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Mylonas SN, Aras T, Dorweiler B. A Systematic Review and an Updated Meta-Analysis of Fenestrated/Branched Endovascular Aortic Repair of Chronic Post-Dissection Thoracoabdominal Aortic Aneurysms. J Clin Med 2024; 13:410. [PMID: 38256542 PMCID: PMC10816959 DOI: 10.3390/jcm13020410] [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: 12/12/2023] [Revised: 01/07/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
The objective of this study is to present the current outcomes of fenestrated/branched endovascular repair (F/BEVAR) for post-dissection thoracoabdominal aortic aneurysms (PDTAAAs). A systematic review of the literature according to PRISMA guidelines up to October 2023 was conducted (protocol CRD42023473403). Studies were included if ≥10 patients were reported and at least one of the major outcomes was stated. A total of 10 studies with 585 patients overall were included. The pooled estimate for technical success was 94.3% (95% CI 91.4% to 96.2%). Permanent paraplegia developed with a pooled rate of 2.5% (95% CI 1.5% to 4.3%), whereas a cerebrovascular event developed with a pooled rate of 1.6% (95% CI 0.8% to 3.0%). An acute renal function impairment requiring new-onset dialysis occurred with a pooled rate of 2.0% (95% CI 1.0% to 3.8%). Postoperative respiratory failure was observed with a pooled estimate of 5.5% (95% CI 3.8% to 8.1%). The pooled estimate for 12-month overall survival was 90% (95% CI 85% to 93.5%), and the pooled estimates for 24-month and 36-month survival were 87.8% (95% CI 80.9% to 92.5%) and 85.5% (95% CI 76.5% to 91.5%), respectively. Freedom from reintervention was estimated at 83.9% (95% CI 75.9% to 89.6%) for 12 months, 82.8% (95% CI 68.7% to 91.4%) for 24 months and 76.1% (95% CI 60.6% to 86.8%) for 36 months. According to the present findings, F/BEVAR can be performed in PD-TAAAs with high rates of technical success and good mid-term results.
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Affiliation(s)
- Spyridon N. Mylonas
- Department of Vascular and Endovascular Surgery, Faculty of Medicine and University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany; (T.A.); (B.D.)
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3D Morphologic Findings Before and After Thoracic Endovascular Aortic Repair for Type B Aortic Dissection. Ann Vasc Surg 2021; 74:220-228. [PMID: 33508451 DOI: 10.1016/j.avsg.2020.12.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 12/09/2020] [Accepted: 12/13/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Stanford type-B aortic dissection (TBAD) is commonly treated by thoracic endovascular aortic repair (TEVAR). Usually, the implanted stent-grafts will not cover the entire dissection-affected region for those patients with dissection extending beyond the thoracic aorta, thus the fate of the uncovered aortic segment is uncertain. This study used 3-dimensional measurement of aortic morphological changes to classify the different remodeling effects of TBAD patients after TEVAR, and hypothesized that not only initial morphological features, but also their change over time at follow-up are associated with the remodeling. METHODS Forty-one TBAD patients underwent TEVAR and CT-angiography before and after the intervention (twice or more follow-ups) were included in this study. According to the false-lumen volume variations post-TEVAR, patients who had abdominal aortic expansion at the second follow-up were classified into the Enlarged (n =12, 29%) and remaining into the Stable group (n = 29, 71%). 3D morphological parameters were extracted on precise reconstruction of imaging datasets. Statistical differences in 3D morphological parameters over time between the 2 groups and the relationship among these parameters were analyzed. RESULTS In the Enlarged group, the number of all tears before TEVAR was significantly higher (P = 0.022), and the size of all tears at the first and second follow-up post-TEVAR were significantly higher than that in the Stable group (P = 0.008 and P = 0.007). The location of the primary tear was significantly higher (P = 0.031) in the Stable group. The cross-sectional analysis of several slices below the primary tear before TEVAR shows different shape features of the false lumen in the Stable (cone-like) and Enlarged (hourglass-like) groups. The number of tears before TEVAR has a positive correlation with the post-TEVAR development of dissection (r = 0.683, P = 0.00). CONCLUSION The results in this study indicated that the TBAD patients with larger tear areas, more re-entry tears and with the primary tear proximal to the arch would face a higher risk of negative remodeling after TEVAR.
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Pang H, Chen Y, He X, Tan X, Wang J, Yao Q, Liu X. Twelve-Month Computed Tomography Follow-Up after Thoracic Endovascular Repair for Acute Complicated Aortic Dissection. Ann Vasc Surg 2020; 71:444-450. [PMID: 32891743 DOI: 10.1016/j.avsg.2020.08.125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 07/25/2020] [Accepted: 08/05/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND To explore the impact of thoracic endovascular aortic repair (TEVAR) on aortic remodeling (AR) and the relationship between AR and complications after TEVAR. METHODS A total of 56 patients (2 type IIIA aortic dissection [AD] and 54 type IIIB AD) with complicated acute type B aortic dissection suitable for TEVAR were prospectively enrolled. There were 44 men (78%) and 12 women (22%) with an average age of 54 ± 13.8 years. Aortic enhanced computed tomography (CT) was performed pre-TEVAR and 3, 6, and 12 months postoperatively. The morphological changes in AR, namely aortic volume and false lumen thrombosis, were obtained by analyzing the CT data. The effect of TEVAR on AR was determined by the morphological changes in the aorta. The relationship between AR index, false lumen thrombosis, and complications was analyzed. RESULTS The volume of the thoracic aortic true lumen gradually increased post-TEVAR, whereas the volume of the thoracic aortic false lumen gradually decreased. The volume of abdominal aortic total lumen and false lumen increased 6 months postoperatively. The AR index increased significantly 3 months postoperatively, which was negatively correlated with complications and mortality. The thoracic and abdominal aortic false lumen thrombosis developed gradually after TEVAR, and the degree of thoracic aortic false lumen thrombosis was negatively correlated with complications and mortality. CONCLUSIONS TEVAR promotes AR. AR index and the degree of thoracic aortic false lumen thrombosis can serve as predictors of complications and mortality.
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Affiliation(s)
- Huajin Pang
- Division of Vascular and Interventional Radiology, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China.
| | - Yong Chen
- Division of Vascular and Interventional Radiology, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaofeng He
- Division of Vascular and Interventional Radiology, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiangliang Tan
- Department of Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Junling Wang
- Department of Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qianqian Yao
- Department of Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xuehan Liu
- Department of Statistics, Huazhong University of Science and Technology, Wuhan, China
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Ueki C, Tsuneyoshi H. Late Aortic Expansion After Thoracic Endovascular Aortic Repair for Chronic DeBakey IIIb Dissection. Ann Thorac Surg 2020; 111:1271-1277. [PMID: 32882195 DOI: 10.1016/j.athoracsur.2020.06.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/14/2020] [Accepted: 06/17/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The efficacy of thoracic endovascular aortic repair (TEVAR) for chronic DeBakey IIIb aortic dissection is still under discussion. This study was performed to investigate the incidence of and risk factors for late aortic expansion after TEVAR for chronic DeBakey IIIb aortic dissection. METHODS From March 2014 to April 2019, a total of 35 patients with chronic DeBakey IIIb aortic dissection underwent TEVAR in our institution. Risk factors for aortic expansion events were examined by stepwise Cox regression analysis. Aortic expansion events were defined as reintervention for expansion or aortic expansion of greater than 5 mm. RESULTS No operative death occurred, and the 2-year survival rate was 96.8%. The 1- and 2-year rates of freedom from reintervention were 87.8% and 80.2%, respectively. During follow-up, 11 patients had late aortic expansion events (4 with expansion of the thoracic aorta and 7 with expansion of the abdominal aorta). The 1- and 2-year rates of freedom from aortic expansion were 87.8% and 68.7%, respectively. Significant risk factors for expansion events were aortic dilation at the celiac level (hazard ratio [HR], 1.11; P = .015), saccular aneurysm formation of the false lumen (HR, 5.08; P = .049), and high number of residual large reentries (>5 mm) (HR, 2.78; P = .027). CONCLUSIONS In patients undergoing TEVAR for chronic DeBakey IIIb aortic dissection, late aortic expansion in both the thoracic and abdominal aorta remains an important issue. Aggressive additional intervention should be considered for high-risk patients with residual large reentries and aortic dilation at the celiac level.
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Affiliation(s)
- Chikara Ueki
- Department of Cardiovascular Surgery, Shizuoka General Hospital, Shizuoka, Japan.
| | - Hiroshi Tsuneyoshi
- Department of Cardiovascular Surgery, Shizuoka General Hospital, Shizuoka, Japan
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Finotello A, Marconi S, Pane B, Conti M, Gazzola V, Mambrini S, Auricchio F, Palombo D, Spinella G. Twelve-year Follow-up Post-Thoracic Endovascular Repair in Type B Aortic Dissection Shown by Three-dimensional Printing. Ann Vasc Surg 2018; 55:309.e13-309.e19. [PMID: 30287292 DOI: 10.1016/j.avsg.2018.07.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 06/22/2018] [Accepted: 07/07/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND Thoracic endovascular repair (TEVAR) is currently considered the therapy of choice for complicated type B acute aortic dissection (TBAAD). Although several papers have reported good outcomes at short- and medium-term follow-up, some questions still remain regarding the long-term durability and re-intervention rate during follow-up. METHODS We describe a case of a patient originally treated with TEVAR for TBAAD complicated by impending aortic rupture. RESULTS Endovascular repair successfully excluded the flow through the primary entry tear but during the 12-year follow-up period the patient experienced several complications and re-interventions. Various full-size three-dimensional (3D) models of the patient-specific vasculature were printed to better explain the different interventional interventions over the 12 years of follow-up and as a hands-on tool for medical education. CONCLUSIONS The present case report, involving long-term follow-up, provides an example of the effectiveness and the safety of TEVAR for the treatment of complicated TBAAD shown at short and medium-term follow-up. However, the long-term complications that were observed in this patient during follow-up support the importance of lifelong CTA surveillance. Furthermore, this study confirms the capability of 3D printing technology as a powerful tool to support communication with patients and residents' education through the physical analysis of the real cases.
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Affiliation(s)
- Alice Finotello
- Department of Experimental Medicine, University of Genoa, Genoa, Italy
| | - Stefania Marconi
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | - Bianca Pane
- Vascular and Endovascular Surgery Unit, Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Michele Conti
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | - Valerio Gazzola
- Vascular and Endovascular Surgery Unit, Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Simone Mambrini
- Vascular and Endovascular Surgery Unit, Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Ferdinando Auricchio
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | - Domenico Palombo
- Vascular and Endovascular Surgery Unit, Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Giovanni Spinella
- Vascular and Endovascular Surgery Unit, Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy.
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Kim TH, Song SW, Lee KH, Baek MY, Yoo KJ, Cho BK. The effect of false lumen procedures during thoracic endovascular aortic repair in patients with chronic DeBakey type IIIB dissections. J Vasc Surg 2018; 68:976-984. [DOI: 10.1016/j.jvs.2018.01.045] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 01/20/2018] [Indexed: 11/25/2022]
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Kim TH, Song SW, Lee KH, Baek MY, Yoo KJ, Lee HS. The fate of the abdominal aorta after endovascular treatment in chronic Debakey IIIb aneurysm. J Thorac Cardiovasc Surg 2018; 156:27-35.e1. [DOI: 10.1016/j.jtcvs.2018.03.118] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 02/10/2018] [Accepted: 03/02/2018] [Indexed: 11/16/2022]
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Xu H, Li Z, Dong H, Zhang Y, Wei J, Watton PN, Guo W, Chen D, Xiong J. Hemodynamic parameters that may predict false-lumen growth in type-B aortic dissection after endovascular repair: A preliminary study on long-term multiple follow-ups. Med Eng Phys 2017; 50:12-21. [PMID: 28890304 DOI: 10.1016/j.medengphy.2017.08.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Revised: 08/03/2017] [Accepted: 08/21/2017] [Indexed: 01/16/2023]
Abstract
Thoracic endovascular aortic repair (TEVAR) is commonly applied in type-B aortic dissection. For patients with dissection affects descending aorta and extends downward to involve abdominal aorta and possibly iliac arteries, false lumen (FL) expansion might occur post-TEVAR. Predictions of dissection development may assist in medical decision on re-intervention or surgery. In this study, two patients are selected with similar morphological features at initial presentation but with different long-term FL development post-TEVAR (stable and enlarged FL). Patient-specific models are established for each of the follow-ups. Flow boundaries and computational validations are obtained from Doppler ultrasound velocimetry. By analyzing the hemodynamic parameters, the false-to-true luminal pressure difference (PDiff) and particle relative residence time (RRT) are found related to FL remodeling. It is found that (i) the position of the first FL flow entry is the watershed of negative-and-positive PDiff and, in long-term follow-ups, and the position of largest PDiff is consistent with that of the greatest increase of FL width; (ii) high RRT occurs at the FL proximal tip and similar magnitude of RRT is found in both stable and enlarged cases; (iii) comparing to the RRT at 7days post-TEVAR, an increase of RRT afterwards in short-term is found in the stable case while a slight decrease of this parameter is found in the enlarged case, indicating that the variation of RRT in short-term post-TEVAR might be potential to predict long-term FL remodeling.
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Affiliation(s)
- Huanming Xu
- School of Life Science, Beijing Institute of Technology, Beijing, 100081, China; Key Laboratory of Convergence Medical Engineering System and Healthcare Technology, The Ministry of Industry and Information Technology, Beijing Institute of Technology, China
| | - Zhenfeng Li
- School of Life Science, Beijing Institute of Technology, Beijing, 100081, China; Key Laboratory of Convergence Medical Engineering System and Healthcare Technology, The Ministry of Industry and Information Technology, Beijing Institute of Technology, China
| | - Huiwu Dong
- Department of Ultrasound Diagnosis, Chinese PLA General Hospital, China
| | - Yilun Zhang
- School of Life Science, Beijing Institute of Technology, Beijing, 100081, China
| | - Jianyong Wei
- School of Life Science, Beijing Institute of Technology, Beijing, 100081, China
| | - Paul N Watton
- Department of Computer Science & INSIGNEO Institute, University of Sheffield, UK; Department of Mechanical Engineering and Material Science, University of Pittsburgh, United States
| | - Wei Guo
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing 100853, China
| | - Duanduan Chen
- School of Life Science, Beijing Institute of Technology, Beijing, 100081, China; Key Laboratory of Convergence Medical Engineering System and Healthcare Technology, The Ministry of Industry and Information Technology, Beijing Institute of Technology, China.
| | - Jiang Xiong
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing 100853, China.
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Zhang MH, Du X, Guo W, Liu XP, Jia X, Ge YY. Early and midterm outcomes of thoracic endovascular aortic repair (TEVAR) for acute and chronic complicated type B aortic dissection. Medicine (Baltimore) 2017; 96:e7183. [PMID: 28700467 PMCID: PMC5515739 DOI: 10.1097/md.0000000000007183] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Thoracic endovascular aortic repair (TEVAR) in the current era has been chosen as a dominant and minimally invasive treatment for complicated aorta dissection. This study aimed to assess safety and feasibility of TEVAR in acute and chronic type B aortic dissection.Between January 2011 and December 2013, 85 patients with complicated type B aortic dissection undergoing TEVAR were divided into acute aortic dissection (AAD) (n = 60) group and chronic aortic dissection (CAD) group (n = 25). Computed tomography was used to evaluate postoperative changes in maximal aortic diameter and true and false lumen diameters at 3 levels during a mean follow-up period of 26.4 ± 15.6 months.The technical success rate was 100%. In-hospital and 30-day rates of death were 3.3% in acute group and 0 in chronic group. Postdischarge rates of type I leak, type II leak, and retrograde type A dissection were 6.7%, 5.2%, and 3.4% (acute) and 0%, 4.0%, and 4.0% (chronic), respectively. The maximal aorta diameter remained stable in all the 3 levels in both acute and chronic group. The cumulative freedom from all-cause mortality at 3 years was similar in acute and chronic groups (89.5% vs 95.5%, P = .308). The cumulative freedom from aortic-related mortality was also not significantly different in the acute and chronic groups (92.8% vs 95.2%, P = .531). In the thoracic aorta, TEVAR treatment resulted in a significant increase in true lumen (TL) diameter and decrease in false lumen (FL). However, in the abdominal aorta, TEVAR did not lead to significant change in TL and FL diameters. The rates of complete thrombosis thoracic false lumens were better than that in the abdominal false lumen.TEVAR was a safe and effect therapy for complicated acute and chronic type B dissection with low early and mid-term mortality and morbidity.
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Endovascular Aortic Repair for Progressive Chronic Thoracoabdominal Aortic Dissections. Ann Vasc Surg 2017; 42:301.e7-301.e12. [PMID: 28341507 DOI: 10.1016/j.avsg.2016.11.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 11/11/2016] [Accepted: 11/25/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Ascending and thoracic aortic dissections progress into thoracoabdominal aneurysms 20-40% of the time, due to the initial aortic injury with associated weakness of the aortic wall. The increased firmness of the intimal flap usually results in a collapsed true lumen that does not spontaneously reexpand even with progressive dilatation of the aorta. In an effort to identify a safe and effective treatment path for this complex disease process, we present 4 cases illustrating successful sequential thoracic endovascular aortic repair (TEVAR) and fenestrated endovascular aortic repair (FEVAR). The treatment of these patients with endovascular techniques is less invasive than open conventional operations. However, multiple procedures are required using various complex novel techniques. METHODS Institutional review board approval was obtained to identify 4 cases between January 2010 and May 2015 of patients with pretreatment hypertension, who initially presented with an aortic dissection. All patients subsequently developed a descending aortic aneurysm and were treated by TEVAR and FEVAR. Monthly and yearly outcomes were analyzed. RESULTS All procedures concluded with branched visceral vessel patency and no type I endoleaks. One patient required extraction of the retrograde superior mesenteric artery stent placed during the acute phase for visceral reperfusion. Another patient developed acute thromboembolic occlusion of the right common femoral artery requiring emergent revascularization in the immediate postoperative period. CONCLUSIONS Aortic dissection is the most common cause of death related to aortic pathology. Treatment of type B aortic dissections has traditionally been initially medical therapy unless complications develop. The treatment of subsequent complications has been associated with a high morbidity and mortality rate. However, the advent of evolving endovascular therapies has resulted in the reassessment of how these patients might be handled. This case series illustrates the treatment of expanding chronic thoracoabdominal aortic dissecting aneurysms with a total endovascular approach using various novel techniques.
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