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Nana P, Spanos K, Panuccio G, Rohlffs F, Detter C, von Kodolitsch Y, Torrealba JI, Kölbel T. Branched and fenestrated endovascular aortic arch repair in patients with native proximal aortic landing zone. J Vasc Surg 2024; 80:621-629.e3. [PMID: 38580160 DOI: 10.1016/j.jvs.2024.03.444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/15/2024] [Accepted: 03/28/2024] [Indexed: 04/07/2024]
Abstract
OBJECTIVE Fenestrated and branched thoracic endovascular repair (f/bTEVAR) have been successfully applied in patients with diverse aortic arch pathologies. The aim of this study is to present the early and mid-term outcomes of patients with native proximal aortic landing (NPAL) managed with f/bTEVAR. METHODS A single-center retrospective analysis of patients with NPAL, managed with f/bTEVAR, between September 1, 2011, and June 30, 2022, was conducted. All patients were treated with custom-made devices (Cook Medical) with landing within Ishimaru zones 0 to 2. Primary outcomes were technical success, mortality, stroke, and retrograde type A dissection at 30 days. Follow-up outcomes were considered secondary. RESULTS A total of 126 patients were included (69.8% males; mean age, 70.8 ± 4.2 years; 18.3% urgent). The main indications (60.4%) for repair were aortic arch (29.4%) and thoracoabdominal aortic aneurysms (31.0%). Seventy-two patients (57.1%) were managed with fTEVAR. Proximal landing in zone 0 and 1 was chosen in 97.6%. Technical success was 94.4%, and 30-day mortality was 11.9%. Strokes were diagnosed in 13.5% of patients and major strokes were identified in 7.9% cases. Retrograde type A dissection rate was 3.9%. The multivariate analysis confirmed landing in Ishimaru zone 0 as an independently related factor for stroke (P = .005), whereas stroke (P < .001), pericardial effusion (P < .001), and acute kidney injury (P < .001) were independently related to 30-day mortality. Mean follow-up was 17.5 ± 9.3 months. The estimated survival rate and the freedom from reintervention rate were 72.6% (standard error, 4.4%) and 46.4% (standard error, 6.0%) at 24-month follow-up, respectively. CONCLUSIONS Stroke rate after endovascular arch repair was alarming among patients with NPAL. Proximal landing to zone 0 was related to higher risk of stroke. Reinterventions were common within the 24-month follow-up.
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Affiliation(s)
- Petroula Nana
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany.
| | - Konstantinos Spanos
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Christian Detter
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Yskert von Kodolitsch
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - José I Torrealba
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
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Nana P, Panuccio G, Torrealba JI, Rohlffs F, Spanos K, Kölbel T. Sex Comparative Analysis of Branched and Fenestrated Endovascular Aortic Arch Repair Outcomes. Eur J Vasc Endovasc Surg 2024; 68:315-323. [PMID: 38677467 DOI: 10.1016/j.ejvs.2024.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/15/2024] [Accepted: 04/21/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVE Female sex is a risk factor for adverse events after endovascular aortic repair. Sex comparative early and midterm outcomes of fenestrated and branched endovascular aortic arch repair (F/B-Arch) are presented. METHODS A single centre retrospective sex comparative analysis of consecutive patients managed with F/B-Arch was conducted according to STROBE. Primary outcomes were sex comparative technical success, death, and cerebrovascular morbidity at 30 days. Kaplan-Meier estimates were used for follow up outcomes. RESULTS Among 209 patients, 38.3% were women. Coronary artery disease (p < .001) and previous myocardial infarction (p = .01) were more common in women. Non-native proximal aortic landing was higher in women (women: 51.3%; men: 31.8%, p = .005) and the aortic dissection rate was lower (28.8% vs. 48.1%, p = .005). Proximal landing to Ishimaru zones showed no difference (zone 0: p = .18; zone 1: p = .47; zone 2: p = .39). Graft configurations were equally distributed. In total, 416 supra-aortic trunks were bridged. The median number of revascularisations per patient was two (interquartile range 1, 3), with no difference between sexes (p = .54). Technical success (women: 97.5%; men: 96.9%, p = .80), 30 day mortality rate (women: 10%; men: 9.3%, p = .86), and cerebrovascular morbidity (women: 11.3%; men: 17.1%, p = .25) were similar. Women presented more access related complications (women: 32.5%; men: 16.3%, p = .006), without affecting access related re-interventions (p = .55). Survival (women: 81.1%, 95% confidence interval [CI] 76.3 - 85.9%; men: 79.8%, 95% CI 76.0 - 83.6%) and freedom from re-intervention (women: 56.6%, 95% CI 50.4 - 62.8%; men: 55.3%, 95% CI 50.1 - 60.5%) at 12 months were similar (log rank, p = .40 and p = .41, respectively). CONCLUSION Both sexes presented similar outcomes after F/B-Arch. Appropriate patient selection may decrease the effect of sex in F/B-Arch outcomes.
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Affiliation(s)
- Petroula Nana
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, Hamburg, Germany.
| | - Giuseppe Panuccio
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, Hamburg, Germany
| | - José I Torrealba
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, Hamburg, Germany
| | - Konstantinos Spanos
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, Hamburg, Germany
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Leone N, Bieliauskas G, Ohrlander T, Resch T. Total Percutaneous Endovascular Aortic Arch Repair With a Triple Inner-Branch Device (the Innominate Approach). J Endovasc Ther 2024; 31:541-547. [PMID: 36382877 DOI: 10.1177/15266028221134892] [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: 02/17/2024]
Abstract
PURPOSE To describe a completely percutaneous approach for endovascular arch repair (arch-percutaneous endovascular aortic repair [PEVAR]) with a triple inner-branch device: the "Innominate Approach." TECHNIQUE After right axillary and single common femoral arteries percutaneous access, the arch stent-graft is introduced and deployed transfemorally using fusion overlay. The brachiocephalic artery (BCA) and the corresponding inner branch are cannulated from the axillary access. Through this access, a steerable-sheath guides antegrade cannulation of the left common carotid artery (LCCA) through its inner branch. Optionally, a wire preloaded through the left subclavian artery (LSA) and the LCCA branch, is snared from the BCA access providing LCCA through and through access. A 10 Fr sheath is then positioned from the BCA branch in the LCCA branch and a second, trans-axillary wire through the same sheath is used to catheterize the LCCA. The LCCA is then stented antegradely (regardless of approach). Finally, the BCA and LSA are bridged to complete the procedure. An additional novelty described is the use of VBX (W. L. Gore) as a bridging stent for the BCA. CONCLUSION Arch-PEVAR is feasible with the use of adjuncts that are well-known for physicians performing complex endovascular repair. The "Innominate Approach" avoids access and exposure of the carotid arteries. CLINICAL IMPACT We aim to describe the feasibility of the axillary artery as the main route to perform the brachiocephalic artery (BCA) and the left common carotid artery bridging stenting in case of arch endovascular repair (arch-EVAR) with a triple Inner-Branch Device. According to the present "Innominate Approach", percutaneous arch-EVAR is feasible using either a steerable sheath or a preloaded through-&-through wire. The Innominate approach, including a VBX bridging stent for the BCA, avoids carotid access and exposure, reduces the number of vascular accesses, and allows the downsizing of the trans-axillary devices.
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Affiliation(s)
- Nicola Leone
- Department of Vascular Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Gintautas Bieliauskas
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Tomas Ohrlander
- Department of Vascular Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Timothy Resch
- Department of Vascular Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Faculty of Health Sciences, Copenhagen University, Copenhagen, Denmark
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Ferrer C, Tinelli G, D'Oria M. Endovascular reconstruction of the aortic arch with new-generation dual-branch and triple-branch endograft: design, applicability, indications, outcomes, and future directions. Expert Rev Med Devices 2024:1-9. [PMID: 38557199 DOI: 10.1080/17434440.2024.2337920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/28/2024] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Repair of aortic arch pathologies such as degenerative aneurysms and dissections still represents a significant challenge for vascular and cardiac surgeons. We focused on the design, evolution, implementation, and prospects of endovascular dual branch technology for treatment of pathologies in the aortic arch. AREAS COVERED The literature search was conducted in a non-systematic fashion through the PubMed and Scopus databases; articles deemed relevant to the scope of the work and fully published in English language from January 12,000 until December 2023 were considered for inclusion. Two companies so far have developed and launched in market a dedicated arch dual branch platform: Terumo Aortic and Cook Medical. EXPERT OPINION A common limitation to the available technology is represented by the fact that urgent cases (i.e. large or rapidly growing aneurysms, symptomatic patients) cannot be treated because the customization process generally takes between 6 and 8 weeks, and there is an inherent risk for aorta-related adverse events to happen during the waiting time. While the future holds much promise, several technical hurdles still exist and further developments (in device design, operators' skills, patients' selection, and outcomes assessment) are needed to establish the safety and effectiveness of treatment particularly over the long-run.
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Affiliation(s)
- Ciro Ferrer
- Vascular and Endovascular Surgery Unit, San Giovanni - Addolorata Hospital, Roma, Italy
| | - Giovanni Tinelli
- Cardio-Thoracic-Vascular Department, Università Cattolica del Sacro Cuore, Rome, Italy
- Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
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Szentiványi A, Borzsák S, Vecsey-Nagy M, Süvegh A, Hüttl A, Fontanini DM, Szeberin Z, Csobay-Novák C. The impact of increasing saline flush volume to reduce the amount of residual air in the delivery system of aortic prostheses-a randomized controlled trial. Front Cardiovasc Med 2024; 11:1335903. [PMID: 38586170 PMCID: PMC10995325 DOI: 10.3389/fcvm.2024.1335903] [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: 11/09/2023] [Accepted: 03/11/2024] [Indexed: 04/09/2024] Open
Abstract
Background Air embolism is a known risk during thoracic endovascular aortic repair (TEVAR) and is associated with an incomplete deairing of the delivery system despite the saline lavage recommended by the instructions for use (IFU). As the delivery systems are identical and residual air remains frequently in the abdominal aortic aneurysm sac, endovascular aortic repair (EVAR) can be used to examine the effectiveness of deairing maneuvers. We aimed to evaluate whether increasing the flush volume can result in a more complete deairing. Methods Patients undergoing EVAR were randomly assigned according to flushing volume (Group A, 1× IFU; Group B, 4× IFU). The Terumo Aortic Anaconda and Treo and Cook Zenith Alpha Abdominal stent grafts were randomly implanted in equal distribution (10-10-10). The quantity of air trapped in the aneurysm sac was measured using a pre-discharge computed tomography angiography (CTA). Thirty patients were enrolled and equally distributed between the two groups, with no differences observed in any demographic or anatomical factors. Results The presence of air was less frequent in Group A compared to that in Group B [7 (47%) vs. 13 (87%), p = .02], and the air volume was less in Group A compared to that in Group B (103.5 ± 210.4 vs. 175.5 ± 175.0 mm3, p = .04). Additionally, the volume of trapped air was higher with the Anaconda graft type (p = .025). Discussion These findings suggest that increased flushing volume is associated with a higher amount of trapped air; thus, following the IFU might be associated with a reduced risk of air embolization. Furthermore, significant differences were identified between devices in terms of the amount of trapped air. Clinical trial registration [NCT04909190], [ClinicalTrials.gov].
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Affiliation(s)
- András Szentiványi
- Department of Interventional Radiology, Semmelweis University, Budapest, Hungary
| | - Sarolta Borzsák
- Department of Interventional Radiology, Semmelweis University, Budapest, Hungary
- Semmelweis Aortic Center, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Milán Vecsey-Nagy
- Department of Interventional Radiology, Semmelweis University, Budapest, Hungary
| | - András Süvegh
- Department of Interventional Radiology, Semmelweis University, Budapest, Hungary
| | - Artúr Hüttl
- Department of Interventional Radiology, Semmelweis University, Budapest, Hungary
- Semmelweis Aortic Center, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Daniele Mariastefano Fontanini
- Department of Interventional Radiology, Semmelweis University, Budapest, Hungary
- Semmelweis Aortic Center, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zoltán Szeberin
- Semmelweis Aortic Center, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Csaba Csobay-Novák
- Department of Interventional Radiology, Semmelweis University, Budapest, Hungary
- Semmelweis Aortic Center, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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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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Jimenez Diaz VA, Kapadia SR, Linke A, Mylotte D, Lansky AJ, Grube E, Settergren M, Puri R. Cerebral embolic protection during transcatheter heart interventions. EUROINTERVENTION 2023; 19:549-570. [PMID: 37720969 PMCID: PMC10495748 DOI: 10.4244/eij-d-23-00166] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/17/2023] [Indexed: 09/19/2023]
Abstract
Stroke remains a devastating complication of transcatheter aortic valve replacement (TAVR), with the incidence of clinically apparent stroke seemingly fixed at around 3% despite TAVR's significant evolution during the past decade. Embolic showers of debris (calcium, atheroma, valve material, foreign material) are captured in the majority of patients who have TAVR using a filter-based cerebral embolic protection device (CEPD). Additionally, in systematic brain imaging studies, the majority of patients receiving TAVR exhibit new cerebral lesions. Mechanistic studies have shown reductions in the volume of new cerebral lesions using CEPDs, yet the first randomised trial powered for periprocedural stroke within 72 hours of a transfemoral TAVR failed to meet its primary endpoint of showing superiority of the SENTINEL CEPD. The present review summarises the clinicopathological rationale for the development of CEPDs, the evidence behind these devices to date and the emerging recognition of cerebral embolisation in many non-TAVR transcatheter procedures. Given the uniqueness of each of the various CEPDs under development, specific trials tailored to their designs will need to be undertaken to broaden the CEPD field, in addition to evaluating the role of CEPD in non-TAVR transcatheter heart interventions. Importantly, the cost-effectiveness of these devices will require assessment to broaden the adoption of CEPDs globally.
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Affiliation(s)
- Victor Alfonso Jimenez Diaz
- Cardiology Department, Hospital Álvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IISGS), SERGAS-UVIGO, Vigo, Spain
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Axel Linke
- Department of Internal Medicine and Cardiology, Heart Center Dresden University Hospital, Dresden, Germany and Technische Universität Dresden, Dresden, Germany
| | - Darren Mylotte
- Department of Cardiology, University Hospital Galway, Galway, Ireland and University of Galway, Galway, Ireland
| | | | - Eberhard Grube
- Department of Medicine II, Heart Center, University Hospital Bonn, Bonn, Germany
| | - Magnus Settergren
- Heart and Vascular Unit, Karolinska University Hospital, Stockholm, Sweden and Karolinska Institutet, Stockholm, Sweden
| | - Rishi Puri
- Department of Cardiovascular Medicine, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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Cao L, Zhang H, Ge Y, Guo W. Avoiding Stroke in Patients Undergoing Endovascular Aortic Arch Repair: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 82:265-277. [PMID: 37438011 DOI: 10.1016/j.jacc.2023.04.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/10/2023] [Accepted: 04/24/2023] [Indexed: 07/14/2023]
Abstract
As the bottleneck of endovascular aortic arch repair, early postoperative stroke remains a devastating complication in high-risk patients and a critical concern for the development of optimal endovascular techniques and devices. The incidence of early postoperative stroke varies widely among currently available endovascular techniques and devices, with reported rates ranging from 0.0% to 42.9%, and is significantly influenced by the severity of the patient's preexisting aortic atherosclerotic burden, air released from the endovascular device, and a variety of factors leading to cerebral perfusion insufficiency. Currently, preidentification of high-risk patients and careful perioperative management appear to play a critical role in reducing stroke incidence. Specific intraoperative prevention methods are still lacking, but embolic protection devices and carbon dioxide or high-volume saline flushing of endovascular devices appear promising. Detailed preoperative stroke risk stratification and screening for optimal endovascular techniques and devices for aortic arch treatment are unmet clinical needs.
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Affiliation(s)
- Long Cao
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China; Department of General Surgery, The 983rd Hospital of Joint Logistic Support Force of PLA, Tianjin, China
| | - Hongpeng Zhang
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Yangyang Ge
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Wei Guo
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China.
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Mario D, Alessandro G, Giovanni P, Gianbattista P, Rocco G, Mauro G, Nicola M, Roberto C, Sandro L, Luca B. Total Transfemoral Branched Endovascular Thoracoabdominal Aortic Repair (TORCH2): Short-term and 1-Year Outcomes From a National Multicenter Registry. J Endovasc Ther 2023:15266028231179864. [PMID: 37326371 DOI: 10.1177/15266028231179864] [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: 06/17/2023]
Abstract
OBJECTIVE The use of steerable sheaths to allow total transfemoral access (TFA) of branched endovascular repair (BEVAR) of thoracoabdominal aortic aneurysms has been proposed as an alternative to upper extremity access (UEA); however, multicenter results from high-volume aortic centers are lacking. MATERIALS AND METHODS The Total Transfemoral Branched Endovascular Thoracoabdominal Aortic Repair (TORCH2) study is a physician-initiated, national, multicenter, retrospective, observational registry (Clinicaltrials.gov identifier: NCT04930172) of patients undergoing BEVAR with a TFA for the cannulation of reno-visceral target vessels (TV). The study endpoints, classified according to Society for Vascular Surgery reporting standards, were (1) technical success; (2) 30-day peri-operative major adverse events; (3) 30-day and midterm clinical success; (4) 30-day and midterm branch instability and TV-related adverse events (reinterventions, type I/III endoleaks). RESULTS Sixty-eight patients (42 males; median age: 72 years) were treated through a TFA. All the centers included their entire experience with TFA: 18 (26%) used a homemade steerable sheath, and in 28 cases (41%), a stabilizing guidewire was employed. Steerable technical success was achieved in 66 patients (97%) with an overall in-hospital mortality of 6 patients (9%, 3 elective cases [3/58, 5%] and 3 urgent/emergent cases [3/12, 25%]) and major adverse event rate of 18% (12 patients). Overall, 257 bridging stents were implanted; of these, 225 (88%) were balloon-expandable and 32 (12%) were self-expanding. No strokes were observed among the patient completing the procedure from a TFA. One patient (2%) who failed to be treated completely from a TFA and needed a bailout UEA suffered an ischemic stroke on postoperative day 2. There were 10 (15%) major access-site complications. At 1-year follow-up, overall survival was 80%, and the rate of branch instability was 6%. CONCLUSIONS A TFA for TV cannulation is a safe and feasible option with high technical success preventing the stroke risk of UEA. Primary patency at midterm seems comparable to historical controls, and future larger studies will be needed to assess potential differences with alternative options. CLINICAL IMPACT Using a transfemoral approach for retrograde cannulation of reno-visceral branches is feasiable, safe and effective, thereby representing a reliable alternative for BEVAR interventions.
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Affiliation(s)
- D'Oria Mario
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Grandi Alessandro
- Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Pratesi Giovanni
- Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Parlani Gianbattista
- Vascular and Endovascular Surgery Unit, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Giudice Rocco
- UOC di Chirurgia Vascolare, Dipartimento Cardiovascolare, Azienda Ospedaliera San Giovanni-Addolorata, Rome, Italy
| | - Gargiulo Mauro
- Unit of Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine (DIMES), S. Orsola-Malpighi Polyclinic, University of Bologna, Bologna, Italy
| | - Mangialardi Nicola
- Department of Vascular Surgery, Ospedale San Camillo-Forlanini, Rome, Italy
| | - Chiesa Roberto
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, "Vita-Salute" San Raffaele University, Milan, Italy
| | - Lepidi Sandro
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Bertoglio Luca
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, "Vita-Salute" San Raffaele University, Milan, Italy
- Division of Vascular Surgery, Department of Surgical and Clinical Sciences, University of Brescia, ASST Spedali Civili, Brescia, Italy
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10
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Rohlffs F, Grandi A, Panuccio G, Detter C, von Kodolitsch Y, Kölbel T. Endovascular Options for the Ascending Aorta and Aortic Arch - A Scoping Review. Ann Vasc Surg 2023:S0890-5096(23)00316-3. [PMID: 37328096 DOI: 10.1016/j.avsg.2023.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/02/2023] [Accepted: 06/06/2023] [Indexed: 06/18/2023]
Abstract
The gold standard for aneurysmal repair of the ascending aorta and the aortic arch has been open surgery with an established track record of good results in suitable patients. In recent years, with innovations in the endovascular field alternative endovascular solutions for pathologies of the aortic arch and ascending aorta became available. At first reserved only for highly selected patients unfit for open surgery, endovascular aortic arch repair is now being offered to patients with suitable anatomy in high volume referral centers after discussion in an interdisciplinary team. The present scoping review aims at providing an overview on indications, available devices, technical aspects and feasibility studies of endovascular arch repair both in elective and emergent situations, including also experiences and considerations from our center.
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Affiliation(s)
- Fiona Rohlffs
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany.
| | - Alessandro Grandi
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Christian Detter
- Cardiothoracic Surgery, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Yskert von Kodolitsch
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
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11
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Crockett S, Hanna L, Singh A, Gunning S, Nicholas R, Bicknell C, Hamady M, Gable D, Sallam M, Modarai B, Abisi S, Lyons O, Gibbs R. Carbon dioxide flushing versus saline flushing of thoracic aortic stents (INTERCEPTevar): protocol for a multicentre pilot randomised controlled trial. BMJ Open 2023; 13:e067605. [PMID: 37105705 PMCID: PMC10151986 DOI: 10.1136/bmjopen-2022-067605] [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: 09/05/2022] [Accepted: 02/21/2023] [Indexed: 04/29/2023] Open
Abstract
INTRODUCTION Thoracic endovascular aortic repair (TEVAR) carries a 3%-6.1% stroke risk, including risk of 'silent' cerebral infarction (SCI). Stent-grafts are manufactured in room air and retain air. Instructions for use recommend saline flushing to 'de-air' the system prior to insertion, but substantial amounts of air are released when deploying them, potentially leading to downstream neuronal injury and SCI. Carbon dioxide (CO2) is more dense and more soluble in blood than air, without risk of bubble formation, so could be used in addition to saline to de-air stents. This pilot trial aims to assess the feasibility of a full-scale randomised controlled trial (RCT) investigating the neuroprotective benefit against SCI with the use of CO2-flushed aortic stent-grafts. METHODS AND ANALYSIS This is a multicentre pilot RCT, which is taking place in vascular centres in the UK, USA and New Zealand. Patients identified for TEVAR will be enrolled after informed written consent. 120 participants will be randomised (1:1) to TEVAR-CO2 or TEVAR-saline, stratified according to TEVAR landing zone. Participants will undergo preoperative neurocognitive tests and quality of life assessments, which will be repeated at 6 weeks, or first outpatient appointment, and 6 months. Inpatient neurological testing will be performed within 48 hours of return to level 1 care for clinical stroke or delirium. Diffusion-weighted MRI will be undertaken within 72 hours postoperatively (1-7 days) and at 6 months to look for evidence and persistence of SCI. Feasibility will be assessed via measures of recruitment and retention, informing the design of a full-scale trial. ETHICS AND DISSEMINATION The study coordination centre has obtained approval from the London Fulham Research Ethics Committee (19/LO/0836) and Southern Health and Disability Ethics Committee (NZ) and UK's Health Regulator Authority (HRA). The study has received ethical approval for recruitment in the UK (Fulham REC, 19/LO/0836), New Zealand (21/STH/192) and the USA (IRB 019-264, Ref 378630). Consent for entering into the study will be taken using standardised consent forms by the local study team, led by a local PI. The results of the trial will be submitted for publication in an open access journal. TRIAL REGISTRATION NUMBER NCT03886675.
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Affiliation(s)
- Stephen Crockett
- Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Lydia Hanna
- Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Abhinav Singh
- Neuroradiology Department, Imperial College Healthcare NHS Trust, London, UK
| | - Stephen Gunning
- Clinical Health and Psychology Department, Imperial College Healthcare NHS Trust, London, UK
| | - Richard Nicholas
- Neurology Department, Imperial College Healthcare NHS Trust, London, UK
| | - Colin Bicknell
- Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Mohamad Hamady
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Dennis Gable
- Vascular Surgery Department, Baylor Scott & White Health, Dallas, Texas, USA
| | - Morad Sallam
- Vascular Surgery Department, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Bijan Modarai
- Vascular Surgery Department, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Said Abisi
- Vascular Surgery Department, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Oliver Lyons
- Vascular Surgery Department, Canterbury District Health Board, Christchurch, New Zealand
| | - Richard Gibbs
- Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
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12
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Wong J, Tenorio ER, Lima G, Dias-Neto M, Baghbani-Oskouei A, Mendes B, Kratzberg J, Ocasio L, Macedo TA, Oderich GS. Early Feasibility of Endovascular Repair of Distal Aortic Arch Aneurysms Using Patient-Specific Single Retrograde Left Subclavian Artery Branch Stent Graft. Cardiovasc Intervent Radiol 2023; 46:249-254. [PMID: 36319711 PMCID: PMC9628377 DOI: 10.1007/s00270-022-03304-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 10/14/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To describe the feasibility and outcomes of endovascular repair of distal aortic arch aneurysms using a patient-specific stent graft with a pre-loaded single retrograde left subclavian artery (LSA) branch stent graft. METHODS We reviewed the clinical data and outcomes of consecutive patients enrolled in an ongoing prospective, non-randomized physician-sponsored investigational device exemption study to evaluate the outcomes of endovascular aortic arch repair using patient-specific arch branch stent grafts (William Cook Europe, Bjaeverskov, Denmark) between 2019 and 2022. All patients received a design with triple-wide scallop and a single retrograde LSA branch with a pre-loaded catheter. RESULTS There were five male patients with median age of 77 years old (72-80) treated using the single LSA branch stent graft. Technical success was achieved in all patients. Median operating time, fluoroscopy time, and total radiation dose area product were 103 (78-134) minutes, 26 (19-39) minutes, and 123 (71-270) mGy.cm2, respectively. There were no 30-day or in-hospital mortality, neurological or other major adverse events (MAEs). During median follow-up of 21 (20-27) months, all patients were alive with patent LSA branches, except for one who died of COVID-19 complications. There was no branch instability or secondary interventions. CONCLUSION This early feasibility study demonstrates successful endovascular repair of distal aortic arch aneurysms using a patient-specific stent graft with single retrograde LSA branch without technical failures, mortality or neurological events. Larger clinical experience and longer follow-up are needed to determined effectiveness of this approach in patients who need endovascular repair with proximal extension into Zone 2.
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Affiliation(s)
- Joshua Wong
- Advanced Aortic Research Program, Department of Cardiothoracic & Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Emanuel R Tenorio
- Advanced Aortic Research Program, Department of Cardiothoracic & Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Guilherme Lima
- Advanced Aortic Research Program, Department of Cardiothoracic & Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Marina Dias-Neto
- Advanced Aortic Research Program, Department of Cardiothoracic & Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Aidin Baghbani-Oskouei
- Advanced Aortic Research Program, Department of Cardiothoracic & Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Bernardo Mendes
- Advanced Aortic Research Program, Department of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jarin Kratzberg
- Advanced Aortic Research Program, Department of Cardiothoracic & Vascular Surgery, Cook Medical Inc., Bloomington, IN, USA
| | - Laura Ocasio
- Advanced Aortic Research Program, Department of Cardiothoracic & Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Thanila A Macedo
- Advanced Aortic Research Program, Department of Cardiothoracic & Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Gustavo S Oderich
- Advanced Aortic Research Program, Department of Cardiothoracic & Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA.
- Texas Medical Center, McGovern Medical School, University of Texas Health Science Center, 6400 Fannin, Suite 2850, Houston, TX, 77030, USA.
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13
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Tenorio ER, Vacirca A, Mesnard T, Sulzer T, Baghbani-Oskouei A, Mirza AK, Huang Y, Oderich GS. Technical tips and clinical experience with the Cook Triple inner arch branch stent-graft. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:9-17. [PMID: 36598743 DOI: 10.23736/s0021-9509.22.12569-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Open surgical repair remains the gold standard for treatment for aortic arch diseases, but these operations can be associated with wide heterogeneity in outcomes and significant morbidity and mortality, particularly in elderly patients with severe comorbidities or those who had prior arch procedures via median sternotomy. Endovascular repair has been introduced as a less invasive alternative to reduce morbidity and mortality associated with open surgical repair. The technique evolved with new device designs using up to three inner branches for incorporation of the supra-aortic trunks. This manuscript summarizes technical tips and clinical experience with the triple inner arch branch stent graft for total endovascular repair of aortic arch pathologies.
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Affiliation(s)
- Emanuel R Tenorio
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Andrea Vacirca
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Thomas Mesnard
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Titia Sulzer
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Aidin Baghbani-Oskouei
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Aleem K Mirza
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Ying Huang
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA -
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14
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C Schaefer T, Greive S, Heiland S, Kramer M, Bendszus M, Vollherbst DF. Investigation of Experimental Endovascular Air Embolisms Using a New Model for the Generation and Detection of Highly Calibrated Micro Air Bubbles. J Endovasc Ther 2022; 30:461-470. [PMID: 35255747 DOI: 10.1177/15266028221082010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Air embolism (AE), especially when affecting the brain, is an underrated and potentially life-threatening complication in various endovascular interventions. This study aims to investigate experimental AEs using a new model to generate micro air bubbles (MAB), to assess the impact of a catheter on these MAB, and to demonstrate the applicability of this model in vivo. MATERIALS AND METHODS Micro air bubbles were created using a system based on microfluidic channels. The MAB were detected and analyzed automatically. Micro air bubbles, with a target size of 85 µm, were generated and injected through a microcatheter. The MAB diameters proximal and distal to the catheter were assessed and compared. In a subsequent in vivo application, 2000 MAB were injected into the aorta (at the aortic valve) and into the common carotid artery (CCA) of a rat, respectively, using a microcatheter, resembling AE occurring during cardiovascular interventions. RESULTS Micro air bubbles with a highly calibrated size could be successfully generated (median: 85.5 µm, SD 1.9 µm). After passage of the microcatheter, the MAB were similar in diameter (median: 86.6 µm) but at a lower number (60.1% of the injected MAB) and a substantially higher scattering of diameters (SD 29.6 µm). In vivo injection of MAB into the aorta resulted in cerebral microinfarctions in both hemispheres, whereas injection into the CCA caused exclusively ipsilateral microinfarctions. CONCLUSION Using this new AE model, MAB can be generated precisely and reproducibly, resulting in cerebral microinfarctions. This model is feasible for further studies on the pathophysiology and prevention of AE in cardiovascular procedures.
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Affiliation(s)
- Tabea C Schaefer
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany.,Clinic for Small Animals, Justus Liebig University Gießen, Gießen, Germany
| | - Svenja Greive
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Sabine Heiland
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Kramer
- Clinic for Small Animals, Justus Liebig University Gießen, Gießen, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Dominik F Vollherbst
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
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15
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Queiroz AB, Lopes JB, Santos VP, Cruz PBAF, Fidelis RJR, Filho JSA, Passos LCS. Physician-Modified Endovascular Grafts for Zone-2 Thoracic Endovascular Aortic Repair. AORTA (STAMFORD, CONN.) 2022; 10:13-19. [PMID: 35640582 PMCID: PMC9179216 DOI: 10.1055/s-0042-1742696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 07/02/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVE This study aims to describe our technique and early experience with physician-modified endovascular grafts (PMEGs) for aortic arch diseases in zone 2. We used a total endovascular technique based on a single fenestrated endograft to preserve left subclavian artery (LSA) patency. METHODS From December 2019 to August 2020, six consecutive patients with a variety of thoracic aortic diseases were treated with handmade fenestrated thoracic aortic grafts: four aortic dissections, one penetrating aortic ulcer, and one intramural hematoma. The planning, endograft modification, surgical technique, and follow-up of the patients were described. We evaluated immediate technical success and after 30 days, the LSA patency, Type-1 endoleak, and postoperative complications. RESULTS Thoracic endovascular aortic repair (TEVAR) was performed for zone 2 in all cases. Immediate technical success, defined as successful alignment of the LSA with a covered stent and no Type-1 endoleak, was achieved in all cases. Patients had a 30-day follow-up computed tomography, which demonstrated LSA patency and no Type-I endoleaks. To date, no strokes, left arm ischemia, paraplegia, or conversions to open surgery have been reported; one patient operated for acute Type B dissection died during the early follow-up. CONCLUSION TEVAR for zone 2 with a PMEG to maintain LSA patency achieved technical success and early durability. It is expected that with longer follow-up and a larger number of cases, these results will be confirmed.
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Affiliation(s)
- André B. Queiroz
- Centro de Doenças da Aorta - CDA, Division of Vascular and Endovascular Surgery, Cardiac Surgery, Cardiology and Anesthesia, Universidade Federal da Bahia, Hospital Ana Nery, Salvador-Bahia, Brazil
- Division of Vascular Surgery, Universidade Federal da Bahia, Hospital Universitário Professor Edgar Santos, Salvador-Bahia, Brazil
| | - Jackson B. Lopes
- Centro de Doenças da Aorta - CDA, Division of Vascular and Endovascular Surgery, Cardiac Surgery, Cardiology and Anesthesia, Universidade Federal da Bahia, Hospital Ana Nery, Salvador-Bahia, Brazil
| | - Vanessa P. Santos
- Division of Vascular Surgery, Universidade Federal da Bahia, Hospital Universitário Professor Edgar Santos, Salvador-Bahia, Brazil
| | - Pedro B. A. F. Cruz
- Centro de Doenças da Aorta - CDA, Division of Vascular and Endovascular Surgery, Cardiac Surgery, Cardiology and Anesthesia, Universidade Federal da Bahia, Hospital Ana Nery, Salvador-Bahia, Brazil
| | - Ronald J. R. Fidelis
- Division of Vascular Surgery, Universidade Federal da Bahia, Hospital Universitário Professor Edgar Santos, Salvador-Bahia, Brazil
| | - José S. Araújo Filho
- Centro de Doenças da Aorta - CDA, Division of Vascular and Endovascular Surgery, Cardiac Surgery, Cardiology and Anesthesia, Universidade Federal da Bahia, Hospital Ana Nery, Salvador-Bahia, Brazil
- Division of Vascular Surgery, Universidade Federal da Bahia, Hospital Universitário Professor Edgar Santos, Salvador-Bahia, Brazil
| | - Luiz C. S. Passos
- Centro de Doenças da Aorta - CDA, Division of Vascular and Endovascular Surgery, Cardiac Surgery, Cardiology and Anesthesia, Universidade Federal da Bahia, Hospital Ana Nery, Salvador-Bahia, Brazil
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16
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Torrealba J, Panuccio G, Kölbel T, Gandet T, Heidemann F, Rohlffs F. Physician-Modified Endograft With Inner Branches for the Treatment of Complex Aortic Urgencies. J Endovasc Ther 2021; 29:697-704. [PMID: 34852653 DOI: 10.1177/15266028211061275] [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
PURPOSE To describe the use of physician-modified endograft (PMEG) with the exclusive use of inner branches or in combination with fenestrations for the urgent treatment of complex aortic aneurysms. TECHNIQUE We present two urgent cases. A patient with a 6.8 cm saccular juxtarenal aneurysm and another patient with a contained rupture of the thoracoabdominal aorta right above the celiac trunk (CT). In both cases, a Cook Zenith TX2 thoracic endograft was back-table modified, in the first case by adding three fenestrations and one inner branch for the left renal artery to improve sealing due to its partial involvement in the aneurysm and, in the second case, with the use of two inner branches for the CT and superior mesenteric artery. Both procedures were successful, with uneventful postoperative courses and complete aneurysm exclusion on postoperative CT angiography. CONCLUSION Use of PMEGs with inner branches is feasible for urgent repair in complex aortic anatomy.
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Affiliation(s)
- Jose Torrealba
- German Aortic Center Hamburg, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center Hamburg, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Gandet
- German Aortic Center Hamburg, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franziska Heidemann
- German Aortic Center Hamburg, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center Hamburg, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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17
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Eilenberg W, Bechstein M, Charbonneau P, Rohlffs F, Eleshra A, Panuccio G, Bhangu JS, Fiehler J, Greenhalgh RM, Haulon S, Kölbel T. Cerebral microbleeds following thoracic endovascular aortic repair. Br J Surg 2021; 109:46-52. [PMID: 34694374 DOI: 10.1093/bjs/znab341] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/27/2021] [Accepted: 08/29/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Stroke and neurological injury are a complication of thoracic endovascular aortic repair (TEVAR). Cerebral microbleeds (CMBs) are common in patients with white matter damage to the brain secondary to chronic vasculopathy. The aim of this study was to examine the occurrence of CMBs after TEVAR, and to evaluate their association with patient and procedural factors. METHODS Patients who underwent TEVAR between September 2018 and January 2020 in two specialist European aortic centres were analysed. All patients underwent postoperative susceptibility-weighted MRI. The location and number of CMBs were identified, and analysed with regard to procedural aspects, clinical outcome, and Fazekas score as an indicator of pre-existing vascular leucoencephalopathy. RESULTS Some 91 patients were included in the study. A total of 1531 CMBs were detected in 58 of 91 patients (64 per cent). In the majority of affected patients, CMBs were found bilaterally (79 per cent). Unilateral CMBs in the right or left hemisphere occurred in 16 and 5 per cent of patients respectively (P < 0.001). More CMBs were found in the middle cerebral than in the vertebrobasilar/posterior and anterior cerebral artery territories (mean(s.d.) 3.35(5.56) versus 2.26(4.05) versus 0.97(2.87); P = 0.045). Multivariable analysis showed an increased probability of CMBs after placement of TEVAR stent-grafts with a proximal diameter of at least 40 mm (odds ratio (OR) 6.85, 95 per cent c.i. 1.65 to 41.59; P = 0.007) and in patients with a higher Fazekas score on postoperative T2-weighted MRI (OR 2.62, 1.06 to 7.92; P = 0.037). CONCLUSION CMBs on postoperative MRI are common after endovascular repair in the aortic arch. Their occurrence appears to be associated with key aspects of the procedure and pre-existing vascular leucoencephalopathy.
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Affiliation(s)
- Wolf Eilenberg
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany.,Department of General Surgery, Division of Vascular Surgery, Medical University of Vienna, Vienna, Austria
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Philippe Charbonneau
- Centre de l'Aorte, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Paris, France
| | - Fiona Rohlffs
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Ahmed Eleshra
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jagdeep Singh Bhangu
- Department of General Surgery, Division of Vascular Surgery, Medical University of Vienna, Vienna, Austria
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | | | - Stephan Haulon
- Centre de l'Aorte, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Paris, France
| | - Tilo Kölbel
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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18
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Kotani S, Inoue Y, Oki N, Yashiro H, Hachiya T. Actual incidence of cerebral infarction after thoracic endovascular aortic repair: a magnetic resonance imaging study. Interact Cardiovasc Thorac Surg 2021; 34:267-273. [PMID: 34632503 PMCID: PMC8766213 DOI: 10.1093/icvts/ivab240] [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: 02/24/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES The actual incidence of cerebral infarction (CI), including asymptomatic infarction, owing to thoracic endovascular aortic repair (TEVAR) has not been reported in detail. This study was performed to investigate the incidence of post-TEVAR CI by using diffusion-weighted magnetic resonance imaging (DW-MRI) and to determine the risk factors for both symptomatic and asymptomatic CI. METHODS We examined 64 patients undergoing TEVAR at our institute between April 2017 and November 2020. Aortic atheroma was graded from 1 to 5 by preoperative computed tomography. Cerebral DW-MRIs were conducted 2 days after the procedure to diagnose postoperative CI. RESULTS A total of 44 new foci were detected by post-interventional cerebral DW-MRI in 22 patients (34.4%). Only one patient developed a symptomatic stroke (1.6%), and TEVAR was successfully completed in all cases. Debranching of the aortic arch and left subclavian artery occlusion with a vascular plug was performed in 19 (29.7%) and 12 (18.8%) patients, respectively. The number of patients with proximal landing zones 0–2 was significantly higher in the CI group than in the non-CI group (68.2% vs 11.9%; P < 0.001). The following risk factors were identified for asymptomatic CI: aortic arch debranching (P < 0.001), left subclavian artery occlusion (P = 0.001) and grade 4/5 aortic arch atheroma (P = 0.048). CONCLUSIONS Over one-third of the patients examined by cerebral DW-MRI after TEVAR were diagnosed with CI. High-grade atheroma and TEVAR landing in zone 0–2 were found to be positively associated with asymptomatic CI. Clinical trial registration 02-014.
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Affiliation(s)
- Sohsyu Kotani
- Department of Cardiovascular Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Yoshito Inoue
- Department of Cardiovascular Surgery, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
| | - Naohiko Oki
- Department of Cardiovascular Surgery, Hiratsuka City Hospital, Kanagawa, Japan
| | - Hideki Yashiro
- Department of Radiology, Hiratsuka City Hospital, Kanagawa, Japan
| | - Takashi Hachiya
- Department of Cardiovascular Surgery, Saiseikai Yokohamashi Tobu Hospital, Kanagawa, Japan
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Endovascular Treatment of Post Type A Chronic Aortic Arch Dissection With a Branched Endograft: Early Results From a Retrospective International Multicenter Study. Ann Surg 2021; 273:997-1003. [PMID: 30973389 DOI: 10.1097/sla.0000000000003310] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate the outcome of endovascular aortic arch repair for chronic dissection with a custom-made branched endograft. BACKGROUND Acute type A aortic dissections are often treated with prosthetic replacement of the ascending aorta. During follow-up, repair of an aneurysmal evolution of the false lumen distal to the ascending prosthesis can be a challenge both for the surgeon and the patient. METHODS We conducted a multicenter, retrospective study of consecutive patients from 14 vascular units treated with a custom-made, inner-branched device (Cook Medical, Bloomington, IN) for chronic aortic arch dissection. Rates of in-hospital mortality and stroke, technical success, early and late complications, reinterventions, and mortality during follow-up were evaluated. RESULTS Seventy consecutive patients were treated between 2011 and 2018. All patients were considered unfit for conventional surgery. In-hospital combined mortality and stroke rate was 4% (n = 3), including 1 minor stroke, 1 major stroke causing death, and 1 death following multiorgan failure. Technical success rate was 94.3%. Twelve (17.1%) patients required early reinterventions: 8 for vascular access complication, 2 for endoleak correction, and 2 for pericardial effusion drainage. Median follow-up was 301 (138-642) days. During follow-up, 20 (29%) patients underwent secondary interventions: 9 endoleak corrections, 1 open repair for prosthetic kink, and 10 distal extensions of the graft to the thoracic or thoracoabdominal aorta. Eight patients (11%) died during follow-up because of nonaortic-related cause in 7 cases. CONCLUSIONS Endovascular treatment of aortic arch chronic dissections with a branched endograft is associated with low mortality and stroke rates but has a high reintervention rate. Further follow-up is required to confirm the benefits of this novel approach.
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20
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Tenorio ER, Oderich GS, Kölbel T, Dias NV, Sonesson B, Karelis A, Farber MA, Parodi FE, Timaran CH, Scott CK, Tsilimparis N, Fernandez C, Jakimowicz T, Jama K, Kratzberg J, Mougin J, Haulon S. Multicenter global early feasibility study to evaluate total endovascular arch repair using three-vessel inner branch stent-grafts for aneurysms and dissections. J Vasc Surg 2021; 74:1055-1065.e4. [PMID: 33865950 DOI: 10.1016/j.jvs.2021.03.029] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We evaluated the outcomes of total endovascular aortic arch repair using three-vessel inner branch stent-grafts for aneurysms and chronic dissections. METHODS We reviewed the clinical data and outcomes of consecutive patients treated by total endovascular aortic arch repair at eight academic centers using three-vessel inner branch stent-grafts (William Cook Europe, Bjaeverskov, Denmark) from 2016 to 2019. All patients received three-vessel designs with two antegrade and one retrograde inner branch, which was used to incorporate the innominate, left common carotid, and left subclavian arteries. The antegrade inner branches were accessed via a carotid or an upper extremity approach. A preloaded catheter was used for access to the retrograde left subclavian artery branch via a transfemoral approach. The endpoints were technical success, mortality, major adverse events, any stroke (minor or major) or transient ischemia attack, secondary interventions, target vessel patency, target vessel instability, aneurysm-related mortality, and patient survival. RESULTS A total of 39 patients (31 men [79%]; mean age, 70 ± 7 years) had undergone treatment of 14 degenerative (36%) and 25 chronic (64%) postdissection arch aneurysms. The clinical characteristics included American Society of Anesthesiologists class ≥III in 28 patients (95%) and previous median sternotomy for ascending aortic repair in 28 patients (72%). The technical success rate was 100%. Two patients had died in-hospital or within 30 days (5%), and two patients had experienced a stroke (one minor). The combined mortality and any stroke rate was 8% (n = 3). Major adverse events occurred in 10 patients (26%), including respiratory failure in 4 (10%) and estimated blood loss >1 L, myocardial infarction, and acute kidney injury in 2 patients each (5%). The median follow-up was 3.2 months (interquartile range, 1-14 months). Of the 39 patients, 12 (31%) required secondary interventions to treat vascular access complications in 5, endoleak in 6 (three type II, one type Ic, one type Ia/Ib, one type IIIa), and target vessel stenosis in 1 patient. At 1 year, the primary and secondary patency rates and freedom from target vessel instability were 95% ± 5%, 100%, and 91% ± 5%, respectively. Freedom from aortic-related mortality and patient survival was 94% ± 4% and 90% ± 6%, respectively. CONCLUSIONS The findings from the present multicenter global experience have demonstrated the technical feasibility and safety of total endovascular aortic arch repair for aneurysms and chronic dissections using three-vessel inner branch stent-grafts. The mortality and stroke rates compare favorably with those after open surgical repair in a higher risk group of patients. However, the rate of secondary interventions was high (31%), emphasizing need for greater experience and longer follow-up.
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Affiliation(s)
- Emanuel R Tenorio
- Department of cardiothoracic and vascular surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Tex
| | - Gustavo S Oderich
- Department of cardiothoracic and vascular surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Tex.
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart Center Hamburg, Hamburg, Germany
| | - Nuno V Dias
- Vascular Center Malmö, Skåne University Hospital, Malmö, Sweden
| | - Björn Sonesson
- Vascular Center Malmö, Skåne University Hospital, Malmö, Sweden
| | - Angelos Karelis
- Vascular Center Malmö, Skåne University Hospital, Malmö, Sweden
| | - Mark A Farber
- Department of Surgery, Division of Vascular Surgery, University of North Carolina, Chapel Hill, NC
| | - F Ezequiel Parodi
- Department of Surgery, Division of Vascular Surgery, University of North Carolina, Chapel Hill, NC
| | - Carlos H Timaran
- Department of Surgery, Division of Vascular Surgery, University of Texas Southwestern, Dallas, Tex
| | - Carla K Scott
- Department of Surgery, Division of Vascular Surgery, University of Texas Southwestern, Dallas, Tex
| | - Nikolaos Tsilimparis
- University Hospital of Munich, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Carlota Fernandez
- University Hospital of Munich, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Tomasz Jakimowicz
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warszawa, Poland
| | - Katarzyna Jama
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warszawa, Poland
| | - Jarin Kratzberg
- Cook medical aortic division, Cook Research Incorporated, Bloomington, Ind
| | - Justine Mougin
- Aortic Center, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Gif-sur-Yvette, France
| | - Stéphan Haulon
- Aortic Center, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Gif-sur-Yvette, France
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21
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Banno H, Mutsuga M, Sugimoto M, Tokuda Y, Kodama A, Usui A, Komori K. Midterm Outcomes of Zone 0 Antegrade Endograft Implantation During Type I Hybrid Aortic Arch Repair. Eur J Vasc Endovasc Surg 2021; 61:938-944. [PMID: 33773906 DOI: 10.1016/j.ejvs.2021.02.044] [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: 11/02/2020] [Revised: 02/05/2021] [Accepted: 02/22/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Type I hybrid arch repair has become popular as a procedure that is less invasive than total arch replacement. The major advantage of this technique is that antegrade endograft implantation can be performed during the procedure, thereby avoiding the complications of introducing the endograft from the groin. The aim of this study was to assess the midterm outcomes of type I hybrid aortic arch repair with antegrade endograft implantation. METHODS Thirty consecutive patients who underwent type I hybrid repair with antegrade endograft implantation from 2009 to 2015 were reviewed retrospectively. Patient demographics, and peri-operative and late results were collected from a prospective database and analysed. RESULTS Four patients (13%) were female and the median age was 78 years. Median aneurysm size was 64 mm. Six patients (20%) developed stroke, and the 30 day mortality rate was 3%. Two patients suffered aortic dissection at the site of debranching anastomosis. The median follow up was 5.2 years. All aneurysms remained stable or had decreased in size at three years, and 82% were stable at five years. Overall survival was 79% at three years and 71% at five years. The rates of freedom from aorta related death were 86% at three and five years, respectively. During the follow up period, three additional left subclavian artery embolisations and one endograft relining due to type IIIb endoleak were required. CONCLUSION Midterm outcomes of type I hybrid aortic arch repair with antegrade endograft implantation for aortic arch aneurysms are reported. Although the incidence of peri-operative stroke was high, late sac behaviour was acceptable.
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Affiliation(s)
- Hiroshi Banno
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Masato Mutsuga
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masayuki Sugimoto
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshiyuki Tokuda
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akio Kodama
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kimihiro Komori
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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22
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D'Oria M, Mani K, DeMartino R, Czerny M, Donas KP, Wanhainen A, Lepidi S. Narrative review on endovascular techniques for left subclavian artery revascularization during thoracic endovascular aortic repair and risk factors for postoperative stroke. Interact Cardiovasc Thorac Surg 2021; 32:764-772. [PMID: 33575743 DOI: 10.1093/icvts/ivaa342] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/04/2020] [Accepted: 12/06/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES The aim of this study was to present a narrative review on endovascular techniques (ET) for revascularization of the left subclavian artery (LSA) during zone 2 thoracic endovascular aortic repair (TEVAR) and on risk factors for postoperative stroke following TEVAR procedures. METHODS Non-systematic search of the literature from the PubMed, Ovid and Scopus databases to identify relevant English-language articles fully published in the period 1 January 2010-1 August 2020. RESULTS Current general agreement is that LSA revascularization should be always attempted in the elective setting. Under urgent circumstances, it can be delayed but might be considered during the same session on a case-by-case basis. Three ET are currently available: (i) chimney/snorkels (also known as parallel grafts), (ii) fenestrations or branches and (iii) proximal scallops. The main issue with ET is the potential for increased peri-operative stroke risk owing to increased manipulation within the aortic arch. Also, they are relatively novel and further assessment of their long-term durability is needed. Intra-operative embolism and loss of left vertebral artery perfusion are hypothesized as the main causes of stroke in patients undergoing TEVAR. CONCLUSIONS The overall risk of stroke seems higher without LSA revascularization during zone 2 TEVAR. As LSA revascularization might have a direct effect in preventing posterior stroke, it should be routinely performed in elective cases, while a case-by-case evaluation can be made under urgent circumstances. While ET can provide effective options for LSA revascularization during zone 2 TEVAR, they are novel and need further durability assessment. Stroke after TEVAR is a multifactorial pathological process and preventing TEVAR-related cerebral injury remains a significant unmet clinical need.
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Affiliation(s)
- Mario D'Oria
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden.,Division of Vascular and Endovascular Surgery, Cardiovascular Department, University of Trieste Medical School, Trieste, Italy.,Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic Rochester Campus, Rochester, MN, USA
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Randall DeMartino
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic Rochester Campus, Rochester, MN, USA
| | - Martin Czerny
- Division of Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Freiburg, Germany
| | - Konstantinos P Donas
- Department of Vascular Surgery, Asklepios Clinic Langen, Goethe-University of Frankfurt, Langen, Germany
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University of Trieste Medical School, Trieste, Italy
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Branzan D, Geisler A, Steiner S, Lautenschlaeger T, Doss M, Matschuck M, Scheinert D, Schmidt A. Stroke rate after thoracic endovascular aortic repair using de-airing of stentgrafts with high-volume of saline solution. VASA 2021; 50:186-192. [PMID: 33559507 DOI: 10.1024/0301-1526/a000937] [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: 11/19/2022]
Abstract
Background: Our aim was to determine the rate of ischemic stroke following thoracic endovascular aortic repair (TEVAR) after reducing gas volume released during stentgraft deployment by de-airing of thoracic stentgrafts with high-volume of 0.9% heparinized saline solution. Patients and methods: A single center retrospective analysis of all consecutive patients undergoing TEVAR from 2014 to 2019 was performed. All thoracic stentgrafts were flushed with 120 ml 0.9% heparinized saline solution before implantation, according to our institutional protocol. Endpoints were in-hospital rates of ischemic stroke and spinal cord ischemia (SCI), and all-cause mortality. Results: One hundred and fifty-four patients (mean age: 66.8 ± 13.6 years, 64.9% males) were treated with TEVAR during the study period. Indications for treatment were thoracic aortic aneurysms (n = 75, 48.7%), acute type B aortic dissections (n = 46, 29.9%), aortic arch aneurysms and penetrating aortic ulcers (n = 28, 18.2%), and blunt traumatic aortic injuries (n = 5, 3.2%). Timing of procedure was urgent in 75 patients (48.7%). Proximal landing zone were zone 0-1-2 (n = 75, 48.7%), zone 3 (n = 66, 42.9%) and zone 4 (n = 13, 8.4%). Supra-aortic vessels were revascularized with custom-made fenestrated stentgrafts in 9 patients (5.8%), using chimney technique in 4 patients (2.6%), and with debranching procedures in 19 patients (12.3%). Left subclavian artery was covered without revascularization in 46 patients (29.9%). In-hospital stroke occurred in two patients (1.3%) and SCI in another two patients (1.3%). In-hospital mortality rate was 0.6%. No further in-hospital events were noted. Conclusions: De-airing of stentgrafts with high-volume of 0.9% heparinized saline solution seems to be safe and can be used as an adjunct to keep occurrence of neurological events after TEVAR as low as possible.
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Affiliation(s)
- Daniela Branzan
- Department of Vascular Surgery, University Hospital Leipzig, Germany
| | - Antonia Geisler
- Department of Vascular Surgery, University Hospital Leipzig, Germany
| | - Sabine Steiner
- Department of Interventional Angiology, University Hospital Leipzig, Germany
| | | | - Markus Doss
- Department of Vascular Surgery, University Hospital Leipzig, Germany
| | - Manuela Matschuck
- Department of Interventional Angiology, University Hospital Leipzig, Germany
| | - Dierk Scheinert
- Department of Interventional Angiology, University Hospital Leipzig, Germany
| | - Andrej Schmidt
- Department of Interventional Angiology, University Hospital Leipzig, Germany
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24
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Charbonneau P, Kölbel T, Rohlffs F, Eilenberg W, Planche O, Bechstein M, Ristl R, Greenhalgh R, Haulon S. Silent Brain Infarction After Endovascular Arch Procedures: Preliminary Results from the STEP Registry. Eur J Vasc Endovasc Surg 2020; 61:239-245. [PMID: 33358103 DOI: 10.1016/j.ejvs.2020.11.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 10/28/2020] [Accepted: 11/12/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Few data exist concerning the rate of silent cerebral ischaemic events following endovascular treatment of the aortic arch. The objective of this work was to quantify these lesions using the STEP registry (NCT04489277). METHODS This multicentre retrospective cohort study included consecutive patients treated with an aortic endoprosthesis deployed in Ishimaru zone 0-3 and brain diffusion weighted magnetic resonance imaging (DW-MRI) within seven days following the procedure. DW-MRI was performed to identify the location and number of new silent brain infarctions (SBI). All endografts were carbon dioxide flushed prior to implantation. RESULTS The study population included 91 patients (mean age, 69 years; men, 64%) from two academic centres treated between September 2018 and January 2020. The procedure was elective in 71 patients (78%). The treatment was performed for a dissection, degenerative aneurysm, or other aortic disease in 44 (49%), 34 (37%), and 13 (14%) patients, respectively. Endografts were deployed in zone 0, 1, 2 or 3 in 23 (25%), 10 (11%), 47 (52%), and 11 (12%) patients, respectively. Endografts were branched (25%), fenestrated (17%), or tubular (58%). At 30 days, there were no deaths or clinical strokes. On cerebral DW-MRI, a total of 245 SBI were identified in 45 patients (50%). Lesions were in the left hemisphere in 63% of the patients (153/245), predominantly in the middle territory (94/245). Deployment in zone 0-1 (p = .026), placement of a branched or fenestrated endograft (p = .038), a proximal endoprosthesis diameter ≥ 40 mm (p = .038), and an urgent procedure (p = .005) were significantly associated with the presence of SBI on univariable analysis, while urgent procedure was found to be an independent predictor on multivariable analysis (binary logistic regression) (p = .002). CONCLUSION SBI following endovascular repair of the aortic arch is frequent, although there were no clinical strokes. Innovative strategies to reduce the risk of embolisation need to be developed.
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Affiliation(s)
- Philippe Charbonneau
- Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Paris, France
| | - Tilo Kölbel
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre, Hamburg, Germany
| | - Wolf Eilenberg
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre, Hamburg, Germany
| | - Olivier Planche
- Radiology Department, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Hamburg-Eppendorf, Germany
| | - Robin Ristl
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre, Hamburg, Germany
| | | | - Stephan Haulon
- Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Paris, France.
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25
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Melissano G, Rinaldi E, Mascia D, Carta N, Bilman V, Bertoglio L, Kahlberg A, De Luca M, Monaco F, Chiesa R. Single-center midterm results with the low-profile Zenith Alpha thoracic endovascular stent graft. J Vasc Surg 2020; 73:1533-1540.e2. [PMID: 33065242 DOI: 10.1016/j.jvs.2020.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 10/04/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The analysis of endovascular treatment of thoracic aortic diseases using new low-profile stent grafts in large series is crucial to understanding the durability of these devices. The present study reports the midterm outcomes of a single-center experience using the Zenith Alpha thoracic endovascular stent graft. METHODS The outcomes of 270 procedures performed on 262 patients (197 men; mean age, 70.5 ± 9.5 years) using the Zenith Alpha thoracic endovascular stent graft from November 2013 to December 2019 for different thoracic aortic diseases were analyzed. The primary endpoints were 30-day clinical success and midterm (5-year) clinical success. The secondary endpoints were the adverse event rate at 30 days and midterm and access- and device-related complications. The follow-up of surviving patients was performed using computed tomography angiography and office visits at 1, 6, and 12 months and annually thereafter. Kaplan-Meier analysis was performed for overall survival, and freedom from thoracic aortic endovascular repair-related mortality and related reinterventions. RESULTS The overall 30-day mortality was 5.2% (2.5% for elective and 30.8% for nonelective cases). Type I endoleaks were identified in six patients. The 30-day primary technical and clinical success rates were 97.8% and 92.6%, respectively. Femoral cutdown was used in 41.1% of cases and percutaneous access in 58.5%. The rate of femoral artery complications after the percutaneous approach was 5.1%, with the need for surgical conversion in 1.9%. The stroke rate was 4.1% (major stroke, 2.2%), and the spinal cord ischemia rate was 3.7% (permanent paraplegia, 0.7%). Of the 248 survivors, 239 complied with the follow-up protocol with adequate computed tomography angiograms available images. Overall follow-up survival was 94.0% at 1 year, 91.6% at 2 years, 88.9% at 3 years, and 88.5% at 5 years. The unplanned secondary endovascular procedure rate was 5.3%. No stent fractures or new-onset type I endoleaks due to stent graft migration were observed in the study cohort. CONCLUSIONS The midterm outcomes of this new generation of low-profile devices were satisfactory. The reported low incidence of secondary procedures and the absence of migrations are promising for the long-term durability of these devices.
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Affiliation(s)
- Germano Melissano
- Division of Vascular Surgery, Vita-Salute University and IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Enrico Rinaldi
- Division of Vascular Surgery, Vita-Salute University and IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Daniele Mascia
- Division of Vascular Surgery, Vita-Salute University and IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Niccolò Carta
- Division of Vascular Surgery, Vita-Salute University and IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Victor Bilman
- Division of Vascular Surgery, Vita-Salute University and IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, Vita-Salute University and IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Kahlberg
- Division of Vascular Surgery, Vita-Salute University and IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Monica De Luca
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabrizio Monaco
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, Vita-Salute University and IRCCS San Raffaele Scientific Institute, Milan, Italy
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26
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Czerny M, Pacini D, Aboyans V, Al-Attar N, Eggebrecht H, Evangelista A, Grabenwöger M, Stabile E, Kolowca M, Lescan M, Micari A, Muneretto C, Nienaber C, de Paulis R, Tsagakis K, Rylski B, Braverman AC, Di Marco L, Eagle K, Falk V, Gottardi R. Current options and recommendations for the use of thoracic endovascular aortic repair in acute and chronic thoracic aortic disease: an expert consensus document of the European Society for Cardiology (ESC) Working Group of Cardiovascular Surgery, the ESC Working Group on Aorta and Peripheral Vascular Diseases, the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC and the European Association for Cardio-Thoracic Surgery (EACTS). Eur J Cardiothorac Surg 2020; 59:65-73. [DOI: 10.1093/ejcts/ezaa268] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 06/04/2020] [Indexed: 12/14/2022] Open
Abstract
Abstract
Since its clinical implementation in the late nineties, thoracic endovascular aortic repair (TEVAR) has become the standard treatment of several acute and chronic diseases of the thoracic aorta. While TEVAR has been embraced by many, this disruptive technology has also stimulated the continuing evolution of open surgery, which became even more important as late TEVAR failures do need open surgical correction justifying the need to unite both treatment options under one umbrella. This fact shows the importance of—in analogy to the heart team—aortic centre formation and centralization of care, which stimulates continuing development and improves outcome . The next frontier to be explored is the most proximal component of the aorta—the aortic root, in particular in acute type A aortic dissection—which remains the main challenge for the years to come. The aim of this document is to provide the reader with a synopsis of current evidence regarding the use or non-use of TEVAR in acute and chronic thoracic aortic disease, to share latest recommendations for a modified terminology and for reporting standards and finally to provide a glimpse into future developments.
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Affiliation(s)
- Martin Czerny
- University Heart Center Freiburg—Bad Krozingen, Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | | | | | - Nawwar Al-Attar
- Golden Jubilee National Hospital, University of Glasgow, Glasgow, UK
| | | | | | | | - Eugenio Stabile
- Department of Advanced Biomedical Sciences, University of Napoli “Federico II”, Naples, Italy
| | | | - Mario Lescan
- Department of Cardiac, Thoracic and Vascular Surgery, University of Tübingen, Tübingen, Germany
| | - Antonio Micari
- Department of Cardiology, Humanitas Gavazzeni, Bergamo, Italy
| | | | | | | | | | - Bartosz Rylski
- University Heart Center Freiburg—Bad Krozingen, Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
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27
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Rylski B, Mayer F, Beyersdorf F, Kondov S, Kolowca M, Kreibich M, Czerny M. How to minimize air embolisms during thoracic endovascular aortic repair with Relay Pro? Interact Cardiovasc Thorac Surg 2020; 30:293-295. [PMID: 31722378 DOI: 10.1093/icvts/ivz261] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 10/07/2019] [Accepted: 10/10/2019] [Indexed: 11/14/2022] Open
Abstract
The aim of this study was to evaluate the volume of air released from Relay Pro NBS thoracic stent grafts using different de-airing methods. The gas volume was measured in an in vitro experimental setting. Stent grafts were de-aired via (i) standard saline flushing (40 ml), (ii) increased volume saline flushing (120 ml), (iii) carbon dioxide followed by 40 ml saline flushing and (iv) de-airing with 40 ml of saline in an ultrasound bath. The volume of gas released was measured separately while introducing the folded stent graft in the delivery device into the simulated aorta (step 1) and while deploying it outside the delivery device (step 2). Median air volumes released during steps 1 and 2 after flushing with 40 ml of saline were 0.09 (1st-3rd quartile 0.06-0.21) and 0.14 (0.11-0.15) ml, respectively. The volume of air released during step 2 was significantly less [0.09 (0.08-0.10) ml] after de-airing with 120 ml saline (P = 0.049). Neither de-airing with carbon dioxide nor in an ultrasonic bath led to a reduction in the volume of gas released during step 2. Air remaining after de-airing with a standard 40 ml of saline was released partially during stent graft introduction into the aorta and partially during final deployment. The most effective method of reducing air volume was de-airing with increased saline volume.
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Affiliation(s)
- Bartosz Rylski
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Florian Mayer
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Maciej Kolowca
- Department of Cardiac Surgery, District Hospital No. 2, University of Rzeszów, Rzeszów, Poland
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Brain Protection in the Endo-Management of Proximal Aortic Aneurysms. HEARTS 2020. [DOI: 10.3390/hearts1020005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Neurological brain injury (NBI) remains the most feared complication following thoracic endovascular aortic repair (TEVAR), and can manifest as clinically overt stroke and/or more covert injury, detected only on explicit neuropsychological testing. Microembolic signals (MES) detected on transcranial Doppler (TCD) monitoring of the cerebral arteries during TEVAR and the high prevalence and incidence of new ischaemic infarcts on diffusion-weighted magnetic resonance imaging (DW-MRI) suggests procedure-related solid and gaseous cerebral microembolisation to be an important cause of NBI. Any intervention that can reduce the embolic burden during TEVAR may, therefore, help mitigate the risk of stroke and the covert impact of ischaemic infarcts to the function of the brain. This perspective article provides an understanding of the mechanism of stroke and reviews the available evidence regarding potential neuroprotective strategies that target high-risk procedural steps of TEVAR to reduce periprocedural cerebral embolisation.
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Spanos K, Kölbel T. Role of Endoluminal Techniques in the Management of Chronic Type B Aortic Dissection. Cardiovasc Intervent Radiol 2020; 43:1808-1820. [PMID: 32601718 PMCID: PMC8490267 DOI: 10.1007/s00270-020-02566-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 06/20/2020] [Indexed: 12/22/2022]
Abstract
In recent guidelines of international societies, the most frequent indication for treatment after chronic type B aortic dissection (cTBAD) is aneurysmal dilatation. Endovascular repair is recommended in patients with moderate to high surgical risk or with contraindications to open repair. During the last decade, many advances have been made in the field of endovascular techniques and devices. The aim of this article is to address the current status of endoluminal techniques for the management of cTBAD including standard thoracic endovascular repair, new devices, fenestrated and branched abdominal aortic devices and false lumen occlusion techniques.
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Affiliation(s)
- Konstantinos Spanos
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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Various Endoluminal Approaches Available for Treating Pathologies of the Aortic Arch. Cardiovasc Intervent Radiol 2020; 43:1756-1769. [PMID: 32588136 PMCID: PMC7649180 DOI: 10.1007/s00270-020-02561-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 06/09/2020] [Indexed: 02/03/2023]
Abstract
Open surgical repair of the aortic arch for degenerative aortic disease in an unfit patient is associated with significant morbidity and mortality. Endoluminal techniques have advanced over the last decade. Contemporary endovascular options including a hybrid approach (supra-aortic debranching and aortic stent graft), inner branched endograft, chimney stents, and scallop or fenestrated endografts are being used frequently as an alternative to open surgical arch repair. Understanding of the available endoluminal technology along with careful planning and effective teamwork is required to minimise complications associated with the endoluminal techniques, particularly neurological ones. Custom made techniques are superior to chimney or parallel technology in terms of their complications and durability. Integration of the protective devices such as embolic protection filters into stent design may reduce the risk of poor neurological sequelae. Long-term data are needed to assess the durability of these devices.
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Spanos K, Panuccio G, Rohlffs F, Heidemann F, Tsilimparis N, Kölbel T. Technical Aspects of Branched Thoracic Arch Graft Implantation for Aortic Arch Pathologies. J Endovasc Ther 2020; 27:792-800. [PMID: 32431247 DOI: 10.1177/1526602820925443] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To describe the implantation steps and tips and tricks for the Inner Branch Arch Endograft designed to treat aortic arch aneurysm and chronic type A aortic dissection. TECHNIQUE Anatomical suitability criteria should be met in order to use this device. The proximal segment of the graft lands in the ascending aorta distally to the sinotubular junction and the distal segment lands in the descending aorta. The device includes 2 inner branches; the proximal branch is used for a connection to the innominate artery (positioned slightly posterior at 12:30 o'clock), while the second branch is positioned slightly anterior at 11:30 o'clock and is used as a connection to the left common carotid artery. Access, implantation technique, deployment of the device, and catheterization of the branches are described thoroughly. CONCLUSION This Inner Branch Arch Endograft is an appealing alternative to treat aortic arch pathology, especially in patients unsuitable for open repair. Nevertheless, complex aortic arch repair is associated with a learning curve. Meticulous preoperative planning and a high level of concentration intraoperatively are mandatory.
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Affiliation(s)
- Konstantinos Spanos
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Franziska Heidemann
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Nikolaos Tsilimparis
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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Piazza M, Squizzato F, Milan L, Miccoli T, Grego F, Antonello M. Incidence and Predictors of Neurological Complications Following Thoracic Endovascular Aneurysm Repair in the Global Registry for Endovascular Aortic Treatment. Eur J Vasc Endovasc Surg 2019; 58:512-519. [DOI: 10.1016/j.ejvs.2019.05.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 05/06/2019] [Accepted: 05/10/2019] [Indexed: 02/05/2023]
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Eleshra A, Saleptsis V, Spanos K, Rohlffs F, Tsilimparis N, Panuccio G, Makaloski V, Debus ES, Kölbel T. Retrospective Comparative Study on Differences in Presence of Gas in the Aneurysm Sac after Endovascular Aortic Aneurysm Repair in Early Postoperative Period between Carbon Dioxide Flushing Technique and Saline Flushing of the Delivery System. Ann Vasc Surg 2019; 61:310-316. [PMID: 31381997 DOI: 10.1016/j.avsg.2019.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/03/2019] [Accepted: 05/03/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Presence of gas is a frequent finding on early postoperative computed tomography angiography (CTA) after endovascular aortic aneurysm repair (EVAR) with unclear clinical relevance. The aim of this study is to examine and compare the presence of gas within the aneurysm sac following EVAR on early postoperative CTA after the use of carbon dioxide (CO2) flushing technique with saline flushing alone. METHODS A retrospective analysis of patients undergoing standard, fenestrated EVAR (fEVAR) or branched EVAR (bEVAR) with flushing of the delivery system with CO2 between January 2016 and August 2018 was undertaken. Data of a previous report using standard saline flushing were included. Patients were classified into 2 main groups: group 1 with saline flushing and group 2 with CO2 flushing and 3 subgroups according to the type of endograft. The presence, position, and volume of gas in the postoperative CTA (within 10 days) was examined and analyzed in terms of anatomical and procedural risk factors. RESULTS Group 1 included 210 patients (mean age 73 ± 8, 84% males), while group 2 included 300 patients (mean age 70 ± 11, 68% males). Presence of gas was more common in group 1 (83, 39% vs. 64, 21%, P = 0.000). Volume of gas was larger in group 1 [0.41 mL (0.01-2.7) vs. 0.2 mL (0.02-1), P = 0.001). In standard EVAR with saline flushing (subgroup 1a), 59 patients (45%) had presence of gas with CO2 flushing (subgroup 2a); 35 patients (25%) had presence of gas (P = 0.005). The mean gas volume was larger in subgroup 1a compared to 2a (0.40 ± 0.47 vs. 0.15 ± 0.17 mL, P = 0.000). The location of the gas was more frequent in contact with the anterior wall of the aorta in both groups, standard EVAR subgroups and fEVAR subgroups. The presence of gas in group 2 was associated with larger preoperative size of the aortic diameter (P = 0.03) and larger perfused lumen diameter (P = 0.05). The type of the graft was not associated with the presence of gas in the aneurysm sac on postoperative CTA. However, the presence of gas was more frequent in standard EVAR than fEVAR and bEVAR. Endoleak type II was not associated with the presence of gas. CONCLUSIONS CO2 flushing of stent grafts during standard and complex EVAR prior to deployment reduces the frequency and volume of gas on postoperative CTA. This study indicates that the CO2 flushing technique may effectively exchange trapped air for a less harmful gas in endografts.
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Affiliation(s)
- Ahmed Eleshra
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg, Hamburg, Germany
| | - Vasilis Saleptsis
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg, Hamburg, Germany
| | - Konstantinos Spanos
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg, Hamburg, Germany
| | - Fiona Rohlffs
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg, Hamburg, Germany
| | - Nikolaos Tsilimparis
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg, Hamburg, Germany
| | - Giuseppe Panuccio
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg, Hamburg, Germany
| | - Vladimir Makaloski
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg, Hamburg, Germany
| | - Eike Sebastian Debus
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg, Hamburg, Germany
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg, Hamburg, Germany.
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Oderich GS. Invited commentary. J Vasc Surg 2019; 69:985-986. [DOI: 10.1016/j.jvs.2018.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 09/20/2018] [Indexed: 11/29/2022]
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Fiorucci B, Kölbel T, Rohlffs F, Heidemann F, Carpenter SW, Debus ES, Tsilimparis N. The role of thoracic endovascular repair in elective, symptomatic and ruptured thoracic aortic diseases. Eur J Cardiothorac Surg 2019; 56:197-203. [DOI: 10.1093/ejcts/ezy482] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 12/18/2018] [Accepted: 12/21/2018] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
Thoracic endovascular aortic repair (TEVAR) has emerged as a safe procedure in the treatment of a wide spectrum of descending thoracic aortic pathologies, with satisfactory results both in elective and urgent settings. We investigated the results of our elective, urgent and emergency TEVAR interventions.
METHODS
A single-centre retrospective analysis of all consecutive patients undergoing TEVAR from 2010 to 2016 was performed. Primary end point of the study was early mortality, whereas the secondary end points included major complications according to the urgency of the procedure. The analysis was further conducted comparing symptomatic, asymptomatic and ruptured cases.
RESULTS
Two hundred and eight patients were treated with TEVAR between January 2010 and April 2016 (mean age 67 ± 12 years, 142 men, 68.3%). Patients undergoing TEVAR as a first-stage procedure for complex thoraco-abdominal repair were excluded. The indication for treatment was a dissection in most cases (n = 92, 44.2%; acute dissection in 40 cases, 19.2%), followed by thoracic aneurysms (n = 64, 30.8%), penetrating aortic ulcers (n = 37, 17.8%), intramural haematomas (n = 8, 3.8%), traumatic ruptures (n = 3, 1.4%) and other indications (n = 4, 1.8%). One hundred and eight procedures were performed electively and 100 urgently. Forty-three patients were treated on an emergency bas for aortic rupture, 44 urgently for thoracic pain and 13 for acute ischaemic complications of aortic dissection or other indications. Ischaemic complications of dissection included 1 case of mesenteric ischaemia, 3 cases of acute renal failure, 4 cases of limb ischaemia and multiple ischaemic complications in 4 cases. Other causes of urgent TEVAR included 1 patient bleeding from a bronchial artery treated with TEVAR after several embolization attempts. In-hospital mortality was 7.7%, significantly higher in the urgent setting (14% vs 1.9%, P = 0.001). Urgent procedures were also more frequently associated with major adverse clinical events (7.4% vs 26%, P = 0.0003) and specifically with paraplegia (2.8% vs 10%, P = 0.043). Perioperative mortality was significantly higher in the ruptured group compared to the symptomatic group (25.6% vs 2.3%, P = 0.002). When the analysis was conducted to compare the symptomatic and the asymptomatic patients, no differences in terms of perioperative mortality were detected.
CONCLUSIONS
TEVAR is an effective treatment strategy in thoracic aortic disease. Though emergency repair of the ruptured thoracic aorta still shows high rates of perioperative mortality and morbidity, symptomatic non-ruptured and asymptomatic patients have comparable early outcomes.
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Affiliation(s)
- Beatrice Fiorucci
- Department of Vascular Medicine, German Aortic Center, Hamburg, Germany
- Unit of Vascular Surgery, Ospedale S. Maria della Misericordia, University of Perugia, Perugia, Italy
- Department of Vascular Surgery, University Aortic Center of the Ludwig-Maximilian University Munich, Munich, Germany
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Center, Hamburg, Germany
| | - Fiona Rohlffs
- Department of Vascular Medicine, German Aortic Center, Hamburg, Germany
| | | | | | | | - Nikolaos Tsilimparis
- Department of Vascular Surgery, University Aortic Center of the Ludwig-Maximilian University Munich, Munich, Germany
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Evidence for Cerebral Embolic Prevention in Transcatheter Aortic Valve Implantation and Thoracic Endovascular Aortic Repair. Ann Vasc Surg 2019; 55:292-306. [DOI: 10.1016/j.avsg.2018.06.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 06/15/2018] [Accepted: 06/18/2018] [Indexed: 12/20/2022]
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37
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Editor's Choice – Current Options and Recommendations for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch: An Expert Consensus Document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2019; 57:165-198. [DOI: 10.1016/j.ejvs.2018.09.016] [Citation(s) in RCA: 122] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Czerny M, Schmidli J, Adler S, van den Berg JC, Bertoglio L, Carrel T, Chiesa R, Clough RE, Eberle B, Etz C, Grabenwöger M, Haulon S, Jakob H, Kari FA, Mestres CA, Pacini D, Resch T, Rylski B, Schoenhoff F, Shrestha M, von Tengg-Kobligk H, Tsagakis K, Wyss TR, Debus S, de Borst GJ, Di Bartolomeo R, Lindholt J, Ma WG, Suwalski P, Vermassen F, Wahba A, von Ballmoos MCW. Current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic surgery (EACTS) and the European Society for Vascular Surgery (ESVS). Eur J Cardiothorac Surg 2019; 55:133-162. [PMID: 30312382 DOI: 10.1093/ejcts/ezy313] [Citation(s) in RCA: 280] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Jürg Schmidli
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sabine Adler
- Department for Rheumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jos C van den Berg
- Department of Radiology, Centro Vascolare Ticino, Ospedale Regionale di Lugano, Lugano, Switzerland.,Department of Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luca Bertoglio
- Division of Vascular Surgery, "Vita salute" University, Ospedale San Raffaele, Milan, Italy
| | - Thierry Carrel
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roberto Chiesa
- Division of Vascular Surgery, "Vita salute" University, Ospedale San Raffaele, Milan, Italy
| | - Rachel E Clough
- Division of Imaging Sciences and Biomedical Engineering, St Thomas' Hospital, King's College London, London, UK
| | - Balthasar Eberle
- Department for Anesthesiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian Etz
- Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | | | - Stephan Haulon
- Aortic Center, Hôpital Marie Lannelongue, Université Paris Sud, Le Plessis-Robinson, France
| | | | - Fabian A Kari
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Carlos A Mestres
- University Clinic for Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | | | - Timothy Resch
- Department of Vascular Surgery, Vascular Center Skåne University Hospital, Malmö, Sweden
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Malakh Shrestha
- Department of Cardio-thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Hendrik von Tengg-Kobligk
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Thomas R Wyss
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Bechara CF. Commentary: Eliminating Air From Stent-Grafts During Arch Endovascular Therapy: One Step Closer to Reducing Stroke. J Endovasc Ther 2018; 26:81-82. [PMID: 30572774 DOI: 10.1177/1526602818819922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Carlos F Bechara
- 1 Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Loyola University Medical Center, Maywood, IL, USA
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Rohlffs F, Trepte C, Ivancev K, Tsilimparis N, Makaloski V, Debus ES, Kölbel T. Air Embolism During TEVAR: Liquid Perfluorocarbon Absorbs Carbon Dioxide in a Combined Flushing Technique and Decreases the Amount of Gas Released From Thoracic Stent-Grafts During Deployment in an Experimental Setting. J Endovasc Ther 2018; 26:76-80. [DOI: 10.1177/1526602818819501] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Purpose:To investigate the influence of flushing thoracic stent-grafts with carbon dioxide and perfluorocarbon on the amount of gas released during stent-graft deployment in thoracic endovascular aortic repair (TEVAR). Materials and Methods: Ten TX2 ProForm thoracic stent-grafts were deployed into a water-filled container with a curved plastic pipe and flushed sequentially with carbon dioxide, 20 mL of liquid perfluorocarbon (PFC), and 60 mL of saline. Released gas was measured using a calibrated setup. The volume of released gas was compared with the results of an earlier published reference group, in which identical stent-grafts were flushed with 60 mL saline alone as recommended in the instructions for use. Results: The average amount of gas released in the test group was 0.076 mL, significantly lower (p<0.001) than the mean 0.79 mL of gas released in the reference group. Big bubbles appearing at the tip of the sheath when deployment was started were seen in all grafts of the reference group but in only 2 of the test group stent-grafts. Small bubbles were less frequent in the test group. Conclusion: The amount of gas released from thoracic stent-grafts during deployment can be influenced by different flushing techniques. The use of PFC in addition to the carbon dioxide flushing technique reduces the volume of gas released during deployment of tubular thoracic stent-grafts to a few microliters. This significant effect is presumably based on the high solubility of carbon dioxide in perfluorocarbon and could be a potential future approach to lower the risk of cerebral injury and stroke from air embolism during TEVAR.
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Affiliation(s)
- Fiona Rohlffs
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Constantin Trepte
- Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Krassi Ivancev
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Nikolaos Tsilimparis
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Vladimir Makaloski
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - E. Sebastian Debus
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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41
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Cerebral embolic protection in thoracic endovascular aortic repair. J Vasc Surg 2018; 68:1656-1666. [DOI: 10.1016/j.jvs.2017.11.098] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 11/27/2017] [Indexed: 01/14/2023]
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Tsilimparis N, Detter C, Law Y, Rohlffs F, Heidemann F, Brickwedel J, von Kodolitsch Y, Debus ES, Kölbel T. Single-center experience with an inner branched arch endograft. J Vasc Surg 2018; 69:977-985.e1. [PMID: 30477941 DOI: 10.1016/j.jvs.2018.07.076] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 07/20/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Whereas open repair is the "gold standard" for most aortic arch diseases, a subgroup of patients might benefit from an endovascular approach. The introduction of branched stent grafts with dedicated design to address the challenges of the ascending aorta and the aortic arch has opened an entirely new area of treatment for these patients. We investigated the early outcomes of branched thoracic endovascular aortic repair (b-TEVAR) in various types of disease of the aortic arch. METHODS A retrospective analysis was conducted of prospectively collected data from a single center of all consecutive patients treated with b-TEVAR. The indication for elective endovascular repair was consented in an interdisciplinary case conference. All patients were treated with a custom-made inner branched arch endograft with two internal branches (Cook Medical, Bloomington, Ind) and left-sided carotid-subclavian bypass. Study end points were technical success, 30-day mortality, and complications as well as late complications and reinterventions. RESULTS Between 2012 and 2017, there were 54 patients (38 male; median age, 71 years) treated with diseases of the aortic arch. Indications for therapy involved degenerative aortic arch or proximal descending aortic aneurysms requiring arch repair (n = 24), dissection with or without false lumen aneurysms (n = 26), and penetrating aortic ulcers (n = 4). Forty-three cases (80%) were performed electively and 11 urgently for contained ruptures (n = 3) or symptomatic aneurysms (n = 8) with endografts already available for the patient or with grafts of other patients with similar anatomy. Technical success was achieved in 53 cases (98%). The 30-day mortality and major stroke incidence were 5.5% (3/54) and 5.5% (3/54), respectively; in-hospital mortality was 7.4% (n = 4), and minor strokes (including asymptomatic new cerebral lesions) occurred in 5.5% (n = 3). There were two cases of transient spinal cord ischemia with complete recovery and one of paraplegia. No retrograde type A dissections or cardiac injuries were observed. Three early stent graft-related reinterventions were necessary to correct proximal endograft kinking with type IA endoleak in one patient, a bridging stent graft stenosis in another patient, and false lumen persistent perfusion from dissected supra-aortic vessels in the last patient. Mean in-hospital stay was 14 ± 8 days. During a mean follow-up of 12 ± 9 months, three nonaorta-related deaths and one aorta-related death distal to the arch repair were observed. CONCLUSIONS Treatment of aortic arch diseases with b-TEVAR is feasible and safe with acceptable mortality and stroke rates.
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Affiliation(s)
- Nikolaos Tsilimparis
- Department of Vascular Medicine, German Aortic Center, University Heart Center, Hamburg, Germany.
| | - Christian Detter
- Department of Cardiovascular Surgery, German Aortic Center, University Heart Center, Hamburg, Germany
| | - Yuk Law
- Department of Vascular Medicine, German Aortic Center, University Heart Center, Hamburg, Germany
| | - Fiona Rohlffs
- Department of Vascular Medicine, German Aortic Center, University Heart Center, Hamburg, Germany
| | - Franziska Heidemann
- Department of Vascular Medicine, German Aortic Center, University Heart Center, Hamburg, Germany
| | - Jens Brickwedel
- Department of Vascular Medicine, German Aortic Center, University Heart Center, Hamburg, Germany
| | - Yskert von Kodolitsch
- Department of Cardiology, German Aortic Center, University Heart Center, Hamburg, Germany
| | - E Sebastian Debus
- Department of Vascular Medicine, German Aortic Center, University Heart Center, Hamburg, Germany
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Center, University Heart Center, Hamburg, Germany
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Tsilimparis N, Detter C, Heidemann F, Spanos K, Rohlffs F, von Kodolitsch Y, Debus SE, Kölbel T. Branched endografts in the aortic arch following open repair for DeBakey Type I aortic dissection. Eur J Cardiothorac Surg 2018; 54:517-523. [PMID: 29608660 DOI: 10.1093/ejcts/ezy133] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 02/25/2018] [Indexed: 12/08/2023] Open
Abstract
OBJECTIVES DeBakey Type I aortic dissections are frequently treated by an ascending aortic tube graft or hemiarch replacement with the residual dissection remaining untreated. We investigated the outcomes of branched thoracic endovascular repair for post-dissection aneurysms of the aortic arch. METHODS We conducted a retrospective, single-centre evaluation of 20 consecutive patients with a false-lumen aneurysm after a DeBakey I aortic dissection treated with branched thoracic endovascular repair. The indication for endovascular repair was agreed on in an interdisciplinary case conference. Study end points were technical success, 30-day mortality rate, complications and late complications and reinterventions. RESULTS Between 2012 and 2016, 20 patients (14 men, age 65 ± 9 years) were treated for false-lumen aneurysm formation after a DeBakey Type I aortic dissection. All patients had undergone open ascending aortic repair either isolated (n = 16) or with partial arch repair (n = 4). Technical success was achieved in 19 of 20 cases. The 30-day mortality rate and incidence of stroke were each 5% (1/20). Simultaneous procedures to exclude false-lumen perfusion included implantation of a Knickerbocker graft in 3 (15%) patients and a candy-plug graft in 7 (35%) patients. Early postoperative computed tomography angiography revealed persistent false-lumen perfusion in 10 cases that required secondary interventions in 6 cases. During 17 ± 14 months of mean follow-up, there was 1 aortic-related death and 2 deaths of non-aortic reasons. The estimated overall survival was 89 ± 7% and 75 ± 15% at 12 and 36 months, respectively. CONCLUSIONS Treatment of residual aortic arch dissections with branched thoracic endovascular repair appears feasible and safe with few deaths and low stroke rates. A high rate of secondary procedures is required to achieve thoracic false-lumen occlusion.
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Affiliation(s)
- Nikolaos Tsilimparis
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, University Hospital Eppendorf, Hamburg, Germany
| | - Christian Detter
- Department of Cardiovascular Surgery, German Aortic Center Hamburg, University Heart Center, University Hospital Eppendorf, Hamburg, Germany
| | - Franziska Heidemann
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, University Hospital Eppendorf, Hamburg, Germany
| | - Konstantinos Spanos
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, University Hospital Eppendorf, Hamburg, Germany
| | - Fiona Rohlffs
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, University Hospital Eppendorf, Hamburg, Germany
| | - Yskert von Kodolitsch
- Department of Cardiology, German Aortic Center Hamburg, University Heart Center, University Hospital Eppendorf, Hamburg, Germany
| | - Sebastian E Debus
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, University Hospital Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, University Hospital Eppendorf, Hamburg, Germany
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Law Y, Tsilimparis N, Rohlffs F, Makaloski V, Debus ES, Kölbel T. Combined Ascending Aortic Stent-Graft and Inner Branched Arch Device for Type A Aortic Dissection. J Endovasc Ther 2018; 25:561-565. [DOI: 10.1177/1526602818790568] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To report the use of the Zenith Ascend stent-graft in conjunction with the Zenith inner branched arch device to treat type A aortic dissection. Case Report: Five patients (mean age 66 years, range 52–78; 4 men) with type A aortic dissection (2 acute) and insufficient distal landing zones were treated with the Zenith Ascend stent-graft and inner branched arch devices to extend the distal landing zone. Left carotid–subclavian bypass was performed in a staged or simultaneous setting depending on the urgency of the condition. Technical success (no type I or III endoleak and successful revascularization of all supra-aortic vessels) was achieved in all patients. Median intensive care unit stay was 5 days (range 4–23) and the median hospital stay was 16 days (range 8–25). The 2 patients with acute dissection died in hospital and at 5 months, respectively. The 3 elective patients were followed for 7, 13, and 19 months, respectively. All had false lumen thrombosis with either a reduced or stable aneurysm diameter. Conclusion: This limited experience demonstrated the feasibility and safety of the combined use of the Ascend stent-graft and inner branched arch devices. This strategy may sometimes be more beneficial than either stent-graft used alone.
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Affiliation(s)
- Yuk Law
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center Hamburg, Germany
- Division of Vascular Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, China
| | - Nikolaos Tsilimparis
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center Hamburg, Germany
| | - Vladimir Makaloski
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center Hamburg, Germany
| | - E. Sebastian Debus
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center Hamburg, Germany
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Rynio P, Kazimierczak A, Jedrzejczak T, Gutowski P. A 3-Dimensional Printed Aortic Arch Template to Facilitate the Creation of Physician-Modified Stent-Grafts. J Endovasc Ther 2018; 25:554-558. [PMID: 30056789 DOI: 10.1177/1526602818792266] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To demonstrate the utility of a 3-dimensional (3D) printed template of the aortic arch in the construction of a fenestrated and scalloped physician-modified stent-graft (PMSG). CASE REPORT A 73-year-old woman with descending thoracic aneurysm was scheduled for thoracic endovascular aortic repair after being disqualified for open surgery. Computed tomography angiography (CTA) revealed no proximal landing zone as the aneurysm began from the level of the left subclavian artery, so a fenestrated/scalloped PMSG was planned. To facilitate accurate placement of the openings in the graft, a 3D printed aortic arch template was prepared from the CTA data and gas sterilized. In the operating room, a Valiant stent-graft was inserted into the 3D printed template and deployed. Using ophthalmic cautery, a fenestration and a scallop were created; radiopaque markers were added. The PMSG was successfully deployed with no discrepancy between the openings and the target vessels. CONCLUSION A 3D printed aortic arch template facilitates handmade fenestrations and scallops in PMSGs and may improve accuracy and quality.
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Affiliation(s)
- Pawel Rynio
- 1 Department of Vascular Surgery, Pomeranian Medical University, Szczecin, Poland
| | | | - Tomasz Jedrzejczak
- 2 Department of Cardiosurgery, Pomeranian Medical University, Szczecin, Poland
| | - Piotr Gutowski
- 1 Department of Vascular Surgery, Pomeranian Medical University, Szczecin, Poland
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Law Y, Chan YC, Cheng SW. Arch branch endografts for arch aneurysms associated with bovine anomaly. Asian Cardiovasc Thorac Ann 2018; 27:127-131. [PMID: 30012000 DOI: 10.1177/0218492318788780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Bovine aortic arch is known to be associated with an increased rate of aortic arch expansion. The most frequently observed human variant of bovine aortic arch is a common origin of the innominate trunk and left common carotid artery. This is a report of two patients who had successful custom-made arch branch endograft treatment for an arch aneurysm associated with bovine arch anomaly. Modular endovascular repair of aortic arch aneurysms using an inner-branched device adds to the armamentarium of treatment options, and is a minimally invasive management modality without the need for sternotomy or intraoperative extracorporeal bypass.
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Affiliation(s)
- Y Law
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong
| | - Y C Chan
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong
| | - S W Cheng
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong
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Saleptsis V, Spanos K, Tsilimparis N, Rohlffs F, Debus SE, Kölbel T. The Presence of Gas in Aneurysm Sac during Early Postoperative Period Is Associated to the Type of Endograft and Perfused Lumen's Size. Ann Vasc Surg 2018; 50:173-178. [DOI: 10.1016/j.avsg.2017.11.067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/16/2017] [Accepted: 11/16/2017] [Indexed: 11/30/2022]
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Falkenberg M, Bokvist F, Skoog P. Commentary: How to Deal With Air Released From Thoracic Endografts: Ignore It or Fear It? J Endovasc Ther 2018; 25:440-441. [PMID: 29936888 DOI: 10.1177/1526602818784027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Mårten Falkenberg
- 1 Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Fredrik Bokvist
- 2 Department of Anesthesiology, Falun Hospital, Falun, Sweden
| | - Per Skoog
- 3 Department of Vascular Surgery and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital and Academy, Gothenburg, Sweden
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Rohlffs F, Tsilimparis N, Trepte C, Kratzberg J, Mogensen J, Debus ES, Kölbel T. Air Embolism During TEVAR: An Additional Flush Port on the Delivery System Pusher Significantly Reduces the Amount of Air Released During Deployment of a Thoracic Stent-Graft in an Experimental Setting. J Endovasc Ther 2018; 25:435-439. [DOI: 10.1177/1526602818780951] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To investigate the influence of (1) an additional side port for flushing the hollow pusher in Zenith thoracic stent-graft delivery systems and (2) additional carbon dioxide flushing on the amount of air released during stent-graft deployment. Methods: Twenty thoracic stent-grafts with an additional flush port to fill the hollow pusher were separated into 2 equal groups (C and D). Both groups were flushed with 20 mL of normal saline through the extra side port connected to the pusher and with 60 mL of saline through the regular flushing port. One group of grafts (group D) was additionally flushed with carbon dioxide through the regular flushing port prior to saline. All grafts were deployed into a curved plastic pipe attached to the bottom of a water-filled container. The released gas was recorded and measured using a calibrated setup. To evaluate the influence of the extra side port irrespective of the carbon dioxide flushing technique, group C was compared with a previously published reference group A without an extra side port that was flushed with the standard 60 mL of saline. Results: Volumes of gas were released in various amounts from the stent-grafts during deployment. The average amount of released gas was 0.51 mL in group C and 0.07 mL in group D (p<0.001). The mean amount of gas from group C samples (0.51 mL) was also significantly lower (p=0.002) compared with the reference group (0.79 mL). Conclusion: Thoracic endografts release air during deployment. Reducing the air-filled space inside the pusher of the catheter assembly using an additional side port can significantly reduce the amount of released air. Using the extra side port in combination with the carbon dioxide flushing technique reduces gas release further to small volumes. In a clinical setting this could be a promising approach to lower the risk of air embolism and stroke during thoracic endovascular aortic repair.
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Affiliation(s)
- Fiona Rohlffs
- German Aortic Center, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Nikolaos Tsilimparis
- German Aortic Center, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Constantin Trepte
- Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - E. Sebastian Debus
- German Aortic Center, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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Ferrer C, Cao P. Endovascular arch replacement with a dual branched endoprosthesis. Ann Cardiothorac Surg 2018; 7:366-371. [PMID: 30155415 DOI: 10.21037/acs.2018.04.08] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background In the light of current evidence, endovascular repair of aortic arch pathologies with custom-made devices should be considered a valid alternative to decrease operative mortality and morbidity associated with open or hybrid repair. Currently, two double inner branch devices are available on the market. Some papers from multicenter experiences have been published about the use of Cook device. We report our single-center experience with Bolton double branch stent graft in the treatment of aortic arch disease. Methods Between 2013 and 2016, nine high-risk patients with arch pathology were treated in our center with a Bolton custom-made branched device. Among these, two with a single branch model were excluded, leaving a subgroup of seven patients of this study. Results Out of the seven male patients (mean age, 76; range, 70-85) included in the study, two (28%) died perioperatively after stroke (14%) and retrograde dissection (14%), respectively. No other death, major complications, including aneurysmal diameter evolution and branch related complications, or secondary intervention was recorded at a mean follow up of 24 [6-53] months. Conclusions Despite the small sample size, our results are in line with the early experiences published on this technique. Endovascular repair of aortic arch disease with custom-made branched devices should always be considered to give high-risk patients a chance of repair.
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Affiliation(s)
- Ciro Ferrer
- Unit of Vascular Surgery, Department of Surgery "Pietro Valdoni", Sapienza University of Rome, Rome, Italy
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