22/2022]
Abstract
Aortic dissection is a life-threatening condition resulting from a tear in the intimal layer of the aorta, requiring emergent diagnosis and prompt multi-disciplinary management strategy for best patient outcomes. While type A dissection involving ascending aorta is best managed surgically due to high early mortality, type B aortic dissection (TBAD) involving descending aorta generally has better outcomes with conservative management and medical therapy as primary strategy is favored. However, there has been a recent paradigm shift in management of TBAD due to late aneurysmal degeneration of TBAD increasing morbidity and mortality at longer-term. Late surgical intervention can be prevented by early endovascular intervention when combined with optimal medical therapy. In this narrative review, we explore available literature on different endovascular therapies for TBAD in different populations of patients.
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Affiliation(s)
- Rakhee R Makhija
- Division of Cardiovascular Medicine, Texas Tech University, El Paso. United States
| | - Debabrata Mukherjee
- Department of Internal Medicine, Division of Cardiovascular Medicine, Texas Tech University, El Paso, United States. United States
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24
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Brown JA, Arnaoutakis GJ, Szeto WY, Serna-Gallegos D, Sultan I. Endovascular repair of the aortic arch: State of the art. J Card Surg 2021; 36:4292-4300. [PMID: 34405439 DOI: 10.1111/jocs.15920] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 08/08/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Open total arch replacement remains the gold standard treatment for aneurysms and dissections involving the aortic arch. However, high-risk surgical candidates may benefit from endovascular techniques to reduce the risk of perioperative mortality and morbidity, especially neurologic complications. Numerous endografts are available for investigational use in the aortic arch as part of investigational device exemption (IDE) programs. Some devices are fenestrated or scalloped, while others are branched, ranging from single branch to triple branch stent-grafts. Furthermore, chimney techniques and in situ fenestration may be utilized in bailout or emergent situations. RESULTS Initial results describing outcomes of complete endovascular repair of the aortic arch are encouraging, with current data estimating that technical success ranges from 84.2% to 100%. Moreover, operative mortality may be as high as 13.2%, while neurologic complications also remain common, with stroke rates being as high as 20% and spinal cord ischemia being as high as 3.1%. However, more data are necessary to determine the comparative treatment effect of endovascular stent-grafting of the aortic arch, compared with conventional open and hybrid repairs. Longitudinal follow-up is also lacking, which will determine the long-term durability of endografts in the aortic arch. Nevertheless, endovascular repair represents an important opportunity for improving outcomes in patients with complex and potentially devastating pathologies of the aortic arch.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - George J Arnaoutakis
- Division of Cardiovascular Surgery, University of Florida, Gainesville, Florida, USA
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Derek Serna-Gallegos
- UPMC Center for Thoracic Aortic Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,UPMC Center for Thoracic Aortic Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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25
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Predicting reintervention after thoracic endovascular aortic repair of Stanford type B aortic dissection using machine learning. Eur Radiol 2021; 32:355-367. [PMID: 34156553 DOI: 10.1007/s00330-021-07849-2] [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: 09/06/2020] [Revised: 12/19/2020] [Accepted: 03/02/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVES To construct models for predicting reintervention after thoracic endovascular aortic repair (TEVAR) of Stanford type B aortic dissection (TBAD). METHODS A total of 192 TBAD patients who underwent TEVAR were included; 68 (35.4%) had indications for reintervention. Clinical characteristics, aorta characteristics on pre- and postoperative computed tomography angiography, and aorta characteristics on immediate postoperative aortic digital subtraction angiography were collected. The least absolute shrinkage and selection operator (LASSO) regression was applied to identify the risk factors for reintervention. Eight classifiers were used for modeling. The models were trained on 100 train-validation random splits with a ratio of 2:1. The performance was evaluated by the receiver operating characteristic curve. RESULTS Seven predictors of reintervention were identified, including maximum false lumen diameter, aortic diameter measured at the level of approximately 15 mm distal to the left subclavian artery, aortic diameter measured at the level of the diaphragm, false lumen diameter measured at the level of the celiac artery, number of bare-metal and covered stents, number of bare-metal stents, and residual perfusion of the false lumen. Logistic regression (LR) yielded the highest performance, with an area under the curve of 0.802. A nomogram built for clinical use showed good calibration. The cutoff value for dividing patients into low- and high-risk subgroups was 0.413. Kaplan-Meier curves showed that the overall survival of high-risk patients was significantly shorter than that of low-risk patients (both p < 0.05). CONCLUSION Our nomogram could predict the reintervention after TEVAR in patients with TBAD, which may facilitate patient selection and surveillance strategies. KEY POINTS • Seven risk factors of reintervention after TEVAR of TBAD were identified for modeling. • Logistic regression performed best in predicting reintervention with an AUC of 0.802. • Patients with a high risk of reintervention had shorter OS than those with a low risk.
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26
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Chen X, Bai M, Sun S, Chen X. Outcomes and risk management in type B aortic dissection patients with acute kidney injury: a concise review. Ren Fail 2021; 43:585-596. [PMID: 33784934 PMCID: PMC8018386 DOI: 10.1080/0886022x.2021.1905664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Purpose Type B aortic dissection is a rare but life-threatening disease. Thoracic endovascular aortic repair (TEVAR) was widely used for Type B aortic dissection patients in the last decade due to the lower mortality and morbidity compared with open chest surgical repair (OCSR). AKI in type B aortic dissection is a well-recognized complication and indicates poor short-term and long-term outcome. The objective of this concise review was to identify the risk factors and the impact of AKI on type B aortic dissection patients. Methods and results A literature search was performed using PubMed, Embase, MEDLINE, and Cochrane Library with the search terms ‘type B aortic dissection’ and ‘acute kidney injury’ (AKI), and all English-language literatures published in print or available online from inception through August 2020 were thoroughly reviewed. Studies that reported relative AKI risks and outcomes in type B aortic dissection patient were included. Major mechanisms of AKI in type B aortic dissection included renal hypoperfusion, inflammation response, and the use of contrast medium. Type B aortic dissection patients with AKI significantly had increased hospital stay duration, need of renal replacement therapy, and 30-d and 1-year mortality. Conclusions AKI in type B aortic dissection is a well-recognized complication and associated with poor short-term and long-term outcome. Early identification of high-risk patients, early diagnosis of AKI, stabilization of the hemodynamic parameters, avoidance of nephrotoxic drugs, and optimization of the use of contrast agents are the major strategies for the reduction of AKI in type B aortic dissection patients.
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Affiliation(s)
- Xiaolan Chen
- The Nephrology Department, Xijing Hospital, The Fourth Military Medical University, Xi'an, PR China
| | - Ming Bai
- The Nephrology Department, Xijing Hospital, The Fourth Military Medical University, Xi'an, PR China
| | - Shiren Sun
- The Nephrology Department, Xijing Hospital, The Fourth Military Medical University, Xi'an, PR China
| | - Xiangmei Chen
- The Nephrology Department, Xijing Hospital, The Fourth Military Medical University, Xi'an, PR China.,Department of Nephrology, State Key Laboratory of Kidney Disease, Chinese People's Liberation Army General Hospital and Military Medical Postgraduate College, Beijing, PR China
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27
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Zeng Z, Zhao Y, Wu M, Bao X, Li T, Feng J, Feng R, Jing Z. False Lumen Stent-Grafts for Repair of Postdissection Aortic Aneurysms. J Vasc Interv Radiol 2021; 32:703-711. [PMID: 33617958 DOI: 10.1016/j.jvir.2021.01.280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 01/22/2021] [Accepted: 01/30/2021] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To evaluate the safety and efficacy of false lumen (FL) stent-grafts in the treatment of postdissection aortic aneurysms. MATERIALS AND METHODS Eleven patients who underwent endovascular repair using FL stent-grafts from January 2016 to June 2019 were included. Among them, 2 patients had a prior history of type A aortic dissection, whereas 9 had undergone a prior endovascular repair for type B aortic dissection. Computed tomography angiography was performed to evaluate the reintervention and technical success rate, aortic remodeling, and other related aortic complications. RESULTS The mean age of patients was 55.6 ± 10.4 years. Technical success was achieved in all patients, and neither early mortality nor paralysis occurred. In total, 8 visceral branch arteries originating from the FL were reconstructed. The true lumen areas at the celiac axis, superior mesenteric artery, renal artery, and abdominal aortic bifurcation were significantly increased from 230.1 mm2 to 312.3 mm2, 212.1 mm2 to 277.5 mm2, 209.1 mm2 to 291.6 mm2, and 214.4 mm2 to 300.6 mm2, respectively (P < .05). The total diameter of the aorta at the 4 designated levels was stable or had shrunk in all patients. At a mean follow-up of 18.9 ± 7.6 months, 1 patient received re-intervention owing to iliac stent-graft occlusion. No aortic-related mortality occurred. CONCLUSIONS FL stent-grafts can safely and effectively treat patients with postdissection aortic aneurysms. This strategy can be used to promote thrombosis of the FL and aortic remodeling. A larger sample and an extended follow-up period are needed to produce more conclusive results.
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Affiliation(s)
- Zhaoxiang Zeng
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, P.R. China
| | - Yuxi Zhao
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, P.R. China
| | - Mingwei Wu
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, P.R. China
| | - Xianhao Bao
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, P.R. China
| | - Tao Li
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, P.R. China
| | - Jiaxuan Feng
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, P.R. China.
| | - Rui Feng
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, P.R. China.
| | - Zaiping Jing
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, P.R. China.
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28
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Patel JJ, Kasprzak P, Pfister K, Tsilimparis N, Kölbel T, Wahlgren C, Hammo S, Mani K, Wanhainen A, Rossi G, Leo E, Böing I, Schelzig H, Oberhuber A, Aasgaard F, Vecchiati E, Fontana A, Modarai B. Early outcomes associated with use of the Zenith TX2 Dissection Endovascular Graft for the treatment of Stanford type B aortic dissection. J Vasc Surg 2021; 74:547-555. [PMID: 33600932 DOI: 10.1016/j.jvs.2021.01.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 01/06/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To evaluate short term outcomes related to the use of the Zenith TX2 Dissection Endovascular Graft (ZDEG) and the Zenith Dissection Bare stent (ZDES) for the treatment of Stanford type B aortic dissections. METHODS This retrospective multicenter case cohort study collated data from 10 European institutions for patients with both complicated and uncomplicated type B aortic dissection treated with ZDEG and ZDES between 2011 and 2018. The primary end point was mortality at 30 and 90 days. Secondary end points included complications related to TEVAR, such as, type Ia endoleak, stroke, paraparesis, paraplegia, and retrograde type A dissection (RTAD). Statistical analysis was carried out using the t test, or one-way analysis of variance and the χ2 or Fisher exact tests. RESULTS We treated 120 patients (87 male; mean age, 62.7 ± 12.2years) either in the acute 76 (63.3%), subacute 16 (13.3%), or chronic 28 (23.3%) phase. Seven patients (5.8%) died within 30 days after the index procedure and two (1.7%) between 30 and 90 days. There was one instance of postoperative RTAD in a patient treated for rupture. Stroke and paraplegia occurred in three (2.5%) and five (4.2%), patients, respectively. Eight patients (6.7%) had a type Ia endoleak in the perioperative period. There were no instances of paraplegia, no permanent dialysis, and no requirement for adjunctive superior mesenteric or celiac artery stenting in the 33 patients (27.5%) who were treated by concurrent placement of ZDES distal to the ZDEG. The length and distal oversizing of ZDEG components used was less in this group. CONCLUSIONS The present series demonstrates a low (<1%) RTAD rate and favorable morbidity and mortality. The lower rate of paraplegia, dialysis, and visceral artery stenting in the cohort that had adjunctive use of ZDES is compelling and merits further assessment.
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Affiliation(s)
- Jayna J Patel
- Academic Department of Vascular Surgery, School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence and the Biomedical Research Centre at Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Piotr Kasprzak
- University Hospital Regensburg, Department of Vascular Surgery, Regensburg, Germany
| | - Karin Pfister
- University Hospital Regensburg, Department of Vascular Surgery, Regensburg, Germany
| | - Nikolaos Tsilimparis
- German Aortic Center Hamburg, Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center Hamburg, Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Carl Wahlgren
- Department of Vascular Surgery, Karolinska University Hospital, and Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Sari Hammo
- Department of Vascular Surgery, Karolinska University Hospital, and Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Kevin Mani
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Anders Wanhainen
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Giovanni Rossi
- Division of Vascular Surgery, Department of Cardiovascular Diseases, A. Manzoni Hospital, Lecco, Italy
| | - Enrico Leo
- Division of Vascular Surgery, Department of Cardiovascular Diseases, A. Manzoni Hospital, Lecco, Italy
| | - Ingeborg Böing
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Hubert Schelzig
- Department of Vascular and Endovasccular Surgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Alexander Oberhuber
- Department of Vascular and Endovascular Surgery, University Hospital Münster, Münster, Germany
| | - Frode Aasgaard
- Department of Vascular Surgery, St Olavs Hospital, Trondheim, Norway
| | - Enrico Vecchiati
- Department of Vascular Surgery, Hospital Santa Maria of Reggio Emilla, Reggio Emilla, Italy
| | - Antonio Fontana
- Department of Vascular Surgery, Hospital Santa Maria of Reggio Emilla, Reggio Emilla, Italy
| | - Bijan Modarai
- Academic Department of Vascular Surgery, School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence and the Biomedical Research Centre at Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK.
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Tanaka A, Sandhu HK, Afifi RO, Miller CC, Ray A, Hassan M, Safi HJ, Estrera AL. Outcomes of open repairs of chronic distal aortic dissection anatomically amenable to endovascular repairs. J Thorac Cardiovasc Surg 2021; 161:36-43.e6. [PMID: 31699416 DOI: 10.1016/j.jtcvs.2019.09.083] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 09/12/2019] [Accepted: 09/15/2019] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To review short-term outcomes and long-term survival and durability after open surgical repairs for chronic distal aortic dissections in patients whose anatomy was amenable to thoracic endovascular aortic repair (TEVAR). METHODS Between February 1991 and August 2017, we repaired chronic distal dissections in 697 patients. Of those patients, we enrolled 427 with anatomy amenable to TEVAR, which included 314 descending thoracic aortic aneurysms (DTAAs) and 105 extent I thoracoabdominal aortic aneurysms (TAAAs). One hundred eighty-five patients (44%) had a history of type A dissection, and 33 (7.9%) had a previous DTAA/TAAA repair. Variables were assessed with logistic regression for 30-day mortality and Cox regression for long-term mortality. Time-to-event analysis was performed using Kaplan-Meier methods. RESULTS Thirty-day mortality was 8.4% (n = 36). In all, 22 patients (5.2%) developed motor deficit (paraplegia/paraparesis), and 17 (4.0%) experienced stroke. Multivariable analysis identified low estimated glomerular filtration rate (eGFR; <60 mL/min/1.73 m2), previous DTAA/TAAA repair, and chronic obstructive pulmonary disease (COPD) as associated with 30-day mortality. Patients without all 3 risk factors had a 30-day mortality rate of 2.6%. During a median follow-up of 6.5 years, 160 patients died. The survival rate was 81% at 1 year and 61% at 10 years. Cox regression analysis identified preoperative aortic rupture, eGFR <60 mL/min/1.73 m2, previous DTAA/TAAA repair, COPD, and age >60 years as predictive of long-term mortality. Forty-five patients required subsequent aortic procedures, including 8 reinterventions to the treated segment. Freedom from any aortic procedures was 85% at 10 years, and aortic procedure-free survival was 45% at 10 years. Hereditary aortic disease was the sole predictor for any aortic interventions (hazard ratio, 3.2; P = .004). CONCLUSIONS Open surgical repair provided satisfactory low neurologic complication rates and durable repairs in chronic distal aortic dissection. Patients without low eGFR, redo, and COPD are the low-risk surgical candidates and may benefit from open surgical repair at centers with similar experience to ours. Patients with hereditary aortic disease warrant close surveillance.
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Affiliation(s)
- Akiko Tanaka
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Harleen K Sandhu
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Rana O Afifi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Charles C Miller
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Amberly Ray
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Madiha Hassan
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Hazim J Safi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex.
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Meisenbacher K, Hagedorn M, Grond-Ginsbach C, Weber D, Böckler D, Bischoff MS. Outcomes of thoracic endovascular aortic repair in thoracic aortic aneurysm and penetrating aortic ulcer using the Conformable Gore TAG within and outside the instructions for use. Vascular 2020; 29:486-498. [PMID: 33131466 DOI: 10.1177/1708538120970033] [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
OBJECTIVE To describe the outcome of thoracic endovascular aortic repair (TEVAR) in thoracic aortic aneurysm and penetrating aortic ulcer with respect to instructions for use status. METHODS Between October 2009 and September 2017, a total of 532 patients underwent TEVAR; of which 195 have been treated using the Conformable GORE® TAG® thoracic endoprosthesis (CTAG). Fifty-six patients of this cohort underwent TEVAR for thoracic aortic aneurysm/penetrating aortic ulcer using the CTAG. Depending on the preoperative computed tomography angiography findings, patients were classified as inside or outside the device's instructions for use. All inside instruction for use patients underwent postoperative reclassification regarding the instructions for use status. Study endpoints included TEVAR-related reintervention, exclusion of the pathology (endoleak type I/III), TEVAR-related mortality, and graft-related serious adverse events. The median duration of follow-up was 29.7 months (range: 0-109.4 months). RESULTS Of the 56 patients, 17 were primarily classified as outside instruction for use, and in additional 13 patients, TEVAR was performed outside instruction for use, leading to 30 outside instruction for use patients (53.6%). Twenty-six patients (46.4%) were treated inside instruction for use. Reintervention-free survival was lower in outside instruction for use patients (P = 0.016) with a hazard ratio of 9.74 (confidence interval 1.2-80.2; P = 0.034) for TEVAR-related reintervention. With respect to endoleak type I/III, relevant difference was detected between inside/outside instruction for use status (P = 0.012). The serious adverse event rate was 30.4%, mainly in outside instruction for use patients (P = 0.004). Logistic regression analysis indicated an association between graft-related serious adverse event/instructions for use status (odds ratio 6.11; confidence interval 1.6-30.06; P = 0.012). In-hospital death was seen more frequently in outside instruction for use patients (P = 0.12) as was procedure-related death (log-rank test: P = 0.21). CONCLUSION TEVAR for thoracic aortic aneurysm/penetrating aortic ulcer is frequently performed outside instruction for use despite preoperative inside instruction for use eligibility, leading to important consequences for technical/clinical outcome. Instructions for use adherence in TEVAR should be of interest for further large-scale studies.
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Affiliation(s)
- Katrin Meisenbacher
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Germany
| | - Matthias Hagedorn
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Germany
| | - Caspar Grond-Ginsbach
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Germany
| | - Dorothea Weber
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Germany
| | - Moritz S Bischoff
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Germany
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Dun Y, Shi Y, Guo H, Liu Y, Qian X, Sun X, Yu C. Secondary Open Arch Operation After Prior Thoracic Endovascular Aortic Repair. Ann Thorac Surg 2020; 111:1545-1553. [PMID: 32976838 DOI: 10.1016/j.athoracsur.2020.07.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 06/18/2020] [Accepted: 07/15/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Many patients required secondary open arch operation due to new aortic pathologies or complications after thoracic endovascular aortic repair (TEVAR). In this study, we investigated the outcome of secondary open arch operation after prior TEVAR. METHODS Fifty-seven consecutive patients underwent secondary open arch operation after prior TEVAR. The major indications were retrograde type A aortic dissection (n = 24), proximal new aortic dissection (n = 8), and type Ⅰa endoleak (n = 16). An elective operation was performed in 35 patients and an emergent operation in 22. The survival and freedom from aortic events during the follow-up were evaluated with the Kaplan-Meier survival curve and the log-rank test. The survival was also analyzed with the Cox analysis. RESULTS The in-hospital mortality was 7.0% (4 of 57). The mean follow-up time was 32.2 ± 19.7 months. Five late deaths occurred. The overall survival at 1 year, 3 years, and 6 years was 89.5%, 84.6%, and 79.9%, respectively. Aortic events developed in 7 patients. Freedom from aortic events after the operation at 1 year, 3 years, and 6 years was 94.2%, 83.0%, and 77.8%, respectively. There were no differences in survival and freedom from aortic events between the elective group and the emergent group. The Cox analysis identified additional coronary artery bypass grafting and hypothermic circulatory arrest as independent factors predicting survival. CONCLUSIONS Secondary open arch operation could be performed to treat the arch pathologies after TEVAR with acceptable early and midterm outcomes.
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Affiliation(s)
- Yaojun Dun
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi Shi
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongwei Guo
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanxiang Liu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiangyang Qian
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaogang Sun
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Cuntao Yu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Çekmecelioglu D, Orozco-Sevilla V, Coselli JS. Open vs. endovascular thoracoabdominal aortic aneurysm repair: tale of the tape. Asian Cardiovasc Thorac Ann 2020; 29:643-653. [PMID: 32772547 DOI: 10.1177/0218492320949073] [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] [Indexed: 11/16/2022]
Abstract
Open surgical repair persists as the gold-standard operation for thoracoabdominal aortic aneurysm; however, endovascular repair has become commonplace. Technical considerations in thoracoabdominal aortic aneurysm treatment are particularly complex, insofar as it involves critical branching arteries feeding the visceral organs. Newer, low-profile devices make total endovascular thoracoabdominal aortic aneurysm repair more feasible and, thus, appealing. For younger and low-risk patients, the choice between open and endovascular therapy remains controversial. Despite the advantages of a minimally invasive procedure, data suggest that endovascular aortic repair incurs a greater risk of spinal cord deficit, and the durability of endovascular aortic repair remains unclear. It is difficult to compare outcomes between endovascular and open thoracoabdominal aortic aneurysm repair, primarily because of the current investigational status of endovascular devices, the variety of approaches to endovascular repair, differing patient populations, lack of prospective randomized studies, and minimal medium- and long-tern follow-up data on endovascular repair. When deciding between open and endovascular approaches, one should consider which is more suitable for each patient. Older patients generally benefit from a less invasive approach. Open repair should be considered for young patients and those with heritable thoracic aortic disease. Infection and fistulae are best treated by open repair, although endovascular intervention as a lifesaving bridge to definitive repair has evolved to become a critical component of initial treatment. It is crucial to have technical expertise in both open and endovascular procedures to provide the best aortic repair for the patient. This may require dedicated aortic programs at tertiary institutions.
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Affiliation(s)
- Davut Çekmecelioglu
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA.,Division of Cardiothoracic Surgery, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Department of Cardiovascular Surgery, CHI St. Luke's Health, Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Vicente Orozco-Sevilla
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA.,Division of Cardiothoracic Surgery, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Department of Cardiovascular Surgery, CHI St. Luke's Health, Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Joseph S Coselli
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA.,Division of Cardiothoracic Surgery, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Department of Cardiovascular Surgery, CHI St. Luke's Health, Baylor St. Luke's Medical Center, Houston, Texas, USA.,Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas, USA
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Acheampong DO, Paul P, Boateng P, Leitman IM. Predictors and Outcomes of Cardiac Events following Thoracic Endovascular Aortic Repair in Descending Thoracic Aortic Aneurysm and Dissection. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2020; 8:6-13. [PMID: 32599627 PMCID: PMC7324254 DOI: 10.1055/s-0040-1701606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Cardiac events following thoracic endovascular aortic repair (TEVAR) have been associated with significant morbidity and mortality. However, predictors of post-TEVAR cardiac events in descending thoracic aortic aneurysm or dissection are poorly understood. METHODS A retrospective analysis of completed TEVAR procedures performed from 2010 to 2016 was conducted using the ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) participant user file database. Adult patients (≥18 years) who underwent TEVAR for descending thoracic aortic aneurysm or dissection were identified and 30-day outcomes were examined. An initial univariate analysis was performed to determine associations between all patient variables and cardiac events, defined as myocardial infarction or cardiac arrest that occurred ≤30 days of surgery. Multivariate logistic regression was subsequently performed to identify independent risk factors for cardiac events following TEVAR. RESULTS The study identified 150 out of 2,905 (5.2%) patients who underwent TEVAR for descending thoracic aortic aneurysm or dissection who developed cardiac events. No significant difference in incidence of cardiac events was noted among patients presenting with aortic aneurysm or dissection (p = 0.339). The overall 30-day mortality rate for all patients was 9.1%. Independent preoperative predictors of post-TEVAR cardiac events included emergency procedure (odds ratio [OR] 2.80, 95% confidence interval [CI] 1.9-4.1, p < 0.01); American Society of Anesthesiologists score >3 (OR 1.71, 95% CI 1.1-2.6, p = 0.01), ventilator dependence (OR 2.33, 95% CI 1.3-4.2, p < 0.01), renal failure (OR 2.53, 95% CI 1.50-4.3, p < 0.01), blood transfusion (OR 1.84, 95% CI 1.1-3.2, p = 0.03), and preoperative leukocytosis (OR 2.45, 1.6-3.8, p < 0.01). After TEVAR, unplanned reintubation (OR 5.52, 95% CI 3.5-8.8, p < 0.01), prolonged mechanical ventilation (OR 1.94, 95% CI 1.2-3.2, p = 0.011), and postoperative blood transfusion (OR 4.02, 95% CI 2.70-6.0, p < 0.01) were independent predictors of cardiac events. Cardiac events greatly increased mortality (60.7 vs. 5.5%), total length of hospital stay (13.2 ± 14.7 days vs. 8.3 ± 9.3 days), and readmission rates (19.3 vs. 8.2%, p < 0.01). CONCLUSIONS Cardiac events following TEVAR are associated with significant mortality. Patients with these risk factors should be appropriately monitored to improve outcomes.
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Affiliation(s)
- Derrick O Acheampong
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Philip Paul
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Percy Boateng
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - I Michael Leitman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
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Sueda T, Takahashi S, Katayama K. Total Aortic Arch Replacement after Thoracic Endovascular Aortic Repair Using Left Subclavian Arterial Perfusion. Ann Thorac Cardiovasc Surg 2020; 26:100-103. [PMID: 29695652 PMCID: PMC7184032 DOI: 10.5761/atcs.cr.18-00001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We present the case of an 86-year-old male with an aortic arch saccular aneurysm who underwent zone 1 thoracic endovascular aortic repair (TEVAR) with debranching from the right subclavian artery to the left carotid and left subclavian arteries. The patient developed a type Ia endoleak 1 month later. Postoperative contrast computed tomography (CT) showed a hematoma around the aneurysm, concerning for impending rupture. He thus underwent emergency endograft removal and replacement with a one-branched graft using selective cerebral perfusion via the left subclavian artery perfusion. The left subclavian artery was used for systemic and cerebral perfusion without need for cannulation of the cervical arteries. The patient was successfully discharged 6 months after surgery.
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Affiliation(s)
- Taijiro Sueda
- Department of Cardiovascular Surgery, Hiroshima University, Graduate School of Medicine, Hiroshima, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Hiroshima University, Graduate School of Medicine, Hiroshima, Hiroshima, Japan
| | - Keijiro Katayama
- Department of Cardiovascular Surgery, Hiroshima University, Graduate School of Medicine, Hiroshima, Hiroshima, Japan
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Yamashiro S, Kise Y, Inafuku H, Nagano T, Kuniyoshi Y. Survival and cause of death after aortic arch aneurysm repair. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:784-789. [PMID: 32186170 DOI: 10.23736/s0021-9509.20.11245-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND This study aimed to identify differences in prognosis, causes of death, and outcomes between open and endovascular repair for aortic arch aneurysms. METHODS We retrospectively analyzed the survival status and causes of death determined from the medical records of 124 consecutive elderly patients (age>70 years) with aortic arch aneurysms that were treated between 2010 and 2018 at our hospital. Forty patients (male, N.=30; mean age, 76 years) underwent open repair and 84 (male, N.=68; mean age, 78 years) underwent endovascular repair. RESULTS Early postoperative complications (10.0% vs. 6.3%; P=0.4) and rates of in-hospital death (2.5% vs. 6.3%; P=0.2) did not significantly differ between open and endovascular repair. Cumulative long-term and event free survival rates at eight years were similar in both groups (78.7% vs. 66.3%, P=0.1 and 66.6% vs. 58.4%; P=0.4, respectively). The causes of death at follow-up after endovascular repair comprised malignancies in 11 (52.4%) patients and cardiopulmonary and cerebral events unrelated to aortic aneurysms in 10 (47.6%). CONCLUSIONS Early and late outcomes did not statistically differ after both procedures. However, the prevalence of cancer-related death occurring late after arch repair was significantly higher after endovascular repair. The most important observation from this series was that significantly more patients died of malignant disease during follow-up after endovascular repair than open repair.
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Affiliation(s)
- Satoshi Yamashiro
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan -
| | - Yuya Kise
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Hitoshi Inafuku
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Takaaki Nagano
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Yukio Kuniyoshi
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
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Early and mid-term mortality and morbidity of contemporary international endovascular treatment for type B aortic dissection - A systematic review and meta-analysis. Int J Cardiol 2020; 301:56-61. [DOI: 10.1016/j.ijcard.2019.09.071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 08/08/2019] [Accepted: 09/20/2019] [Indexed: 11/19/2022]
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Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J 2019; 39:739-749d. [PMID: 29106452 DOI: 10.1093/eurheartj/ehx319] [Citation(s) in RCA: 201] [Impact Index Per Article: 40.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 06/13/2017] [Indexed: 01/16/2023] Open
Abstract
Acute aortic syndromes (AAS) encompass a constellation of life-threatening medical conditions including classic acute aortic dissection (AAD), intramural haematoma, and penetrating atherosclerotic aortic ulcer. Given the non-specific symptoms and physical signs, a high clinical index of suspicion is necessary to detect the disease before irreversible lethal complications occur. In order to reduce the diagnostic time delay, a comprehensive flowchart for decision-making based on pre-test sensitivity of AAS has been designed by the European Society of Cardiology guidelines on aortic diseases and should be thus applied in the emergency scenario. When the definitive diagnosis is made, prompt and appropriate therapeutic interventions should be undertaken if indicated by a highly specialized aortic team. Urgent surgery for AAD involving the ascending aorta (Type A) and medical therapy alone for AAD not involving the ascending aorta (Type B) are typically recommended. In complicated Type B AAD, thoracic endovascular aortic repair (TEVAR) is generally indicated. On the other hand, in uncomplicated Type B AAD, pre-emptive TEVAR rather than medical therapy alone to prevent late complications, while intuitive, requires further study in randomized cohorts. Finally, it should be highlighted that there is an urgent need to increase awareness of AAS worldwide, including dedicated education/prevention programmes, and to improve diagnostic and therapeutic strategies, outcomes, and lifelong surveillance.
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Affiliation(s)
| | - Troy M LaBounty
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr, Ann Arbor, MI 48105, USA
| | - Kim A Eagle
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr, Ann Arbor, MI 48105, USA
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Ferber L, Ferber M, Mata DS, Firpe LM, Soares RR, Ferreira M. TAA 25. A New Off-Label Technique for a Total Endovascular Aortic Arch Repair. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.08.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Fairman AS, Beck AW, Malas MB, Goodney PP, Osborne NH, Schermerhorn ML, Wang GJ. Reinterventions in the modern era of thoracic endovascular aortic repair. J Vasc Surg 2019; 71:408-422. [PMID: 31327616 DOI: 10.1016/j.jvs.2019.04.484] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 04/20/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Using a national data set, we sought to describe the population of patients and the nature and timing of reinterventions after thoracic endovascular aortic repair (TEVAR) by aortic disease as well as their impact on survival. METHODS We evaluated the national data set for TEVAR in the Vascular Quality Initiative from 2010 to 2017. Student t-test and χ2 analysis were used to compare continuous and categorical variables in the reintervention and no reintervention groups, respectively. Freedom from reintervention and survival analysis was performed using Kaplan-Meier methods. RESULTS A total of 7006 patients were evaluated: 51.2% thoracic aortic aneurysm, 33.5% type B dissection (TBD), 7.0% penetrating aortic ulcer, 6.7% trauma, and 1.6% intramural hematoma. Overall, 553 patients (7.9%) underwent at least one reintervention, with an in-hospital reintervention rate of 3.5%. Reinterventions were most commonly performed for TBD (11.5%), with reinterventions for other diseases occurring at lower rates: thoracic aortic aneurysm, 6.7%; intramural hematoma, 5.4%; penetrating aortic ulcer, 4.8%; and trauma, 1.8%. The most common cause of reintervention across all aortic diseases was type I endoleak. The most common long-term reinterventions were placement of endovascular stent graft (65%), other surgical treatments (15.9%), other endovascular treatment (13%), endovascular branch treatment (12.4%), surgical treatment with no device removal (11.0%), and surgical branch treatment (10.4%). Freedom from reintervention was decreased for TBD compared with other diseases (P < .001). There was no difference in survival comparing patients undergoing reinterventions and those without (P = .87). However, patients undergoing in-hospital reintervention trended toward increased mortality (P = .075). CONCLUSIONS Whereas reinterventions were not rare after TEVAR, there was no difference in mortality between patients undergoing reintervention and those without. Patients undergoing TEVAR for TBD demonstrated the highest reintervention rate. This study highlights the importance of long-term follow-up to address disease-specific patterns of reintervention.
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Affiliation(s)
- Alexander S Fairman
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama Birmingham Hospital, Birmingham, Ala
| | - Mahmoud B Malas
- Divison of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego Health System, San Diego, Calif
| | - Philip P Goodney
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Nicholas H Osborne
- Section of Vascular Surgery, University of Michigan Medical Center, Ann Arbor, Mich
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa.
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Alfonsi J, Murana G, Smeenk HG, Kelder H, Schepens M, Sonker U, Morshuis WJ, Heijmen RH. Open surgical repair of post-dissection thoraco-abdominal aortic aneurysms: early and late outcomes of a single-centre study involving over 200 patients. Eur J Cardiothorac Surg 2019; 54:382-388. [PMID: 29462490 DOI: 10.1093/ejcts/ezy050] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 01/13/2018] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES Chronic, post-dissection thoraco-abdominal aortic aneurysms (TAAAs) are increasingly being treated by (hybrid) endovascular means. Although it is less invasive, thoracic endovascular aortic repair is technically complex with the risk of incomplete aneurysm exclusion, necessitating frequent reinterventions with potentially reduced long-term outcomes. The aim of this study was to evaluate contemporary early and late outcomes after open surgical repair of post-dissection TAAA. METHODS At our centre, 633 patients underwent open repair for TAAA over a 20-year period (1994-2015), including 217 (34%) patients for post-dissection TAAA, who were included in this analysis. Circulatory support was obtained by either left heart bypass (173 patients, 79.7%), deep hypothermic circulatory arrest (41 patients, 18.9%) or simple aortic cross-clamping in 3 patients. We analysed all relevant perioperative and intraoperative variables with respect to adverse outcomes. Additionally, long-term survival and the need for aortic reinterventions were studied. RESULTS The mean age was 60.2 ± 11.9 years (men 68.2%). We identified 66 Type I (30.4%), 113 Type II (52.1%), 25 Type III (11.5%), 10 Type IV (4.6%) and 3 Type V (1.4%) TAAAs. Early mortality and spinal cord deficit were 5.9% and 5.5%, respectively. Follow-up was 100% complete (mean 6.0 ± 5.8 years), with long-term survival of 71.4% at 10 years, and freedom from death and reoperation was 68.2% at 10 years. CONCLUSIONS Although it is more invasive than current endovascular approaches for post-dissection TAAA, open surgical repair can be performed safely with acceptable rates of morbidity and mortality when it is done in a specialized aortic centre. Long-term survival and freedom from aortic reintervention are excellent and should also be taken into account when evaluating less invasive alternatives.
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Affiliation(s)
- Jacopo Alfonsi
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Giacomo Murana
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Henri G Smeenk
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Hans Kelder
- Department of Cardiology Research and Statistical Analysis, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Marc Schepens
- Department of Cardiothoracic Surgery, AZ St. Jan, Bruges, Belgium
| | - Uday Sonker
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Wim J Morshuis
- Department of Cardiac Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Robin H Heijmen
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, Netherlands.,Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, Netherlands
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Son SA, Lee DH, Oh TH, Cho JY, Lee YO, Kim YE, Kim JW, Kim GJ. Risk Factors Associated With Reintervention After Thoracic Endovascular Aortic Repair for Descending Aortic Pathologies. Vasc Endovascular Surg 2019; 53:181-188. [PMID: 30866751 DOI: 10.1177/1538574418814989] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND: Thoracic endovascular aortic repair (TEVAR) is associated with several short-term benefits, including reduced morbidity and mortality; however, the long-term durability of TEVAR and the need for secondary aortic reintervention remain unclear. We aimed to determine the adverse outcomes, including aortic reintervention, after TEVAR for thoracic aortic aneurysms and dissection. METHODS: Between October 2009 and July 2016, 130 patients underwent TEVAR at Kyungpook National University Hospital. We excluded 35 patients with traumatic injury and included the remaining 95 patients in our study after TEVAR. The patients included in this study were categorized into 2 groups (reintervention [R] and nonintervention [N] groups) according to the need for reintervention. The mean follow-up period for all 95 patients was 22.4 (20.6) months. RESULTS: The overall actuarial survival rates were 83.7% (4.1%) and 63.6% (8.8%) at 1 and 5 years, respectively. The rates of freedom from aortic reintervention after TEVAR were 94.0% (3.5%), 72.8% (8.2%), and 48.9% (10.5%) at 2, 3, and 5 years, respectively. The independent risk factors for aortic reintervention were endoleaks after TEVAR (odds ratio [OR] 6.13, P = .017), increase in aortic size by over 5% per year (OR 20.40, P = .001), and peripheral vascular occlusive disease (PVOD; OR 13.62, P = .007). Patients with preoperative hemoptysis tended to show a greater need for aortic reintervention ( P = .059). Increase in aortic size by over 5% per year and PVOD were the primary risk factors for endoleaks (OR 3.82, P = .013 and OR 4.37, P = .021, respectively). CONCLUSION: Survival after TEVAR for thoracic aortic pathologies was satisfactory in most of the patients chosen as candidates for the procedure. However, the occurrence of endoleaks, increase in aortic size by over 5% per year, and PVOD were the primary causes of aortic reintervention.
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Affiliation(s)
- Shin-Ah Son
- 1 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Deok Heon Lee
- 1 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Tak-Hyuk Oh
- 1 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Joon Yong Cho
- 1 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Young Ok Lee
- 1 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Young Eun Kim
- 1 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Jung Won Kim
- 1 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Gun-Jik Kim
- 1 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
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Outcomes of upper extremity access during fenestrated-branched endovascular aortic repair. J Vasc Surg 2019; 69:635-643. [DOI: 10.1016/j.jvs.2018.05.214] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 05/05/2018] [Indexed: 11/22/2022]
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43
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Watkins AC, Huasen AB, Hill A, Nand P, Holden A. Endovascular Aortic Repair for Early Complications After Implantation of the Thoraflex Hybrid Graft. Ann Thorac Surg 2019; 107:e171-e174. [DOI: 10.1016/j.athoracsur.2018.07.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 07/06/2018] [Accepted: 07/09/2018] [Indexed: 01/16/2023]
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44
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Chiu P, Goldstone AB, Schaffer JM, Lingala B, Miller DC, Mitchell RS, Woo YJ, Fischbein MP, Dake MD. Endovascular Versus Open Repair of Intact Descending Thoracic Aortic Aneurysms. J Am Coll Cardiol 2019; 73:643-651. [PMID: 30765029 PMCID: PMC6675458 DOI: 10.1016/j.jacc.2018.10.086] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/22/2018] [Accepted: 10/30/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND For the management of descending thoracic aortic aneurysms, recent evidence has suggested that outcomes of open surgical repair may surpass thoracic endovascular aortic repair (TEVAR) in as early as 2 years. OBJECTIVES The purpose of this study was to evaluate the comparative effectiveness of TEVAR and open surgical repair in the treatment of intact descending thoracic aortic aneurysms. METHODS Using the Medicare database, a retrospective study using regression discontinuity design and propensity score matching was performed on patients with intact descending thoracic aortic aneurysms who underwent TEVAR or open surgical repair between 1999 and 2010 with follow-up through 2014. Survival was assessed with restricted mean survival time. Perioperative mortality was assessed with logistic regression. Reintervention was evaluated as a secondary outcome. RESULTS Matching created comparable groups with 1,235 open surgical repair patients matched to 2,470 TEVAR patients. The odds of perioperative mortality were greater for open surgical repair: high-volume center, odds ratio (OR): 1.97 (95% confidence interval [CI]: 1.53 to 2.61); low-volume center, OR: 3.62 (95% CI: 2.88 to 4.51). The restricted mean survival time difference favored TEVAR at 9 years, -209.2 days (95% CI: -298.7 to -119.7 days; p < 0.001) for open surgical repair. Risk of reintervention was lower for open surgical repair, hazard ratio: 0.40 (95% CI: 0.34 to 0.60; p < 0.001). CONCLUSIONS Open surgical repair was associated with increased odds of early postoperative mortality but reduced late hazard of death. Despite the late advantage of open repair, mean survival was superior for TEVAR. TEVAR should be considered the first line for repair of intact descending thoracic aortic aneurysms in Medicare beneficiaries.
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Affiliation(s)
- Peter Chiu
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, California; Department of Health and Research Policy, Stanford University, School of Medicine, Stanford, California
| | - Andrew B Goldstone
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, California; Department of Health and Research Policy, Stanford University, School of Medicine, Stanford, California
| | | | - Bharathi Lingala
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, California
| | - D Craig Miller
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, California
| | - R Scott Mitchell
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, California
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, California
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, California
| | - Michael D Dake
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, California.
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Wojciechowski J, Znaniecki L, Kaszubowski M, Rogowski J. Late Aortic Remodeling after Endovascular Repair of Complicated Type B Aortic Dissection—TEVAR Protects Only the Covered Segment of Thoracic Aorta. Ann Vasc Surg 2019; 55:148-156. [DOI: 10.1016/j.avsg.2018.05.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 05/02/2018] [Accepted: 05/10/2018] [Indexed: 11/28/2022]
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Janczak D, Ziomek A, Kobecki J, Malinowski M, Pormańczuk K, Chabowski M. Neurological complications after thoracic endovascular aortic repair. Does the left subclavian artery coverage without revascularization increase the risk of neurological complications in patients after thoracic endovascular aortic repair? J Cardiothorac Surg 2019; 14:5. [PMID: 30621728 PMCID: PMC6325786 DOI: 10.1186/s13019-018-0825-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 12/26/2018] [Indexed: 01/05/2023] Open
Abstract
Introduction One of the most severe complications after TEVAR is ischemic stroke and spinal cord ischemia (SCI) resulting in severe disability. These complications can be fatal up to 30% of cases, so it is very important to define risk factors associated with the occurrence of such events. The aim of this study was to define the causes and risk factors associated with the occurrence of neurological complications in patients after TEVAR. Materials and methods We performed a retrospective analysis of 51 patients undergoing TEVAR in the Department of Vascular Surgery of Military Teaching Hospital in Wroclaw between 2014 and 2017. In 18 patients LSA coverage was managed without revascularization (35.29%), and in 33 patients LSA remained uncovered (64.71%). Results We did not find any statistically significant difference in the incidence of stroke and spinal cord ischemia in patients with covered and uncovered LSA (stroke p = 0.37, SCI p = 0.58). In the group of patients with covered and uncovered LSA, we did not find any significant differences in the incidence of additional comorbidities such as obesity, ischemic heart disease, hypertension or previous stroke. Conclusions There is no difference in stroke and SCI occurrence between patients with covered and uncovered LSA. Although there are many studies analysing the risk of such complications, there is no specific consensus regarding the treatment of LSA coverage. Randomised clinical trials on a large group of patients are still needed.
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Affiliation(s)
- Dariusz Janczak
- Department of Vascular, General and Transplantation Surgery, Faculty of Postgraduate Medical Training, Wroclaw Medical University, 213 Borowska street, 50-556, Wroclaw, Poland
| | - Agnieszka Ziomek
- Department of Vascular, General and Transplantation Surgery, Faculty of Postgraduate Medical Training, Wroclaw Medical University, 213 Borowska street, 50-556, Wroclaw, Poland.,Department of Surgery, 4th Military Teaching Hospital, 5 Weigla street, 50-981, Wroclaw, Poland
| | - Jakub Kobecki
- Department of Surgery, 4th Military Teaching Hospital, 5 Weigla street, 50-981, Wroclaw, Poland
| | - Maciej Malinowski
- Department of Vascular, General and Transplantation Surgery, Faculty of Postgraduate Medical Training, Wroclaw Medical University, 213 Borowska street, 50-556, Wroclaw, Poland
| | - Kornel Pormańczuk
- Department of Surgery, 4th Military Teaching Hospital, 5 Weigla street, 50-981, Wroclaw, Poland.,Division of Surgical Specialties, Department of Clinical Nursing, Faculty of Health Science, Wroclaw Medical University, 5 Bartla Street, 51-618, Wroclaw, Poland
| | - Mariusz Chabowski
- Department of Surgery, 4th Military Teaching Hospital, 5 Weigla street, 50-981, Wroclaw, Poland. .,Division of Surgical Specialties, Department of Clinical Nursing, Faculty of Health Science, Wroclaw Medical University, 5 Bartla Street, 51-618, Wroclaw, Poland.
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Auricchio F, Conti M, Romarowski RM, de Beaufort HW, Grassi V, Trimarchi S. Computational tools for thoracic endovascular aortic repair planning. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2019. [DOI: 10.23736/s1824-4777.18.01386-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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48
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D'cruz RT, Wee IJ, Syn NL, Choong AM. The association between diabetes and thoracic aortic aneurysms. J Vasc Surg 2019; 69:263-268.e1. [DOI: 10.1016/j.jvs.2018.07.031] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 07/30/2018] [Indexed: 11/25/2022]
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49
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Zhang H, Qiao T. Aortic remodeling in Type B aortic dissection after thoracic endovascular aortic repair with an aortic extender cuff implantation. Clin Interv Aging 2018; 13:2359-2366. [PMID: 30532526 PMCID: PMC6241866 DOI: 10.2147/cia.s179526] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Objective This study investigated the safety and efficiency of thoracic endovascular aortic repair (TEVAR) plus an aortic extender cuff placement in treating Stanford Type B aortic dissections (TBADs). Methods Clinical data on 157 patients with TBADs who underwent TEVAR in two tertiary medical centers from February 2013 to March 2018 were analyzed retrospectively. An estimated mismatch rate >120% was the indication for placement of an aortic extender cuff. Results in the perioperative and follow-up periods (≥3 months) were analyzed, especially those of aortic remodeling. Results In total, 106 patients (67.5%) underwent standard TEVAR, and 51 (32.5%) received TEVAR plus an aortic extender cuff placement. The primary technical success rate was 96.8% (152/157). Perioperative adverse events included endoleak (2%, 3/157), spinal cord ischemia (SCI) (1.3%, 2/157), and transient renal failure (0.6%, 1/157), with no between-group differences. The median follow-up was 15 months (range 3–71 months). Ten cases of late stent complications were observed, including three endoleak, one upper limb ischemia, one stent distortion, and five stent graft-induced distal re-dissection (SIDR). Patients with a cuff had less distal re-dissection and fewer second interventions, but the differences lacked significance. In the last follow-up, the TEVAR+Cuff group were found to have better true lumen recovery and false lumen shrinkage, and increased complete false lumen thrombosis in the thoracic and abdominal segments; however, no statistical difference was evident in comparison with the TEVAR group (P>0.05). Conclusion TEVAR plus an aortic extender cuff implantation improves remodeling of the dissected thoracic aorta, thus reducing the potential of SIDR. Furthermore, the covered stent with a length of 250 mm does not increase the rate of SCI or paraplegia. However, these results should be confirmed in a larger series of patients with longer follow-up.
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Affiliation(s)
- Honggang Zhang
- Department of Vascular Surgery, Lianyungang Clinical College of Nanjing Medical University, Lianyungang 222000, Jiangsu, China
| | - Tong Qiao
- Department of Vascular Surgery, Gulou Clinical College of Nanjing Medical University, Nanjing 210000, Jiangsu, China,
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Tsilimparis N, Debus S, Chen M, Zhou Q, Seale MM, Kölbel T. Results from the Study to Assess Outcomes After Endovascular Repair for Multiple Thoracic Aortic Diseases (SUMMIT). J Vasc Surg 2018; 68:1324-1334. [DOI: 10.1016/j.jvs.2018.02.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 02/08/2018] [Indexed: 10/17/2022]
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