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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: 0] [Impact Index Per Article: 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.
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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
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Wang Z, Fang C, Song H, Wei D, Meng X, Bai X, Liu C, Zhao X. Endovascular repair of thoracic aortic disease with isolated left vertebral artery and unfavorable proximal landing zone using fenestrated castor stent-graft. Front Cardiovasc Med 2023; 10:1168180. [PMID: 37692046 PMCID: PMC10483811 DOI: 10.3389/fcvm.2023.1168180] [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: 02/17/2023] [Accepted: 08/11/2023] [Indexed: 09/12/2023] Open
Abstract
Objective The main purpose of this study was to evaluate the safety and efficacy of Castor single-branched stent-graft combined with fenestrated technique in treatment of thoracic aortic disease (TAD) with unfavorable proximal landing area (PLZ) and isolated left vertebral artery (ILVA). Methods From January 2018 to March 2022, 8 patients with TAD (6 patients with type B aortic dissections, 1 patient with type B intramural hematomas, and 1 patient with thoracic aortic aneurysm) underwent thoracic endovascular aortic repair with fenestrated Castor stent-graft due to the existence of ILVA and unfavorable PLZ. Demographic characteristics, surgical details, postoperative complications, follow-up and postoperative CTA imaging results were collected and analyzed. Results The primary technical success rate was 100%. The mean operation time was 115 min (range, 70-180 min). All the left subclavian arteries (LSAs) and ILVAs of the eight patients were revascularized by fenestrated Castor stent-grafts. During the follow-up period, no deaths and complications were observed. No internal leakage, aortic rupture, retrograde type A dissection were found on computed tomography angiography. All of the LSAs and ILVAs maintained patency without stenosis. Conclusion Castor single-branched stent-graft implantation combined with fenestration technique may be safe and feasible for TAD patients with ILVA and unfavorable PLZ.
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Affiliation(s)
- Zhenhua Wang
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Jinan, China
- Institute of Thoracoscopy in Cardiac Surgery, Shandong University
| | - Changcun Fang
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Jinan, China
- Institute of Thoracoscopy in Cardiac Surgery, Shandong University
| | - Han Song
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Jinan, China
- Institute of Thoracoscopy in Cardiac Surgery, Shandong University
| | - Duoliang Wei
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Jinan, China
- Institute of Thoracoscopy in Cardiac Surgery, Shandong University
| | - Xiangbin Meng
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Jinan, China
- Institute of Thoracoscopy in Cardiac Surgery, Shandong University
| | - Xiao Bai
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Jinan, China
- Institute of Thoracoscopy in Cardiac Surgery, Shandong University
| | - Chunxiao Liu
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Jinan, China
- Institute of Thoracoscopy in Cardiac Surgery, Shandong University
| | - Xin Zhao
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Jinan, China
- Institute of Thoracoscopy in Cardiac Surgery, Shandong University
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Steffner KR, Cheung AT. Preservation of Spinal Cord Function. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00023-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Ibrahim M, Chung JCY, Lindsay TF, Ouzounian M. Commentary: Aberrant vertebral arteries in aortic repair: Small but mighty! JTCVS Tech 2021; 7:57-58. [PMID: 34318206 PMCID: PMC8312118 DOI: 10.1016/j.xjtc.2021.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 03/28/2021] [Accepted: 03/31/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Marina Ibrahim
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer C.-Y. Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F. Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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Chait JD, Alsheekh A, Hingorani AP, Singh N, Marks NA, Ascher E. Partial subclavian artery coverage in TEVAR patients for acute type B aortic dissections: an alternative solution. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 62:230-233. [PMID: 33635042 DOI: 10.23736/s0021-9509.21.11677-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Acute type B aortic dissection with origin of the left subclavian artery (LSA) is generally managed with endovascular therapy for acute coverage of the LSA with: 1) no revascularization; 2) revascularization with open methods; or 3) endovascular revascularization. To identify an alternative solution, we critically evaluated a small cohort of patients who had partial coverage of their LSA. METHODS Three thoracic endovascular repairs were performed from January-March 2015. Patients were deemed eligible for endovascular repair after they had failed conservative management. Indications included acute type B dissection with lower extremity ischemia, ruptured dissection, and persistent symptoms of dissection after medical therapy. RESULTS Technical success was achieved in all three patients, and all procedures were performed percutaneously. The mean distance between the ostium of the LSA and the entry point of dissection was 11.1±3.4 mm. Within the 30-day postoperative period, there were no deaths, aortic ruptures, myocardial infarctions, or conversions to open repair. Freedom from re-intervention was noted in all 3 patients. There was no spinal cord ischemia. CONCLUSIONS There is no strong evidence to support the current optimal approach for treatment of the thoracic aorta. Partial coverage of LSA in patients with <2 cm seal zones may be considered as an alternative. However, due to our small sample size, limited follow-up, and lack of comparison cohort, further investigation is necessary.
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Affiliation(s)
| | | | | | - Nikita Singh
- Vascular Institute of New York, Brooklyn, NY, USA -
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Fang C, Wang C, Liu K, Pang X. Early Outcomes of Left Subclavian Artery Revascularization Using Castor Single-Branched Stent-Graft in the Treatment of Type B Aortic Dissection or Intramural Hematoma. Ann Thorac Cardiovasc Surg 2020; 27:251-259. [PMID: 33342930 PMCID: PMC8374093 DOI: 10.5761/atcs.oa.20-00166] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: More evidence was required to guide the management of left subclavian artery (LSA) during thoracic endovascular aortic repair (TEVAR). The present study aimed to compare the outcomes of LSA coverage with LSA revascularization. Another purpose of this study was to share our experience of LSA revascularization with castor single-branched stent-graft. Methods: From January 2016 to December 2019, 134 patients with type B aortic dissection (TBAD) or intramural hematoma (IMH) were enrolled and divided into two groups, the LSA-covered group (n = 61) and the LSA-revascularized group (with castor single-branched stent-graft, n = 73). The results, such as in-hospital and 30-day mortality, stroke, paraplegia, left arm ischemia, operation time, endoleak, were compared between the two groups. Results: The incidence of 30-day stroke in the LSA-covered group (8.2%) was significantly higher compared with the LSA-revascularized group (0%, P = 0.018). 30-day ischemia of left arm occurred in more patients in the LSA-covered group (11.5%, P = 0.003). No statistical difference was found in the incidences of paraplegia, endoleak, in-hospital mortality, and 30-day mortality. Conclusions: LSA should be revascularized during TEVAR to reduce the incidences of stroke and left arm ischemia. Castor single-branched stent-graft was feasible and safe for treating TBAD or IMH.
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Affiliation(s)
- Changcun Fang
- Department of Cardiovascular Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Chen Wang
- Department of Cardiovascular Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Kai Liu
- Department of Cardiovascular Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xinyan Pang
- Department of Cardiovascular Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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Baciewicz FA. Commentary: Dealer's choice! J Thorac Cardiovasc Surg 2019; 159:2200-2201. [PMID: 31668544 DOI: 10.1016/j.jtcvs.2019.08.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 08/06/2019] [Accepted: 08/07/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Frank A Baciewicz
- Division of Cardiothoracic Surgery, Wayne State University School of Medicine, Detroit, Mich; Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit, Mich.
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Zhu J, Xi EP, Zhu SB, Yin GL, Wang RP, Zhang Y. Management of the vertebral artery during thoracic endovascular aortic repair with coverage of the left subclavian artery. J Thorac Dis 2017; 9:1273-1280. [PMID: 28616278 DOI: 10.21037/jtd.2017.04.27] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The application of thoracic endovascular aortic repair (TEVAR), a minimally invasive operation, in the aortic arch has been a challenge of cardiovascular surgery in recent years. This study aimed to investigate management of the vertebral artery with coverage of the left subclavian artery (LSA) during TEVAR. METHODS From January 2007 to September 2014 in the Department of Cardiothoracic Surgery at Wuhan General Hospital of Guangzhou Military Region, 160 patients underwent LSA closure or partial coverage during TEVAR of an aortic lesion near the LSA. The vertebral artery treatment, the reason for the surgical approach selection, and the prognosis were analyzed. RESULTS In 94 patients with partial LSA coverage during TEVAR, no treatment was provided for the vertebral arteries, revealing blood flow of the left vertebral artery forward into the skull after surgery. For 66 patients with full LSA coverage (closure) during TEVAR, right carotid artery-left common carotid artery bypass surgery was performed before TEVAR in ten patients, without any treatment for the vertebral artery, showing reverse blood flow of the left vertebral artery after surgery. Left common carotid artery-LSA bypass surgery was performed before TEVAR in four patients; right common carotid artery-left common carotid artery-LSA bypass surgery was performed before TEVAR in three cases, and 6 out of these 7 patients underwent proximal LSA ligation, showing no obvious blood flow in the left vertebral artery. The closure of the LSA aortic arch opening using an occluder was performed in one patient, preserving the forward blood flow in the left vertebral artery. Among the 160 patients in this study, postoperative recurrent laryngeal nerve injury occurred in one patient after right common carotid artery-left common carotid artery-LSA bypass surgery, and the remaining 159 patients had no significant severe complications or death within 1 postoperative month. CONCLUSIONS Appropriate management of the aortic arch branch vessels may expand the application of TEVAR to the aortic arch and reduce complications, especially for high-risk patients who have a difficult time tolerating thoracotomy.
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Affiliation(s)
- Jian Zhu
- Department of Thoracic Cardiovascular Surgery, Wuhan General Hospital of the People's Liberation Army, Wuhan 430070, China
| | - Er-Ping Xi
- Department of Thoracic Cardiovascular Surgery, Wuhan General Hospital of the People's Liberation Army, Wuhan 430070, China
| | - Shui-Bo Zhu
- Department of Thoracic Cardiovascular Surgery, Wuhan General Hospital of the People's Liberation Army, Wuhan 430070, China
| | - Gui-Lin Yin
- Department of Thoracic Cardiovascular Surgery, Wuhan General Hospital of the People's Liberation Army, Wuhan 430070, China
| | - Rong-Ping Wang
- Department of Thoracic Cardiovascular Surgery, Wuhan General Hospital of the People's Liberation Army, Wuhan 430070, China
| | - Yu Zhang
- Department of Thoracic Cardiovascular Surgery, Wuhan General Hospital of the People's Liberation Army, Wuhan 430070, China
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Maxwell BG, Harrington KB, Beygui RE, Oakes DA. Congenital anomalies of the aortic arch in acute type-a aortic dissection: implications for monitoring, perfusion strategy, and surgical repair. J Cardiothorac Vasc Anesth 2014; 28:467-72. [PMID: 24731741 DOI: 10.1053/j.jvca.2013.12.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To assess whether management of acute Stanford type-A aortic dissection differs in patients with congenital anomalies of the aortic arch compared with standard institutional practice. DESIGN Retrospective analysis of all consecutive patients from 2001 through 2011. SETTING Quaternary referral center for surgical management of thoracic aortic disease. PARTICIPANTS All patients with arch anomalies who underwent surgery for acute Stanford type-A aortic dissection during the study period (n = 43). INTERVENTIONS Surgical management, anesthetic monitoring, and perfusion strategy were analyzed in a retrospective fashion. No new interventions were undertaken as part of this study. MEASUREMENTS AND MAIN RESULTS Management differed most in patients with an aberrant right subclavian artery (n = 5), because the institutional standard of right axillary artery cannulation with left upper extremity arterial pressure monitoring was not possible. In patients with one of two "bovine" arch patterns (n = 32), management differed in the conduct of selective antegrade cerebral perfusion, which could include clamping above or below the takeoff of the left common carotid artery (and, therefore, produced unilateral or bilateral antegrade cerebral perfusion). All patients with a connective tissue disorder exhibited a bovine arch pattern. Management of patients with a right arch (n = 3) reflected the opposite of management for normal anatomy (for patients with traditional mirror-image branching) or opposite that of the aberrant right subclavian group (for patients who had a corresponding aberrant left subclavian artery). CONCLUSIONS Rational management reflected the anatomic variations observed. These results support the importance of interdisciplinary planning, especially in an emergency, to optimize outcome.
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Affiliation(s)
- Bryan G Maxwell
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Katherine B Harrington
- Department of Cardiothoracic Surgery, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Ramin E Beygui
- Department of Cardiothoracic Surgery, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Daryl A Oakes
- Departments of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
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Wang L, Guo D, Jiang J, Shi Z, Fu W, Wang Y. Severe Compression of a Bailout Self-Expanding Chimney Stent for Rescuing the Miscoverage of Left Common Carotid Artery during TEVAR of a Type B Aortic Dissection. Ann Vasc Surg 2014; 28:742.e9-12. [DOI: 10.1016/j.avsg.2013.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Revised: 09/01/2013] [Accepted: 09/08/2013] [Indexed: 10/26/2022]
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Kiguchi M, Chaer RA. Endovascular repair of thoracic aortic pathology. Expert Rev Med Devices 2014; 8:515-25. [DOI: 10.1586/erd.11.17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Ferrero E, Ferri M, Viazzo A, Robaldo A, Zingarelli E, Sansone F, Casabona R, Nessi F. Is total debranching a safe procedure for extensive aortic-arch disease? A single experience of 27 cases. Eur J Cardiothorac Surg 2012; 41:177-82. [PMID: 21820909 DOI: 10.1016/j.ejcts.2011.05.058] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Thoracic, arch, and proximal descending thoracic aorta diseases are still considered an enormous challenge. The hybrid approach developed in recent years (supra-aortic trunks debranching and thoracic endovascular repair aortic repair; TEVAR) may improve the morbidity and mortality of the population at risk. The aim of this study was to analyze retrospectively our experience in the hybrid treatment of aortic-arch aneurysms and dissections. METHOD We carried out a retrospective review of 27 patients who required a surgical debranching of the supra-aortic trunks and a TEVAR in the management of the aortic arch and proximal descending thoracic aortic disease. The aortic lesions included 18 degenerative arch-aortic aneurysms, four complicated aortic dissections, two subclavian artery aneurysms, and three penetrating atherosclerotic ulcers. Technical success was achieved in all patients. RESULTS The 30-day mortality rate was 11.1% (3/27). Mean follow-up was 16.7 months (range, 1-56), and the survival rate was 77.8%. The endoleaks' rate was 3.7% (1/27), due to a stent-graft migration. CONCLUSION Hybrid approaches may represent an alternative option in the treatment of complex aortic lesions involving the arch and the proximal descending thoracic aorta in high-risk patients and emergency cases. However, the promising early results need to be confirmed by longer follow-up and larger comparative series.
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Affiliation(s)
- Emanuele Ferrero
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Largo Turati 62, 10128 Turin, Italy.
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Nathan DP, Woo EY, Fairman RM, Wang GJ, Pochettino A, Desai ND, Bavaria JE, Jackson BM. Stent grafting for aneurysmal degeneration of chronic descending thoracic aortic dissections. J Vasc Surg 2012; 55:963-7. [DOI: 10.1016/j.jvs.2011.11.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 10/28/2011] [Accepted: 11/01/2011] [Indexed: 01/12/2023]
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Tholpady A, Hendricks DE, Bozlar U, Turba UC, Sabri SS, Angle JF, Arslan B, Cherry KJ, Dake MD, Matsumoto AH, Saad WEA, Park AW, Bonatti H, Hagspiel KD. Percutaneous occlusion of the left subclavian and celiac arteries before or during endograft repair of thoracic and thoracoabdominal aortic aneurysms with detachable nitinol vascular plugs. J Vasc Interv Radiol 2011; 21:1501-7. [PMID: 20801685 DOI: 10.1016/j.jvir.2010.05.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Revised: 05/14/2010] [Accepted: 05/19/2010] [Indexed: 10/19/2022] Open
Abstract
PURPOSE To review an experience with the Amplatzer vascular plug (AVP) for prevention of type II endoleaks during endovascular aneurysm repair (EVAR) of thoracic and thoracoabdominal aneurysms. MATERIALS AND METHODS Retrospective review was undertaken of 14 patients undergoing transcatheter occlusion of the left subclavian (n = 12) or celiac artery (n = 2) with the AVP as part of EVAR of thoracic and thoracoabdominal aneurysms at a single institution. Procedural criteria evaluated were success at target vessel occlusion, the number of AVPs used, use of adjunctive embolization devices, and embolization-related ischemic end-organ events. Follow-up imaging criteria included evaluation of persistent target vessel occlusion, evidence of device migration, and the presence and characterization of endoleak secondary to AVP failure. RESULTS Complete target vessel occlusion was documented for all cases. In six cases, more than one AVP was placed, with an average of 1.5 devices per patient. In two cases, adjunctive coils were placed. Computed tomographic or magnetic resonance angiography follow-up was available for all patients (mean follow-up, 419 days; range 28-930 d). No case showed evidence of device migration or type II endoleak resulting from AVP failure. There was a single instance of left subclavian artery recanalization without type II endoleak. There were no embolization-related ischemic end-organ events. CONCLUSIONS Transcatheter arterial occlusion of the subclavian and celiac arteries with the AVP is a valuable adjunct to endografting in cases in which side branch embolization is necessary to extend the landing zone.
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Affiliation(s)
- Ashok Tholpady
- Department of Radiology, University of Virginia Health System, Box 800170, Lee Street, Charlottesville, VA 22908, USA
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Brinster CJ, Szeto WY, Bavaria JE, Woo EY, Fairman RM, Jackson BM. Endovascular repair of extent I thoracoabdominal aneurysms with landing zone extension into the aortic arch and mesenteric portion of the abdominal aorta. J Vasc Surg 2010; 52:460-3. [PMID: 20541342 DOI: 10.1016/j.jvs.2010.03.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Revised: 03/04/2010] [Accepted: 03/05/2010] [Indexed: 11/30/2022]
Abstract
Thoracic endovascular aortic repair (TEVAR) has emerged as an alternative for patients at prohibitive risk for open thoracic or thoracoabdominal surgery, decreasing perioperative morbidity and mortality. Aneurysms that involve both the left subclavian artery (LSA) proximally and the celiac artery (CA) distally present a unique challenge to the use of TEVAR. We report a series of six high-risk patients presenting with extent I thoracoabdominal aortic aneurysms who were successfully treated with TEVAR including coverage of the LSA and the CA.
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Affiliation(s)
- Clayton J Brinster
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa 19104, USA.
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Holt PJ, Johnson C, Hinchliffe RJ, Morgan R, Jahingiri M, Loftus IM, Thompson MM. Outcomes of the endovascular management of aortic arch aneurysm: Implications for management of the left subclavian artery. J Vasc Surg 2010; 51:1329-38. [DOI: 10.1016/j.jvs.2009.10.131] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2009] [Revised: 10/20/2009] [Accepted: 10/21/2009] [Indexed: 10/19/2022]
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Karmy-Jones R, Kouchoukos NT. Endovascular credentialing and assembling the endovascular team. J Card Surg 2009; 24:334-42. [PMID: 19438793 DOI: 10.1111/j.1540-8191.2009.00839.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Riyad Karmy-Jones
- Department of Thoracic and Vascular Surgery, Southwest Washington Medical Center, Vancouver, Washington, USA
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Adams JD, Garcia LM, Kern JA. Endovascular Repair of the Thoracic Aorta. Surg Clin North Am 2009; 89:895-912, ix. [DOI: 10.1016/j.suc.2009.06.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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McDonnell CO, Haider SN, Colgan MP, Shanik GD, Moore DJ, Madhavan P. Endovascular management of thoracic aortic pathology. Surgeon 2009; 7:24-30. [PMID: 19241982 DOI: 10.1016/s1479-666x(09)80063-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Endovascular technology has revolutionised the management of abdominal aortic aneurysmal disease but the less frequent occurrence of pathology in the thoracic aorta has meant that evidence demonstrating the primacy of endovascular treatment strategies in this portion of the vessel is less convincing. Herein we summarise the best available evidence to date. METHODS A comprehensive search of the surgical and radiological literature using the search term 'endovascular thoracic aorta' was conducted. FINDINGS AND CONCLUSIONS The vast majority of patients treated by thoracic aortic stent grafting have had their treatment outside the context of a randomised trial. While it would seem that endovascular repair is the treatment of choice for the thoracic aorta, the present evidence is based on single centre case series and is anecdotal at best.
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Affiliation(s)
- C O McDonnell
- Department ofVascular Surgery, Mater Misericordiae University Hospital, Dublin, Ireland.
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Abstract
In 2005, the findings of the multicenter Gore Tag study led to United States Food and Drug Administration approval for endovascular repair of thoracic aortic aneurysms (TEVAR). TEVAR provides a therapeutic option for patients who have thoracic aortic aneurysm and for the treatment of type B aortic dissection with malperfusion. Spinal cord ischemia and stroke are recognized neurologic complications of TEVAR. Identification of high-risk patients combined with targeted anesthetic and perioperative management may decrease the risk of neurologic complications after TEVAR.
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Qu L, Raithel D. Two-Year Single-Center Experience With Thoracic Endovascular Aortic Repair Using the EndoFit Thoracic Stent-Graft. J Endovasc Ther 2008; 15:530-8. [DOI: 10.1583/08-2364.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Woo EY, Carpenter JP, Jackson BM, Pochettino A, Bavaria JE, Szeto WY, Fairman RM. Left subclavian artery coverage during thoracic endovascular aortic repair: A single-center experience. J Vasc Surg 2008; 48:555-60. [DOI: 10.1016/j.jvs.2008.03.060] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2008] [Revised: 03/28/2008] [Accepted: 03/31/2008] [Indexed: 10/21/2022]
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Noor N, Sadat U, Hayes PD, Thompson MM, Boyle JR. Management of the Left Subclavian Artery During Endovascular Repair of the Thoracic Aorta. J Endovasc Ther 2008; 15:168-76. [DOI: 10.1583/08-2406.1] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Gutsche JT, Cheung AT, McGarvey ML, Moser WG, Szeto W, Carpenter JP, Fairman RM, Pochettino A, Bavaria JE. Risk factors for perioperative stroke after thoracic endovascular aortic repair. Ann Thorac Surg 2007; 84:1195-200; discussion 1200. [PMID: 17888969 DOI: 10.1016/j.athoracsur.2007.04.128] [Citation(s) in RCA: 137] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Revised: 04/23/2007] [Accepted: 04/24/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Stroke has emerged as an important complication of thoracic endovascular aortic repair (TEVAR). Identifying risk factors for stroke is important to define the risks of this procedure. METHODS All neurologic complications were analyzed in a prospective database of patients in thoracic aortic stent graft trials from 1999 to 2006. Serial neurological examination was performed. Stroke was defined as any new onset focal neurologic deficit. RESULTS The TEVAR was performed on 171 patients; 52 had lesions requiring coverage of the proximal descending thoracic aorta (extent A), 50 requiring coverage of the distal descending aorta (extent B), and 69 requiring coverage of the entire descending thoracic aorta (extent C). The incidence of stroke was 5.8%. Eighty-nine percent (8 of 9) of strokes occurred within 24 hours of operation. Stroke was associated with a 33% in-hospital mortality rate. Risk factors identified for stroke included prior stroke (odds ratio [OR] 9.4, confidence interval [CI] 2.3 to 38.1, p = 0.002) and extent A or C coverage (OR 5.5, CI 1.7-12.5, p = 0.001). The stroke rate in patients with both prior stroke and extent A or C coverage was 27.7%. Severe atheromatous disease involving the aortic arch by computed tomographic scan was strongly associated with perioperative stroke (OR = 14.8, CI 1.7 to 675.6, p = 0.0016). Transesophageal echocardiography demonstrated mobile atheroma in two patients with stroke. CONCLUSIONS Stroke after TEVAR was associated with a high mortality. The TEVAR of the proximal descending aorta (extent A or C) in patients with a history of stroke had the highest perioperative stroke rate. These risk factors, together with high grade aortic atheroma of the aortic arch, predicted a high probability for cerebral embolization and can be used to identify patients at high risk for stroke as a consequence of TEVAR.
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Affiliation(s)
- Jacob T Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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