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Nana PN, Brotis AG, Tsolaki V, Spanos K, Mpatzalexis K, Zakynthinos E, Giannoukas AD, Kouvelos GN. Transesophageal echocardiography during endovascular procedures for thoracic aorta diseases: sensitivity and specificity analysis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 62:79-86. [PMID: 32909705 DOI: 10.23736/s0021-9509.20.11427-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION The widespread use of endovascular repair in thoracic aorta (TEVAR) pathologies has ameliorated postoperative outcomes. This meta-analysis was designed to investigate the intra-operative use of transesophageal echocardiography (TEE) compared to angiography in patients undergoing TEVAR. EVIDENCE ACQUISITION The meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement (PRISMA) guidelines. A data search of the English literature was conducted, using PubMed, EMBASE and CENTRAL databases, until November 30, 2019. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of evidence and the summary of findings for each of the included outcomes. EVIDENCE SYNTHESIS The final analysis included 7 articles (183 patients). All patients underwent TEVAR using intra-operative TEE and angiography. The sensitivity and specificity rates of entry points were 0.624 (95% CI: 0.145-0.97) and 0.377 (95% CI: 0.029-0.856), respectively. Regarding the detection of adequate guidewire advancement, the sensitivity was 0.778 (95% CI: 0.288-939) and specifity 0.346 (95% CI: 0.019-0.844). TEE could detect endograft incomplete deployment within acceptable rates of sensitivity and specifity, estimated at 0.616 (95% CI: 0.141-0.971) and 0.365 (95% CI: 0.028-0.845), respectively. The intra-operative detection of endoleaks presented a sensitivity estimated at 0.875 (0.51-0.998) and specificity at 0.698 (95% CI: 0.284-0.904). CONCLUSIONS Despite the limitations of this analysis, TEE may be evaluated in the current endovascular era, as a useful tool, providing adequate information, on graft deployment and early endoleaks.
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Affiliation(s)
- Petroula N Nana
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, Larissa University Hospital, University of Thessaly, Larissa, Greece -
| | - Alexandros G Brotis
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, Larissa University Hospital, University of Thessaly, Larissa, Greece
| | - Vassiliki Tsolaki
- Intensive Care Unit, Faculty of Medicine, School of Health Sciences, Larissa University Hospital, University of Thessaly, Larissa, Greece
| | - Konstantinos Spanos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, Larissa University Hospital, University of Thessaly, Larissa, Greece
| | - Konstantinos Mpatzalexis
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, Larissa University Hospital, University of Thessaly, Larissa, Greece
| | - Epaminondas Zakynthinos
- Intensive Care Unit, Faculty of Medicine, School of Health Sciences, Larissa University Hospital, University of Thessaly, Larissa, Greece
| | - Athanasios D Giannoukas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, Larissa University Hospital, University of Thessaly, Larissa, Greece
| | - George N Kouvelos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, Larissa University Hospital, University of Thessaly, Larissa, Greece
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Gabel JA, Patel ST, Tomihama RT, Hasaniya NW, Abou-Zamzam AM, Kiang SC. Debranching of Supra-aortic Vessels via Femoral Artery Inflow for Late Ascending Aortic Rupture. Ann Vasc Surg 2018; 57:49.e1-49.e5. [PMID: 30476606 DOI: 10.1016/j.avsg.2018.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 10/15/2018] [Accepted: 10/16/2018] [Indexed: 11/28/2022]
Abstract
A 56-year-old man with a history of Marfan's syndrome, total arch replacement, descending thoracic endovascular aortic repair, and twice redo sternotomy for pseudoaneurysm repair, presented with a pulsatile chest mass secondary to a contained rupture of the ascending aorta. The patient underwent supra-aortic debranching via the superficial femoral artery and ascending thoracic stent-graft placement under continuous transesophageal echocardiography. Completion angiography demonstrated successful exclusion of the contained rupture. Postoperatively, the patient was neurologically intact, the pulsatile mass resolved, and the bypass grafts remained patent. Chronic respiratory failure and multidrug-resistant pneumonia led to late mortality. This case demonstrates that hybrid repair is effective in the emergent setting of ascending aortic rupture. Debranching of the ascending arch using the superficial femoral artery as inflow is feasible and provides adequate cerebral perfusion despite the length of the bypass. The use of transesophageal echocardiography during stent-graft deployment allows precise device placement in the high-risk area of the ascending aorta proximal to the innominate artery.
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Affiliation(s)
- Joshua A Gabel
- Department of Vascular Surgery, Loma Linda University Health, Loma Linda, CA
| | - Sheela T Patel
- Department of Vascular Surgery, Loma Linda University Health, Loma Linda, CA
| | - Roger T Tomihama
- Department of Radiology, Loma Linda University Health, Loma Linda, CA
| | - Nahidh W Hasaniya
- Department of Cardiothoracic Surgery, Loma Linda University Health, Loma Linda, CA
| | - Ahmed M Abou-Zamzam
- Department of Vascular Surgery, Loma Linda University Health, Loma Linda, CA
| | - Sharon C Kiang
- Department of Vascular Surgery, Loma Linda University Health, Loma Linda, CA.
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Abstract
Stanford type B aortic dissections (TBADs) involve the descending aorta and can present with complications, including malperfusion syndrome or aortic rupture, which are associated with significant morbidity and mortality if left untreated. Clinical diagnosis is straightforward, typically confirmed using CT angiography. Treatment begins with immediate anti-impulse medical therapy. Acute TBAD with complications should be repaired with emergent thoracic endovascular aortic repair (TEVAR). Uncomplicated TBAD with high-risk features should undergo TEVAR in the subacute phase. Open surgical repair is seldom required and reserved only for select cases. It is critical to follow these patients clinically and radiographically in the outpatient setting.
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Affiliation(s)
- Daniel B Alfson
- Division of Vascular Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, 1520 San Pablo Street, HCC II, Suite 4300, Los Angeles, CA 90033-5330, USA
| | - Sung W Ham
- Division of Vascular Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, 1520 San Pablo Street, HCC II, Suite 4300, Los Angeles, CA 90033-5330, USA.
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Nauta FJH, Trimarchi S, Kamman AV, Moll FL, van Herwaarden JA, Patel HJ, Figueroa CA, Eagle KA, Froehlich JB. Update in the management of type B aortic dissection. Vasc Med 2016; 21:251-63. [DOI: 10.1177/1358863x16642318] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Stanford type B aortic dissection (TBAD) is a life-threatening aortic disease. The initial management goal is to prevent aortic rupture, propagation of the dissection, and symptoms by reducing the heart rate and blood pressure. Uncomplicated TBAD patients require prompt medical management to prevent aortic dilatation or rupture during subsequent follow-up. Complicated TBAD patients require immediate invasive management to prevent death or injury caused by rupture or malperfusion. Recent developments in diagnosis and management have reduced mortality related to TBAD considerably. In particular, the introduction of thoracic stent-grafts has shifted the management from surgical to endovascular repair, contributing to a fourfold increase in early survival in complicated TBAD. Furthermore, endovascular repair is now considered in some uncomplicated TBAD patients in addition to optimal medical therapy. For more challenging aortic dissection patients with involvement of the aortic arch, hybrid approaches, combining open and endovascular repair, have had promising results. Regardless of the chosen management strategy, strict antihypertensive control should be administered to all TBAD patients in addition to close imaging surveillance. Future developments in stent-graft design, medical therapy, surgical and hybrid techniques, imaging, and genetic screening may improve the outcomes of TBAD patients even further. We present a comprehensive review of the recommended management strategy based on current evidence in the literature.
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Affiliation(s)
- Foeke JH Nauta
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA
| | - Santi Trimarchi
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy
| | - Arnoud V Kamman
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy
| | - Frans L Moll
- Vascular Surgery Department, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joost A van Herwaarden
- Vascular Surgery Department, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - C Alberto Figueroa
- Departments of Biomedical Engineering and Surgery, University of Michigan, USA
| | - Kim A Eagle
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA
| | - James B Froehlich
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA
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Agricola E, Slavich M, Rinaldi E, Bertoglio L, Civilini E, Melissano G, Marone E, Fisicaro A, Marini C, Tufaro V, Cappelletti A, Margonato A, Chiesa R. Usefulness of contrast-enhanced transoesophageal echocardiography to guide thoracic endovascular aortic repair procedure. Eur Heart J Cardiovasc Imaging 2015; 17:67-75. [PMID: 26034095 DOI: 10.1093/ehjci/jev118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 04/15/2015] [Indexed: 11/13/2022] Open
Abstract
AIMS Thoracic endovascular aortic repair (TEVAR) is commonly considered as a valid alternative to surgery. Endoleaks occurrence is one of the principal limitations of TEVAR. Transoesophageal echocardiography (TEE) is often adopted in adjunct to fluoroscopy and angiography (ANGIO) during stent-graft implantation. In the present study, we compare intraprocedural ANGIO, TEE, and contrast-enhanced TEE (cTEE), and we also evaluate their accuracy in early endoleaks detection and characterization. METHODS AND RESULTS Fifty-four patients with thoracic aortic disease suitable for TEVAR were prospectively enrolled in the study. After stent placement, the result of the procedure was assessed by ANGIO, TEE, and cTEE. The use of contrast (Sonovue, Bracco) significantly improved TEE quality (P = 0.0001). cTEE was superior in entry tears, false and true lumen and aneurysm thrombosis identification, and microtears and ulcer-like projections detection before stent deployment. After stent deployment, cTEE was more accurate than TEE and ANGIO in the detection of slow flow in the false lumen and in the aneurismal sac (P = 0.0001), and in the remaining flow identification (P = 0.0001). Notably, cTEE is more accurate in the endoleaks detection (P = 0.0001) and in the incomplete stent expansion diagnosis and need for a further balloon inflation (P 0.002), or a further stent implantation (P 0.006), compared with TEE and ANGIO. CONCLUSION TEVAR procedures are improved by the complimentary use of contrast fluoroscopy, multiplane TEE with Doppler flow interrogation, and cTEE. This triple imaging approach provides additional information in all phases of the procedure improving safety of stent-grafting and the procedural outcomes.
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Affiliation(s)
- Eustachio Agricola
- Division of Non-Invasive Cardiology, San Raffaele Hospital, Via Olgettina 58, Milan 20100, Italy
| | - Massimo Slavich
- Division of Non-Invasive Cardiology, San Raffaele Hospital, Via Olgettina 58, Milan 20100, Italy
| | - Enrico Rinaldi
- Division of Vascular Surgery, San Raffaele Hospital, Milan 20100, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, San Raffaele Hospital, Milan 20100, Italy
| | - Efrem Civilini
- Division of Vascular Surgery, San Raffaele Hospital, Milan 20100, Italy
| | - Germano Melissano
- Division of Vascular Surgery, San Raffaele Hospital, Milan 20100, Italy
| | - Enrico Marone
- Division of Vascular Surgery, San Raffaele Hospital, Milan 20100, Italy
| | - Andrea Fisicaro
- Division of Non-Invasive Cardiology, San Raffaele Hospital, Via Olgettina 58, Milan 20100, Italy
| | - Claudia Marini
- Division of Non-Invasive Cardiology, San Raffaele Hospital, Via Olgettina 58, Milan 20100, Italy
| | - Vincenzo Tufaro
- Division of Non-Invasive Cardiology, San Raffaele Hospital, Via Olgettina 58, Milan 20100, Italy
| | - Alberto Cappelletti
- Division of Non-Invasive Cardiology, San Raffaele Hospital, Via Olgettina 58, Milan 20100, Italy
| | - Alberto Margonato
- Division of Non-Invasive Cardiology, San Raffaele Hospital, Via Olgettina 58, Milan 20100, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, San Raffaele Hospital, Milan 20100, Italy
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Crimi E, Lee JT, Dake MD, van der Starre PJA. Transesophageal echocardiography guidance for stent-graft repair of a thoracic aneurysm is facilitated by the ability of partial stent deployment. Ann Vasc Surg 2012; 26:861.e7-9. [PMID: 22794345 DOI: 10.1016/j.avsg.2012.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 01/25/2012] [Accepted: 01/28/2012] [Indexed: 11/16/2022]
Abstract
Transesophageal echocardiography (TEE) is routinely used in our Institution for monitoring correct positioning of thoracic aortic stent grafts. We present a case of successful endovascular repair of three discrete thoracic aortic aneurysms with Zenith TX2 endovascular stent grafts in an 82-year-old female patient. Our focus is on the increased value of TEE guidance because of the ability of partial stent deployment and manipulation during insertion.
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Affiliation(s)
- Ettore Crimi
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA 94305, USA
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7
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Grabenwöger M, Alfonso F, Bachet J, Bonser R, Czerny M, Eggebrecht H, Evangelista A, Fattori R, Jakob H, Lönn L, Nienaber CA, Rocchi G, Rousseau H, Thompson M, Weigang E, Erbel R. Thoracic Endovascular Aortic Repair (TEVAR) for the treatment of aortic diseases: a position statement from the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur J Cardiothorac Surg 2012; 42:17-24. [PMID: 22561652 DOI: 10.1093/ejcts/ezs107] [Citation(s) in RCA: 165] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Martin Grabenwöger
- Department of Cardiovascular Surgery, Hospital Hietzing, Vienna, Austria
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8
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Grabenwöger M, Alfonso F, Bachet J, Bonser R, Czerny M, Eggebrecht H, Evangelista A, Fattori R, Jakob H, Lönn L, Nienaber CA, Rocchi G, Rousseau H, Thompson M, Weigang E, Erbel R. Thoracic Endovascular Aortic Repair (TEVAR) for the treatment of aortic diseases: a position statement from the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2012; 33:1558-63. [PMID: 22561257 DOI: 10.1093/eurheartj/ehs074] [Citation(s) in RCA: 173] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Martin Grabenwöger
- Department of Cardiovascular Surgery, Hospital Hietzing, Vienna, Austria
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9
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Casana R, Tolva V, Majnardi AR, Bianchi PG, Addobati L, Bertoni GB, Cireni LV, Silani V. Endovascular Management of Symptomatic Cerebral Malperfusion Due to Carotid Dissection After Type A Aortic Dissection Repair. Vasc Endovascular Surg 2011; 45:641-5. [DOI: 10.1177/1538574411414301] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: Type A acute aortic dissection is a surgical emergency, and supra-aortic trunk involvement may be complicated by stroke in 6% to 20% of cases. A 66-year-old Caucasian female patient underwent a composite repair of the ascending aorta for type A aortic dissection. Postoperative period was complicated by episodes of “drop attack.” Doppler ultrasound of supra-aortic trunks revealed an intimal flap occluding right internal carotid artery. Technique: Multiple stenting was performed from carotid bifurcation to internal carotid artery in order to exclude the dissection intimal flap. After endovascular procedure physiatrist considered that motor functional improvement was better than expected, and we support that endovascular resolution of carotid malperfusion led to a better outcome. Conclusion: According to other experience, endovascular procedure resulted as a safe and effective way. Moreover, ultrasound monitoring of supra-aortic trunks in postoperative period is recommended.
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Affiliation(s)
- R. Casana
- Vascular Surgery, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - V. Tolva
- Vascular Surgery, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - A. Robecchi Majnardi
- Neurological Rehabilitation Department San Luca Hospital, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - P. G. Bianchi
- Vascular Surgery, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - L. Addobati
- Department of Neurology and Stroke Unit, Istituto Auxologico Italiano IRCCS, University of Milan, Milan, Italy
| | - G. B. Bertoni
- Vascular Surgery, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - L. V. Cireni
- Vascular Surgery, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - V. Silani
- Department of Neurology and Stroke Unit, Istituto Auxologico Italiano IRCCS, University of Milan, Milan, Italy
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Boufi M, Hartung O, Dona B, Di Pasquale F, Hakam Z, Marani I, Alimi YS. [Is endovascular treatment of acute thoracic aortic disease possible in centers where extracorporal circulation is not available?]. ACTA ACUST UNITED AC 2008; 33:72-8. [PMID: 18434054 DOI: 10.1016/j.jmv.2008.01.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2007] [Accepted: 01/23/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To determine whether access to extra-corporal circulation (ECC) is necessary to treat acute descending thoracic aorta disease. METHOD From January 2004 to May 2006, 16 patients underwent endovascular stent-graft repair of the descending thoracic aorta, among them 13 (81%) were treated in an emergency setting (nine men, mean age: 75.4 years, range 30-94 years). The indication was traumatic aortic rupture (n=3, 23%), complicated acute type B dissection (n=4; 31%), symptomatic or ruptured thoracic aortic aneurysm (n=4; 31%), aorto-esophageal fistula (n=1; 7,5%) and aortic intramural haematoma (n=1; 7,5%). Computed tomography showed hemomediastin and/or hemothorax in five patients (38%). Transesophageal echocardiography and angiography were performed in two (15%) and one patients respectively. Cerebrospinal fluid drainage was performed for two patients (15%). RESULTS Endovascular repair was successfully completed in 92.3% of cases. The 30-day mortality was 7.5% (n=1). There was one case (7.5%) of delayed paraplegia. Follow-up ranged between two and 24 months (mean 10.2), no rupture occurred. Three type I endoleaks were detected and only two were treated. Two none related additional mortalities were observed. None of these patients has needed ECC. CONCLUSION The unavailability of ECC does not seem to be a compromising factor in the management of thoracic aorta disease, however a good experience in endovascular techniques is required.
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Affiliation(s)
- M Boufi
- Service de chirurgie vasculaire, hôpital Nord, chemin des Bourrelly, 13915 Marseille cedex 20, France
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Oakes DA, Sze DY, Frisoli JK, Mitchell RS, Harris EJ, Thu C, van der Starre PJA. Intraoperative monitoring of elephant trunk kinking with transesophageal echocardiography. J Cardiothorac Vasc Anesth 2007; 21:584-6. [PMID: 17678793 DOI: 10.1053/j.jvca.2006.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2006] [Indexed: 11/11/2022]
Affiliation(s)
- Daryl A Oakes
- Department of Anesthesiology, Stanford University Medical Center, Stanford, CA 94305-5236, USA.
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12
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Fattori R, Russo V. Degenerative aneurysm of the descending aorta. Endovascular treatment. Multimed Man Cardiothorac Surg 2007; 2007:mmcts.2007.002824. [PMID: 24415213 DOI: 10.1510/mmcts.2007.002824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The incidence of thoracic aortic aneurysms has a rate of occurrence of 10.9 cases per 100,000 person/year, with an estimated 5-year risk of rupture ranging from 16% (diameter between 4 and 5.9 cm) to 31% (6 cm or more). Despite increasing awareness of the important role of early diagnosis in treatment options, guidelines about therapeutic strategies are actually lacking, as well as definite evidence of pharmacological treatment able to resolve or delay the disease progression. Endovascular treatment proposed as alternative to surgery has been considered a therapeutic innovation, especially because of low invasiveness, which allows to treat even high surgical risk patients. The procedure is performed under general anesthesia, mechanical ventilation and blood pressure invasive monitoring (right radial artery cannulation). The common femoral artery or external iliac artery are used for access after surgical exposure. After exposition of the artery, a 6F sheath is inserted and 5000 UI of heparin administered. Angiography is then performed to identify the lesion, landing zones and its relation to side branches. Endovascular stent-graft is thus loaded on an extra-stiff guidewire and delivered, with induced hypotension, under fluoroscopic and transesophageal echo control. Post procedural angiography and echocardiography control are performed to reveal the final result.
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Affiliation(s)
- Rossella Fattori
- Cardiothoracovascular Department, Cardiovascular Radiology Unit, University Hospital S. Orsola, Padiglione 21-Via Massarenti 9, 40138 Bologna, Italy
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13
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Rocchi G, Lofiego C, Biagini E, Piva T, Bracchetti G, Lovato L, Parlapiano M, Ferlito M, Rapezzi C, Branzi A, Fattori R. Transesophageal echocardiography–guided algorithm for stent-graft implantation in aortic dissection. J Vasc Surg 2004; 40:880-5. [PMID: 15557900 DOI: 10.1016/j.jvs.2004.08.041] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Endovascular stent-graft placement is replacing traditional surgery in type B aortic dissection. Usually stent-graft implantation is performed under fluoroscopic and angiographic guidance, but this relatively new procedure is still burdened with some complications. We investigated the value of a developed algorithm based on transesophageal echocardiography (TEE) for guiding stent-graft implantation in type B aortic dissection. METHODS Forty-two patients with type B aortic dissection (chronic in 28 patients with aneurysmal dilatation of the false lumen, and acute complicated in 14 patients) underwent endovascular stent-graft reconstruction of the descending thoracic aorta. TEE was always performed after angiography. TEE-induced variations of the procedure, based on the algorithm, were compared with initial angiography-based decisions. RESULTS TEE was decisive for guidewire repositioning (not possible with fluoroscopy) from the false to the true lumen in 3 patients and for correct guidewire entrance in an elephant trunk prosthesis in another patient. After stent-graft implantation color Doppler TEE enabled detection of proximal peri-stent leaks in 13 patients, whereas only 6 (46%) of the 13 leaks were detectable at angiography (P = .008). Most leaks were subsequently eliminated with balloon dilation or further stent grafting. Pulsed Doppler TEE was also useful for differentiating true leaks (13 patients) from Dacron porosity (7 patients). A pulsed-Doppler velocity cutoff value of 50 cm/s enabled differentiation of Dacron porosity (characterized by slow blood flow) from true peri-stent leak (fast flow). After stent-graft implantation TEE demonstrated new intimal tears in the thoracic aorta in 7 patients, whereas only 2 of the 7 new tears were detectable at angiography (P = .024); in 6 of 7 patients the new distal tears were subsequently resolved with placement of additional stents, whereas in a patient with Marfan syndrome new proximal tears determined a type I endoleak, which could not be resolved. Overall, TEE furnished decisive information additional to angiography in determining successful procedural changes in 16 of 42 patients (38%). There were no in-hospital deaths, and pre-discharge spiral computed tomograms showed a good outcome of stent-graft implantation in 37 of 42 patients (88%), with 5 residual type I endoleaks, all previously detected with TEE but impossible to eliminate with either balloon molding or further stent implantation. All but 2 patients (95%) are currently alive at mean follow-up of 30 +/- 18 months. CONCLUSIONS TEE algorithm is an easy and useful tool in the operating room to guide correct stent-graft positioning in type B aortic dissection.
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Affiliation(s)
- Guido Rocchi
- Institute of Cardiology, S. Orsola University Hospital, 40138 Bologna, Italy.
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