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Cao L, Zhang H, Ge Y, Guo W. Avoiding Stroke in Patients Undergoing Endovascular Aortic Arch Repair: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 82:265-277. [PMID: 37438011 DOI: 10.1016/j.jacc.2023.04.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/10/2023] [Accepted: 04/24/2023] [Indexed: 07/14/2023]
Abstract
As the bottleneck of endovascular aortic arch repair, early postoperative stroke remains a devastating complication in high-risk patients and a critical concern for the development of optimal endovascular techniques and devices. The incidence of early postoperative stroke varies widely among currently available endovascular techniques and devices, with reported rates ranging from 0.0% to 42.9%, and is significantly influenced by the severity of the patient's preexisting aortic atherosclerotic burden, air released from the endovascular device, and a variety of factors leading to cerebral perfusion insufficiency. Currently, preidentification of high-risk patients and careful perioperative management appear to play a critical role in reducing stroke incidence. Specific intraoperative prevention methods are still lacking, but embolic protection devices and carbon dioxide or high-volume saline flushing of endovascular devices appear promising. Detailed preoperative stroke risk stratification and screening for optimal endovascular techniques and devices for aortic arch treatment are unmet clinical needs.
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Affiliation(s)
- Long Cao
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China; Department of General Surgery, The 983rd Hospital of Joint Logistic Support Force of PLA, Tianjin, China
| | - Hongpeng Zhang
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Yangyang Ge
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Wei Guo
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China.
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Crockett S, Hanna L, Singh A, Gunning S, Nicholas R, Bicknell C, Hamady M, Gable D, Sallam M, Modarai B, Abisi S, Lyons O, Gibbs R. Carbon dioxide flushing versus saline flushing of thoracic aortic stents (INTERCEPTevar): protocol for a multicentre pilot randomised controlled trial. BMJ Open 2023; 13:e067605. [PMID: 37105705 PMCID: PMC10151986 DOI: 10.1136/bmjopen-2022-067605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 02/21/2023] [Indexed: 04/29/2023] Open
Abstract
INTRODUCTION Thoracic endovascular aortic repair (TEVAR) carries a 3%-6.1% stroke risk, including risk of 'silent' cerebral infarction (SCI). Stent-grafts are manufactured in room air and retain air. Instructions for use recommend saline flushing to 'de-air' the system prior to insertion, but substantial amounts of air are released when deploying them, potentially leading to downstream neuronal injury and SCI. Carbon dioxide (CO2) is more dense and more soluble in blood than air, without risk of bubble formation, so could be used in addition to saline to de-air stents. This pilot trial aims to assess the feasibility of a full-scale randomised controlled trial (RCT) investigating the neuroprotective benefit against SCI with the use of CO2-flushed aortic stent-grafts. METHODS AND ANALYSIS This is a multicentre pilot RCT, which is taking place in vascular centres in the UK, USA and New Zealand. Patients identified for TEVAR will be enrolled after informed written consent. 120 participants will be randomised (1:1) to TEVAR-CO2 or TEVAR-saline, stratified according to TEVAR landing zone. Participants will undergo preoperative neurocognitive tests and quality of life assessments, which will be repeated at 6 weeks, or first outpatient appointment, and 6 months. Inpatient neurological testing will be performed within 48 hours of return to level 1 care for clinical stroke or delirium. Diffusion-weighted MRI will be undertaken within 72 hours postoperatively (1-7 days) and at 6 months to look for evidence and persistence of SCI. Feasibility will be assessed via measures of recruitment and retention, informing the design of a full-scale trial. ETHICS AND DISSEMINATION The study coordination centre has obtained approval from the London Fulham Research Ethics Committee (19/LO/0836) and Southern Health and Disability Ethics Committee (NZ) and UK's Health Regulator Authority (HRA). The study has received ethical approval for recruitment in the UK (Fulham REC, 19/LO/0836), New Zealand (21/STH/192) and the USA (IRB 019-264, Ref 378630). Consent for entering into the study will be taken using standardised consent forms by the local study team, led by a local PI. The results of the trial will be submitted for publication in an open access journal. TRIAL REGISTRATION NUMBER NCT03886675.
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Affiliation(s)
- Stephen Crockett
- Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Lydia Hanna
- Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Abhinav Singh
- Neuroradiology Department, Imperial College Healthcare NHS Trust, London, UK
| | - Stephen Gunning
- Clinical Health and Psychology Department, Imperial College Healthcare NHS Trust, London, UK
| | - Richard Nicholas
- Neurology Department, Imperial College Healthcare NHS Trust, London, UK
| | - Colin Bicknell
- Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Mohamad Hamady
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Dennis Gable
- Vascular Surgery Department, Baylor Scott & White Health, Dallas, Texas, USA
| | - Morad Sallam
- Vascular Surgery Department, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Bijan Modarai
- Vascular Surgery Department, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Said Abisi
- Vascular Surgery Department, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Oliver Lyons
- Vascular Surgery Department, Canterbury District Health Board, Christchurch, New Zealand
| | - Richard Gibbs
- Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
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C Schaefer T, Greive S, Heiland S, Kramer M, Bendszus M, Vollherbst DF. Investigation of Experimental Endovascular Air Embolisms Using a New Model for the Generation and Detection of Highly Calibrated Micro Air Bubbles. J Endovasc Ther 2022; 30:461-470. [PMID: 35255747 DOI: 10.1177/15266028221082010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Air embolism (AE), especially when affecting the brain, is an underrated and potentially life-threatening complication in various endovascular interventions. This study aims to investigate experimental AEs using a new model to generate micro air bubbles (MAB), to assess the impact of a catheter on these MAB, and to demonstrate the applicability of this model in vivo. MATERIALS AND METHODS Micro air bubbles were created using a system based on microfluidic channels. The MAB were detected and analyzed automatically. Micro air bubbles, with a target size of 85 µm, were generated and injected through a microcatheter. The MAB diameters proximal and distal to the catheter were assessed and compared. In a subsequent in vivo application, 2000 MAB were injected into the aorta (at the aortic valve) and into the common carotid artery (CCA) of a rat, respectively, using a microcatheter, resembling AE occurring during cardiovascular interventions. RESULTS Micro air bubbles with a highly calibrated size could be successfully generated (median: 85.5 µm, SD 1.9 µm). After passage of the microcatheter, the MAB were similar in diameter (median: 86.6 µm) but at a lower number (60.1% of the injected MAB) and a substantially higher scattering of diameters (SD 29.6 µm). In vivo injection of MAB into the aorta resulted in cerebral microinfarctions in both hemispheres, whereas injection into the CCA caused exclusively ipsilateral microinfarctions. CONCLUSION Using this new AE model, MAB can be generated precisely and reproducibly, resulting in cerebral microinfarctions. This model is feasible for further studies on the pathophysiology and prevention of AE in cardiovascular procedures.
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Affiliation(s)
- Tabea C Schaefer
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany.,Clinic for Small Animals, Justus Liebig University Gießen, Gießen, Germany
| | - Svenja Greive
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Sabine Heiland
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Kramer
- Clinic for Small Animals, Justus Liebig University Gießen, Gießen, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Dominik F Vollherbst
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
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Tsilimparis N, Stana J, Konstantinou N, Chen M, Zhou Q, Kölbel T. Identifying risk factors for early neurological outcomes following thoracic endovascular aortic repair using the SUMMIT database. Eur J Cardiothorac Surg 2021; 62:6420381. [PMID: 34734253 DOI: 10.1093/ejcts/ezab476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 09/27/2021] [Accepted: 10/03/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim of this study was to assess risk factors for early neurological complications following thoracic endovascular aortic repair (TEVAR) for multiple thoracic aortic diseases using an aggregated dataset. METHODS The Study to Assess Outcomes After Endovascular Repair for Multiple Throacic Aortic Disease dataset included data from 6 studies evaluating Zenith thoracic endografts. Post hoc analysis identified early (30-day) neurological complications by TEVAR indication and corresponding risk factors. RESULTS The study included 594 TEVAR patients (67% male; mean age 66 ± 15 years) with thoracic aortic aneurysm (n = 329), ulcer (n = 56), acute (n = 126) or non-acute (n = 33) type B aortic dissection (TBAD) or blunt injury (n = 50). Overall early stroke rate was 3.5% (n = 21). Overall early paraplegia and paraparesis rates were 1.3% (n = 8) and 2.5% (n = 15), respectively. Multivariable analysis identified acute TBAD [versus others, odds ratio (OR) = 3.47, 95% confidence internal (CI): 1.41-8.52) and longer procedural time (OR = 1.33, CI: 1.02-1.73) as early stroke risk factors. Risk factors for paraplegia or paraparesis included more endografts deployed (OR = 2.43, CI: 1.30-4.55), older age (OR = 1.05, CI: 1.01-1.10) and higher preoperative serum creatinine (OR = 1.31, CI: 1.05-1.64). Endografts landing proximal to the left subclavian artery (LSA) increased stroke rate (versus distal to the LSA; 6.8% vs 2.3%, P = 0.014). Intraoperative LSA revascularization was performed in 20.9% of patients with endografts proximal to the LSA; revascularization did not significantly alter stroke rate (8.1% with revascularization vs 6.4% without, P = 0.72). CONCLUSIONS Acute TBAD and prolonged procedure time increased early stroke risk, while more endografts placed, age and preoperative renal impairment increased early paraplegia or paraparesis risk. For acute TBAD, endograft placement proximal to the LSA, but not LSA patency, increased stroke risk.
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Affiliation(s)
- Nikolaos Tsilimparis
- Department of Vascular Surgery, Ludwig-Maximilians University Hospital, Munich, Germany
| | - Jan Stana
- Department of Vascular Surgery, Ludwig-Maximilians University Hospital, Munich, Germany
| | - Nikolaos Konstantinou
- Department of Vascular Surgery, Ludwig-Maximilians University Hospital, Munich, Germany
| | - Min Chen
- Cook Research Incorporated, West Lafayette, IN, USA
| | - Qing Zhou
- Cook Research Incorporated, West Lafayette, IN, USA
| | - Tilo Kölbel
- German Aortic Center, University Heart & Vascular Center, Hamburg, Germany
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Banno H, Mutsuga M, Sugimoto M, Tokuda Y, Kodama A, Usui A, Komori K. Midterm Outcomes of Zone 0 Antegrade Endograft Implantation During Type I Hybrid Aortic Arch Repair. Eur J Vasc Endovasc Surg 2021; 61:938-944. [PMID: 33773906 DOI: 10.1016/j.ejvs.2021.02.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 02/05/2021] [Accepted: 02/22/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Type I hybrid arch repair has become popular as a procedure that is less invasive than total arch replacement. The major advantage of this technique is that antegrade endograft implantation can be performed during the procedure, thereby avoiding the complications of introducing the endograft from the groin. The aim of this study was to assess the midterm outcomes of type I hybrid aortic arch repair with antegrade endograft implantation. METHODS Thirty consecutive patients who underwent type I hybrid repair with antegrade endograft implantation from 2009 to 2015 were reviewed retrospectively. Patient demographics, and peri-operative and late results were collected from a prospective database and analysed. RESULTS Four patients (13%) were female and the median age was 78 years. Median aneurysm size was 64 mm. Six patients (20%) developed stroke, and the 30 day mortality rate was 3%. Two patients suffered aortic dissection at the site of debranching anastomosis. The median follow up was 5.2 years. All aneurysms remained stable or had decreased in size at three years, and 82% were stable at five years. Overall survival was 79% at three years and 71% at five years. The rates of freedom from aorta related death were 86% at three and five years, respectively. During the follow up period, three additional left subclavian artery embolisations and one endograft relining due to type IIIb endoleak were required. CONCLUSION Midterm outcomes of type I hybrid aortic arch repair with antegrade endograft implantation for aortic arch aneurysms are reported. Although the incidence of peri-operative stroke was high, late sac behaviour was acceptable.
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Affiliation(s)
- Hiroshi Banno
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Masato Mutsuga
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masayuki Sugimoto
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshiyuki Tokuda
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akio Kodama
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kimihiro Komori
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Branzan D, Geisler A, Steiner S, Lautenschlaeger T, Doss M, Matschuck M, Scheinert D, Schmidt A. Stroke rate after thoracic endovascular aortic repair using de-airing of stentgrafts with high-volume of saline solution. VASA 2021; 50:186-192. [PMID: 33559507 DOI: 10.1024/0301-1526/a000937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: Our aim was to determine the rate of ischemic stroke following thoracic endovascular aortic repair (TEVAR) after reducing gas volume released during stentgraft deployment by de-airing of thoracic stentgrafts with high-volume of 0.9% heparinized saline solution. Patients and methods: A single center retrospective analysis of all consecutive patients undergoing TEVAR from 2014 to 2019 was performed. All thoracic stentgrafts were flushed with 120 ml 0.9% heparinized saline solution before implantation, according to our institutional protocol. Endpoints were in-hospital rates of ischemic stroke and spinal cord ischemia (SCI), and all-cause mortality. Results: One hundred and fifty-four patients (mean age: 66.8 ± 13.6 years, 64.9% males) were treated with TEVAR during the study period. Indications for treatment were thoracic aortic aneurysms (n = 75, 48.7%), acute type B aortic dissections (n = 46, 29.9%), aortic arch aneurysms and penetrating aortic ulcers (n = 28, 18.2%), and blunt traumatic aortic injuries (n = 5, 3.2%). Timing of procedure was urgent in 75 patients (48.7%). Proximal landing zone were zone 0-1-2 (n = 75, 48.7%), zone 3 (n = 66, 42.9%) and zone 4 (n = 13, 8.4%). Supra-aortic vessels were revascularized with custom-made fenestrated stentgrafts in 9 patients (5.8%), using chimney technique in 4 patients (2.6%), and with debranching procedures in 19 patients (12.3%). Left subclavian artery was covered without revascularization in 46 patients (29.9%). In-hospital stroke occurred in two patients (1.3%) and SCI in another two patients (1.3%). In-hospital mortality rate was 0.6%. No further in-hospital events were noted. Conclusions: De-airing of stentgrafts with high-volume of 0.9% heparinized saline solution seems to be safe and can be used as an adjunct to keep occurrence of neurological events after TEVAR as low as possible.
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Affiliation(s)
- Daniela Branzan
- Department of Vascular Surgery, University Hospital Leipzig, Germany
| | - Antonia Geisler
- Department of Vascular Surgery, University Hospital Leipzig, Germany
| | - Sabine Steiner
- Department of Interventional Angiology, University Hospital Leipzig, Germany
| | | | - Markus Doss
- Department of Vascular Surgery, University Hospital Leipzig, Germany
| | - Manuela Matschuck
- Department of Interventional Angiology, University Hospital Leipzig, Germany
| | - Dierk Scheinert
- Department of Interventional Angiology, University Hospital Leipzig, Germany
| | - Andrej Schmidt
- Department of Interventional Angiology, University Hospital Leipzig, Germany
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Abstract
Systemic arterial air embolism (SAAE) is a rare but potentially life-threatening condition that may occur when air enters into pulmonary veins or directly into the systemic circulation after pulmonary procedures (biopsy or resection) or penetrating trauma to the lung. While venous air embolism is commonly reported, arterial air embolism is rare. Even a minor injury to the chest along with positive-pressure ventilation can cause SAAE. Small amounts of air may cause neurological or cardiac symptoms depending on the affected arteries, while massive embolism can result in fatal cardiovascular collapse. We discuss the various causes of SAAE, including trauma, computed tomography-guided lung biopsy, and various intervention procedures such as mechanical circulatory support device implantation, coronary catheterization, and atrial fibrillation repair. SAAE diagnosis can be overlooked because its symptoms are not specific, and confirmation of the presence of air in the arterial system is difficult. Although computed tomography is the optimal imaging tool for diagnosis, patient instability and resuscitation often precludes its use. When imaging is performed, awareness of the causes of SAAE allows the radiologist to promptly diagnose the condition and relay findings to the clinicians so that treatment, namely hyperbaric oxygen therapy, may be started promptly.
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Brain Protection in the Endo-Management of Proximal Aortic Aneurysms. HEARTS 2020. [DOI: 10.3390/hearts1020005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Neurological brain injury (NBI) remains the most feared complication following thoracic endovascular aortic repair (TEVAR), and can manifest as clinically overt stroke and/or more covert injury, detected only on explicit neuropsychological testing. Microembolic signals (MES) detected on transcranial Doppler (TCD) monitoring of the cerebral arteries during TEVAR and the high prevalence and incidence of new ischaemic infarcts on diffusion-weighted magnetic resonance imaging (DW-MRI) suggests procedure-related solid and gaseous cerebral microembolisation to be an important cause of NBI. Any intervention that can reduce the embolic burden during TEVAR may, therefore, help mitigate the risk of stroke and the covert impact of ischaemic infarcts to the function of the brain. This perspective article provides an understanding of the mechanism of stroke and reviews the available evidence regarding potential neuroprotective strategies that target high-risk procedural steps of TEVAR to reduce periprocedural cerebral embolisation.
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Eleshra A, Saleptsis V, Spanos K, Rohlffs F, Tsilimparis N, Panuccio G, Makaloski V, Debus ES, Kölbel T. Retrospective Comparative Study on Differences in Presence of Gas in the Aneurysm Sac after Endovascular Aortic Aneurysm Repair in Early Postoperative Period between Carbon Dioxide Flushing Technique and Saline Flushing of the Delivery System. Ann Vasc Surg 2019; 61:310-316. [PMID: 31381997 DOI: 10.1016/j.avsg.2019.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/03/2019] [Accepted: 05/03/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Presence of gas is a frequent finding on early postoperative computed tomography angiography (CTA) after endovascular aortic aneurysm repair (EVAR) with unclear clinical relevance. The aim of this study is to examine and compare the presence of gas within the aneurysm sac following EVAR on early postoperative CTA after the use of carbon dioxide (CO2) flushing technique with saline flushing alone. METHODS A retrospective analysis of patients undergoing standard, fenestrated EVAR (fEVAR) or branched EVAR (bEVAR) with flushing of the delivery system with CO2 between January 2016 and August 2018 was undertaken. Data of a previous report using standard saline flushing were included. Patients were classified into 2 main groups: group 1 with saline flushing and group 2 with CO2 flushing and 3 subgroups according to the type of endograft. The presence, position, and volume of gas in the postoperative CTA (within 10 days) was examined and analyzed in terms of anatomical and procedural risk factors. RESULTS Group 1 included 210 patients (mean age 73 ± 8, 84% males), while group 2 included 300 patients (mean age 70 ± 11, 68% males). Presence of gas was more common in group 1 (83, 39% vs. 64, 21%, P = 0.000). Volume of gas was larger in group 1 [0.41 mL (0.01-2.7) vs. 0.2 mL (0.02-1), P = 0.001). In standard EVAR with saline flushing (subgroup 1a), 59 patients (45%) had presence of gas with CO2 flushing (subgroup 2a); 35 patients (25%) had presence of gas (P = 0.005). The mean gas volume was larger in subgroup 1a compared to 2a (0.40 ± 0.47 vs. 0.15 ± 0.17 mL, P = 0.000). The location of the gas was more frequent in contact with the anterior wall of the aorta in both groups, standard EVAR subgroups and fEVAR subgroups. The presence of gas in group 2 was associated with larger preoperative size of the aortic diameter (P = 0.03) and larger perfused lumen diameter (P = 0.05). The type of the graft was not associated with the presence of gas in the aneurysm sac on postoperative CTA. However, the presence of gas was more frequent in standard EVAR than fEVAR and bEVAR. Endoleak type II was not associated with the presence of gas. CONCLUSIONS CO2 flushing of stent grafts during standard and complex EVAR prior to deployment reduces the frequency and volume of gas on postoperative CTA. This study indicates that the CO2 flushing technique may effectively exchange trapped air for a less harmful gas in endografts.
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Affiliation(s)
- Ahmed Eleshra
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg, Hamburg, Germany
| | - Vasilis Saleptsis
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg, Hamburg, Germany
| | - Konstantinos Spanos
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg, Hamburg, Germany
| | - Fiona Rohlffs
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg, Hamburg, Germany
| | - Nikolaos Tsilimparis
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg, Hamburg, Germany
| | - Giuseppe Panuccio
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg, Hamburg, Germany
| | - Vladimir Makaloski
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg, Hamburg, Germany
| | - Eike Sebastian Debus
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg, Hamburg, Germany
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg, Hamburg, Germany.
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van Bakel TMJ, Houben IB, van Herwaarden JA. Commentary: Air Embolization During TEVAR. J Endovasc Ther 2019; 26:456-457. [PMID: 31169065 DOI: 10.1177/1526602819852924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Ignas B Houben
- 2 Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
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11
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Makaloski V, Rohlffs F, Trepte C, Debus ES, Øhlenschlaeger B, Schmidli J, Kölbel T. Distribution of Air Embolization During TEVAR Depends on Landing Zone: Insights From a Pulsatile Flow Model. J Endovasc Ther 2019; 26:448-455. [DOI: 10.1177/1526602819849931] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To analyze the distribution of air bubbles in the supra-aortic vessels during thoracic stent-graft deployment in zones 2 and 3 in an aortic flow model. Materials and Methods: Ten identical, investigational, tubular, thoracic stent-grafts were deployed in a glass aortic flow model with a type I arch: 5 in zone 2 and 5 in zone 3. A pulsatile pump generated a flow of 5 L/min with systolic and diastolic pressures (±5%) of 105 and 70 mm Hg, respectively. The flow rates (±5%) were 300 mL/min in the subclavian arteries, 220 mL/min in the vertebral arteries, and 400 mL/min in the common carotid arteries (CCAs). The total amounts of air released in each supra-aortic branch and in the aorta were recorded. Results: The mean amounts of air measured were 0.82±0.23 mL in the zone-2 group and 0.94±0.28 mL in the zone-3 group (p=0.49). In the zone-2 group compared with zone 3, the amounts of released air were greater in the right subclavian artery (0.07±0.02 vs 0.02±0.02 mL, p<0.01) and right CCA (0.30±0.8 vs 0.18±07 mL, p=0.04). There were no differences between the groups concerning the mean amounts of air measured in the right vertebral and all left-side supra-aortic branches. The amount of air released in the descending aorta was significantly higher in the zone-3 group vs the zone-2 group (0.48±0.12 vs 0.13±0.08 mL, p<0.01). Small bubbles were observed continuously during deployment, whereas large bubbles appeared more commonly during deployment of the proximal stent-graft end and after proximal release of the stent-graft. Conclusion: Air is released into all supra-aortic branches and the descending aorta during deployment of tubular thoracic stent-grafts in zones 2 and 3 in an aortic flow model. Higher amounts of air were observed in right-side supra-aortic branches during deployment in zone 2, whereas significantly greater amounts of air were observed in the descending aorta during deployment in zone 3.
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Affiliation(s)
- Vladimir Makaloski
- German Aortic Center, Department of Vascular Medicine, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Fiona Rohlffs
- German Aortic Center, Department of Vascular Medicine, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - Constantin Trepte
- German Aortic Center, Department of Vascular Medicine, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - E. Sebastian Debus
- German Aortic Center, Department of Vascular Medicine, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Jürg Schmidli
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
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12
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Masoomi R, Lancaster E, Robinson A, Hacker E, Krajcer Z, Gupta K. Safety of EndoAnchors in real-world use: A report from the Manufacturer and User Facility Device Experience database. Vascular 2019; 27:495-499. [PMID: 30991897 PMCID: PMC6767639 DOI: 10.1177/1708538119844041] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives A hostile proximal neck anatomy is the most common cause of abdominal aorta endovascular aneurysm repair failure leading to a higher risk of device migration, proximal type I endoleak, and subsequent open surgical repair. Endostapling is a technique to attain better fixation of the endograft to the aortic wall, and the only available device in the USA is Aptus Heli-FX EndoAnchor system (Medtronic Vascular, Santa Rosa, CA, USA). Preliminary data have shown efficacy and safety of its use, and the aim of this study is to assess device-related adverse events in real-world clinical use. Methods We quarried data from the publicly available Manufacturer and User Facility Device Experience database to identify Aptus Heli-FX EndoAnchor system-related adverse reports in endovascular aneurysm repair since FDA approval till August 31, 2017. An estimate of total devices implanted in the United States was quoted around 7,000 (Medtronic marketing internal data). Results Our query identified 229 separate reports, of which there were 85 adverse events (1.2% of the estimated EndoAnchor systems used). The most common adverse events were device dislodgement/fracture (65) and applicator malfunction (20). Conclusion In early post-FDA approval use in a real-world setting, the EndoAnchor system is associated with a low rate of adverse events. Device dislodgement and embolization remain the most common adverse events. With increasing use of these devices in more difficult anatomy, careful patient selection and careful attention to technique may help to reduce these events even further.
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Affiliation(s)
- Reza Masoomi
- Division of Cardiovascular Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Emily Lancaster
- Division of Internal Medicine, Cornell University, Ithaca, NY, USA
| | - Alexander Robinson
- Division of Cardiovascular Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Ethan Hacker
- Division of Cardiovascular Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Zvonimir Krajcer
- Division of Cardiovascular Medicine, Texas Heart Institute, Houston, TX, USA
| | - Kamal Gupta
- Division of Cardiovascular Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
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Rohlffs F, Trepte C, Ivancev K, Tsilimparis N, Makaloski V, Debus ES, Kölbel T. Air Embolism During TEVAR: Liquid Perfluorocarbon Absorbs Carbon Dioxide in a Combined Flushing Technique and Decreases the Amount of Gas Released From Thoracic Stent-Grafts During Deployment in an Experimental Setting. J Endovasc Ther 2018; 26:76-80. [DOI: 10.1177/1526602818819501] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Purpose:To investigate the influence of flushing thoracic stent-grafts with carbon dioxide and perfluorocarbon on the amount of gas released during stent-graft deployment in thoracic endovascular aortic repair (TEVAR). Materials and Methods: Ten TX2 ProForm thoracic stent-grafts were deployed into a water-filled container with a curved plastic pipe and flushed sequentially with carbon dioxide, 20 mL of liquid perfluorocarbon (PFC), and 60 mL of saline. Released gas was measured using a calibrated setup. The volume of released gas was compared with the results of an earlier published reference group, in which identical stent-grafts were flushed with 60 mL saline alone as recommended in the instructions for use. Results: The average amount of gas released in the test group was 0.076 mL, significantly lower (p<0.001) than the mean 0.79 mL of gas released in the reference group. Big bubbles appearing at the tip of the sheath when deployment was started were seen in all grafts of the reference group but in only 2 of the test group stent-grafts. Small bubbles were less frequent in the test group. Conclusion: The amount of gas released from thoracic stent-grafts during deployment can be influenced by different flushing techniques. The use of PFC in addition to the carbon dioxide flushing technique reduces the volume of gas released during deployment of tubular thoracic stent-grafts to a few microliters. This significant effect is presumably based on the high solubility of carbon dioxide in perfluorocarbon and could be a potential future approach to lower the risk of cerebral injury and stroke from air embolism during TEVAR.
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Affiliation(s)
- Fiona Rohlffs
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Constantin Trepte
- Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Krassi Ivancev
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Nikolaos Tsilimparis
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Vladimir Makaloski
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - E. Sebastian Debus
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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14
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Cerebral embolic protection in thoracic endovascular aortic repair. J Vasc Surg 2018; 68:1656-1666. [DOI: 10.1016/j.jvs.2017.11.098] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 11/27/2017] [Indexed: 01/14/2023]
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15
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Makaloski V, Rohlffs F, Spanos K, Debus S, Tsilimparis N, Kölbel T. Bubble Counter for Measurement of Air Bubbles During Thoracic Stent-Graft Deployment in a Flow Model. J Surg Res 2018; 232:121-127. [PMID: 30463707 DOI: 10.1016/j.jss.2018.06.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 04/24/2018] [Accepted: 06/01/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND The aim of our study was to describe and validate the use of a bubble counter in an aortic flow model assessing the distribution of air bubbles in the supra-aortic vessel during thoracic stent-graft deployment. MATERIALS AND METHODS In an aortic flow model made by glass, identical tubular thoracic stent grafts (Zenith TX2 ProForm; Cook Medical, Bjaeverskov, Denmark) were deployed distal to the left subclavian artery. Four steps were defined during deployment: (1) introduction of the stent graft in the arch; (2) deployment of the stent graft; (3) proximal release of the stent graft; and (4) retrieval of the introduction system. On both sides, the common carotid and the vertebral artery were connected together, and the air bubbles were measured with one bubble counter probe per side. The number of air bubbles, as well as their size and distribution, is analyzed during these four steps for the left and right sides with a bubble counter. RESULTS Ten thoracic stent grafts were included in the study. The total number of air bubbles measured during all steps was significantly higher on the left side (1091 ± 255 versus 545 ± 288, P < 0.00001). During the third step, significantly higher numbers of bubbles were observed on the left side (P = 0.0000001) compared with the right side. The analysis of all bubbles by size revealed that a higher number of bubbles ranged 100-200 μm (P < 0.02) and 200-300 μm (P < 0.03) on the left side. Small bubbles were observed during all steps of deployment, whereas large bubbles appeared more commonly during the second and third steps. CONCLUSIONS A significant number of air bubbles are released during deployment of tubular thoracic stent grafts distally of the left subclavian artery in an aortic flow model. The distribution of air bubbles is bilateral with a higher number of air bubbles released on the left side.
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Affiliation(s)
- Vladimir Makaloski
- German Aortic Center, Department of Vascular Medicine, University Heart Center Hamburg-Eppendorf, Hamburg, Germany; Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Fiona Rohlffs
- German Aortic Center, Department of Vascular Medicine, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - Konstantinos Spanos
- German Aortic Center, Department of Vascular Medicine, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sebastian Debus
- German Aortic Center, Department of Vascular Medicine, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nikolaos Tsilimparis
- German Aortic Center, Department of Vascular Medicine, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
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Falkenberg M, Bokvist F, Skoog P. Commentary: How to Deal With Air Released From Thoracic Endografts: Ignore It or Fear It? J Endovasc Ther 2018; 25:440-441. [PMID: 29936888 DOI: 10.1177/1526602818784027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Mårten Falkenberg
- 1 Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Fredrik Bokvist
- 2 Department of Anesthesiology, Falun Hospital, Falun, Sweden
| | - Per Skoog
- 3 Department of Vascular Surgery and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital and Academy, Gothenburg, Sweden
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Rohlffs F, Tsilimparis N, Trepte C, Kratzberg J, Mogensen J, Debus ES, Kölbel T. Air Embolism During TEVAR: An Additional Flush Port on the Delivery System Pusher Significantly Reduces the Amount of Air Released During Deployment of a Thoracic Stent-Graft in an Experimental Setting. J Endovasc Ther 2018; 25:435-439. [DOI: 10.1177/1526602818780951] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To investigate the influence of (1) an additional side port for flushing the hollow pusher in Zenith thoracic stent-graft delivery systems and (2) additional carbon dioxide flushing on the amount of air released during stent-graft deployment. Methods: Twenty thoracic stent-grafts with an additional flush port to fill the hollow pusher were separated into 2 equal groups (C and D). Both groups were flushed with 20 mL of normal saline through the extra side port connected to the pusher and with 60 mL of saline through the regular flushing port. One group of grafts (group D) was additionally flushed with carbon dioxide through the regular flushing port prior to saline. All grafts were deployed into a curved plastic pipe attached to the bottom of a water-filled container. The released gas was recorded and measured using a calibrated setup. To evaluate the influence of the extra side port irrespective of the carbon dioxide flushing technique, group C was compared with a previously published reference group A without an extra side port that was flushed with the standard 60 mL of saline. Results: Volumes of gas were released in various amounts from the stent-grafts during deployment. The average amount of released gas was 0.51 mL in group C and 0.07 mL in group D (p<0.001). The mean amount of gas from group C samples (0.51 mL) was also significantly lower (p=0.002) compared with the reference group (0.79 mL). Conclusion: Thoracic endografts release air during deployment. Reducing the air-filled space inside the pusher of the catheter assembly using an additional side port can significantly reduce the amount of released air. Using the extra side port in combination with the carbon dioxide flushing technique reduces gas release further to small volumes. In a clinical setting this could be a promising approach to lower the risk of air embolism and stroke during thoracic endovascular aortic repair.
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Affiliation(s)
- Fiona Rohlffs
- German Aortic Center, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Nikolaos Tsilimparis
- German Aortic Center, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Constantin Trepte
- Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - E. Sebastian Debus
- German Aortic Center, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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