1
|
Golestani S, Dubose JJ, Efird J, Teixeira PG, Cardenas TC, Trust MD, Ali S, Aydelotte J, Bradford J, Brown CV. Nonoperative Management for Low-Grade Blunt Thoracic Aortic Injury. J Am Coll Surg 2024; 238:1099-1104. [PMID: 38407302 DOI: 10.1097/xcs.0000000000001056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) is the standard of care for the treatment of blunt thoracic aortic injury (BTAI) requiring intervention. Data suggest that low-grade BTAI (grade I [intimal tears] or grade II [intramural hematoma]) will resolve spontaneously if treated with nonoperative management (NOM) alone. There has been no comparison specifically between the use of NOM vs TEVAR for low-grade BTAI. We hypothesize that these low-grade injuries can be safely managed with NOM alone. STUDY DESIGN Retrospective analysis of all patients with a low-grade BTAI in the Aortic Trauma Foundation Registry from 2016 to 2021 was performed. The study population was 1 primary outcome was mortality. Secondary outcomes included complications, ICU length of stay, and ventilator days. RESULTS A total of 880 patients with BTAI were enrolled. Of the 269 patients with low-grade BTAI, 218 (81%) were treated with NOM alone (81% grade I, 19% grade II), whereas 51 (19%) underwent a TEVAR (20% grade I, 80% grade II). There was no difference in demographic or mechanism of injury in patients with low-grade BTAI who underwent NOM vs TEVAR. There was a difference in mortality between NOM alone and TEVAR (8% vs 18%, p = 0.009). Aortic-related mortality was 0.5% in the NOM group and 4% in the TEVAR group (p = 0.06). Hospital and ICU length of stay and ventilator days were not different between the 2 groups. CONCLUSIONS NOM alone is safe and appropriate management for low-grade BTAI, with lower mortality and decreased rates of complication when compared with routine initial TEVAR.
Collapse
Affiliation(s)
- Simin Golestani
- From the Department of Surgery, Dell Medical School, University of Texas at Austin, Austin, TX
| | | | | | | | | | | | | | | | | | | |
Collapse
|
2
|
Alanezi T, Altoijry A, AlSheikh S, Al-Mubarak H, Alhamzah M, Alomran F, Abdulrahim O, Aljabri B, Greco E, Hussain MA, Al-Omran M. Predicting the need for subclavian artery revascularization in thoracic endovascular aortic repair: A systematic review and meta-analysis. J Vasc Surg 2024:S0741-5214(24)00985-6. [PMID: 38621636 DOI: 10.1016/j.jvs.2024.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/21/2024] [Accepted: 04/09/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVE This systematic review and meta-analysis aims to investigate the effectiveness of left subclavian artery revascularization compared with non-revascularization in thoracic endovascular aortic repair, and to summarize the current evidence on its indications. METHODS A computerized search was conducted across multiple databases, including MEDLINE, SCOPUS, Cochrane Library, and Web of Science, for studies published up to November 2023. Study selection, data abstraction, and quality assessment (using the Newcastle-Ottawa Scale) were independently conducted by two reviewers, with a third author resolving discrepancies. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models and publication bias was assessed using funnel plots. RESULTS In the 76 included studies, left subclavian artery revascularization was associated with reduced risks of stroke (OR, 0.67; 95% CI, 0.45-0.98; n = 15,331), spinal cord ischemia (OR, 0.75; 95% CI, 0.56-0.99; n = 11,995), and arm ischemia (OR, 0.09; 95% CI, 0.01-0.59; n = 8438). No significant reduction in paraplegia (OR, 0.56; 95% CI, 0.21-1.47; n = 1802) or mortality (OR, 0.77; 95% CI, 0.53-1.12; n = 11,831) was observed. Moreover, the risk of endoleak was comparable in both groups (OR, 1.25; 95% CI, 0.55-2.84; P = .60; n = 793), whereas the risk of reintervention was significantly higher in the revascularization group (OR, 1.98; 95% CI, 1.03-3.83; P = .04; n = 272). Both groups had similar risks of major (OR, 0.45; 95% CI, 0.19-1.09; P = .08; n = 1113), minor (OR, 0.21; 95% CI, 0.01-3.45; P = .27; n = 183), renal (OR, 0.61; 95% CI, 0.12-3.06; P = .55; n = 310), and pulmonary (OR, 0.59; 95% CI, 0.16-2.15; P = .42; n = 8083) complications. The most frequent indications for left subclavian artery revascularization were primary prevention of spinal cord ischemia, augmentation of the landing zone, and primary stroke prevention. CONCLUSIONS Left subclavian artery revascularization in thoracic endovascular aortic repair was associated with reduced neurological complications but was not found to impact mortality. The study highlights important indications for revascularization as well as significant predictors of complications, providing a basis for clinical decision-making and future research.
Collapse
Affiliation(s)
- Tariq Alanezi
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulmajeed Altoijry
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Sultan AlSheikh
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Husain Al-Mubarak
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Musaad Alhamzah
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Faris Alomran
- Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Omer Abdulrahim
- Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Badr Aljabri
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Elisa Greco
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Mohamad A Hussain
- Harvard Medical School, Boston, MA; Division of Vascular and Endovascular Surgery and the Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston
| | - Mohammed Al-Omran
- Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
| |
Collapse
|
3
|
Wang Y, Li S, Jin M, Xue Y, Wang D, Zhou Q. Surgical treatment for right-side aortic arch concomitant with Kommerell's diverticulum: techniques selection and follow-up results. Eur J Med Res 2024; 29:10. [PMID: 38172972 PMCID: PMC10762982 DOI: 10.1186/s40001-023-01595-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 12/13/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Right-side aortic arch concomitant with Kommerell's diverticulum (KD) is a rare and complex ailment, and there is no consensus on the optimal strategy to deal with this congenital anomaly. We retrospectively analyzed and summary of the cases treated in our center with individual treatment methods for different situations. METHODS Between September 2018 and December 2021, 10 patients experienced surgical therapy at our institution who presented with a Kommerell's diverticulum arising from an aberrant subclavian artery from the right-side aortic arch. Four main surgical techniques were applied to those patients: 1. total arch replacement with frozen elephant trunk implantation (n = 2); 2. hybrid procedure combining open arch repair and endovascular intervention (n = 1); 3. total endovascular repair using thoracic endovascular aortic repair (TEVAR) with or without left subclavian artery (LSCA) revascularization (n = 6); 4. direct repair underwent endoaneurysmorrhaphy. Clinical characteristics and outcomes were collected. RESULTS The mean age of these 10 patients was 56.5 years (range 29-79 years) and only 1 woman. The pathology includes aortic dissection (n = 6) and aneurysm (n = 4). The mean diverticulum size was 41.4 [24.2-56.8] mm. There were no in-hospital deaths, and the median hospital stay was 22 [15-43] days. During the follow-up period (21.4 months, 1-44 months), one died of an unknown cause and one died of esophageal fistula. Two patients underwent second-stage endovascular intervention for distal lesion. And none of the patients had endoleak during the follow-up period. CONCLUSIONS Each of the procedures we have mentioned here has its advantages and disadvantages; individualized treatment should meet the appropriate indications. A single-branched stent graft is feasible and effective in the treatment of aortic disease combined with Kommerell's diverticulum.
Collapse
Affiliation(s)
- Yali Wang
- Department of Thoracic and Cardiovascular Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Shuchun Li
- Department of Thoracic and Cardiovascular Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Min Jin
- Department of Thoracic and Cardiovascular Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Yunxing Xue
- Department of Thoracic and Cardiovascular Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Dongjin Wang
- Department of Thoracic and Cardiovascular Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Qing Zhou
- Department of Thoracic and Cardiovascular Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China.
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China.
| |
Collapse
|
4
|
Derycke L, Tomasi J, Desgranges P, Pesteil F, Plissonier D, Pernot M, Millon A, Martinez R, Chakfe N, Alsac JM. Assessment of Thoracic Endovascular Aortic Repair Using Relay Proximal Scallop: Results of a French Prospective Multicentre Study. Eur J Vasc Endovasc Surg 2023; 66:821-829. [PMID: 37567339 DOI: 10.1016/j.ejvs.2023.08.002] [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: 12/10/2022] [Revised: 06/01/2023] [Accepted: 08/02/2023] [Indexed: 08/13/2023]
Abstract
OBJECTIVE A proximal scallop design allows aortic arch repair without complex endovascular manipulation in the aortic arch. The aim was to assess the safety and efficacy at one year of the Relay proximal scallop stent graft. METHODS A prospective multicentre study evaluated consecutive patients treated with the Relay proximal scallop stent graft in 10 French aortic centres. All consecutive patients eligible for elective thoracic endovascular repair with proximal scallop in the 10 participating centres between January 2015 and July 2018 were included. Primary endpoints were 30 day mortality, stroke, and spinal cord ischaemia (SCI) rates. Outcomes including safety and efficacy, technical and clinical success, all cause death, neurological events, vessel patency, and device specific complications were analysed. Survival and survival without severe complications were estimated using Kaplan-Meier estimates. RESULTS Ten aortic centres treated 40 patients for thoracic aortic aneurysm (45%), penetrating atherosclerotic aneurysm (30%), and dissection (25%). Half of the procedures (50%) targeted zone 0 of the aortic arch (zone 0 in 17.5% and zones 0/1 in 32.5%), 37.5% targeted zone 2 (35% zone 2 alone; 2.5% zones 1/2), and 15% targeted zone 1 (12.5% zone 1 alone). Median follow up was one year. Thirty day mortality, stroke, and SCI rates were 10%, 5%, and 0% respectively. Primary technical success was 95%. Type Ia, Ib, and III endoleaks rates were 5.4%, 0%, and 0% respectively at one month. The overall mortality rate at one year was 17.5%. Aneurysm expansion was > 5 mm in one case at one year associated with type Ia endoleak (3%). There was no supra-aortic trunk thrombosis, one (2%) graft kink, and no migration. CONCLUSION One year outcomes showed that the Relay proximal scallop stent graft is an acceptable answer to thoracic aortic disease to deal with short proximal landing zones.
Collapse
Affiliation(s)
- Lucie Derycke
- Department of Cardio-Vascular and Vascular Surgery, Hôpital Européen Georges Pompidou, Paris, France.
| | - Jacques Tomasi
- Department of Thoracic and Cardiovascular Surgery, University Hospital Centre-INSERM LTSI 1099, Rennes, France
| | - Pascal Desgranges
- Department of Vascular Surgery, Centre Hospitalier Universitaire Henri Mondor, Créteil, France
| | - Francis Pesteil
- Department of Vascular Medicine and Surgery, Dupuytren University Hospital, Limoges, France
| | - Didier Plissonier
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
| | - Mathieu Pernot
- Department of Cardiology and Cardio-Vascular Surgery, Hopital Cardiologique de Haut-Leveque, Bordeaux University Hospital, Pessac, France
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France
| | - Robert Martinez
- Department of Cardiovascular Surgery, University Hospital of Tours, Tours, France
| | - Nabil Chakfe
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Jean-Marc Alsac
- Department of Cardio-Vascular and Vascular Surgery, Hôpital Européen Georges Pompidou, Paris, France
| |
Collapse
|
5
|
Natour AK, Shepard A, Onofrey K, Peshkepija A, Nypaver T, Weaver M, Lee A, Kabbani L. Left subclavian artery revascularization is associated with less neurologic injury after endovascular repair of acute type B aortic dissection. J Vasc Surg 2023; 78:1170-1179.e2. [PMID: 37524152 DOI: 10.1016/j.jvs.2023.07.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/16/2023] [Accepted: 07/22/2023] [Indexed: 08/02/2023]
Abstract
OBJECTIVE The aim of this study was to analyze patients with acute type B aortic dissection (aTBAD) requiring thoracic endovascular aortic repair (TEVAR) with left subclavian artery (LSA) coverage to determine whether LSA revascularization decreased the risk of neurologic complications. METHODS The national Vascular Quality Initiative TEVAR module was queried for all procedures performed between 2014 and 2021. Patients presenting with aortic aneurysms or aortic ruptures were excluded from the analysis. Patients were divided into two groups according to whether their LSA was revascularized (prior to or during TEVAR) or not. Univariate followed by multivariate analysis was used to account for possible confounders and evaluate the association of LSA revascularization with the primary outcome of neurologic injury (stroke or spinal cord ischemia). RESULTS Among patients who had TEVAR for aTBAD, 501 patients had the LSA covered. The LSA was revascularized prior to or concomitant with TEVAR in 28% of these patients (n = 139). Average age was 57 years, and 73% (n = 366) were male. Neurologic injury developed in 88 patients (18%). On univariate analysis, patients who had their LSA revascularized were significantly less likely to develop neurologic injury (10% vs 20%; P < .01). This association persisted after accounting for potential confounders (odds ratio, 0.4; P = .02). No significant difference was seen when comparing 30-day or 1-year mortality between patients who had LSA revascularization and those who did not. Follow-up averaged 1.9 years (range, 0-8.1 years). Long-term survival did not differ between the two groups on Kaplan-Meier analysis. CONCLUSIONS In this study of patients with aTBAD who underwent LSA coverage during TEVAR, the addition of a LSA revascularization procedure was associated with a significantly lower incidence of neurological injury including spinal cord ischemia and/or stroke.
Collapse
Affiliation(s)
| | | | - Kevin Onofrey
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
| | - Andi Peshkepija
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
| | - Timothy Nypaver
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
| | - Mitchell Weaver
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
| | - Alice Lee
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
| | - Loay Kabbani
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
| |
Collapse
|
6
|
Noda K, Koga M, Toyoda K. Recognition of Strokes in the ICU: A Narrative Review. J Cardiovasc Dev Dis 2023; 10:jcdd10040182. [PMID: 37103061 PMCID: PMC10145112 DOI: 10.3390/jcdd10040182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 04/28/2023] Open
Abstract
Despite the remarkable progress in acute treatment for stroke, in-hospital stroke is still devastating. The mortality and neurological sequelae are worse in patients with in-hospital stroke than in those with community-onset stroke. The leading cause of this tragic situation is the delay in emergent treatment. To achieve better outcomes, early stroke recognition and immediate treatment are crucial. In general, in-hospital stroke is initially witnessed by non-neurologists, but it is sometimes challenging for non-neurologists to diagnose a patient's state as a stroke and respond quickly. Therefore, understanding the risk and characteristics of in-hospital stroke would be helpful for early recognition. First, we need to know "the epicenter of in-hospital stroke". Critically ill patients and patients who undergo surgery or procedures are admitted to the intensive care unit, and they are potentially at high risk for stroke. Moreover, since they are often sedated and intubated, evaluating their neurological status concisely is difficult. The limited evidence demonstrated that the intensive care unit is the most common place for in-hospital strokes. This paper presents a review of the literature and clarifies the causes and risks of stroke in the intensive care unit.
Collapse
Affiliation(s)
- Kotaro Noda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita 564-8565, Japan
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8519, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita 564-8565, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita 564-8565, Japan
| |
Collapse
|
7
|
Wu X, Li Y, Zhao Y, Zhu Y, Wang S, Ma Q, Liu D, Gao B, Wei S, Wang W. Efficacy of left subclavian artery revascularization strategies during thoracic endovascular aortic repair in patients with type B dissection: A single-center experience of 105 patients. Front Cardiovasc Med 2023; 10:1084851. [PMID: 37077745 PMCID: PMC10106686 DOI: 10.3389/fcvm.2023.1084851] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 03/15/2023] [Indexed: 04/05/2023] Open
Abstract
BackgroundLeft subclavian artery (LSA) revascularization during thoracic endovascular aortic repair (TEVAR) is necessary to reduce postoperative complications in patients with Stanford type B aortic dissection and an insufficient proximal anchoring area. However, the efficacy and safety of different LSA revascularization strategies remain unclear. Here, we compared these strategies to provide a clinical basis for selecting an appropriate LSA revascularization method.MethodsIn this study, we included 105 patients with type B aortic dissection who were treated using TEVAR combined with LSA reconstruction in the Second Hospital of Lanzhou University from March 2013 to 2020. They were divided into four groups according to the method used for LSA reconstruction, namely, carotid subclavian bypass (CSB; n = 41), chimney graft (CG; n = 29), single-branched stent graft (SBSG; n = 21), and physician-made fenestration (PMF; n = 14) groups. Finally, we collected and analyzed the baseline, perioperative, operative, postoperative, and follow-up data of the patients.ResultsThe treatment success rate was 100% in all the groups, and CSB + TEVAR was the most commonly used procedure in emergency settings compared with the other three procedures (P < 0.05). The estimated blood loss, contrast agent volume, fluoroscopic time, operation time, and limb ischemia symptoms during the follow-up were significantly different in the four groups (P < 0.05). Pairwise comparison among groups indicated that the estimated blood loss and operation time in the CSB group were the highest (adjusted P < 0.0083; P < 0.05). The contrast agent volume and fluoroscopy duration were the highest in the SBSG groups, followed by PMF, CG, and CSB groups. The incidence of limb ischemia symptoms was the highest in the PMF group (28.6%) during the follow-up. The incidence of complications (except limb ischemia symptoms) during the perioperative and follow-up periods was similar among the four groups (P > 0.05) The median follow-up time of CSB, CG, SBSG, and PMF groups was significantly different (P < 0.05), and the CSB group had the longest follow-up.ConclusionOur single-center experience suggested that the PMF technique increased the risk of limb ischemia symptoms. The other three strategies effectively and safely restored LSA perfusion in patients with type B aortic dissection and had comparable complications. Overall, different LSA revascularization techniques have their advantages and disadvantages.
Collapse
Affiliation(s)
- Xiangyang Wu
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Yongnan Li
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Yinglu Zhao
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Yilin Zhu
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Shixiong Wang
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Qi Ma
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Debin Liu
- Department of Cardiac Surgery, Hainan General Hospital, Hainan, China
| | - Bingren Gao
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Shilin Wei
- Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
- Correspondence: Weifan Wang Shilin Wei
| | - Weifan Wang
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
- Correspondence: Weifan Wang Shilin Wei
| |
Collapse
|
8
|
Cheng Z, Liu Y, Ma X. Comparative Analysis of Endovascular Repair of Single-Branched Stent-Graft and Hybrid Procedure for Patients With Type B Acute Aortic Dissection Involving the Left Subclavian Artery. J Endovasc Ther 2023:15266028221149920. [PMID: 36945730 DOI: 10.1177/15266028221149920] [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: 03/23/2023]
Abstract
PURPOSE Thoracic endovascular aortic repair (TEVAR) with left subclavian artery (LSA) revascularization has been used in patients with type B aortic dissection (TBAD), with inadequate proximal landing zone (PLZ). The outcomes of comparisons between TEVAR and hybrid procedure on patients with TBAD, with inadequate PLZ, are rarely reported. This study sought to compare and clarify the early and midterm outcomes between TEVAR and hybrid procedure in patients with TBAD, with inadequate PLZ. MATERIALS AND METHODS Between January 2019 and December 2021, 93 patients with TBAD, with inadequate PLZ, who underwent TEVAR or hybrid procedure, were retrospectively evaluated in Beijing Anzhen hospital. Demographics, comorbidities, preoperative imaging features, periprocedural details, and follow-up outcomes were analyzed. Survival was analyzed according to Kaplan-Meier method. RESULTS TEVAR procedures were performed on 41 patients (TEVAR group) and hybrid procedures on 52 patients (hybrid group). Early events, 30 day mortality, and all-cause mortality, were not significantly different between the 2 groups. However, patients receiving TEVAR had significantly shorter procedure time (p<0.001), hospital stay (p<0.001), and intensive care unit (ICU) stay (p=0.001) compared with those in the hybrid group. Patients receiving TEVAR had significantly lower midterm events (p=0.014) and re-intervention (p=0.015) compared with those in the hybrid group. CONCLUSION The study indicated that TEVAR with LSA revascularization for TBAD with inadequate PLZ is associated with a trend toward lower rates of midterm events, while the early and midterm mortalities were comparable with those in hybrid procedure. CLINICAL IMPACT This study is novel as it compared the outcomes between thoracic endovascular aortic repair (TEVAR) and hybrid procedure in patients with type B aortic dissection (TBAD), with inadequate proximal landing zone, which has been rarely reported previously. We believe that our study makes a significant contribution to the literature because it is clinically relevant as it demonstrated that TEVAR with left subclavian artery (LSA) revascularization for TBAD with inadequate proximal landing zone is associated with a trend toward lower rates of mid-term events, while the early and mid-term mortalities were comparable with those in the hybrid procedure.
Collapse
Affiliation(s)
- Zhang Cheng
- Department of Interventional Diagnosis and Treatment, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yongmin Liu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaohai Ma
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
9
|
Carrel T, Sundt TM, von Kodolitsch Y, Czerny M. Acute aortic dissection. Lancet 2023; 401:773-788. [PMID: 36640801 DOI: 10.1016/s0140-6736(22)01970-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/04/2022] [Accepted: 09/27/2022] [Indexed: 01/13/2023]
Abstract
Although substantial progress has been made in the prevention, diagnosis, and treatment of acute aortic dissection, it remains a complex cardiovascular event, with a high immediate mortality and substantial morbidity in individuals surviving the acute period. The past decade has allowed a leap forward in understanding the pathophysiology of this disease; the existing classifications have been challenged, and the scientific community moves towards a nomenclature that is likely to unify the current definitions according to morphology and function. The most important pathophysiological pathway, namely the location and extension of the initial intimal tear, which causes a disruption of the media layer of the aortic wall, together with the size of the affected aortic segments, determines whether the patient should undergo emergency surgery, an endovascular intervention, or receive optimal medical treatment. The scientific evidence for the management and follow-up of acute aortic dissection continues to evolve. This Seminar provides a clinically relevant overview of potential prevention, diagnosis, and management of acute aortic dissection, which is the most severe acute aortic syndrome.
Collapse
Affiliation(s)
- Thierry Carrel
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland.
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts' General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yskert von Kodolitsch
- Department of Vascular Medicine, German Aortic Center, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Germany; Faculty of Medicine, Albert Ludwig University Freiburg, Freiburg, Germany
| |
Collapse
|
10
|
Li RD, Chia MC, Eskandari MK. Thoracic Endovascular Aortic Repair with Supra-Aortic Trunk Revascularization is Associated with Increased Risk of Periprocedural Ischemic Stroke. Ann Vasc Surg 2022; 87:205-212. [PMID: 35835381 PMCID: PMC9901212 DOI: 10.1016/j.avsg.2022.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/20/2022] [Accepted: 06/23/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Ischemic stroke is a devastating complication of thoracic endovascular aortic repair (TEVAR). This risk may be higher in more proximal aneurysms that require arch manipulation. The purpose of this study is to (1) describe 30-day stroke and death rates in patients undergoing TEVAR, (2) compare stroke rates in patients undergoing TEVAR for arch versus descending aneurysm pathology, and (3) identify predictive factors associated with stroke after TEVAR. METHODS The Vascular Quality Initiative registry was queried (2015-2021) for TEVAR procedures performed for degenerative aneurysms. Our primary outcomes were any stroke or death at 30 days. Patient-, procedure-, and hospital-level predictors of stroke were assessed using multivariable Poisson regression. RESULTS Among 3,072 patients with degenerative aneurysms (197 [6.4%] arch versus 2,875 [93.6%] descending) treated with elective TEVAR, the median age was 73 years (interquartile range 67-79) and 54.8% were male. Within the arch aneurysm group, there were 27.4% zone 0, 22.8% zone 1, and 49.8% zone 2 interventions. Overall 30-day stroke and death rates were 3.2% and 3.8%. The distribution of stroke events was bilateral (52.9%), left carotid (20.7%), left vertebrobasilar (11.5%), right carotid (9.2%), and right vertebrobasilar (5.7%). Although mortality was similar between groups, the rate of ischemic stroke was higher for patients undergoing TEVAR for arch aneurysm versus descending aneurysms (7.1% arch versus 2.9% descending, P = 0.001). Factors that were associated with ischemic stroke after TEVAR included age (>79 years, relative risk [RR] 1.79, 95% confidence interval [CI] 1.08-2.98 vs. <79 years), dependent functional status (RR 1.73, 95% CI 1.07-2.78), procedural time (RR 1.25, 95% CI 1.15-1.36), and endovascular intervention for supra-aortic trunk revascularization (RR 2.66, 95% CI 1.06-6.70 versus no intervention). CONCLUSIONS Ischemic stroke risk after TEVAR was increased for arch aneurysms compared to descending aneurysms. More proximal zone coverage and endovascular interventions on the supra-aortic trunks were associated with increasing risk for stroke. Adequate preparation for stroke prevention is necessary prior to TEVAR with supra-aortic trunk revascularization.
Collapse
Affiliation(s)
- Ruojia Debbie Li
- Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL
| | - Matthew C Chia
- Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL
| | - Mark K Eskandari
- Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.
| |
Collapse
|
11
|
Grigorian A, Lewis M, Wlodarczyk JR, Chien CY, Park T, Demetriades D. Left subclavian artery coverage during endovascular repair of thoracic aorta injury in trauma and non-trauma patients. Eur J Trauma Emerg Surg 2022; 48:4425-4429. [PMID: 35713681 DOI: 10.1007/s00068-022-02027-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/28/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE In thoracic endovascular aortic repair (TEVAR), the left subclavian artery (LSA) is often occluded. Although most patients tolerate this, some develop ischemic symptoms to the brain or left upper extremity (LUE). A revascularization procedure may be associated with significant complications. The purpose of this review was to assess the incidence of LSA occlusion, resulting ischemic symptoms, and complications related to revascularization operations in trauma patients compared to non-trauma patients. METHODS Studies from 2010 to 2020 were fully reviewed if they discussed incidence of LSA coverage, LUE ischemia, carotid-subclavian bypass, or complications associated with carotid-subclavian bypass. RESULTS Seventeen articles were included in this analysis. A total of 167 patients were identified as trauma cases. Incidence of LSA occlusion in trauma was 91/167 (54%) compared to 281/1446 (19%) in the population exclusive of trauma (p < 0.001). Following LSA occlusion, the rate of LUE claudication/ischemia was 21/56 (38%) for trauma, compared to 12/193 (6%) in non-trauma cases (p < 0.001). The overall complication rate after carotid-subclavian rescue bypass was 29.2% (33/112), with phrenic nerve palsy (24%), recurrent laryngeal nerve palsy (5%), and pseudoaneurysm (1.7%) being the most common. CONCLUSION LSA coverage following TEVAR is common and associated with significant complications, often requiring operative management. The incidence of ischemic complications after occlusion of the LSA is significantly higher in the trauma population. Revascularization procedures to correct the occlusion have a high rate of complications.
Collapse
Affiliation(s)
- Areg Grigorian
- Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA.
| | - Meghan Lewis
- Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA
| | - Jordan R Wlodarczyk
- Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA
| | - Chih Ying Chien
- Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA
| | - Timothy Park
- Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA
| | - Demetrios Demetriades
- Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA
| |
Collapse
|
12
|
MacGillivray TE, Gleason TG, Patel HJ, Aldea GS, Bavaria JE, Beaver TM, Chen EP, Czerny M, Estrera AL, Firestone S, Fischbein MP, Hughes GC, Hui DS, Kissoon K, Lawton JS, Pacini D, Reece TB, Roselli EE, Stulak J. The Society of Thoracic Surgeons/American Association for Thoracic Surgery clinical practice guidelines on the management of type B aortic dissection. J Thorac Cardiovasc Surg 2022; 163:1231-1249. [PMID: 35090765 DOI: 10.1016/j.jtcvs.2021.11.091] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 01/16/2023]
Affiliation(s)
| | - Thomas G Gleason
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | | | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Md
| | - Davide Pacini
- Department of Cardiac Surgery, University of Bologna, Bologna, Italy
| | - T Brett Reece
- Department of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| |
Collapse
|
13
|
MacGillivray TE, Gleason TG, Patel HJ, Aldea GS, Bavaria JE, Beaver TM, Chen EP, Czerny M, Estrera AL, Firestone S, Fischbein MP, Hughes GC, Hui DS, Kissoon K, Lawton JS, Pacini D, Reece TB, Roselli EE, Stulak J. The Society of Thoracic Surgeons/American Association for Thoracic Surgery Clinical Practice Guidelines on the Management of Type B Aortic Dissection. Ann Thorac Surg 2022; 113:1073-1092. [PMID: 35090687 DOI: 10.1016/j.athoracsur.2021.11.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 02/07/2023]
Affiliation(s)
| | - Thomas G Gleason
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Florida
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Texas
| | | | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, California
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Davide Pacini
- Department of Cardiac Surgery, University of Bologna, Bologna, Italy
| | - T Brett Reece
- Department of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
14
|
Chusooth J, Kongkamol C, Suwannanon R, Premprabha D, Chittithavorn V, Benjhawaleemas P, Sriplung H, Sathirapanya P. A Single Center Study on the Risks of Peri-Intervention Stroke in Thoracic Endovascular Aortic Repair (TEVAR) and Endovascular Abdominal Aortic Repair (EVAR). J Cardiovasc Dev Dis 2022; 9:jcdd9010010. [PMID: 35050220 PMCID: PMC8781003 DOI: 10.3390/jcdd9010010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/05/2021] [Accepted: 12/29/2021] [Indexed: 02/05/2023] Open
Abstract
(1) Background: The risk factors of peri-intervention stroke (PIS) in thoracic endovascular aortic repair (TEVAR) and endovascular abdominal aortic repair (EVAR) are different. This study aimed to compare the risks of PIS in both interventions. (2) Methods: Patients who had suffered a PIS related to TEVAR or EVAR from January 2008 to June 2015 in Songklanagarind Hospital were selected as the cases, while patients who had not suffered PIS were randomly selected to create a 1:4 case: control ratio for analysis. The associations between the factors from pre- to post-intervention and PISs in TEVAR or EVAR cases were analyzed by univariable analysis (p < 0.1). The independent risks of PIS were identified by multivariable analysis and presented in odds ratios (p < 0.05). (3) Results: A total of 17 (2.2%) out of 777 patients who had undergone TEVAR or EVAR experienced PIS, of which 9/518 (1.7%) and 8/259 (3.1%) cases were in TEVAR and EVAR groups, respectively. PIS developed within the first 24 h in nine (52.9%) cases. Large vessel ischemic stroke or watershed infarctions were the most common etiologies of PIS. The independent risks of PIS were the volume of intra-intervention blood loss (1.99 (1.88–21.12), p < 0.001) in the TEVAR-related PIS, and intervention time (2.16 (1.95–2.37), p = 0.010) and post-intervention hyperglycemia (18.60 (1.60–216.06), p = 0.001) in the EVAR-related PIS. There were no differences in the rate of PIS among the operators, intervention techniques, and status of the interventions performed. (4) Conclusion: The risks of PIS in TEVAR or EVAR in our center were different and possibly independent of the operator expertise and intervention techniques.
Collapse
Affiliation(s)
- Jirayoot Chusooth
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Thailand;
| | - Chanon Kongkamol
- Department of Family and Preventive Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Thailand;
| | - Ruedeekorn Suwannanon
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Thailand;
| | - Dhanakom Premprabha
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Thailand; (D.P.); (V.C.)
| | - Voravit Chittithavorn
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Thailand; (D.P.); (V.C.)
| | - Pannawit Benjhawaleemas
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Thailand;
| | - Hutcha Sriplung
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Thailand;
| | - Pornchai Sathirapanya
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Thailand;
- Correspondence:
| |
Collapse
|
15
|
Huang B, Jia H, Lai H, Chen Z, Sun Y, Wang C. OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6546749. [PMID: 35274139 DOI: 10.1093/ejcts/ezac102] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 01/25/2022] [Accepted: 02/01/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ben Huang
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hao Jia
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hao Lai
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhenhang Chen
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yongxin Sun
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chunsheng Wang
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| |
Collapse
|
16
|
Brusa J, Lutz E, Schoenhoff FS, Weiss S, Schmidli J, Makaloski V. One-year outcome of postoperative stroke and nerve injury after supraclavicular revascularization of the left subclavian artery for proximal landing zone extension in thoracic endovascular aortic repair. Ann Vasc Surg 2021; 83:265-274. [PMID: 34954037 DOI: 10.1016/j.avsg.2021.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 11/22/2021] [Accepted: 12/04/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess the outcome of stroke and nerve injury after supraclavicular revascularization of the left subclavian artery for proximal landing zone extension in thoracic endovascular aortic repair (TEVAR). METHODS Retrospective analysis of all patients undergoing left-sided carotid-subclavian bypass (CSB) and subclavian-carotid transposition (SCT) with simultaneous or staged TEVAR between January 2010 and June 2019. Endpoints were perioperative cerebrovascular events and nerve injuries, patency and re-intervention due to the debranching, and mortality at 30 days and during follow-up. RESULTS Forty-eight patients (median age 66 years, 81 % male) had 25 (52%) CSB and 23 (48%) SCT. TEVAR was performed simultaneously in 39 (81%) patients, eleven (23%) of them in an emergent setting. There were seven (15%) re-interventions within 30 days: three due to local hematoma, one for bypass occlusion, two for stenosis (of which one was not confirmed intraoperatively), and one after initially abandoned SCT with subsequent CSB on the next day. Thirty-day mortality was 2%; one patient died on the first postoperative day after emergency coronary artery bypass surgery and multiorgan failure. Four (8%) patients suffered postoperative strokes; three occurred after simultaneous emergency procedures and none was fatal. There were nine (19%) left neck nerve injuries in eight patients, five patients had SCT and three CSB. During a median follow-up of 37.5 months (IQR 23-83) with a Follow-up Index of 0.77, there were no reinterventions or occlusions, and no graft infections. Primary patency was 90% and primary assisted patency 98% during follow-up. Eight patients died during follow-up, all of them with patent cervical debranching. CONCLUSION Supraclavicular LSA revascularization for proximal landing zone extension in TEVAR is safe with an acceptable rate of early re-interventions. There is higher risk for perioperative stroke during concomitant emergency LSA revascularization and TEVAR. Left neck nerve injuries are common complications but resolve completely in vast majority of the cases during first postoperative year. During follow-up, excellent patency could be expected.
Collapse
Affiliation(s)
- Juliette Brusa
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Eric Lutz
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Florian S Schoenhoff
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Salome Weiss
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Juerg Schmidli
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Vladimir Makaloski
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland.
| |
Collapse
|
17
|
Chatterjee S, Preventza O, Orozco-Sevilla V, Coselli JS. Perioperative management of patients undergoing thoracic endovascular repair. Ann Cardiothorac Surg 2021; 10:768-777. [PMID: 34926179 DOI: 10.21037/acs-2021-taes-74] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 09/25/2021] [Indexed: 11/06/2022]
Abstract
Thoracic endovascular aortic repair (TEVAR) is a less invasive method for treating thoracic and some thoracoabdominal aortic aneurysms, dissections of the thoracic aorta and blunt traumatic aortic injury, compared with conventional open surgery. Maximizing the likelihood of a successful outcome requires diligent multidisciplinary (surgical, critical care, nursing, pharmacy, nutrition and physical therapy) perioperative care. In this article, we discuss fundamentals for managing patients after endovascular aortic aneurysm repair. These principles focus on the transition between the operating room and the intensive care unit, prevention and management of spinal cord deficits (SCD), and vital neurological, respiratory, cardiovascular, renal, gastrointestinal and hematological concerns. The better the care team understands the expected postoperative course, the earlier that deviations can be recognized and the more likely that successful rescue can be achieved to reduce the incidence and severity of adverse outcomes. Achieving optimal results after TEVAR requires attention to detail across the preoperative, intraoperative and postoperative phases of care.
Collapse
Affiliation(s)
- Subhasis Chatterjee
- Division of General Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA.,Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas, USA
| | - Vicente Orozco-Sevilla
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA.,Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas, USA
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA.,Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas, USA
| |
Collapse
|
18
|
Rizk MAEMAES, Ismail MIM, Gohar KS. Stroke, spinal cord ischemia and upper limb ischemia in patients undergoing TEVAR with coverage of the left subclavian artery: a case series study. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2021. [DOI: 10.1186/s43055-021-00654-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
We performed routine spinal fluid drainage for patients who underwent TEVAR for thoracic aortic pathology together with left subclavian artery coverage, which was needed for achievement of a safe proximal sealing zone. We assessed the occurrence of spinal cord ischemia as well the rate of occurrence of other complications such as stroke, and upper limb ischemia.
Results
This was a case series study done between July 2014 and April 2020, in them all the left subclavian artery was covered to ensure a proximal safe seal zone. Routine spinal fluid drainage was done, keeping the spinal fluid pressure < 10–15 mmHg with catheter in place for 48 h. Data was obtained from twenty-three patients who underwent TEVAR for thoracic aortic dissection (73.91%), thoracic aortic aneurysm (21.74%), or ulcer (4.35%). Planning was based upon multi-slice computed tomographic angiography and covering the left subclavian was mandatory to achieve a proximal sealing zone. Technical success was achieved in 100% of cases. 4.35% of patients had three endograft, 56.52% had two endografts, 39.13% had one endograft. All patients lost their radial pulsations immediately after implantation, 8.70% developed post implantation syndrome(fever) that was managed conservatively, 4.35% developed stroke related to the anterior circulation, 4.35% developed signs of spinal cord ischemia. During the follow up, one patient died within 6 h after the procedure due to extensive myocardial infarction (patient was scheduled for CABG after our procedure). 17.40% developed upper limb symptoms that were tolerable and were managed conservatively.
Conclusion
By adopting routine spinal cord drainage and pressure monitoring, we can consider not to revascularize the left subclavian artery prior to TEVAR if it will be covered.
Collapse
|
19
|
Short-Term Outcomes of In Situ Fenestration in Total Endovascular Aortic Arch Treatment. Ann Vasc Surg 2021; 81:105-112. [PMID: 34780960 DOI: 10.1016/j.avsg.2021.09.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/06/2021] [Accepted: 09/06/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The aim of this study was to analyze the short-term outcomes of in situ fenestration and discuss its feasibility and safety for the treatment of aortic dissection or aneurysm involving aortic arch. METHODS A retrospective single-center review was conducted on patients who were treated with ISF technique to revascularize supra-arch branches from Jun 2017 to Oct 2019. Computed tomographic angiography (CTA) was performed to assess the patency of bridging stents, endoleaks and prognosis prior to discharge, after 3 months, 6 months, 12 months and yearly thereafter. Patient demographics, operative details, clinical outcomes, and complications were analyzed and then discussed in this paper. RESULTS A total of 21 patients were diagnosed with arch pathologies, 5 type A aortic dissections, 12 type B aortic dissections and 4 thoracic aortic aneurysms. There were 19 men and 2 women (mean age 60.7 ± 15.3). 8 cases were treated with t hree-fenestration stent grafts, 1 case with two-fenestration stent graft, and 12 case with single-fenestration stent grafts. Overall technical success rate was 95.2%. Mean operation time was 227.4 ± 143.8 min. Complications were intraoperative hemorrhage (>1000 ml, 2), stroke (2), hydropericardium (1) and endoleaks (2 type Ⅲ, 1 type Ⅰ). There was no aorta-related mortality or late endoleaks during the mean follow-up of 25.5 ± 6.2 months. All the bridging stents remained patent and there was no migration according to follow-up CTA. CONCLUSION With low complication and mortality rate, ISF is an effective and feasible method for the total endovascular aortic arch repair. Long-term follow-up study is needed to evaluate its durability.
Collapse
|
20
|
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.
Collapse
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
| |
Collapse
|
21
|
Cohen-Mussali S, Leon M, Ramírez-Cerda C, Cobos-Gonzalez E, Valdes-Flores J. Hybrid Procedure for Coexistence of Coarctation of the Aorta and Aberrant Right Subclavian Artery: A Case Report and Review of the Literature. Vasc Endovascular Surg 2021; 56:190-195. [PMID: 34569376 DOI: 10.1177/15385744211048309] [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: 11/15/2022]
Abstract
Background: Coarctation of the aorta (CoA) can either present alone as an isolated condition or in association with other aortic arch or cardiac anomalies. One percent of patients with CoA have concomitant an aberrant right subclavian artery (ARSA). Purpose: We report the case of a 35-year-old woman with uncontrolled hypertension who was found to have CoA and ARSA. Results: The patient was treated successfully using a hybrid procedure comprising ARSA ligation and subclavian to carotid transposition, followed by thoracic endovascular aortic repair. Conclusions: Patients with CoA should be carefully studied, considering the possible coexistence of other congenital aortic arch defects, such as ARSA. Hybrid repair is a safe and effective approach for this condition.
Collapse
Affiliation(s)
| | - Monica Leon
- 61188Centro Medico ABC, Ciudad de Mexico, Mexico
| | | | - Ernesto Cobos-Gonzalez
- 61188Centro Medico ABC, Ciudad de Mexico, Mexico.,Hospital Diomed, Ciudad de Mexico, Mexico
| | | |
Collapse
|
22
|
Naazie IN, Gupta JD, Azizzadeh A, Arbabi C, Zarkowsky D, Malas MB. Prediction of thirty-day mortality risk after thoracic endovascular aortic repair for intact descending thoracic aortic aneurysms: Derivation of risk calculator in the Vascular Quality Initiative. J Vasc Surg 2021; 75:833-841.e1. [PMID: 34506896 DOI: 10.1016/j.jvs.2021.08.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 08/05/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm (DTAA) is associated with high perioperative survival, although mortality is a possible outcome. However, no risk score has been developed to predict mortality after TEVAR for intact DTAA to aid in risk discussion and preoperative patient selection. Our objective was to use a multi-institutional database to develop a 30-day mortality risk calculator for TEVAR after DTAA repair. METHODS The Vascular Quality Initiative database was queried for patients treated with TEVAR for intact DTAA between August 2014 and August 2020. Univariable and multivariable analyses aided in developing a 30-day mortality risk score. Internal validation was done with K-fold cross-validation and calibration curve analysis. RESULTS Of 2141 patients included in the analysis, 90 (4.2%) died within 30 days after the procedure. Clinically relevant variables identified to be independently associated with 30-day mortality and therefore used to derive the predictive model included age 75 years or greater (odds ratio [OR], 2.27; 95% confidence interval [CI], 1.50-3.44; P < .001), coronary artery disease (OR, 1.60; 95% CI, 1.03-2.47; P = .036), American Society of Anesthesiologists class IV/V (OR, 2.39; 95% CI, 1.39-4.10; P = .002), urgent vs elective procedure (OR, 3.47; 95% CI, 1.90-6.33; P < .001), emergent vs elective procedure (OR, 5.27; 95% CI, 2.36-11.75; P < .001), prior carotid revascularization (OR, 3.24; 95% CI, 1.64-6.39; P = .001), and proximal landing zone <3 (OR, 2.51; 95% CI, 1.65-3.81; P < .001). The model showed an area under the receiver operating characteristic curve of 0.75. Internal validation demonstrated a bias-corrected area under the receiver operating characteristic curve of 0.73 (95% CI, 0.66-0.79) and a calibration slope of 1.00 with a corresponding intercept of 0.00. CONCLUSIONS This study provides a novel clinically relevant risk prediction model to estimate 30-day mortality risk after TEVAR for DTAA. The TEVAR Mortality Risk Calculator provides useful prognostic information to guide patient selection and facilitate preoperative discussions and shared decision making. An easily accessible online version of the TEVAR Mortality Risk Score is available to facilitate ease of use.
Collapse
Affiliation(s)
- Isaac N Naazie
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, Calif
| | - Jaideep Das Gupta
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, Calif
| | - Ali Azizzadeh
- Division of Vascular Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Cassra Arbabi
- Division of Vascular Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Devin Zarkowsky
- Division of Vascular Surgery, Department of Surgery, University of Colorado, Aurora, Colo
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, Calif.
| |
Collapse
|
23
|
Li X, Zhang L, Song C, Zhang H, Xia S, Li H, Jing Z, Lu Q. Outcomes of Total Endovascular Aortic Arch Repair with Surgeon-Modified Fenestrated Stent-Grafts on Zone 0 Landing for Aortic Arch Pathologies. J Endovasc Ther 2021; 29:109-116. [PMID: 34427153 DOI: 10.1177/15266028211036478] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES This study evaluated the feasibility and safety of total endovascular aortic arch repair with surgeon-modified fenestrated stent-graft on zone 0 landing for aortic arch pathologies. METHODS Between June 2016 and October 2019, 37 consecutive patients underwent total endovascular arch repair with surgeon-modified fenestrated stent-grafts on zone 0 landing. Outcomes included technical success, perioperative and follow-up morbidity and mortality, and branch artery patency. RESULTS During the study period, 37 patients were treated with total endovascular aortic arch repair with surgeon-modified fenestrated stent-graft. Twenty-one (56.8%) patients were diagnosed with aortic dissections, 15 (40.5%) patients with aneurysms, and 1 (2.7%) patient required reintervention due to endoleak and sac expansion from previous thoracic endovascular aortic repair for thoracoabdominal aneurysm. The proximal landing zone for all patients were in zone 0, and all branch arteries of aortic arch were reconstructed. Technical success was achieved in 34 cases (91.9%). Three (8.1%) patients had fenestrations misaligned with target arteries, and the chimney technique was applied as a complementary measure. Thirty-day mortality rate was 5.4% (n=2). Thirty-day stroke rate was 5.4% (n=2). Thirty-day reintervention rate was 2.7% (n=1). At a median follow-up of 20 months (range, 3-49 months), 5 (13.5%) patients died, including 2 aortic-related deaths, 1 nonaortic-related death, and 2 deaths of unknown reason. One (2.7%) patient had stroke. Four patients (10.8%) had reintervention during the follow-up, including 2 cases of left subclavian artery occlusion and 2 cases of type II endoleak. The estimated survival (±SE) at 2 years was 72.4%±9.7% (95% CI 53.4%-91.4%). The estimated freedom from reintervention (±SE) at 2 years was 87.4%±5.9% (95% CI 75.84%-98.96%). CONCLUSIONS Total endovascular aortic arch repair with surgeon-modified fenestrated stent-grafts on zone 0 landing is an alternate option for the treatment of aortic arch pathologies in experienced centers.
Collapse
Affiliation(s)
- Xiaoye Li
- Department of General Surgery, Division of Vascular Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Lei Zhang
- Department of General Surgery, Division of Vascular Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Chao Song
- Department of General Surgery, Division of Vascular Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Hao Zhang
- Department of General Surgery, Division of Vascular Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Shibo Xia
- Department of General Surgery, Division of Vascular Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Haiyan Li
- Department of General Surgery, Division of Vascular Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zaiping Jing
- Department of General Surgery, Division of Vascular Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qingsheng Lu
- Department of General Surgery, Division of Vascular Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| |
Collapse
|