1
|
Thoracic Endovascular Aortic Repair (TEVAR) First in Patients with Lower Limb Ischemia in Complicated Type B Aortic Dissection: Clinical Outcome and Morphology. J Clin Med 2022; 11:jcm11144154. [PMID: 35887918 PMCID: PMC9320233 DOI: 10.3390/jcm11144154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 07/03/2022] [Accepted: 07/15/2022] [Indexed: 11/17/2022] Open
Abstract
Acute Type B aortic dissection (TBAD) can cause organ malperfusion, e.g., lower limb ischemia (LLI). Thoracic endovascular aortic repair (TEVAR) represents the standard treatment for complicated TBAD; however, with respect to LLI, data is scant. The aim of this study was to investigate clinical and morphological outcomes in patients with complicated TBAD and LLI managed with a "TEVAR-first" policy. Between March 1997 and December 2021, 731 TEVAR-procedures were performed, including 106 TBAD-cases. Cases with TBAD + LLI were included in this retrospective analysis. Study endpoints were morphological/clinical success of TEVAR, regarding aortic and extremity-related outcome, including extremity-related adjunct procedures (erAP) during a median FU of 28.68 months. A total of 20/106 TBAD-cases (18.8%, 32-82 years, 7 women) presented with acute LLI (12/20 Rutherford class IIb/III). In 15/20 cases, true lumen-collapse (TLC) was present below the aortic bifurcation. In 16/20 cases, TEVAR alone resolved LLI. In the remaining four cases, erAP was necessary. A morphological analysis showed a relation between lower starting point and lesser extent of TLC and TEVAR success. No extremity-related reinterventions and only one major amputation was needed. The data strongly suggest that aTEVAR-first-strategy for treating TBAD with LLI is reasonable. Morphological parameters might be of importance to anticipate the failure of TEVAR alone.
Collapse
|
2
|
Surgical Fenestration for Lower Limb Ischemia Developing from Chronic Type B Aortic Dissection: A Report of 2 Cases. Ann Vasc Surg 2015; 31:208.e9-208.e14. [PMID: 26627318 DOI: 10.1016/j.avsg.2015.08.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 08/22/2015] [Accepted: 08/27/2015] [Indexed: 11/21/2022]
Abstract
Lower limb ischemia caused by type B aortic dissection typically presents with a leg-threatening condition in the acute phase. However, in some cases, lower limb ischemia symptom develops as intermittent claudication in the chronic phase. Although surgical fenestration has been used for treating ischemic complications of aortic dissection, it has recently become an alternative option for such cases because of the significant advance of endovascular treatments. We report 2 cases of chronic type B aortic dissection complicated by lower limb ischemia. Two male patients aged 57 and 43 years presented with intermittent claudication more than 2 weeks after the onset of the disease. On the basis of anatomic condition of the dissected aorta, we successfully performed surgical fenestration through a median laparotomy. In the current endovascular era, surgical fenestration remains an effective and durable option for treating lower limb ischemia caused by chronic type B aortic dissection.
Collapse
|
3
|
Gargiulo M, Bianchini Massoni C, Gallitto E, Freyrie A, Trimarchi S, Faggioli G, Stella A. Lower limb malperfusion in type B aortic dissection: a systematic review. Ann Cardiothorac Surg 2014; 3:351-67. [PMID: 25133098 DOI: 10.3978/j.issn.2225-319x.2014.07.05] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 07/19/2014] [Indexed: 11/14/2022]
Abstract
BACKGROUND Lower limb malperfusion (LLM) syndrome occurs in up to 40% of complicated type B aortic dissections (TBAD) and in up to 71% of TBAD with malperfusion syndrome. This syndrome is associated with higher 30-day mortality. The aim of this systematic review was to provide clinical and procedural data of patients with LLM syndrome secondary to TBAD. METHODS The PubMed database was systematically searched from January 2000 to June 2014 for English-language publications reporting on demographic data of patients with LLM secondary to TBAD. RESULTS A total of 29 papers were included (10 original articles and 19 case reports), reporting on a total of 138 patients (mean age =58±12 years; male =87%). Lower limb complications developed in acute and chronic TBAD in 134 (97%) and 4 (3%) cases, respectively. LLM presented with acute limb ischemia in 120 (87%) patients. Bilateral clinical presentation occurred in 56% (40/72) of cases. LLM was the only clinically detected malperfusion in 52% of cases (44/84). In 40% (35/84) and 25% (21/84) of cases, LLM was clinically associated with renal and visceral malperfusion, respectively. Radiological imaging showed renal, celiac trunk and superior mesenteric artery involvement in 53% (47/88), 31% (27/88) and 34% (30/88) of cases, respectively. Medical, surgical and endovascular treatments were performed in 22 (16%), 51 (37%) and 65 (47%) patients, respectively. Thirty-day morbidity was 31% (13/42) and 46% (6/13) following surgical and endovascular treatment, respectively. Thirty-day mortality was 14% (5/36) and 8% (2/26) following surgical and endovascular treatment, respectively. CONCLUSIONS LLM syndrome secondary to TBAD usually developed during the acute phase and, in most cases, presented with acute limb ischemia. Bilateral clinical presentation occurred in more than half of cases. Renal and visceral malperfusion were frequently associated with lower limb flow reduction but LLM was the only clinically detected malperfusion in more than half of patients. Surgical fenestration was burdened with significant complication rates and 30-day mortality. Endovascular procedures showed lower mortality but complication rates remained high.
Collapse
Affiliation(s)
- Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Policlinico Sant'Orsola-Malpighi, Bologna, Italy ; 2 Vascular Surgery, Department of Cardiovascular Surgery, Thoracic Aortic Research Center, Policlinico San Donato I.R.C.C.S., University of Milan, Italy
| | - Claudio Bianchini Massoni
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Policlinico Sant'Orsola-Malpighi, Bologna, Italy ; 2 Vascular Surgery, Department of Cardiovascular Surgery, Thoracic Aortic Research Center, Policlinico San Donato I.R.C.C.S., University of Milan, Italy
| | - Enrico Gallitto
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Policlinico Sant'Orsola-Malpighi, Bologna, Italy ; 2 Vascular Surgery, Department of Cardiovascular Surgery, Thoracic Aortic Research Center, Policlinico San Donato I.R.C.C.S., University of Milan, Italy
| | - Antonio Freyrie
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Policlinico Sant'Orsola-Malpighi, Bologna, Italy ; 2 Vascular Surgery, Department of Cardiovascular Surgery, Thoracic Aortic Research Center, Policlinico San Donato I.R.C.C.S., University of Milan, Italy
| | - Santi Trimarchi
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Policlinico Sant'Orsola-Malpighi, Bologna, Italy ; 2 Vascular Surgery, Department of Cardiovascular Surgery, Thoracic Aortic Research Center, Policlinico San Donato I.R.C.C.S., University of Milan, Italy
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Policlinico Sant'Orsola-Malpighi, Bologna, Italy ; 2 Vascular Surgery, Department of Cardiovascular Surgery, Thoracic Aortic Research Center, Policlinico San Donato I.R.C.C.S., University of Milan, Italy
| | - Andrea Stella
- 1 Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Policlinico Sant'Orsola-Malpighi, Bologna, Italy ; 2 Vascular Surgery, Department of Cardiovascular Surgery, Thoracic Aortic Research Center, Policlinico San Donato I.R.C.C.S., University of Milan, Italy
| |
Collapse
|